The Evolution of Forward 

Surgery in the US Army

F R O M T H E R E V O L U T I O N A RY WA R T O T H E 

COMBAT OPERATIONS OF THE 21ST CENTURY

Edited by

LANCE P. STEAHLY, MD

Colonel, Medical Corps

US Army (Retired)

and

DAVID W. CANNON, SR.

Major, Medical Service Corps

US Army (Retired)

BORDEN INSTITUTE

US Army Medical Department Center and School

Health Readiness Center of Excellence

Fort Sam Houston, Texas
Edward A. Lindeke, Colonel (Retired), MS, US Army 

Director, Borden Institute

Linette Sparacino

Volume Editor, Borden Institute

Joan Redding

Senior Production Editor, Borden Institute

Christine Gamboa-Onrubia, MBA 

Creative Director and Production Manager, Fineline Graphics, LLC

The views expressed are those of the authors and do not necessarily represent those of the US Army, the US Department of Defense, or the United States Government. Use of trade or brand names in this publication does not 

imply endorsement by the Department of Defense. Partial support for this book was provided by Defense Health 

Horizons, a policy analysis unit at the Uniformed Services University of the Health Sciences.

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Published by the 

BORDEN INSTITUTE

US Army Medical Department Center and School 

Health Readiness Center of Excellence | Fort Sam Houston, Texas

2018

Library of Congress Cataloging-in-Publication Data

Names: Steahly, Lance P., editor. | Cannon, David W., Sr., editor.

Title: The evolution of forward surgery in the US Army : from the 

 Revolutionary War to the combat operations of the 21st century / edited by 

 Lance P. Steahly, MD, Colonel, Medical Corps US Army (Retired) and David 

 W. Cannon, Sr., Major, Medical Service Corps US Army (Retired).

Description: Sam Houston, Texas : Borden Institute, [2018] | Includes 

 bibliographical references and index. 

Identifiers: LCCN 2018047833 (print) | LCCN 2018048270 (ebook) | ISBN 

 9780160940088 (ebook) | ISBN 9780160940095 (ebook) | ISBN 9780160940101 (ebook) | ISBN 

9780160947841 (pbk.)

Subjects: LCSH: Medicine, Military—United States—History. | Surgery, 

 Military—United States—History. | United States. Army—Medical care—History.

Classification: LCC UH223 (ebook) | LCC UH223 .E94 2018 (print) | DDC 

 355.3/450973—dc23

LC record available at Caution-https://lccn.loc.gov/2018047833

For sale by the Superintendent of the Documents, U.S. Government Publishing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC area (202) 512-1800

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ISBN No. 978-0-16-094784-1

PRINTED IN THE UNITED STATES OF AMERICA

247-809_text_CX.indb 2 12/27/18 
ACKNOWLEDGMENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

ABOUT THE AUTHORS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

FOREWORD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii

1 Casualty Care From the Revolutionary War to the War of 1812. . . . . . . . . . . . . . . . . . 1

Lance P. Steahly

2 Surgery and Medicine in the War of 1812: A New Nation Challenged. . . . . . . . . 33

Lance P. Steahly

3 The Civil War: Military Medical Care in the War Between the States. . . . . . . . . . 65

Lance P. Steahly

4 Transitions: Army Medicine in the Post-Civil War Period to the 

Start of World War I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

Lance P. Steahly

5 Forward Surgery in the Great War: A War of New Technologies. . . . . . . . . . . . . . . 141

Lance P. Steahly

6 World War II: Army Forward Surgery on a Worldwide Scale. . . . . . . . . . . . . . . . . 173

Lance P. Steahly

7 Forward Surgery in the Korean War: The Mobile Army Surgical Hospitals. . . . 239

Scott C. Woodard

8 Vietnam: The Rise of Helicopter Medical Evacuation in a 

War Against a New Kind of Enemy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285

Lance P. Steahly

Contents
i v • FORWARD SURGERY

9 From the Falklands to the Balkans: Toward Formal 

Designation of the Forward Surgical Team. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321

Christopher A. VanFosson

10 Put to the Test: Forward Surgical Teams Challenged 

During the Global War on Terrorism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355

Jason M. Seery and David W. Cannon

11 Homeland Defense, Contingency Operations, and Future Directions. . . . . . . . . . 429

David C. Lynn and Jason M. Seery

ACRONYMS AND ABBREVIATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431

INDEX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
THE AUTHORS HAVE NOTHING BUT PRAISE for our wonderful Borden Institute 

Volume Editor, Linette Sparacino. Linette has been extremely patient in bringing along the 

authors. She has provided excellent editing at all levels. Her gracious and kind demeanor 

has added to our success. Linette and Lieutenant Colonel Daniel Banks, former Director of 

the Borden Institute, worked well together in the review and editing process, as did Linette 

and Colonel John Garr, the following Director.

We are indebted to Mary E. Hope, Senior Archivist, and Carlos Alvarado, Archivist, Army 

Medical Department Center of History and Heritage, Fort Sam Houston, Texas, for their 

great help in securing artworks and photographs from a number of sources. We appreciate 

their diligence in researching the copyright status of the illustrations and their pursuit of 

photographs of museum artifacts. Their help added greatly to the book’s coverage of the 

events.

We would like to recognize the contribution of Second Lieutenant Molly Steahly to the 

process. She was an Army ROTC Scholarship recipient at Arizona State University. Molly 

is now enrolled as a second-degree nursing student at George Washington University in 

Washington, DC. She is a reserve officer in the US Army Reserves. She has assisted us in 

assembling information, proofreading, and fact checking for many of these chapters. Molly 

has thereby gained an interest in military medical history of her own and has worked with 

Dr. Dale Smith, Professor of Medical History at the Uniformed Services University of the 

Health Sciences. 

LANCE P. STEAHLY, MD, FACS

DAVID W. CANNON, SR.

March 2017

Acknowledgments

DAVID C. LYNN, MD, is a Board-Certified General Surgeon and Fellow of the American 

College of Surgeons. His first duty assignment as an active duty surgeon was at Womack 

Army Medical Center at Fort Bragg, North Carolina, in 2009. He deployed to Iraq with 

the 21st Combat Support Hospital in 2010. He commanded the 759th Forward Surgical 

Team (Airborne) at Fort Bragg from January 2011 to February 2013, and carried out both 

Global Response Force and Defense Chemical-Biological-Radiological-Nuclear Response 

Force missions during this time. He deployed to Afghanistan in 2013 and was honorably 

discharged from the Army in 2014. He worked at Womack for an additional year as a 

civilian contractor, while continuing to work on special projects regarding forward surgery 

for the Department of Defense. 

JASON M. SEERY, MD, is a Board-Certified General Surgeon and Fellow of the 

American College of Surgeons. He is currently serving as the Deputy Commander for 

Surgical Services at Martin Army Community Hospital, Fort Benning, Georgia. Prior to 

this assignment, he served for more than three years as the sixth director of the US Army 

Trauma Training Center, Jackson-Memorial Hospital, Ryder Trauma Center, in Miami, 

Florida. He deployed to Iraq from October 2003 through July 2004 with the 2d Armor 

Cavalry Regiment as the Squadron Flight Surgeon and had a 3-year assignment as the 

commander of the 541st Forward Surgical Team (Airborne) at Fort Bragg, North Carolina. 

From February 2010 through February 2011 he deployed to combat in Afghanistan with 

the 541st Forward Surgical Team (Airborne). His unit supported both Global Response 

Force and Defense Chemical-Biological-Radiological-Nuclear Response Force missions. 

LTC(P) Seery is a guest lecturer at the Forward Surgical Team Commanders Course 

and Brigade and Divisions Surgeons Course. He is also a consultant to various special 

operations forces units on combat trauma management concepts.

LANCE P. STEAHLY, MD, is a Fellow of the American College of Surgeons and board 

certified by the American Board of Ophthalmology. He is an ophthalmologist who has 

worked in settings including the military, academia, Veterans Administration, and private 

practice. He now serves as the Supervisory Physician of the Medical Evaluation Board and 

Director of the Integrated Disability Evaluation System, San Antonio Military Medical 

Center, Joint Base San Antonio–Fort Sam Houston, Texas. He is a retired colonel in the 

US Army. Dr. Steahly has been interested in military history for many years. His interest 

About the Authors
viii • FORWARD SURGERY

especially peaked while involved in the Command and General Staff curriculum. COL 

Steahly has served in many continental US medical facilities, Germany, and Hawaii. He has 

served as an Army Chief of Surgery and as a Commander of the 900th US Army Hospital 

Surgical Mobile, a MASH unit.

CHRISTOPHER A. VANFOSSON, MSN/MHA, RN, is an Army nurse with 24 months 

of service in combat. He deployed with the 28th Combat Support Hospital in support 

of Operation Iraqi Freedom (2003–2004), where he served as a medical/surgical and 

critical care nurse. LTC VanFosson also deployed to Afghanistan in support of Operation 

Enduring Freedom from February 2010 through February 2011, where he served as the 

chief nurse and critical care nurse on the 541st Medical Detachment, Forward Surgical 

Team (Airborne). He serves as a subject matter expert for a Department of Defense-level 

evaluation of the Role 2 medical resources in the Afghanistan Theater of operations. 

Previously, LTC VanFosson served as the Clinical Nurse Officer in Charge of the Burn 

Progressive Care Unit at the US Army Burn Center, US Army Institute of Surgical Research, 

Joint Base San Antonio–Fort Sam Houston, Texas. He also served from 2010 through 

2012 as a subject matter expert and reviewer for the Army Medical Department Lessons 

Learned-developed Forward Surgical Team Guide. 

SCOTT C. WOODARD, MA, is a historian in the Office of Medical History at the US 

Army Medical Department Center of History and Heritage, having previously served in the 

US Army for over 22 years. He holds a bachelor’s in history from The Citadel, The Military 

College of South Carolina, and a master’s in military medical history from the Uniformed 

Services University of the Health Sciences, Bethesda, Maryland. “Woody” is a certified 

Military Historian from the US Army Center of Military History. He has traveled in 24 

countries and most recently deployed in 2014 to Kuwait and Afghanistan as a Department 

of the Army Historian. 

DAVID W. CANNON, MA, is a retired major in the Medical Service Corps, US Army. He 

holds both his BA and MA degrees in psychology from the University of Maine, Orono, 

Maine, and has completed a fellowship in military medical history at the Uniformed 

Services University of the Health Sciences, Bethesda, Maryland. He served in a variety of 

assignments while on active duty, including instructor in military medical history at the 

Academy of Heath Sciences and chief of the Army Medical Department doctrine literature 

branch, Fort Sam Houston, Texas. He currently works as a Lessons Learned Analyst at 

the Army Medical Department Center and School, Health Readiness Center of Excellence, 

Joint Base San Antonio–Fort Sam Houston, Texas.
THE PRIMARY MISSION OF ARMY MEDICINE is to support the warfighter. 

Fundamental to that mission is our ability to provide trauma resuscitation or surgical 

capability on the battlefield. During the most recent era of combat operations in the US 

Army Central Command area of responsibility, our trained and ready medical providers 

contributed to a survivability rate of 92%, the highest in the history of warfare. Surgical 

capability employed far forward was a key component in achieving these survivability 

rates. To build on these accomplishments, we look to the past, to provide lessons learned 

and document innovative advances, in order to best prepare for the next conflict. To that 

end, this book examines the history of forward surgery.

The authors have focused on tracing the evolution of forward surgery in the US Army, 

but the scope of this book also encompasses the history of the Army Medical Department 

from the Revolutionary War to the present. The chapters describe the progression of care 

to wounded, injured, and ill Soldiers from very rudimentary procedures and methods 2 

centuries ago, to the advanced medical and surgical technologies now available. The latest 

in Borden Institute’s historical series, this book adds to our knowledge of how military 

medicine advanced during the nation’s history, detailing a new aspect of our medical legacy 

by examining the changes in forward surgery. 

As documented in this volume, the lessons of past conflicts can easily be forgotten, only to 

be rediscovered during the next war. Today, Army Medicine has made a renewed effort to 

utilize past experiences and apply historical lessons to develop new and improved combat 

casualty care capabilities. Newly developed procedures must be responsive to operational 

needs and effective in a Joint/Combined environment characterized by expeditionary 

operations and minimal, if any, preestablished health service infrastructure. This volume 

speaks to the courage, dedication, and selfless service of Army healthcare professionals 

from this nation’s earliest days to the present. In the challenging times faced by our nation 

and military today, Soldiers and their Families can continue to rely on the Army to provide 

responsive medical capabilities and the most advanced care to our wounded, injured, and 

ill Soldiers, Department of the Army civilians, and their Families.

NADJA Y. WEST

Lieutenant General, US Army

The Surgeon General and 

 Commanding General, USAMEDCOM

Foreword

THIS BOOK ORIGINALLY WAS CONCEIVED as a history of the evolution of the 

mobile Army surgical hospital (MASH) into the modern day forward surgical team 

(FST). Dr Dale Smith, Professor of Medical History and the former Senior Vice President, 

Uniformed Services University of the Health Sciences, Bethesda, Maryland, wisely suggested 

that the scope of this writing be expanded to the evolution of forward surgery in the Army 

in the 20th century and now the 21st century. Once the active editing of the book began, 

the subject was expanded again to include all the wars fought by the United States from the 

Revolutionary War onward.

The evolving story of forward surgical care begins during the Revolutionary War. The 

Medical Department of the Continental Army was created by the Continental Congress in 

July 1775. At that point there was only a poorly defined organizational structure (largely 

manned by Massachusetts physicians and surgeons), which had few funds with which to 

buy basic medicines or supplies. The British medical system was in many ways a role model 

for the Americans because many of the colonies’ senior surgeons had experience with the 

British during the French and Indian War. Most physicians were trained by the apprentice 

system or self-trained; only a few American surgeons had attended either a foreign 

medical college or one of the two in existence in America. The American system had to 

deal with inadequate manpower, shortage of funds and supplies, and inadequate central 

administration throughout the entire conflict.

Following the Revolutionary War, the American aversion to standing armies and 

taxes led to the extreme downsizing of the Army, which was to be replaced by militias and 

volunteer organizations. Only by 1789 had some semblance of an army returned. The 

period from 1789 up to the War of 1812 featured a small military organization deployed 

on the frontier to deal with Indian incursions.

In the War of 1812, there had been little change in field surgery since the Revolutionary 

War. Surgery was directed to the removal of a bullet or shrapnel. The continued shortage 

of doctors hindered medical care for the wounded. The many diseases afflicting the troops 

were treated by the often inadequate methods available at the time. A notable exception 

was the smallpox menace, which was reduced due to the advent of Jenner’s vaccination 

method. 

Introduction

[Opposite] Lawrence Beall Smith’s The Man Without a Gun, Normandy 1944, personifies the unselfish 

service of the medical personnel of all wars to save the lives of other soldiers. Artwork courtesy of the 

Army Art Collection, Image #13-151-45.
xii • FORWARD SURGERY

The period between the War of 1812 and the Civil War featured always limited 

budgets, isolated posts, and a constant battle against Indians and diseases such as typhoid, 

cholera, malaria, and yellow fever. Indian conflicts included the Blackhawk War, and the 

First through the Third Seminole Wars. The Mexican-American War required dealing with 

more illness and casualties due to the increased scale of conflict. After that conflict, Army 

medicine returned to isolated posts on the frontier keeping the Indians in check. 

The Civil War caught the medical departments of both the Union and the Confederacy 

in an unprepared state. The scale of the troop dispositions and consequent casualties 

forced change. Doctors William Hammond (as Surgeon General) and Jonathan Letterman 

brought progress. Hammond advocated improved hospitals and supported Letterman’s 

ideas about the use of ambulances in the evacuation and treatment of the wounded. The 

medical care of the time included surgical procedures for amputations of more serious 

extremity wounds, removal of musket balls, dressings for minor wounds, and bandaging 

and splinting of fractures, along with the use of better analgesics including alcohol, opiates, 

chloroform, and ether. 

The period after the Civil War witnessed shrinkage of the Army and consequent 

reduction in medical assets available to the smaller Army. Aside from occupation duty 

in the South and a brief war scare with Mexico in the face of French intervention, Army 

medicine reverted to the care of small isolated garrisons. The varied Indian wars featured 

small numbers of casualties, often treated away from permanent medical facilities. 

Advances in medicine helped Army medicine at the end of the 19th century. The onset of 

the Spanish-American War and the later challenges of distant warfare in such places as the 

Philippines and China showed that Army medicine could respond. Army medicine brought 

advances in infectious disease understanding and treatment through the works of leaders 

such as Walter Reed, William Gorgas, and George Sternberg. 

The period of the new 20th century leading up to World War I featured the 1916 

Mexican border incursions and slow preparedness for involvement in the European war, 

which had started in 1914. Leaders such as Doctors George Crile and Harvey Cushing, 

as well as liaisons with the British and French, helped awaken America to the challenges 

ahead. 

World War I was the first truly modern war in all of its devastation. The World War 

I experience with mobile surgical hospitals was noteworthy in a war that quickly became 

immobile on its fighting fronts. The need for forward surgery was clearly seen in this 

conflict due to the high-velocity weapons and explosives effects, which produced massive 

numbers of traumatic injuries. The war’s surgical hospitals and relays of surgical teams 

worked to perform the many operations required under these conditions. Many famous 

surgeons, such as Cushing and Crile, contributed to US medical readiness and to the care of 

American and Allied casualties. 

The Spanish Civil War proved to be a testing ground for military medical advances, in 

addition to the obvious trials of advanced weapons and tactics. Tetanus vaccine (introduced 

in 1931) found use in the war. Sulfonamides found a war use for the first time in the 

Spanish conflict. The stage was set for World War II.
INTRODUCTION • xiii

The US Army in World War II created the portable surgical hospital (PSH) to meet 

the specific needs of the China-Burma-India (CBI) and Pacific theaters of operations. The 

PSH was a direct attempt to provide forward surgery as close as possible to the front lines 

under austere environmental conditions. The PSHs accompanied the troops through jungle 

terrain, set up in tents and other field expedient shelters, and provided surgical care for 

patients until they could be evacuated to rear medical treatment facilities. The PSHs could 

be moved within hours as needed. They were staffed with 37 personnel, consisting of four 

medical officers and 33 enlisted men, with a 25-bed patient capability. The PSHs worked 

well and were eventually deployed to all theaters; however, the European PSHs arrived 

after fighting ended there. The PSHs often had younger and less experienced surgeons than 

those assigned to the larger hospitals in the rear, despite the lessons from World War I that 

experienced surgeons should be forward. World War II saw the increased use of antibiotics 

(especially penicillin), improved blood banking, and enhanced surgical techniques that 

resulted in a dramatic decrease in died-of-wounds (DOW) rates from the previous wars.

The Korean War MASH was an outgrowth of the field surgical hospital units 

employed in the European theater and the PSHs in the CBI and Pacific theaters. The 

concept was to provide high-level surgical care as far forward as possible. The MASH was 

approved for development in 1945; five MASH units were created on paper between 1948 

and 1950. However, they were not ready when war came in 1950. The MASH designation 

was an early war use; units were officially designated as “Surgical Hospital (Mobile 

Army).” Advances made in Korea included improvements in anesthesia, management of 

shock, and vascular surgery. Units were also set up to deal with renal insufficiency.

The success of the MASH in the Korean War led to its use in the Vietnam War. 

Helicopter medical evacuation, used for the first time toward the end of World War II, 

saw extensive use during the Korean War and became the norm in Vietnam as medical 

evacuation helicopters picked wounded soldiers directly from the battlefield and sped 

them to medical facilities, within minutes in many cases. Advances in wound management 

along with the proximity of the battlefield to hospitals, improvements in blood banking, 

and better vascular surgery techniques were a few of the advances that enabled so many 

soldiers to survive. The Army DOW rate dropped from 3.5% in World War II, to 2.5% 

in the Korean War, but rose to 3.3% in Vietnam War.1

 The rise in the Vietnam War DOW 

rate was due in large part to the widespread use of helicopter evacuation. This rapid 

transportation got the very seriously injured soldiers quickly back to hospitals. These were 

the men who in previous wars would have died on the battlefield. Unfortunately, some 

were so gravely wounded that even rapid transport could not save them; thus the slightly 

higher DOW rate in Vietnam.

The Persian Gulf War saw the first use of the deployable medical systems (DEPMEDS) 

equipped hospitals that consisted of shelter systems, generators, and environmental control 

units, along with modular medical and dental materiel sets. Although a vast improvement 

over the Vietnam-era Medical Unit, Self-Contained, Transportable (MUST) equipment 

used in combat zone hospitals, the weight and size of the DEPMEDS hospital units limited 

their mobility in the Persian Gulf War. MASH units could not keep pace with the combat 
xiv • FORWARD SURGERY

units and were forced to leave much of their surgical and bed capacity behind when they 

had to move forward. Lessons from Operation Just Cause in 1989 in Panama, and the 

1990–1991 Persian Gulf War, led to the development of the forward surgical team (FST) 

concept to meet the need for a small, easily deployable surgical facility that could perform 

trauma surgical procedures on US casualties from the moment fighting begins.2 The first 

two FSTs were fielded in the early 1990s and consisted of personnel and operating room 

equipment, generators, and medical supplies capable of being parachuted in at the same 

time. This delivery system enabled the FSTs to provide wounded paratroopers immediate 

access to life-saving trauma operations at the start of combat operations. The highly 

mobile FSTs each consisted of 20 personnel and equipment necessary to perform 30 lifesaving operations in 72 hours. This was more robust and capable than the surgical squads 

and surgical detachments that the rapid deployment divisions and corps of the era had 

employed during Operation Just Cause and Operation Desert Storm (1990–1991). The 

new FSTs were initially deployed to various missions in Central and Eastern Europe and 

throughout Africa before supporting combat brigade-size units during the wars in Iraq 

and Afghanistan. These units proved their value in saving lives. The FST concepts continue 

to evolve in the Global War on Terrorism, which continues under different names and in 

different areas of the world. The ongoing terrorism threat will continue to challenge the 

Army Medical Department. The challenge of homeland defense and future contingency 

operations will require new thinking in forward surgery.

Future innovations in the FST design will enhance the mobility, scalability, and 

flexibility of the Army’s forward surgical capability to meet any threat scenario. The goal is 

to create a forward surgical capability that consists of five key tasks: (1) mission command, 

(2) advanced trauma management (including damage control resuscitation), (3) surgical 

services (including damage control surgery), (4) postsurgical/anesthesia and critical care 

services, and (5) ancillary support services. 

This volume chronicles how forward surgery on the battlefield has evolved to this 

point and the way forward. Just as there will always be wars, there will always be a need 

and an obligation to provide the most immediate care possible for those who are wounded 

or injured.

REFERENCES

1. Neel S. Hospitalization and evacuation. In: Neel S. Vietnam Studies: Medical Support of the 

US Army in Vietnam 1965–1970. Washington, DC: Department of the Army; 1991: Chap 4. 

2. Thomas RW. Ensuring Good Medicine in Bad Places: Utilization of Forward Surgical Teams on 

the Battlefield [research project]. Carlisle Barracks, PA: US Army War College; 2006: 13–14.
THIS BOOK IS DEDICATED TO THE 

FIRST-LINE MEDICAL PERSONNEL WHO FREQUENTLY 

PULL THE WOUNDED BACK FROM THE EDGE OF DEATH, 

STABILIZE THEM ENOUGH TO TRANSPORT, 

AND THEN SEND THEM ON TO THE NEXT ECHELON OR 

LEVEL OF CARE WITHOUT EVER KNOWING 

IF THEY ULTIMATELY LIVED OR DIED. 

THESE ARE THE MEDICAL PERSONNEL 

WHO SELFLESSLY SERVE FOR THE BETTERMENT OF 

THEIR FELLOW SOLDIERS.

INTRODUCTION

AN OVERVIEW OF THE REVOLUTIONARY WAR will help the reader understand the 

role of military medicine in the conflict. The American Revolution was the culmination of 

years of grievances and a growing sense of distance from British rule in the American colonies. As Savas and Dameron point out in their book, A Guide to the Battles of the American Revolution,

1

 the coalition of states (or colonies) had a common cause in the American 

Revolution, but had many differences on almost every major topic.1(pxxv) While the English 

were consumed with their own conflicts during the English Civil War of the 1640s, the 

colonies were left on their own, for the most part.2(p485) When the colonists were on their 

own, their tendency to independent action and mind was reinforced. Years later, the colonists felt that they had contributed to the winning of the French and Indian Wars because 

they had contributed much manpower and financial aid to bring about victory. The French 

and Indian Wars were only the North American part of a worldwide conflict. The colonies 

felt pride in their contributions, but felt that their efforts were not appreciated by the British. The British felt that the colonies should largely pay for their own defense.

EARLY CONFLICT

Antagonisms Increase

The British imposed a series of taxes on the colonists, in part to pay for Colonial 

defense and to recoup British expenses during the French and Indian War. The Americans 

were burdened also with the Sugar Act, the Currency Act, and the Quartering Act. In 

1767, the Townsend Acts were passed by Parliament and fanned the cry “taxation without 

representation.” The Navigation Acts, and later the Intolerable Acts, were particularly 

unpopular. The Navigation Acts started in 1651 and were renewed at various intervals. 

Chapter One

Casualty Care 

From the Revolutionary War 

to the War of 1812

LANCE P. STEAHLY, MD
2 • FORWARD SURGERY

These acts restricted use of foreign shipping for trade and precluded the colonies from 

direct trading with foreign countries. The Intolerable Acts (known as the Coercive Acts 

by the British) were punitive acts passed in 1774 in response to the Boston Tea Party that 

occurred on 16 December 1773. The Coercive Acts had many punitive consequences for 

the colonies, which were greatly resented by them. The most egregious sections included the 

following: (1) appointed Royal officials would not be held accountable locally for criminal 

misdeeds; (2) Massachusetts governance was suspended and elected officials were replaced 

with appointed British authorities; (3) British troops were billeted locally in seized private 

homes; and (4) the Port of Boston was closed until the Crown received restitution for the 

lost tea.2(p2) The Restraining Act in 1775 was yet another grievance. The act, also known 

as the New England Trade and Fisheries Act, was approved by King George III in March 

1775. This act limited Colonial access to the North Atlantic fisheries and restricted New 

England to trading only with British sources.2(pp486–487)

The famous “shot heard ’round the world” happened at Lexington, Massachusetts, 

on 19 April 1775. The rebellion, which evolved into the Revolutionary War, was a major 

conflict. The Americans initially relied on ad hoc militias, but soon found it necessary to 

field their own army to contend with the British. The Americans who fought at Lexington 

and Concord were New England militia. However, these militia units went on to form 

the core of the Continental Army. The national army became known as the Continental 

Line.1(ppxxiv–xxv) The nascent army positioned outside occupied Boston had mostly makeshift 

regimental hospitals available to deal with the wounded. In the Boston area, the only 

hospitals available were those managed by Massachusetts in Cambridge, Roxbury, and 

Watertown.3(p51) 

After the famous encounter at Lexington and Concord, the 1,800 Redcoat troops were 

harassed by farmers from Lexington to Boston. During the trek, some 273 casualties (73 

killed, 174 wounded, and 26 missing) were sustained by the British. The Americans had 

49 killed, 41 wounded, and five missing.1(p5) The colonists then sealed off Boston, beginning 

the siege of the city, on 19 April 1775.1(p6),4(p3) The British had occupied Dorchester Heights, 

so the rebels decided to occupy Bunker Hill, and later Breed’s Hill, to balance the British 

move.4(p4) Boston was a well-established American city surrounded by a number of small 

towns including Roxbury, Charlestown, Dorchester Heights, and Cambridge.1(p7) Men 

from Massachusetts, Connecticut, and New Hampshire made up the American contingent. 

New Hampshire’s troops were always short of supplies, especially ammunition. Their 

commander, Lieutenant Colonel Isaac Wyman, sent to Cambridge where a little powder 

was found along with lead from the church’s organ.4(p12) The Americans were given a 

new confidence after their fighting skills had been amply demonstrated at Breed’s Hill. Dr 

Joseph Warren (Figure 1-1), a physician and leader of the Boston contingent, was killed 

there. The British left Boston for Halifax on 17 March 1776, ending the siege of Boston.1(p7)

The army that Washington had for the siege of Boston was composed of soldiers whose 

enlistment was over at the end of the year. The Continental Congress had selected 

Washington as the Commander of a Continental Army, which was created on 14 June 

1775. Washington pushed Congress to rely on a long-term army with specific periods of 

enlistment, rather than militia forces. He urged Congress to provide funding and legislation 

to support a standing army based on the British and European model.1(p7)
CHAPTER ONE • 3

FIGURE 1-1. Joseph Warren. A Boston physician, Dr Warren was a leader of troops in the early Boston 

conflict with the British at Bunker Hill. Artwork courtesy of the National Library of Medicine, Image 

#B025354.
4 • FORWARD SURGERY

Continental Congress Responds

The chronology of the actions of the Continental Congress echoed the rising popular 

sentiment against Britain. The First Continental Congress convened in Philadelphia, 

Pennsylvania, on 5 September 1774 and submitted a petition for redress to King George 

III. After the battles of Lexington and Concord on 19 April 1775, the Second Continental 

Congress convened in Philadelphia on 10 May 1775. Jefferson and Dickinson produced 

for Congress on 6 July 1775 “The Declaration of the Causes and Necessity of Taking 

up Arms.”5(p15) King George III issued a proclamation on 23 August 1775 declaring the 

colonies to be in rebellion.5(p16) On 26 October 1775, the king addressed Parliament, 

saying he would seek foreign alliances to suppress the colonists. By 9 November 1775, 

Congress was informed that the king would not receive its “Olive Branch Petition.”5(p16)

The Declaration of Independence was approved by Congress on 4 July 1776 and then 

sent to the printers. New York, the sole hold out, voted on 9 July 1776 for independence. 

The actual signing of the declaration took several months, starting on 2 August 1776. By 

January 1777, the declaration was fully signed.5(pp17–19) There was but one way forward for 

the colonies.

Continental Army Created

The American Continental Army was created officially by the Continental Congress 

on 14 June 1775. The following day, George Washington was selected to lead the nascent 

forces gathered around Boston as the beginnings of the Continental Army.1(ppx–xvi) As noted 

by Wood in his book, Battles of the Revolutionary War, 1775–1781,4 George Washington’s 

contributions to the war effort included brilliant leadership and planning at Trenton and 

Princeton in the Christmas period of 1776. Wood points out that his good work then 

was counterbalanced by inept handling at Brandywine only 9 months later (September 

1777) when Washington was outmaneuvered by the British and forced to retreat. Howe 

then moved his Army closer to Philadelphia, which forced the Continental Congress to 

abandon the city.4(ppxvi,92–114) In his evaluation of George Washington (as interpreted by John 

SD Eisenhower in his Foreword), Wood described an inexperienced officer in the French 

and Indian War who evolved into a mature and capable officer who learned from his 

experiences and losses.4(pxvii)

Savas and Dameron point out in their book, A Guide to the Battles of the 

Revolutionary War,

1 that the state militias participated together with the Regulars in 

most conflicts. However, in some battles, such as the 1781 South Carolina battle at Kings 

Mountain, a combination of militiamen from several southern states were victorious over 

the British.1(pxxv)

In his recent essay in the Journal of Military History, Hall speaks to the idea that 

Washington preferred Regular troops rather than the militia due to the militias’ indiscipline, 

irregular methods of fighting, and being incapable of offensive operations.6(p970) Hall notes 

that Washington utilized his Regulars for training and offensive operations. Washington 

kept his Regulars just beyond the reach of the British. Hall points out that Washington 

rarely defended terrain or the people living there. However, the militias’ operations did 

help set the stage for Washington’s Princeton and Trenton successes.6(p979) Hall notes that 

Washington did (despite his views) regard the militia as part of his defensive strategy. 
CHAPTER ONE • 5

He would fault them largely for their inability to wage the grand war (grande guerre) 

as opposed to the small war (petite guerre). Hall comments that the “British and their 

German allies were perhaps more impressed with the militia than was Washington [who 

was focused on the militias’] inconstancy and indiscipline.”6(p980) These irregularities made 

matters of planning for supply and medical facilities/medicines problematic. 

The numbers of soldiers in militias varied, but the total numbers of the Continental 

Line Army reported by Secretary of War Henry Knox in 1789 ranged from a low of 27,443 

(1775) to a high of 46,891 (1776). By 1781, only 13,292 were reported.1(px) Washington 

followed the British organization in setting up his forces.1(ppxlviii–xlix) 

Expanding the Battlefront

The Revolutionary War wasn’t just fought on land that would ultimately become 

part of the new United States. Indeed, the Americans launched an attack on Canada 

after being emboldened by the capture of Fort Ticonderoga on 10 May 1775 and of 

Crown Point on 12 May 1775. Washington envisioned the bold plan to capture the 

British Canadian Capital of Quebec as a way of subduing the interior of Canada. He 

selected General Benedict Arnold to lead an attack from the Maine area. Montreal was 

taken and then General Richard Montgomery and Benedict Arnold combined forces to 

attack Quebec.7(pp151–152),8(p211) The attack was carried out in a driving snow storm, during 

which Arnold was wounded. A year later, in May 1776, the Americans withdrew after 

an unsuccessful siege attempt, which effectively ended any further Canadian ventures for 

the duration of the conflict.1(pp15–16) The conquest of Canada was for many a way to gain 

a fourteenth colony.7(p5) Anderson, in his book The Battle for the Fourteenth Colony: 

America’s War of Liberation in Canada, 1774–1776,9 believes that the goal of the 

Continental Congress, which dispatched an ideologically based invitation to the Canadian 

Quebec Province, was for Quebec to join the American rebels, rather than being a defensive 

campaign to shore up the colonies’ weak border. Anderson feels that this venture was 

America’s “first war of liberation,” which he views as anytime when America sought to 

relieve/liberate an oppressed people.9(p2)

Washington’s Successes and Failures

Washington’s Army was to suffer a number of losses, which imperiled morale and 

brought up more questions about Washington’s leadership skills. The Battle of Long Island, 

27–29 August 1776, was a significant loss for the Americans.1(p55) After the American Army 

defeat on Long Island, the British waited to see if negotiations would occur. General Sir 

William Howe met with John Adams, Benjamin Franklin, and Edmund Rutledge at his 

headquarters on Staten Island in September 1776. The meeting, called the “Staten Island 

Peace Conference,” did not succeed in ending hostilities.1(p62)

General Howe’s forces then invaded New York proper, beginning in September 1776. 

(General Howe’s forces had previously taken Staten Island in June 1776.) Additional 

reinforcements from Halifax arrived for the British, which included German mercenaries 

(Hessians).10(p143) The Americans eventually abandoned Long Island with a rear guard 

action at White Plains in October 1776.10(p149) The American General Nathaniel Greene 

had to be replaced, due to a high fever, by General Israel Putnam. General Howe’s 
6 • FORWARD SURGERY

victory sent the American morale to new lows; Washington’s fitness to lead was further 

questioned.1(pp55–61) The New York Campaign, from September 1776 to November 1776, 

involved fighting at Kip’s Bay, Harlem Heights, and Fort Washington. Washington was 

criticized for overextending his forces. The result was that New York was secured as 

a British stronghold until the end of the conflict. The series of defeats there seemed to 

show the world that the rebellion was near its end.1(pp61–68) The British tactical win at 

Germantown (part of the Philadelphia Campaign) on 4 October 1777 allowed the British 

to maintain control of Philadelphia, with the British fleet controlling the Delaware River. 

After these successes in the autumn, General Howe placed most of his troops in winter 

quarters. Howe directed General Charles Cornwallis to continue to pursue Washington, 

who had escaped to Pennsylvania from New Jersey. Cornwallis placed troops at various 

points in New Jersey. He also placed Hessians at Trenton and Burlington.1(p82) Who were 

these “Hessian” hired mercenary troops? The Hessian troops actually came from six 

states in Germany: the majority (12,805) came from Hesse-Cassel. The Regiment von 

Knyphausen, the Regiment von Lossburg, and the Regiment von Rall were all from HesseCassel and were to play a role in Washington’s attack on Trenton.1(ppxlv–xlvi) Brunswick 

(4,300) supplied the next largest number. Anspach-Beyreuth (1,285) followed the two 

states. Hesse Hanau, Waldeck, and Anhalt Zerbst all supplied much smaller numbers of 

troops.1(pxliv) The German contingent was an important part of the British forces. It should 

be recalled that the King of England and the prior Hanoverian monarchs were German in 

origin. At the conclusion of the Revolutionary War, 29,000 German troops had served the 

British cause. The troops were professionally trained and had a strong tradition of excellent 

service. The troops provided much needed revenue for themselves and the leaders of the 

independent German states.1(pxliv)

One of Washington’s more famous successes occurred when he was able to subdue 

Hessian regiments at Trenton, New Jersey. The Hessian commander there, Colonel 

Johann von Rahl, was known to like drink and celebration, as well as bands and parades. 

Hence Christmas Eve was selected as the date to launch the American attack, hoping 

the celebrating Germans would let their guard down. Washington formulated a plan 

involving a water crossing on 24 December 1776, to be followed by a 9-mile march to 

reach Trenton. As the result of the successful attack, two of the best Hessian regiments 

(the Regiment von Rall and the Regiment von Lossberg) surrendered, but the Regiment 

von Knyphausen escaped to try to warn the British about the Americans. Between the two 

captured regiments, Washington and his troops had 948 prisoners,10(pp166–169),11(pp118–119) but 

they had to reach Princeton before the escaping Hessians did. The third Hessian regiment 

was subsequently located and driven to a creek, and gave up shortly thereafter.12(pp303–304) The 

Americans defeated Howe’s troops left at Princeton before Cornwallis could intervene with 

his forces. The Trenton victory has been regarded as the first meaningful Continental victory 

of the war. Washington gained 40 horses, six artillery pieces, and 1,000 muskets, along with 

valuable supplies. The material gains were great, but the morale lift was even greater.1(p87)

The victory over the Hessian regiments at Trenton added luster to the Continental 

cause.4(pp51–61,69–70) One Hessian officer said that he and his troops had not slept one night in 

peace. Colonel von Rahl, one of the Hessian commanders, had been mortally wounded in 

the fighting at Trenton. Certainly these factors added to Washington’s chances of success. 
CHAPTER ONE • 7

Many Hessians were captured and taken to Philadelphia where there was British criticism 

of their treatment.13(p355) One effect of the 10-day Colonial victory celebration at Princeton 

and Trenton was that militia volunteers became numerous. In fact, there were so many 

volunteers that Washington couldn’t handle the numbers, despite gaining all of the Hessian 

supplies. The victory at Trenton was a turning point for Washington’s reputation, which 

had been threatened by the popularity of American General Charles Lee.13(p274)

Washington decided to move his troops some 20 miles away from the British at 

Philadelphia to Valley Forge. His 6-month encampment there in the winter of 1777 

tested the young Continental Army in the extreme. Washington designed the 14 x 16 

foot log cabins himself. The cabins housed the majority of soldiers, but some tents were 

needed. Supplies became very scarce there, with shortages of food, clothing, and feed 

for the animals.12(p356) Typhus was common. The polluted water led to cases of typhoid 

and dysentery. Food shortages were such that “fire cake” was the main staple. It was 

a mixture of flour and water cooked on heated firestones. It has been estimated that 

of the approximately 10,000 troops who went to Valley Forge, 2,500 died during the 

period, and another 2,000 deserted.12(p357) It was at this point in the war that a group of 

officers, including Horatio Gates and Thomas Conway, worked against Washington, 

suggesting to Congress that he was a weak leader who should be replaced by Gates. The 

support of Marquis de Lafayette, with his connections at the French court, greatly helped 

Washington’s cause during this difficult winter period.12(pp365–368) (While encamped at Valley 

Forge, there was also an issue with the poor discipline of doctors, especially in regard to 

their frequently taking leaves and furloughs. Washington had to order that only leaves 

signed by Director General John Cochran would be honored.3(pp86–87) Cochran was the 

physician in charge of the Valley Forge “flying hospital,” which consisted of two huts per 

brigade. General Washington requested that the soldiers be hospitalized as close as possible 

to camp.3(pp85–87))

THE WAR CONTINUES

Other Major Battles of the Revolutionary War

British General John Burgoyne provided a victory for the British with the capture of 

Fort Ticonderoga, on 6 July 1777, which caused morale issues among the Continental 

forces in the north. The American defenders included many inexperienced militia members 

under the command of the American General Arthur St Clair.12(pp324–325) Ethan Allen and 

Benedict Arnold had captured the fort originally in 1775. Ticonderoga was located on Lake 

Champlain between New York and Quebec Province. At that time, the New Englanders 

won control of the lake, which could be viewed as a way to the heart of Canada.10(p107)

However, at the Battle of Bennington, on 16 August 1777, a Tory/German mercenary 

force was defeated by the Americans. The American Northern Army (a part of the 

Continental Army but designated as a specific command) was first commanded by Phillip 

Schuyler and later Horatio Gates. Burgoyne was later defeated at Saratoga by the same 

Northern Continental Army. British forces under Burgoyne’s command included British 

Regulars, Hessian and Brunswick German troops, Canadians, and Indians.14(p245) The 
8 • FORWARD SURGERY

American Northern Army relied on volunteers entirely.14(p9) Logusz makes the case that 

there was varied ethnic makeup of the American forces.14 He describes some 30 languages 

and dialects used within the Northern Army.14(p10) He also addresses minorities and women 

in the conflict. He even mentions that a group of “400 armed women rallied to defend 

Pittsfield, Vermont.”14(p13) 

The Americans suffered another defeat on 11 September 1777 at the Battle of 

Brandywine as part of the Philadelphia Campaign. The American casualties were significant 

with the loss of 1,100 men.1pp115–120) Lafayette received a leg wound at Brandywine, and 

was taken to Bethlehem, where Moravian sisters cared for him. Lafayette wrote to his 

wife that the wound healed quickly due to his excellent care at the orders of General 

Washington.12(p347) After his wounding, Lafayette, who was a major general, was given his 

own command by Congress upon Washington’s recommendation.12(p348)

The British defeat at Saratoga on 19 September 1777 had far-reaching consequences, 

in that an entire British Army had been subdued. Among the British officers taken captive 

were six members of Parliament. The British and Hessian prisoners were sent to Boston, 

while the captured Canadians were returned to Canada.15(p256) Ketchum views Saratoga as 

the watershed event in the fight for American independence. He points out that because of 

the American win at Saratoga, France entered the war as a Colonial ally.13(p1) The famous 

Jonathan Trumbull painting of the surrender at Saratoga, titled “The Turning Point,” 

shows British General Burgoyne offering his sword to General Gates, who subsequently 

returned it. Not only did Gates return the sword, he also invited Burgoyne to dine with 

him in his tent.10(pp197–198) However, Corbett, in his book, No Turning Point: The Saratoga 

Campaign in Perspective,16 written after examining archival sources, describes Saratoga 

as a stage in a civil conflict that continued and that little changed for people in the region. 

Corbett describes civil discord going back at least 15 years, with animosity between the 

local inhabitants of New York and surrounding states. Furthermore, there were residents 

loyal to England as well as those favoring independence. The larger group just wanted to be 

left alone. He did not see Saratoga as a “turning point.” Corbett feels, instead, that British 

General Burgoyne’s plans were altered by the civil war in the region.16(p5)

After the events at Saratoga, the wounded of both sides were numerous. It is 

noteworthy that the Indian allies of the British inflicted cruel wounds.15(pp257–258) Indeed, the 

wounded that fell into the Indian allies’ hands after Saratoga were often tortured before 

being scalped and killed. Duncan cited a case of a Captain Gregg, who survived scalping 

and other wounds despite being left for dead.15(p258)

Logusz also points to one factor contributing to the British defeat: General Howe 

decided to move his troops, normally based in New York, to Philadelphia rather than 

north to join Burgoyne.14 Saratoga, a village west of the Hudson River, provided natural 

positions of strength for the Americans. Burgoyne’s forces were defeated at the battles of 

Bemis Heights and Freeman’s Farm. The Americans encircled the British, leading to their 

surrender on 17 October 1777.14(pp14–16) 

The French were awaiting such a triumph as that of Saratoga to provide a basis for 

assistance. The French were more concerned with causing problems for England after their 

losses in the French and Indian Wars. After signing a treaty with America on 6 February 

1778, the French formally recognized America’s independence on 4 May 1778.1(plxiii)
CHAPTER ONE • 9

The Spanish also provided financial and material support for America, starting in 

1776. In 1779, the Spanish attacked the British in Louisiana, Mississippi, and west Florida. 

Spanish naval forces supported land forces in the capture of Pensacola and the Spanish 

naval presence allowed the French to participate in the Yorktown campaign.1(pplxvi–lxvii) The 

siege of Pensacola, from 9 March 1781 to 10 May 1781, was a factor in Great Britain’s 

defeat that is often overlooked. Spanish Governor Galvez won victories that secured 

Pensacola, navigation on the Mississippi River, and the Caribbean. As Savas and Dameron 

point out, “the multi-national effort at Pensacola was eerily similar to what General 

Cornwallis was about to face in Virginia at Yorktown.”1(pp302–303) As these authors also note, 

in both campaigns, a siege on land was coupled with control of the seas to bring about the 

surrender of the British.1(pp302–303)

Naval Battles

Although the majority of writings about the Revolutionary War focus on the battles on 

land, the conflict also involved naval engagements. However, the Continental Congress had 

few naval assets of its own available. To remedy this deficiency, the Continental Congress 

issued commissions for privateers (private shipowners granted license to wage war). The 

privateers had limited successes against British warships and merchant vessels, but they 

did provide transport for French and Dutch supplies.2(p487) All matters improved when the 

French signed the Treaty of Amity and Commerce in 1778 with the colonies. This signing 

happened after the American successes on the Great Lakes with vessels under the command 

of Benedict Arnold.2(p487) After the Americans’ naval victory on the Great Lakes, General 

Howe returned to England, turning over the command to General Clinton. Hearing of a 

rumored French fleet coming, Howe ordered the evacuation of his troops from Philadelphia 

and a return to New York.2(p487)

Other Battles to Consider

The tactical draw that resulted from the Battle of Monmouth Court House (in 

Monmouth, New Jersey) on 28 June 1778 was the last major battle in the Northern 

colonies for the rest of the war. Monmouth was the longest continuous battle of the war 

(lasting from 10:00 am until 6:00 pm) with the largest artillery exchange of the war. Even 

if the Battle of Monmouth Court House was not a resounding victory, the ability of an 

American Army to meet a British Army as an equal had come.1(p177) For this battle, the 

British and the Americans each had approximately 15,000 troops. The British reported 65 

killed, 170 wounded, and 70 missing, while the Americans had 70 killed, 161 wounded, 

and 131 missing. Several churches and the courthouse of Monmouth were used as 

makeshift hospitals.15(p268)

Because there was promise of a strong loyalist contingent in the South, the British 

turned their attention there. North Carolina had a varied population but many were 

loyal to England. Tory forces and British Army recruits were organized in the state.15(p310)

The Siege of Savannah, Georgia, from 16 September 1779 to 19 October 1779, ended in 

disaster for the French and Americans. The French Admiral d’Estaing was wounded and 

his French Marines sustained significant losses. Admiral d’Estaing was unhappy with the 

performance of the American troops, led by Major General Benjamin Lincoln. The loss of 
1 0 • FORWARD SURGERY

French confidence led d’Estaing to withdraw and to sail his ships and men back to France 

after the defeat.1(pp227–232) In a repeat loss, the Siege of Charleston, South Carolina, of 18 

April 1780 to 12 May 1780 was a serious loss for French and American forces. It brought 

a worldwide loss of confidence in the American cause. As an example of the fallout from 

the loss, the Spanish had declared war against England in June 1779, but delayed a formal 

alignment with the Americans.1(pp233–237)

The British and the Americans both suffered significant illness in the Southern climate. 

Indeed, both armies in the Carolinas were ill with “[m]alarial fevers and diarrhoeas not 

usually fatal.”15(p311) In fact, it was reported that the British General Cornwallis was himself 

ill at one point. It was speculated that he had malaria.15(p312) In a letter to General Henry 

Clinton, Cornwallis wrote that the climate in South Carolina was so bad within 100 

miles of the coast from June until the middle of October that British troops could not be 

stationed there during that time without being rendered useless due to illness.15(p312) It was 

not just on land that the troops were ill. American prisoners (after the defeat of General 

Gates in 1780) were held on prison ships where illness prevailed, especially smallpox and 

dysentery.15(p319)

The Battle of Cowpens, South Carolina, on 17 January 1781 represented a victory 

for the American General Daniel Morgan, which raised morale in all parts of the country. 

Clark describes it as “the most brilliant single victory of the Revolutionary War.”12(p495)

Morgan defeated the forces of General Banastre Tarleton, one of the more notorious British 

commanders, while escaping with his forces into North Carolina to join General Nathaniel 

Greene and his American troops. Cornwallis tried to catch Morgan, but Morgan’s 

successful exit into North Carolina precluded Cornwallis’s catching up.1(pp281–282) The Battle 

of Guilford Courthouse, North Carolina, on 15 March 1781 resulted from the pursuit. 

The British held the field but lost 25% of their force. General Greene’s forces survived 

with presumably fewer casualties. A large number of the American missing were said to be 

militia that left when the fighting ended.1(p291)

The Yorktown, Virginia, campaign was a major victory for the French-American 

forces.4(pp262–263,268–269) At Yorktown, the French fleet caught the English on one side, gaining 

control over the Chesapeake Bay, and blockading Cornwallis from British naval support. 

The Continental Army caught the English on the other side, coming down from New 

York City. This forced Cornwallis to surrender.1(p488) The Siege of Yorktown lasted from 28 

September 1781 until 18 October 1781. On 19 October, the British and Hessian troops 

defending Yorktown surrendered. Although it showcased Washington at his best, the 

French contribution was critical to his success. This victory meant the end of fighting in 

the North and Middle States (aside from minor skirmishes), although the British remained 

in New York until 25 November 1783.1(p336) The French thereafter withdrew any financial 

support because they became financially stretched with the major costs involved in a 

conflict with the British. The Dutch stepped in to offer loans, with the American John 

Adams pushing the concept.12(p552) After Yorktown, the fighting was limited to local fighting 

and two battles. In present day Kentucky, the Battle of Blue Licks took place on 19 August 

1782. The other major battle, the Battle of Arkansas Post, transpired on 17 April 1783 in 

Spanish Territory (Louisiana and West Florida).1(pp337–343)
CHAPTER ONE • 11

Revolutionary War Casualties

In the period 1775 to 1783, approximately 184,000 to 250,000 men were estimated 

to serve in the various American forces, including the militias. Of the recorded casualties, 

the Defense Casualty Analysis System lists 4,435 died and 6,188 as wounded within the 

Regular forces.17 As Savas and Dameron point out, however, these numbers do not include 

militias, which had significant casualties.1(ppxxvii–xxviii) Reliable numbers for British, German, 

and Indian forces are not available. Peckham, in his 1974 The Toll of Independence: 

Engagements and Battle Casualties of the Revolution,18 reported 7,000 Americans died in 

battle and 10,000 died of disease.18(p130)

The Continental Army’s Medical Department

The Continental Army’s Medical Department was created by the Continental Congress 

in July 1775. The inexperienced staff had to contend with no existing infrastructure, 

little funding for medicines and supplies, and a poorly defined organizational structure. 

The Continental Congress did not deal with the expansion of the department beyond 

Massachusetts, so as to define the reporting relationships of the heads of hospitals to the 

Director General and Chief Physician (who was appointed as the nominal head in July 

1775). Congress established the “Hospital for the Army,” which was, in fact, to be the 

Army Medical Department.19(p25) Massachusetts’ surgeons and facilities were being used for 

the Continental Army that General George Washington took command of on 3 July 1775. 

As Gillet points out, only legislation passed by Congress in April 1777 and later in March 

1781 gave the Director General authority to supervise all medical services.3(p23)

In September 1775, the Continental Congress created the Medical Committee to 

deal with medicine shortages. Its role expanded with the participation of Dr Benjamin 

Rush, until he lost his bid for reelection to Congress in 1777. A Medical Committee in 

various iterations remained until its functions were taken over by the Board of War in May 

1781.3(p23)

The terms used for the highest authority in the Medical Department varied over the 

course of the Revolutionary War. The office of “Director General and Chief Physician” 

was established in July 1775. In September 1775, in addition to the office of Director 

General, another Director General and a Chief Physician in the North were added. In June 

1776, a Director General and a Chief Physician in the South were added to the Medical 

Department. The relationship of these offices to the main Director General was unclear.3(p23)

In August 1777, in addition to the Director General, a Director of the Hospitals in the 

South was appointed. In September 1780, a Deputy Director General for areas south of 

Virginia was named. The reporting schemes for these various medical officers were unclear 

for much of the time. The distinction between physicians and surgeon generals was to 

remain until 1780.3(p37) Finally in March 1781, a Director General was named along with a 

Deputy Director in the South.3(p23)
12 • FORWARD SURGERY

THE BRITISH MEDICAL SYSTEM—TO BE EMULATED 

By 1660, the English King, Charles II, had created a standing Army and a standing 

surgeon staff. The British surgeons purchased their positions and could also serve in 

combat. Of interest, the British soldier had to pay for his own medicines. Later, Winston 

Churchill’s ancestor, John Churchill, the Duke of Marlborough, developed regimental aid 

stations.20(p4)

The British had an enviable number of medical leaders to provide tradition for the 

provision of medical services to their military. The relationship of American and British 

medicine was further enhanced by the fact that many of the Colonial medical leaders 

had studied at London, England, or at Edinburgh, Scotland. The Hunter brothers were 

an example of this. Dr John Hunter was renowned for his pioneering and controversial 

operations. He achieved some notoriety for his methods of securing anatomical parts for 

which he was said to pay above the norm for materials.21(p5) Among his accomplishments, 

he had removed a massive tumor from the neck of a coachman.4(p3) John Hunter had also 

removed a popliteal aneurysm,21(p7) devising the technique with input from his brother, 

William Hunter. The Hunters used a dog to research the procedure.21(p8) It is rumored that 

they also completed a successful appendectomy in 1789.22(p13)

A number of important Revolutionary War physicians spent time in London with 

John and William Hunter. William Shippen,3(p38) appointed the Director General (charged 

with leading the department) of the Continental Hospital Department on 11 April 

1777, studied with the Hunters after gaining his MD degree from Edinburgh.23(p40) John 

Morgan, an earlier Director General, studied with the Hunters after receiving his MD from 

Edinburgh.23(p11) John Cullen of Edinburgh was another European medical luminary who 

was sought out for training by many students.3(p19)

The colonies had only the British medical system as a role model. To that end, it is of 

interest that a number of the influential doctors in the Continental Hospital Department 

had prior service with British and Colonial troops in the French and Indian War. This 

experience helped prepare them, to some extent, for the events ahead. They also gained 

familiarity with the British system, which had not changed appreciably by the time of the 

Revolutionary War. John Morgan, a Director General, was a surgeon in the war. John 

Cochran, also a Director General, was a surgeon’s mate in the French and Indian War. 

Cochran was apprentice trained in England.23(p41) Ammi R Cutter, later a Physician General, 

served with the British forces at Louisburg in the French and Indian War and on the Indian 

frontier with the rangers.23(p41) Samuel Stringer, a Director of Hospitals in the North, served 

in the British Army in the regular forces. James Craik, a Chief Physician and Surgeon 

General of the Army, had trained in Edinburgh and served in the French and Indian War. 

Dr Philip Turner, later in charge of the Eastern Department, served as an assistant surgeon 

with General Jeffrey Amherst at Ticonderoga in the French and Indian War.23(p43)

There were some deficiencies in the British system. For instance, at the time of the 

Revolutionary War, the British had no regular bearer troops to carry the wounded; 

furthermore, the British were always short of wagons.16(p8) The British soldier had a portion 

of his pay deducted to pay for the surgeon. Each regiment (approximately 550 men) had 

one surgeon and 12 assistants.20(p4)
CHAPTER ONE • 1 3

In many areas the Continental Army Hospital Department attempted to emulate the 

British system. One of the earliest handbooks consulted by the British and the Americans, 

detailing the treatment of wounded soldiers, was published in 1758 by Baron Gerhard Von 

Swieten, titled Swieten’s Diseases Incident to Armies. Reiss points out that it filled the same 

need as the Merck Manual in modern times. Treatments were outlined in the manual. It 

was thought to be most useful when a surgeon was not available and the care of the sick 

was left to whomever was there to minister aid.3(p4)

Of note, in contrast to the American Army, a British physician had to be a graduate 

of one of the great European medical colleges or of the College of Physicians of London. 

However, the requirement to be a surgeon was less rigorous.15(p18) For example, regimental 

surgeon commissions were purchased as were other Army commissions. The purchase 

funds were paid to the retiring officer, which served for him as an annuity or retirement 

fund. Duncan quoted cash payments for regimental surgeon positions—one example was 

£150. Positions were purchased for rates as high as £500 to £600.15(p18) At this time, the 

practice of medicine was sharply distinguished from that of surgery. The physicians were 

presumed to treat the sick in general hospitals, while the regimental surgeon treated the 

wounded soldiers in regimental hospitals. In practice, there was less distinction.

John Hunter reformed the purchase system in 1790 (but the old system returned after 

his death in 179315(p18)). The regimental surgeons were not eligible for promotion, which 

made the required purchase less desirable. Hunter mandated that the highest positions 

could be filled only by men who had seen prior service. Hunter also removed restrictions on 

promotions for regimental and higher surgeons (but that also ended with his death15(p18)).

The leadership of the British Medical Service was in the form of a council, consisting 

of a physician general, a surgeon general, and an inspector general. These men were chosen 

from the famous or favored London professionals, and were not necessarily experienced 

Army medical officers.3(p20),15(p18) The council members were actually civilians, which would 

be unexpected for a military system.3(p20)

A typical British army as fielded would consist of 20,000 to 30,000 men who would be 

divided into divisions of 4,000 to 5,000 soldiers. The fielded army would have an inspector 

general, while the divisions would each have an inspector. The regimental surgeons had no 

real rank, although they had commissions. They were ranked with the chaplain and listed 

after the lowest-ranking ensign.15(p19) The British intended that each regiment would have its 

own surgeon. In wartime, the regimental surgeon would have two assistants, along with a 

tent or house for a hospital. In the French and Indian War, the British found that a sergeant 

and two orderlies were needed to maintain order in the larger hospitals.3(p20) Most surgeons 

preferred the small regimental hospital instead of a large general facility due to the presence 

of many sick in the latter. It was noted that disease mortality and morbidity were actually 

increased in the larger facilities.15(p20)

A general hospital was set up in existing facilities for the army, while the regiment 

would have a small hospital in a building such as a church. Tents were the choice of last 

resort. The typical general British hospital would have 400 beds, with six medical officers 

and 48 assistants, clerks, and nurses. The officer group would be composed of a physician 

(with two assistants) and a surgeon (with two assistants), as well as an apothecary to 

provide the medicines. Apparently the assistants were hired because there were no enlisted 
1 4 • FORWARD SURGERY

medical troops in the British Army.15(p19) No special areas were designated for surgical 

operations generally. A room in a house or a designated tent in a field might be used for 

surgery. 

The British provided wine as a part of the daily ration for all troops. Duncan 

comments that the free-flowing liquor in the hospital cost more than the bread ration. 

Aside from bread rations, the patients ate much the same fare as the regular troops. Often 

the rations were obtained locally by foraging sweeps and could include chickens, pigs, 

cattle, and available fruits and vegetables in season. Generally, the menu was not varied or 

nutritious.15(p20)

THE AMERICAN MEDICAL SYSTEM 

The American medical experience is difficult to evaluate because, as Gillet points out, 

there were few surviving official records until 1814. She speculates that the few records 

kept were lost by fire in 1800 or in the 1814 British burning of Washington, DC. Much 

of the records extant were kept in state archives or in private records and correspondence. 

Gillet’s book, The Army Medical Department 1778–1818,3 provides an excellent coverage 

of the Revolutionary War medical issues.3(pxi) 

In America at the beginning of the Revolutionary War, there were only two medical 

colleges—one in New York City and the other in Philadelphia, Pennsylvania. They were 

closed during the war because both New York and Philadelphia were under British 

occupation at various times in the war. However, they had only had 50 graduates total 

prior to the onset of hostilities. Apprenticeships of varying lengths with practicing 

physicians were the norm for most.15(p7) As already noted, some of the prominent medical 

men, such as Rush, Shippen, and Church, studied in European medical colleges such as at 

Edinburgh in Scotland.15(p8)

Most surgeons/physicians did not have the benefit of a European course of study 

leading to a formal medical degree. Indeed, most were either apprentices (studying 3 to 

7 years with a mentor) or self-trained.3(p1) The majority of the surgeons entering Colonial 

military service had no prior experience, unlike the British, with the exception of some 

surgeons who had served with British or Colonial forces in the French and Indian 

War.3(pp19–20) Gillet points out that during this time the traditional humoral explanation of 

disease was beginning to lose its appeal. The humoral medicine approach had been given 

great prestige by Galen, to the extent that it lasted until the 18th century. The humoral 

approach posited that health and disease were determined by the presence of the four 

body humors—blood, yellow and black bile, and phlegm—and their relationship with 

the four elemental humors—fire, air, earth, and water.24(p10) In its place, conflicting ideas 

for competing systems attempted to use fact rather than theory to explain disease. While 

diagnosis was gaining momentum, the treatments all were still reduced to bleeding, 

blistering, and purging.3(p1)

The Dutch system devised by Hermann Boerhaave placed emphasis on chemical and 

physical qualities to explain disease. He used qualities such as acid and base, or tension 

versus relaxation, instead of the humors. Boerhaave felt that nature should be used to aid 
CHAPTER ONE • 1 5

in any cure. However, William Cullen, of the University of Edinburgh and the mentor to 

many Revolutionary War surgeons, challenged that view, instead favoring the approach 

of nervous tension underlying disease.3(pp1–2) Cullen felt that an excess or debit of nervous 

tension would cause a disease. A fever meant an excess of nervous tension, which would be 

dealt with by bleeding, purges, restricted diets, and sedation. A chill would mean a lack of 

nervous tension, which called for restorative methods.3(p2) Specific diseases were not singled 

out, but Cullen called for their study. In time, Benjamin Rush would somewhat modify 

Cullen’s approach and advocate limited study of each disease as an entity. In general, 

however, Rush applied Cullen’s principles in a rigid fashion.3(pp2–3)

Hospitals in America and Organization of Continental Medicine

As previously noted, only two civilian hospitals existed in America in the colonial 

period. One was in New York City (hospital founded in 1711) and the other was in 

Philadelphia (hospital founded in 1755). As with many other philanthropic efforts, 

Benjamin Franklin was involved in the Philadelphia effort.15(p8) Nonetheless, hospitals in 

the colonies and in Europe had high death rates, which is not surprising given the lack of 

antibiotics and the dearth of knowledge about human physiology and disease processes.15(p9)

The history of the hospital department of the Army started with the siege of Boston in 

1775. After the Battle of Breed’s Hill in Boston, a hospital was established in Cambridge 

within private homes. Director (Doctor [Dr]) John Warren was placed in charge of the 

hospital.23(p4) [Note that these physicians were referred to both as a Director and a doctor, 

hence Director (Dr) in the text that follows.] The Second Provincial Congress ordered “that 

the President pro tempore, Doctor Church, Doctor Taylor, Doctor Holten and Doctor 

Dunsmore be a committee to examine such persons as are, or may be recommended for 

Surgeons for the Army.”23(p4) In a screening of 16 applicant surgeons, six were rejected.23(p4)

A letter, or warrant of appointment, was issued by the Provincial Congress of 

Massachusetts Bay recognizing the status of the military surgeons. In 1775, General 

Washington had accepted appointment as Commander-in-Chief. The Colonial Provincial 

Congress provided for the appointment of general officers and officers of the general staff, 

but made no provision for the creation of a hospital department.23(p6) General Washington 

wrote a letter about the lack of a hospital litter and Congress passed a resolution after a 

committee provided in a bill that they would approve the appointment of one Director 

General and Chief Physician (pay of four dollars per day). Four surgeons were to be 

appointed (at one-and-a-third dollars pay per day). Furthermore, one apothecary would be 

employed at the same rate of pay per day. Twenty surgeon’s mates were to be selected with 

pay of two-thirds of a dollar per day. The bill also provided for the appointment of one 

clerk, two storekeepers, one nurse, and laborers as needed.23(pp6–7)

The necessity for a reorganization of the Hospital Department was increasingly 

apparent by 1780. The inefficiencies of separate departments with their own hierarchies 

were finally dealt with in the reorganization plan put to Congress. The resolution to 

accomplish this renovation before Congress was presumably the work of Director (Dr) 

John Cochran. The most important piece of the plan was that the Medical Director was to 

have centralized authority and would have three assistants. The separate departments and 

their staff were abolished. A “flying hospital” (a field hospital) was to go with the Army 
1 6 • FORWARD SURGERY

and the Medical Director was to remain in the field. This was a response (and a rebuke) to 

Director (Dr) Shippen, who was always seeking comfortable lodgings.15(pp329–330) 

Congress appointed surgeons to the battalions in New Jersey and Pennsylvania at a 

monthly pay of $25. They later added that each regiment should have a surgeon’s mate, 

paid $18 a month. Congress did this because most regiments were raised by various states 

without regard to the provision for medical attendance. In the winter of 1775 to 1776, very 

severe weather was experienced. At the time, there was the appearance of smallpox in the 

north. The troops of the middle and southern states presented with typhus, typhoid fever, 

and dysentery.23(p14)

As troops were being assembled in the late summer and early fall of 1775 for an 

invasion of Canada,3(p57) a new and separate department was considered necessary—the 

Northern Department. General Philip Schuyler was given command.3(p57) However, a 

smallpox epidemic had struck the Northern Department troops in Quebec in the spring and 

summer of 1776, with particular severity.3(p59) An attempt was made to start an inoculation 

program, which was not successful. The American men at Sorel and Montreal numbered 

3,200, of which 1,900 were ill with smallpox. Smallpox threatened to destroy the Northern 

Army before the invasion plans were cancelled because the force required evacuation. 

In fact, the epidemic was so widespread that Major General (MG) John Thomas, who 

commanded at Quebec, died of smallpox.3(p60) The surgeons were unable to obtain medical 

supplies and medications (including opiates), which would have been of little use in dealing 

with the epidemic.3(p62) The only treatment for the pox was isolation.3(p74) Interestingly, the 

British Army did not have smallpox, but it reportedly had significant dysentery.3p63)

The colonies varied in their responses to smallpox. Maryland, for instance, advocated 

inoculation and offered to pay for it. On the other hand, The Council of Massachusetts 

asked that the practice be stopped after hearing that MG Ward was allowing inoculation 

of troops outside Boston. Inoculations were banned in Boston because it was feared that 

those inoculated would spread smallpox. The official Continental Army order to inoculate 

all troops came in February 1777, although Virginia would not allow its troops to be 

inoculated. Washington ordered segregation of recently inoculated troops, and was thus 

able to reverse the Virginia policy after he wrote personally to the Virginia Governor, 

Patrick Henry.3(p75) The mortality rate from this inoculation effort was reported as four of 

every 500 Continental soldiers inoculated. The rates of infection for noninoculated troops 

were quite variable but could involve the majority of the contingent. Washington ordered 

the inoculations repeated at Valley Forge in 1778.3(p75)

As discussed in John Morgan’s A Recommendation of Inoculation According to the 

Baron Dimsdale Method,24 the inoculation method used in America was styled after the 

Dimsdale or Sutton methods of the English, which required an arduous 2-week period 

of preparation, consisting of purges, bleeding, and the use of mercury. The inoculation 

involved taking a piece of tissue from a pox lesion of an active human case and placing it in 

a puncture wound, thereby introducing the foreign tissue.25 Arnold Klebs wrote an involved 

history of the evolution of variolation, which showed much experience leading up to the 

procedure as practiced in the Revolutionary War.25 The use of mercury in the preparation 

period involved its own toxicities, as Cochran pointed out in 1772.3(p14) (It is now known 

that complications include mercury-induced cognitive impairments such as inattention, 
CHAPTER ONE • 17

excitement, and hallucinations. In addition, there also can be neuronal damage and cerebral 

infarctions.26 Vaccination would come after Jenner’s work in 1798, with the American 

Army finally ordering vaccination for all of its soldiers in May 1812.3(p14))

Several categories of hospitals existed in the Continental system. The “Regimental 

Hospitals” were built and run by regimental surgeons for their own regiment. The “Flying 

Hospitals” were temporary and perhaps more mobile facilities, often located in a hut or a 

tent with a few beds and a surgeon’s table. They were run by Continental Army personnel. 

The “General Hospitals” were run by Continental personnel located in more stable (less 

combat) locations. These were not dedicated facilities in the modern sense, but rather were 

conducted in homes, churches, government buildings, or college buildings.23(pp25,26)

Surgeons/Physicians of Note

JOHN JONES

Rogers, in an article published in 1972 in the Plastic and Reconstructive Surgery—

Journal of the American Society of Plastic Surgeons, clearly felt strongly about the 

Revolutionary War contributions of Dr John Jones. He states in his article that, “Our 

knowledge of Revolutionary War surgery comes to us exclusively from one man, John 

Jones . . . a New Yorker by birth, [who] was and should be rightfully called [the] ‘Father of 

American Surgery.’”27(p1)

Jones studied medicine under his father and later studied in England (under John 

Harvey’s direction), Scotland (Edinburgh), and France (Paris).15(p23) Jones received his 

degree in medicine from Rheims (in France) in 1751.15(p18) Jones was a founder and the first 

full Professor of Surgery of the Medical School of King’s College in New York City. For a 

surgeon, such a position was not possible in European medical schools or in Philadelphia 

(the other American medical center). Distinct chairs of surgery did not exist because of the 

subservient role of “surgeons” to “physicians” of the times.3(p1) Jones’ manual of surgery, 

Plain Concise Practical Remarks on the Treatment of Wounds and Fractures, was the 

first surgical text published by an American in what would become the United States. The 

treatise was published in 1775; two editions were later printed in 1776 and, posthumously, 

in 1795.27(pp1–2)

Jones made a number of recommendations. For example, most compound fractures 

called for amputation as the prevailing standard of practice. In gunshot wounds, he 

suggested removal of the ball; to deal with bleeding he suggested a ligature. The British used 

a smooth bore musket that had a ball about 3⁄4 inches in diameter.15(p13) The musket could 

cause significant damage within its 100-yard range. As in later conflicts, the bayonet was 

used infrequently and there were few artillery wounds. Due to the use of Indian fighters by 

the British, there were reported a number of knife, hatchet, and club wounds.15(p12) Jones 

recommended expanding the opening of many wounds. For chest or abdominal wounds, 

however, bleeding was often excessive and the prognosis was grim.15(p12)

BENJAMIN CHURCH

Director (Dr) Benjamin Church was selected as the first head (the Director General 

and Chief Physician) of the Hospital Department of the Army.3(p26) Church was appointed 
1 8 • FORWARD SURGERY

through an act of Congress dated 17 July 1775.15(p60) In addition to being a prominent 

physician, he was a member of the “Sons of Liberty.” Church was also described as a poet 

who wrote “liberty songs.”3(p26) He had graduated from Harvard College in 1754 and 

studied medicine with Dr Joseph Pynchon, a prominent Boston physician. Church then 

went on to study medicine in London. He later practiced in Boston. Church became a 

member of the Continental Congress in 1775, and a member of the Committee on Public 

Safety.15(pp61–62)

The wounded and sick were being cared for in 30 or more hospitals. Massachusetts’ 

surgeons were generally the only ones to work with Church because he was from the state. 

Church felt that general hospitals were more efficient; he did not trust the care provided 

in the small regimental hospitals. The regimental surgeons would complain to their Army 

commanders whenever the general hospitals would not give them medicines. Church got 

Washington to support the general hospital concept but the controversy continued.3(p27)

Washington said that a soldier who was too ill to stay in camp should be sent to the general 

hospital.15(p62) Washington established a Court of Inquiry within each brigade to call on 

the regimental surgeons and the Director General to testify as to their views. However, the 

inquiries did not proceed because of Director Church’s arrest (as detailed in the following 

paragraphs).3(pp27–28),15(pp62–63)

Church’s term was also beset with controversy as to the reporting structure for the 

newly appointed Chief Physician and Surgeon for the Army in the Northern Department. 

Dr Samuel Stringer had been so appointed by the Congress, although his exact status visa-vis Church was not spelled out by the Congress.3(p27) Church had so many complaints 

filed against him that General Washington had to seek an investigation; inquiries were 

conducted at the brigade level. Church felt the regimental hospitals were too expensive 

to operate (as well as inefficient), and that their supplies should largely be sent to larger 

hospitals, which added to the political rumblings.3(p28) Before the various disputes could 

be resolved, Church was arrested on charges of treason because he was trying to pass 

correspondence to the British in Boston.3(p11) Church had written a letter in cipher to a 

British major and given the letter to a young woman to transmit. The letter was taken 

from her and indirectly given to General Washington.15(p63) A Reverend Ward was able to 

decode the letter, which described disposition of American forces, but its total reading was 

not viewed as rising to the level of treason.15(pp63–64) Still, Church was removed from office 

and placed in confinement for a period. When he was released, he set sail from Boston, but 

the vessel apparently sank. Church’s wife applied to King George III for a pension, stating 

that Dr Church was, in fact, a loyalist.3(p28) Congress replaced him with Director (Dr) John 

Morgan of Philadelphia. A noteworthy suggestion of Church’s was his urging that special 

units for convalescents be set up because there was a very high relapse rate after soldiers 

were released from the hospital.15(p62)

JOHN MORGAN

Director (Dr) John Morgan (Figure 1-2), from Pennsylvania, had graduated from 

the College of Philadelphia in 1757.15(p65) He then studied in Europe in 1760 with John 

Hunter, and later spent time in France and Italy. Morgan obtained a Doctor of Medicine 
CHAPTER ONE • 1 9

degree in Edinburgh in 1764. 

When he returned to America, 

he was elected the first Chair 

of the Theory and Practice of 

Medicine in the newly formed 

medical school in Philadelphia. He 

held the position until he died in 

1789.3(pp28–29)

Morgan was selected by the 

Congress on 17 October 1775 

to be the next Director despite 

General Washington’s preference 

for Dr William Shippen. Morgan 

took more than a month before 

he reported for duty, even though 

Washington implored him to 

promptly report for duty because 

the medical situation required 

urgent attention.3(p29) Morgan also 

experienced the same conflicts 

between the general hospital and 

the regimental hospitals as did 

Church. Morgan saw his role to 

be that of increasing the efficiency 

and organization of hospital 

medical care. However, it was felt 

by some that Morgan was stockpiling medicines and supplies rather than releasing them to 

the regimental units.3(pp30–31) Like Church, Morgan ran into problems with Dr Stringer, who 

was attempting to carve his own independent niche.3(pp32–33) The intrigues and charges came 

from a number of sources, but especially from Shippen. Morgan had prepared his rebuttal 

of charges.28(p826) Congress did not resolve the controversy, but instead created another 

Physician and Director General for a system based in Virginia as a way of avoiding more 

controversy.3(pp32–33) Congress dismissed Morgan on 9 January 1777.3(p35) Although he was 

eventually cleared of any charges of wrongdoing in 1779, Morgan was not reinstated.3(p35)

While he did receive vindication from Congress, he failed to resume his prior leadership 

role in Philadelphia by not resuming his professorship and subsequently resigning from the 

staff of the Pennsylvania Hospital.28(p826)

BENJAMIN RUSH

Director (Dr) Benjamin Rush (Figure 1-3) is perhaps the most famous of the 

physicians/surgeons of the Revolutionary War period, in part because of his overall 

impact medically and politically. Rush was one of the 56 signers of the Declaration of 

Independence, for which he is today remembered.29(p8) Although he was not the head of 

FIGURE 1-2. John Morgan. Despite the fact that General 

George Washington preferred another candidate, Congress 

appointed Dr John Morgan as the Director in the fall of 1775; 

he left his post in early 1777, amid accusations of misconduct. 

Although he was exonerated in 1779, Morgan did not regain 

his post. Artwork courtesy of the National Library of Medicine, 

Image #B019169.
2 0 • FORWARD SURGERY

the Medical Department (but was 

appointed to head the Middle 

Department), Rush had great 

influence due to his professional 

reputation and his position as 

a member of the Continental 

Congress, as well as being one 

of the physicians on the Medical 

Committee of the Congress.29(pp8–9)

When Benjamin Rush was just 

6 years old, his father died. Rush 

then studied at the school run by 

his maternal uncle. He graduated 

at age 14 from Princeton, from 

which he received a bachelor’s 

degree in 1760.29(p11),30(p24) After 

an apprenticeship with Dr John 

Redman (a leading physician and 

apothecary) of Philadelphia, which 

ran between 1760 and 1766, Rush 

attended medical courses at the 

University of Pennsylvania, during 

his last 2 years as an apprentice. 

Dr Redman advised him to study 

further in Europe. Hence, Rush 

went to the University of Edinburgh,30(p46) where Director William Cullen was his mentor. 

Of interest, Benjamin Franklin, who had been in London representing the Colonies since 

1764, provided a reference for Rush to the Edinburgh faculty.30(p43)

Rush returned to Philadelphia in July 1769 and joined the Philadelphia militia 

in 1775. He took care of the militia sick and wounded in various encounters around 

the Philadelphia area. There are no totals on the numbers involved or of the sick and 

wounded.30(p59) Rush offered his services to Washington’s forces after the Continental 

Congress adjourned in 1776. Rush and John Cochran took care of the wounded at 

Trenton, New Jersey, before Washington moved to Princeton, New Jersey.3(p72) The 

wounded were moved by Rush and Cochran to Bordentown, New Jersey, and later 

Princeton, after they obtained wagons. (In contrast to Rush, Cochran had a more 

rudimentary training, first as an apprentice trained in England and later service as a 

surgeon’s mate in the French and Indian Wars.15(p333),23(p42))

Rush was appointed to the Congressional Medical Committee in August 1776. The 

committee was set up “to devise ways and means for supplying the Continental Army with 

Medicines,”3(p23) but became involved with hiring and firing of medical personnel and other 

details of operation. Rush was not reelected to Congress in February 1777 and therefore 

left the committee.3(p23)

FIGURE 1-3. Benjamin Rush. Dr Rush remains the most famous 

of the physicians/surgeons of the Revolutionary War period 

because of his overall impact both medically and politically. 

Rush was a member of the Continental Congress and served 

on its Medical Committee. Artwork courtesy of the National 

Library of Medicine, Image #B022631.
CHAPTER ONE • 2 1

As part of Rush’s plan to reorganize the Army medical services (in his role as a 

Congressional Medical Committee member), Director (Dr) John Morgan was removed 

and Director (Dr) William Shippen was named the new Director General of the medical 

department. Dr Benjamin Rush was then named the Director General of the Middle 

Department of the Army on 1 July 1777. The Middle Department’s jurisdiction extended 

from the Hudson River in New York to the Potomac River, south of Maryland. Rush held 

the position for over a year.

Rush then became a chief medical officer of the area that was under the personal 

command of George Washington, although he was not the overall director.31(p177) Rush was 

officially appointed as Physician General of the Middle Department of the Continental 

Army.30(p200) Rush reported to Director Shippen and to his deputy, Director Thomas 

Bond Jr. Rush reported to Morristown, New Jersey, where the winter quarters of George 

Washington’s troops were located.30(p181) Rush was stationed at Princeton but he moved 

constantly around military hospitals scattered throughout New Jersey to supervise the 

attending surgeons and their staffs.

After the Battle of Brandywine, Pennsylvania, Rush had to deal with over 900 soldiers 

killed and 600 wounded. Rush led a group of surgeons into the British camp under 

a flag of truce granted by General Howe of the British forces to “dress the American 

wounded.”30(p187) Rush was quite impressed by the way the British tended to the men, both 

the British and American wounded, in marked contrast to the way the Americans treated 

their own.30(p187) Rush stated that British officers went out of their way to make sure their 

surgeons treated the Americans and their own wounded well. He attributed this to the 

standards of their medical establishment.30(p188)

Rush became involved in the controversy over the poor administration of the Army 

hospital, which was but one of many controversies in which he was involved. Rush 

reported on Shippen’s many failures30(p189); the controversy ultimately led to Rush’s 1778 

resignation. Much of the controversy involving Army medicine was due to infighting within 

the Continental Congress.30(p177) However, Rush’s involvement in controversy in many areas 

really did not help the Continental Army’s cause. In that regard, Rush was also said to have 

engaged in criticism of General Washington.30(p209) 

After the war, Rush was named in October 1789 to succeed Morgan as the Professor 

of Theory and Practice of Medicine in the College of Philadelphia. He continued to make 

contributions in many areas of medicine. Rush initially endorsed William Cullen’s view 

of disease as involving disordered nervous tension,30(p49) but later modified it somewhat, 

although it remained essentially Cullen’s. In fact, Rush was said to think of himself as 

Cullen’s chief disciple.30(p49) Rush called for treatment to include purges with calomel 

(mercury chloride) and jalap (a purgative), and bleeding until the patient fainted.3(pp2–

3),30(pp254,341) He recommended purges to begin the cure of all “febrile diseases.”30(p91) Rush 

discussed the cause of yellow fever epidemic in Philadelphia in 1793 and spoke to fact 

that yellow fever and malaria were avoidable through proper hygiene and appropriate 

environment.3(p3),30(pxvii)) To his great credit, Rush purged the Army formulary of many 

medications that he recognized as ineffective. He did so also for the civilian sector, purging 

the material medical of many remedies that simply didn’t work or could cause serious 

side effects. 
2 2 • FORWARD SURGERY

The fact that Rush advocated more progressive treatment of the mentally ill has been 

an often cited accomplishment that seems forward looking in scope as opposed to some of 

his other practices.30(pxvii) During his tenure, Rush was said to have trained more than 2,500 

students who made their own contributions.30(pxvii) (In 1804, Rush learned that letters he 

had written critical of Washington had been received by John Marshall, who planned to 

use it in his written life of Washington. Rush protested to Marshall, who used the letters 

without Rush’s name.30(p375))

WILLIAM SHIPPEN

The controversy and charges surrounding John Morgan led to his replacement by 

Director (Dr) William Shippen (Figure 1-4).3(p40) As with other privileged elites, Shippen 

graduated from Princeton, then studied medicine in his father’s office for 3 years. At the 

recommendation of his father, 

he went to Europe to study 

medicine, where he lived in the 

home of Director (Dr) John 

Hunter, with whom he studied 

anatomy. He studied midwifery 

with his brother, William Hunter. 

He then studied at Edinburgh 

under Director (Dr) Cullen and 

graduated in 1761, after which he 

studied in France for a year. He 

ultimately became the professor 

of anatomy at a medical college 

in Philadelphia. Shippen became 

the head of a “flying camp,” 

which was considered a more 

mobile field facility, at Trenton 

and later the head of all hospitals 

on the west bank of the Hudson 

River.3(p40)

Shippen came into his 

own criticisms, especially from 

Benjamin Rush, who was one of 

his more energetic critics.30(p189)

Supplies were short and personal 

rivalries were prevalent. Shippen 

was especially under fire for 

continuing to teach anatomy and 

not devoting his time and energies fully to his military job.3(p38) Rush accused Shippen of 

selling hospital supplies for his own profit. In 1779, Shippen asked for courts-martial for 

himself to provide a forum to rebut the charges. The protracted proceeding was finally 

FIGURE 1-4. William Shippen. Prior to becoming the Director, Dr Shippen had been the head of a “flying camp” in New 

Jersey. Dr Benjamin Rush was an ardent critic and supported 

charges against Shippen, who requested a courts-martial in 

1779. The lengthy proceedings were not finally settled until 

August 1780, resulting in no conviction. After the decision, 

Shippen was reinstated but resigned shortly thereafter. 

Artwork courtesy of the National Library of Medicine, 

Image #B023782.
CHAPTER ONE • 2 3

settled on 18 August 1780, with no conviction. Subsequently, Shippen was reinstated as 

Medical Director in 1780, but resigned on 3 January 1781.3(pp42–43)

JOHN COCHRAN

Director (Dr) John Cochran (Figure 1-5), appointed Director General of the Hospital 

Department in 1781, was the last of the medical directors during the Revolutionary 

War.3(p44) Cochran had been surgeon’s mate in the French and Indian War, which 

gave him some military 

experience.3(p44),15(pp333–334) He had 

studied medicine as an apprentice 

with Director John Thompson of 

Lancaster, Pennsylvania. He was 

practicing in New Jersey when 

the war started. Cochran was an 

Assistant Director of a flying camp 

hospital in 1776, and in 1777 

became the Surgeon General of 

the Middle Department. Cochran 

became the Chief Physician and 

Surgeon of the Army in 1780 

before becoming the Director 

General in 1781 (after Director 

Shippen resigned).3(p44)

In the 1780 to 1781 period, 

severe shortages of supplies were 

experienced.3(p45) Robert Morris, 

appointed as the Superintendent 

of Finance, restored some order to 

Congressional finances, but it took 

the French supplement to alleviate 

the crisis.3(p46) Further help was 

on its way from France, which 

in 1782 sent supplies and gold, 

even though the war was winding down.3(p46) Pay was 2 years behind for both officers and 

enlisted. Financial difficulties had reached the point that Director Cochran could not afford 

to get to Philadelphia in performance of his oversight duties.3(p47) In an effort to resolve the 

situation, Congress issued some warrants for pay, which were devalued due to inflation. 

Attempts to deal with the inflation loss of income for medical officers led to warrants being 

issued to be filled by the states. New York refused to participate.3(pp46,47) 

Cochran was ordered to start closing hospitals for financial reasons by the Board of War 

even before the British surrendered at Yorktown. He tried to delay the closure of the Boston 

and the Albany hospitals. Cochran remained until after the signing of the Treaty of Paris 

on 3 September 1783; Congress dissolved the Army on 3 November 1783. The Hospital 

Department existing during the war was replaced by an institution to aid the veterans.3(p48)

FIGURE 1-5. John Cochran. Cochran was the last of the medical directors during the Revolutionary War. Before the war 

had ended, he was ordered to start closing hospitals to save 

money. Cochran remained the Medical Director until Congress 

dissolved the Army in late 1783. Artwork courtesy of the 

National Library of Medicine, Image #B04815.
2 4 • FORWARD SURGERY

The American Soldier

For the Colonial Army, the recruits had to meet certain standards. Traditionally, men 

from the countryside were preferred because they were considered better able to handle 

the stresses of soldiering. The rural men were thought to benefit from the healthy country 

life with its hard work, availability of a more varied diet than the city dweller, and less 

exposure to the contagions of close living. The recruit was to be healthy and without 

obvious skin sores. Venereal disease, hernias, epilepsy, and alcoholism were to be avoided 

in the recruit.23(p6)

Benjamin Rush observed the British, Hessian, and American forces and concluded 

that men under 20 were more likely to experience “camp diseases,”20(p6) under which 

he included all diseases with fever as a common symptom (malaria, dysentery, various 

gastrointestinal illnesses, and typhoid, among others). During the war, Rush described 

many of his views regarding cleanliness and the proper environment for troops. Rush 

opined that Southern troops were more sickly than Northern troops, and that Native 

Americans were more sickly in the Army than foreign born. Rush concluded that the 

healthiest soldiers were above age 30. He dismissed the Southern troops for being ill due 

to “lack of salted provisions.”20(pp6–7) In all armies, standards depend upon supply and 

demand. In the 18th century, infantry soldiers were to be at least 5 feet 4 inches tall while 

cavalry were to be 5 feet 3 inches to 5 feet 6 inches in height. The age range was to be 

from 18 to 40 years.20(p8) There was generally agreement that an army on the march was 

healthier than one in camp.20(p11) The problems that the permanent camps had in common 

were poor sanitation, animal and human waste, and contaminated water.20(p11)

At the start of the Revolutionary War, the men from Connecticut had the most liberal 

ration allowance. The weekly ration called for 1 pound pork or beef, 1 pound bread/flour, 

and 3 pints of beer. Weekly, the Connecticut soldier would also get rice, butter, peas, or 

other vegetables. Calorie counts were not available for the Continental soldier because the 

diet varied according to local availability.20(p8) The Continental Congress set out specifics for 

a daily ration. Feeding an Army on the march was a difficult problem. Rations, including 

meat, generally were salted for preservation. However, because most salt was obtained 

from Britain, the meat to be eaten had instead to be “driven on the hoof.”20(p7) Rations 

could be supplemented with flour, which could be added to water and cooked on rocks in a 

fire (a concoction called “fire cakes” by the soldiers). Purchasing vegetables and fruits was 

difficult for the Colonial troops because farmers preferred the hard currency of the British 

rather than the Continental currency. In places like Valley Forge and during the first winter 

at Morristown, New Jersey, scurvy was common.20(p9) Food was seasoned only with vinegar 

and salt. Vinegar was used especially during the summer because it was believed that it kept 

away disease. Spruce beer (one of America’s oldest beer styles, which utilized the distilled 

oils from local spruce trees, molasses, and dates, when available) was added to the diet to 

prevent scurvy.20(p7)

The Army’s clothing was always an issue. For the Continental Army, standardized 

uniforms were late in coming to the war. Militias and the troops often wore whatever 

clothing they had on hand. Director Benjamin Rush recommended “that officers 

wear flannel shirts next to their skin rather than linen to protect them from fever and 
CHAPTER ONE • 2 5

disease.”20(p10) Director John Jones called for lighter clothes during the excessive heat of 

colonial summers.20(p10) Indeed, the ever-present threat of the heat was always a concern for 

the troops and the consequences could be dire. For example, at the Battle of Monmouth, 

New Jersey, 59 Hessians, wearing all-wool uniforms, died of heat exhaustion and sunstroke 

before meeting the Colonials.20(p10)

Van Swieten’s Diseases Incident to Armies (originally published in 1758) was a useful 

guide to common diseases and their treatments. The book was published in 1762 in 

England, where it became available to Colonial outlets. The book was then published in 

Philadelphia and later Boston (1776 and 1777, respectively).20 Specifics for the disposition 

of a camp were discussed. The camp was to be on dry land with a low water table and 

located away from the forest where animals of the forest could be a problem. Van Swieten 

described illnesses in early spring including sore throat, cough, pleurisy, pneumonia, and 

rheumatism. Bleeding and purges were featured in the treatments. He discussed jaundice, 

especially after prolonged or intermittent fevers.20(pp12–14)

Diseases of the day included dysentery, “camp fever,” smallpox, and the most 

feared, putrid fever. Putrid fever included typhoid fever and typhus. (There is controversy 

concerning whether the doctors of the day could distinguish between them.31(p232)) Cures 

included mercury,32 “Peruvian bark” (containing quinine) mixed with wine,33 and salts.15(p14)

Venereal diseases were common.34(p59) Dr John Hunter felt that gonorrhea and syphilis were 

both a form of the same disease.34(p117),35(p450)

In the Revolutionary War, diseases were the main nemesis for the military surgeon/

physician. There really was no signature wound of the conflict other than an abundance of 

disease. There were certainly some wounds to be treated, but disease was the main issue. 

Musket wounds, bayonet and knife wounds, the assorted Indian arrow and tomahawk 

wounds, and attempted scalpings would otherwise occupy the surgeon.

Vaccination for smallpox wasn’t available until 1798. (Vaccination involves the 

introduction of a vaccine functioning as an antigenic stimulus. The individual’s immune 

system is prompted to form an adaptive immunity to a pathogen—bacterial or viral.) 

Inoculation (or variolation) involved the direct introduction of material from the pustule 

of a smallpox victim into another person. A milder form of smallpox would result with 

consequent immunity to the disease. Morgan didn’t favor inoculation but his successor, 

Shippen, did recommend its use. As previously discussed, George Washington was 

apparently himself inoculated.15(p16)

The most common disease in the Colonies was termed “fever,” thought by Boyd, 

writing in the American Journal of Tropical Medicine and Hygiene, to be malaria. It was 

endemic from New England to Florida.33(p229) The incidence of malaria was said to be 

increased during the Revolutionary War, perhaps related to the large numbers of people 

traveling in endemic areas. Malaria was an issue for the British, the Loyalists, and the 

Colonial regular and irregular forces without discrimination. Yellow fever had a terrible 

reputation for severity. Fortunately, yellow fever was endemic largely in the deep South, 

although outbreaks in port cities such as Charleston, South Carolina, also occurred.23(p4)

Fresh air was advocated for health; Benjamin Franklin was one of the major 

proponents.3(p7) Good air supply was central to planning for hospitals; it could be helped 
2 6 • FORWARD SURGERY

by high ceilings in buildings and by avoiding overcrowding. Use was made of the Hales 

ventilators (manually operated large bellows) to remove poor air. Eighteenth-century 

hospitals also used incense or burned berries or sulfur. Placing hospitals in forests was to be 

avoided because the air could not circulate as well under a canopy of trees.3(p9) Sanitation 

in hospitals meant scrubbing of floors, walls, ceilings, and bedframes. Straw was easier to 

change in pillows/mattresses than feathers, and felt to be cleaner and less expensive.3(p9)

The British were also interested in avoiding overcrowding, providing good sanitation, 

and having sufficient air circulation and ventilation.3(p20) Mercury was often prescribed 

for pleurisy, inflammatory diseases, pneumonia, and rheumatism, but was increasingly 

given for an expanded list. Opium was also increasingly used, usually in the form of 

laudanum.3(pp7–8) Scurvy was the only recognized deficiency disease. James Lind had shown 

that oranges, lemons, and limes cured even the most severe cases of scurvy.3(p11) There may 

have been a recognition of cases attributable to scurvy as evidenced by large orders for lime 

juice in 1778.3(p84)

THE WAR COMES TO AN END

In the period 1778 to 1781, the majority of the operations of the Continental Army 

were in the South,3(p101) where malaria severely affected the Army. There were rumors that 

the British had used infected slaves to spread smallpox to the Colonials, but this was not 

confirmed.3(p125) A Corps of Invalids was established at this point (1782–1783) to deal with 

the convalescents. The fact that there was a general improvement of health in the period 

1780 to 1783 spoke to inoculation for smallpox, and improved sanitation and discipline of 

the troops to follow health guidance.3(p102)

The wounded in the North were largely replaced with soldiers afflicted with diseases, 

which were not abated due to shortages of medicines and medical supplies. For example, 

in the period of 1777 to 1778, there were extreme shortages of lint (used for dressings) and 

bandages.3(p83) Moravian women in the North were tasked with making more lint to help 

with the diminished supplies. The shortage of medicine bottles was helped when the glass 

works at Manheim, Pennsylvania, was reopened to make glass bottles.3(p87) The shortage 

of surgeons’ chests was also an issue. These chests, made from wood with felt linings, were 

to hold instruments such as scalpels and saws, and medicines. There was a controversy 

in the Medical Department as to the optimal size: large or small. The smaller chests won 

out because they were less costly to procure.3(p84) There were also shortages of surgeons 

because they were often prisoners of war. However, Washington reached an agreement with 

British General Frederick Howard, the Earl of Carlisle, that surgeons, surgeons’ mates, and 

chaplains would not be treated as prisoners of war when captured. They would instead be 

returned to their respective lines when possible, otherwise they were not to be incarcerated 

if return could not be readily accomplished.3(p47)

In the waning days of the war, the British were largely quartered in New York City 

proper. The British had set up their fortress in New York because Washington had not 

stopped the British withdrawal to New York at the 1778 Battle of Monmouth. However, 

from November 1781 going forward, there was an unofficial truce in the area.3(p123)
CHAPTER ONE • 2 7

At the close of the war, on 23 October 1783, the Hospital Department was replaced 

by an organization to aid the “invalids of the Army and Navy.”3(p48) In 1783, after lobbying 

efforts, Congress agreed to provide the same pensions for physicians and surgeons as other 

officers.3(p6) As early as 1636, Plymouth Colony had passed a law to care for its soldiers 

injured in various wars with the Indians in the region. In 1776, Congress made provisions 

for pensions to invalid soldiers and officers. Officers were to receive half pay for total 

disability, and a proportionate amount for less, while enlisted received about $5 per month. 

Incomplete records and the ever-present lack of funds prevented payments to an estimated 

6,000 wounded.3(pp127–128)

The success of the Revolutionary War was in question for much of the conflict. 

Lockhart highlights the importance of a number of men in the early pivotal times.36(pp2–6)

Dr Joseph Warren was the principal organizer of the Massachusetts forces, but he was 

killed at Bunker Hill. General Artemas Ward was the field commander of those forces, 

but had to resign his commission due to illness. His deputy, Dr John Thomas, died of 

smallpox. All of these men were connected with the identification and resolution of 

numerous medical issues. One can only speculate about their impact had they not died 

prematurely.36(pp2–6),37

ADVANCES RESULTING FROM THE 

REVOLUTIONARY WAR

While there were no revolutionary medical/surgical advances that resulted from the 

war, there were, in fact, some advances. One advance that is not often appreciated was 

the use of various types of tourniquets. The crude tourniquet was replaced in 1718 with a 

screw type of tourniquet devised by the French surgeon Jean Louis Petit. Various types of 

ligatures and sutures were tried. The famed English surgeon John Hunter preferred “dry 

sutures” (the use of “sticking plaster”), except for penetrating injuries.1(p16) Amputations 

exposed the injured to more blood loss. The higher up on the extremity the amputation, 

the greater the risk of blood loss. Ligatures provided improved blood loss control over the 

previous use of cauterization.37(pp101–103)

Eichner, in a 2003 paper, noted positive effects coming from the Revolutionary War 

that included: (a) beginning principles of sanitation and hygiene were recognized; (b) steps 

in disease control were initiated; (c) importance of smallpox inoculation was established; 

(d) policy for battlefield treatment of the wounded, and the importance of the evacuation 

of those injured was recognized; and (e) initial efforts to structure a military medical 

department were made.19(p32)

AFTER THE REVOLUTIONARY WAR 

The first Treaty of Paris, in 1763, ended the Seven Years War (the French and Indian 

War) and allowed the English to receive control of North America, and to neutralize French 

bases in India. The second Treaty of Paris, in 1783, ended the Revolutionary War, which 
2 8 • FORWARD SURGERY

also had global dimensions involving England, Spain, and France, as well as the financial 

involvement of the Dutch. The newly independent nation was now on its own.38(p12)

The American citizenry had an aversion to standing armies after the war. This aversion 

and suspiciousness was also fueled by a strong dislike of taxes.23(p70) The English aversion 

to standing armies can be traced to the English Civil War. The populace felt that standing 

armies could lead to loss of independence and more taxes because they would need to 

pay for the armies. Congress and the populace seemed to prefer militias to stand up when 

needed on the frontier. Thus the standing army of the war period would soon be gone, 

to be replaced by militias and volunteer units. By June 1784, only eight soldiers were left 

in the Continental Army. Seven hundred men were called up from state militias to form 

an active regiment for a 1-year period of service.3(p130) These troops were to secure the 

Northwestern frontier and to take possession of Western forts vacated by British forces. 

These were militia troops of the states and any surgeons were provided by the involved 

states.23(p70) There was no formal medical department during this period.3(p130) From 1785 

until 1789, there was one surgeon and four surgeon mates to care for the next 700-man 

regiment. 

After the Constitutional Convention was concluded in 1787, the first Congress 

(meeting in New York) created three executive departments while setting up the organization of the government. The War Department, the Treasury Department, and the 

Department of Foreign Affairs were the three departments. A formal Department of War 

was created in 1789.3(p129) The newly created Department of War was to be guided by MG 

Henry Knox as the Secretary of War in 1789. Knox had a small number of clerks to help 

him in the newly created organization. He first directed his attention to increasing the 

number of soldiers serving in the military.15(p71) The Indians were an issue in the West 

where British agents were stirring up trouble. A federal force of 700 troops was organized 

to serve there.23(p71)

Of interest, the three Secretaries of War that served between the Revolutionary War 

and the War of 1812 were all physicians (Henry Dearborn, William Eustis, and James 

McHenry).3(p129) In December of 1792, the Army was reorganized into a legion, with four 

sublegions (1,280 soldiers each). (By comparison, a regiment prior to 1812 had 1,000 

soldiers.) There was one appointed surgeon general for the legion. Each sublegion had one 

surgeon and three surgeons’ mates. The legion configuration lasted until May of 1796, 

when the Army was organized into four regiments. The Medical Department was created 

by Congress in 1799 to care for the troops.3(p130),15(p74)

War threats arose again in 1794 concerning issues of failure to indemnify for lost 

slaves, British occupation of Western forts, and the activities of British agents with the 

Indians. John Jay settled the issues by diplomatic work in London.11(p74) The reorganization 

of the Army in 1796 was brought about by concerns of war with Revolutionary 

France.11(p75) The France that had been an American ally in the Revolutionary War was 

the Royalist France. The Revolutionary France that replaced the monarchy seemed to 

back away from its prior friends, including America. France tried to prevent all trade with 

England, which remained a major trading partner with America. 
CHAPTER ONE • 2 9

The military had it first postwar engagement in 1791 against the Indians in the 

Northwest Territory. No specifics of medical care available are extant, although 

contemporary commentaries note a high rate of illness. The first incursion resulted in an 

Indian victory. In 1792, Arthur St Clair, Governor of the Northwest Territory and later 

designated a major general in the Army, launched a second campaign against the Indians. 

St Clair had a force of 1,500 militia and 600 Regulars; he also had prior medical training of 

note. Unfortunately, St Clair suffered from severe gout, which hampered his leadership. The 

Miami Indians defeated the force, inflicting many casualties.3(pp133–135) St Clair lost 632 killed 

and 264 wounded. Not all the wounded were taken with the retreating force, but those 

that were taken were left at Fort Jefferson for care.3(p134–135)

With the appointment of MG Anthony Wayne, the young nation had a victory over 

the Indians at the Battle of Fallen Timbers, Ohio, in 1794. Wayne likewise suffered from 

gout, which flared even before the Fallen Timbers campaign. Malaria also became a major 

health issue for his command. Medicine and supply shortage issues plagued the command 

through 1796. The last Indian campaign in the Northwest came in October to November 

of 1811. Three hundred Regular troops and 600 or so militia were deployed against an 

unknown number of Indians. William Henry Harrison was the general engaging Tecumseh 

at Vincennes. Harrison had also trained as a physician.2(pp136–137)

Harrison won a victory against the Indians at the Tippecanoe River near Lafayette, 

Indiana. Harrison had 900 to 1,000 men in his command and had been commissioned as 

a brigadier general. The Indians launched the attack on 7 November 1811. (This victory 

became part of a slogan for Harrison’s later presidential campaign.) He received 200 

casualties, of which 137 were wounded. In the evacuation by boat, an additional 25 of the 

wounded died before reaching the fort.3(pp138–139)

James Wilkinson had also trained as a physician but left the practice of medicine 

to become a soldier. He was appointed a brigadier general for service in 1808 in the 

Louisiana Territory.3(p142) In 1813, Wilkinson became the Army Commanding General. 

He was ordered to the Canadian border to lead troops, but was dismissed from the Army 

in 1814 for his incompetence in battle. (Wilkinson was also involved in many scandals, 

most notably his involvement with Aaron Burr. The Burr scandal resulted in a famous 

trial and acquittal for Burr. He and his colleagues, including Wilkinson, were charged with 

attempting to make Spanish territory and Louisiana a separate country. Wilkinson was also 

alleged to have been a paid informant for the Spanish.3(p141),39(p230))

The provision of healthcare for the soldiers was the sole responsibility of the individual 

surgeons and surgeon mates because there was little organization or support for a 

nonexistent medical department. Because the British had been impressing American seamen 

and giving aid to the western Indians for some years, the coming of the War of 1812 was 

anticipated. Despite this, the preparations were inadequate. The actual declaration of war 

did not come until 18 June 1812, but America was ill prepared for another war so soon 

after the Revolutionary War and the various skirmishes with the Indians in the West.1(p148)
3 0 • FORWARD SURGERY

REFERENCES

1. Savas TP, Dameron JD. A Guide to the Battles of the American Revolution. El Dorado Hills, 

Calif: Savas Beatie LLC; 2013.

2. Paine L. The Sea and Civilization. New York, NY: Alfred A. Knopf; 2003.

3. Gillet MC. The Army Medical Department 1775–1818. Washington, DC: US Government

Printing Office; 1981.

4. Wood WJ. Battles of the Revolutionary War. 1775–1781: Major Battles and Campaigns. Chapel 

Hill, NC: Algonquin Books of Chapel Hill; 1990.

5. Allen D. Our Declaration: A Reading of the Declaration of Independence in Defense of 

Equality. New York, NY: Liveright Publishing Corporation; 2014.

6. Hall JW. An irregular reconsideration of George Washington and the American military 

tradition. J Mil Hist. 2014;78(3):961–993.

7. Desjardin TA. Through a Howling Wilderness: Benedict Arnold’s March to Quebec, 1775. New 

York, NY: St Martin’s Griffin; 2006.

8. Lefkowitz AS. Benedict Arnold’s Army: The 1775 Invasion of Canada During the Revolutionary 

War. El Dorado Hills, Calif: Savas Beatie LLC; 2014.

9. Anderson MR. The Battle for the Fourteenth Colony: America’s War of Liberation in Canada, 

1774–1776. Lebanon, NH: University Press of New England; 2013.

10. Lancaster B. The American Revolution. New York, NY: Houghton Mifflin Harcourt; 2001.

11. Randall WS. Alexander Hamilton: A Life. New York, NY: Harper Collins Publishers; 2003.

12. Clark H. All Cloudless Glory: The Life of George Washington From Youth to Yorktown. 

Washington, DC: Regnery Publishing, Inc.; 1996.

13. Ketchum RM. The Winter Soldiers: The Battles for Trenton and Princeton. New York, NY: 

Henry Holt and Company; 1973.

14. Logusz MO. With Musket and Tomahawk: The Saratoga Campaign and the Wilderness War of 

1777. Havertown, Penn: Casemate Publishers; 2012.

15. Duncan LC. Medical Men in the American Revolution 1775–1783. Carlisle Barracks, Penn: 

Medical Field Service School; 1931.

16. Corbett T. No Turning Point: The Saratoga Campaign in Perspective. Norman, Okla.: 

University of Oklahoma Press; 2012.

17. Defense Casualty Analysis System. Principal Wars in Which the United States Participated: 

US Military Personnel Serving and Casualties. https://www.dmdc.osd.mil/dcas/pages/report_

principal_wars.xhtml. Accessed 19 March 2015.

18. Peckham HH. The Toll of Independence: Engagements and Battle Casualties of the Revolution.

Chicago, Ill: University of Chicago Press; 1974.

19. Eichner LG. The military practice of medicine during the Revolutionary War. http://www.

tehistory.org/hqda/pdf/v41/Volume41_N1_025.pdf. Accessed 19 March 2015.

20. Reiss O. Medicine and the American Revolution: How Diseases and Their Treatment Affected 

the Colonial Army. Jefferson, NC: McFarland and Co.; 2004.

21. Moore W. The Knife Man: Blood, Body Snatching and the Birth of Modern Surgery. New York, 

NY: Broadway Books; 2005.

22. Hunter J. Treatise on the Blood, Inflammation and Gunshot Wounds. (Originally published 

London, England, 1794). Bethesda, MD: Classics of Medicine Library (Gryplon Edition); 1982.

23. Brown HE. The Medical Department of the United States Army from 1775 to 1783. 

Washington, DC: Surgeon General’s Office; 1873.

24. Morgan J. A Recommendation of Inoculation According to the Baron Dimsdale Method. 

Boston, Mass: J Gill; 1776.
CHAPTER ONE • 3 1

25. Klebs AC. The historic evolution of variolation. Bull Johns Hopkins Hosp. 1913;(24):69–83.

26. Bynum W. The History of Medicine: A Very Short Introduction. Oxford, England: Oxford 

University Press; 2008.

27. Rogers BO. Surgery in the Revolutionary War: contributions of John Jones, MD (1729–1791).

Plastic Reconstr Surg. 1972;49(1):1–13.

28. Editor. John Morgan (1735–1789) Founder of American medical education. JAMA. 

1965;194(7):826.

29. Barton D. Benjamin Rush: Signer of the Declaration of Independence. Aledo, Tex: Wall Builders; 

1999.

30. Brodsky A. Benjamin Rush: Patriot and Physician. New York, NY: St Martin’s Press; 2005.

31. Duffy J. Epidemics in Colonial America. Baton Rouge, La: Louisiana State University Press; 

1953.

32. Olson DA. Mercury toxicity. http://emedicine.medscape.com/article/1175560-

overview#aw2aab6b2b2aa. Accessed 19 March 2015.

33. Boyd MF. An historical sketch of the prevalence of malaria in North America. Am J Trop Med 

Hyg. 1941;(21):223–244.

34. Hunter J. A Treatise on the Venereal Disease. [Reprinted by Nabu Press (book in common 

domain originally published 1789)]Charleston, SC: Nabu Press; 2011.

35. Applegate HL. Remedial medicine in the American Revolutionary Army. Mil Med. 

1961;(126):450–453.

36. Lockhart P. The Whites of Their Eyes: Bunker Hill, the First American Army and the Emergence 

of George Washington. New York, NY: Harper Collins; 2011.

37. Wangensteen OH, Smith J, Wangensteen SD. Some highlights in the history of amputation 

reflecting lessons in wound healing. Bull Hist Med. 1967;(41):97–131.

38. Miranda J. When lions sailed: naval strategy and the rise of Europe. Strategy & Tactics.

2011;268:6–12.

39. Melton BF. Aaron Burr: Conspiracy to Treason. New York, NY: John Wiley and Sons; 2002.
‘‘In the War of 1812, there had been 

little change in the art of surgery since the 

Revolutionary War. As in the previous 

conflict, field surgery was a very crude 

attempt to extract a bullet or a piece of 

shell fragment. The wound would be 

cleaned and dressed. Extremity wounds 

often resulted in amputation, particularly 

if the fracture was complicated, 

although simple fractures could be 

splinted. Mortality rates were 9% for 

simple fractures, 42% for compound 

or complicated fractures, and 50% for 

gunshot wounds.”
THE WAR OF 1812

Contemporary Views of the War 

A NUMBER OF CONTEMPORARY AUTHORS have written about the War of 1812. 

Yet, the war has not enjoyed very much fame or even notoriety among America’s conflicts. 

Hickey, in his book The War of 1812: A Forgotten Conflict,

1 attributes this, in part, to a 

lack of a defined “war leader.” President Madison was not a war president such as Lincoln, 

Wilson, or Roosevelt would be in later years. Nor was Madison a skilled orator or a leader 

who inspired confidence. Hickey points out that Madison was unable to impose his will on 

Congress or indeed the country.1(p34) Furthermore, Hickey feels that the best generals (by his 

choice Andrew Jackson, Winfield Scott, and Jacob Brown) were confined to secondary theaters. He also cites the complex issues that motivated the war and the fact that the Treaty 

of Ghent ending the War of 1812 brought only the benefit that America didn’t have to 

make significant concessions or reparations.1(pp1–2) In fact, the outcome was a treaty that returned both countries to the status quo that existed at the beginning of the war. Hickey also 

points out that prior to 1812, the incompetence in the American officer corps had reached 

such a level that the enlisted detested most of the officers.1(p8) There was little professionalism because most of the leaders had no formal military training. Most, in fact, owed their 

appointments to political connections. The state of the forces was due to Republican fiscal 

economies and the intent to rely on militias and privateers (privately owned ships with 

government licenses to wage war) in the maritime arena.1(p9)

Taylor, in his book The Civil War of 1812: American Citizens, British Subjects, Irish 

Rebels, & Indian Allies,

2

 saw the war as a civil war “between competing visions of America: one still loyal to the [British] empire and the other defined by its republican revolution against that empire.”2(p12) Sheads, in his book The Chesapeake Campaigns 1813–15: 

Middle Ground of the War of 1812,

3

 saw the war as a “culmination of the struggle for the 

North American continent”3(p5) that involved the French and Indian War, the Revolutionary 

Chapter Two

Surgery and Medicine in the 

War of 1812: 

A New Nation Challenged 

LANCE P. STEAHLY, MD
3 4 • FORWARD SURGERY

War, and the War of 1812.3(p5) And Vogel, in his book Through the Perilous Fight: From 

the Burning of Washington to the Star Spangled Banner: The Six Weeks That Saved the 

Nation,

4

 points out that the British during the Napoleonic Wars were fighting in their view 

for their very survival and that Britain would not hesitate to impinge on American rights to 

survive.4(p6) And, finally, Latimer in his book, 1812: War With America,5 has an excellent 

discussion about the war, but from a British perspective. Latimer points out that the “strain 

of war and threat of invasion loomed large in British minds.”5(p19)

Background

In 1796, George Washington decided not to run for a third term as president. Washington’s party, called the Federalist Party, represented the commercial interests of New 

England and the mid-Atlantic states. The opposition party, the Democratic Republicans, 

represented largely southern agricultural interests. John Adams, the Federalist candidate, 

succeeded Washington as president.5(p14) The Federalists expanded the military gradually 

until 1798, enlarging the almost nonexistent Army and restarting the Navy, which had 

been retired after the Revolutionary War. The Federalists clearly were pro-British in their 

policies and attitudes, as evidenced in 1794 by their signing the Jay Treaty with England, 

which brought continued peace with England and allowed American commerce to flourish. One aspect of the treaty allowed the British most favored nation trading status. The 

French (who were at war with England at the time) did not like the Jay Treaty, viewing it 

as a unilateral break with the French nation despite its help in the Revolutionary War. The 

French Revolution, however, had changed the attitude of the French because America had 

previously dealt with the French monarchy. The radical Republican French government 

resulting from the French Revolution seized more than 300 American ships carrying British 

goods as part of France’s war with England.5(pp14–15) The United States subsequently had a 

limited, undeclared naval war, the “Quasi-War,” with the French, lasting from 1798 until 

1801. The Quasi-War involved real conflict despite its undeclared status. In response to 

these ship seizures, the American Navy was created in 1798 under the Federalists’ direction. 

In a series of individual ship actions, they took control of 80 French privateers and put out 

of action three French warships.5(p15) The French privateers, fortunately, were more interested in prize money than fighting and thus would often decline battle.1(p7) The Quasi-War 

was ended by the strong Federalist naval campaign. In 1801, the Republicans gained power 

at the end of the undeclared war, reversing course because they viewed the policies under 

the Federalist Party as being too pro-British, the taxes too burdensome, and the attempts to 

control immigration too restrictive to continue.1(p7)

James Madison was hostile to the British, in part to counter the pro-British leanings of 

Alexander Hamilton and the Federalists. Madison had been Jefferson’s Secretary of State 

during the near war with Britain after the 1807 Chesapeake-Leopard affair in which a 

British ship, looking for English deserters, stopped an American ship and involuntarily impressed Americans into the British Navy. The Chesapeake-Leopard affair revived the hope of 

the Indians for a new conflict that they could join with the British against the Americans.6(p38)

Indeed, the British Indian Department began to enlist Indian help in the event of another 

American invasion of Canada.5(p25) The British were aware that an invasion of Canada was 

being advocated in America, especially by those in the southern states. The taking of Canada 
CHAPTER TWO • 3 5

had been a feature of the Revolutionary War, with continued interest in the years following. The Americans reasoned that the French Canadians could not be happy with their lot 

in an English colony. The British started negotiations with Indian leaders such as Tecumseh 

and his brother, Tenskwatawa, to enlist their help in the event of an American invasion.5(p25)

Latimer points out that there were as many reasons for America to go to war with France as 

England. However, there was no interest in the quarters of Jefferson and Madison for such 

a war because Jefferson’s Republicans were more in tune with the revolutionary sentiment 

of the French.1(p7) Latimer also points out that America could have enjoyed unhindered trade 

and protection for its ships had it allied itself with England.5(pp25–26)

Strategies and Goals

President Madison outlined five grievances against the British (representing the ideas 

of those favoring war with the British) in a secret message to Congress. Four of the five 

areas that he outlined dealt with maritime issues relating to blockade, search and seizure, 

and impressment of seamen (presumed to be British). The British recognized as American those who lived in the United States before 1783 or were born in the United States 

subsequently.5(p17) The fifth area concerned British support for Indian warfare on the frontier. The maritime states were busily evading the British rules and were engaged in smuggling. The states of New York and those to the north were in favor of peace. The states 

of Pennsylvania and those to its south were for war. War against Great Britain was finally 

declared on 18 June 1812, barely passing Congress, with the votes for or against reflecting regional differences.5(p34) The Americans were unaware that the British had suspended 

the 1807 “Orders” (Orders-in-Council—regulations issued by the British that hindered 

American trade with the European Continent, specifically France) with the plan that envisioned that the Americans would repeal their Non-Importation Act of 1811 (in essence an 

embargo or restrictive system that cut trade with belligerents in the Napoleonic Wars).3(p6)

It is certain that the war bill would not have passed at this juncture had the Congress 

known about these recent British moves. As it unfolded, the bill received the least amount 

of Congressional support of any declaration of war in America’s history. The senators and 

congressmen from New York to Maine voted for peace, while the senators and congressmen south of Pennsylvania voted for war.5(p34) This stark geographical difference in voting 

was explained by the different economies of the North and South, and the impact of British 

actions on these respective economies, as described below.

It was policy that the British would seize any ship sailing for France. The British had 

already seized approximately 400 American ships by 1812, which necessarily caused 

problems for American commerce. An economic depression in the South resulted from an 

inability to successfully export cotton and tobacco, and further explained why the senators 

and congressmen in the region voted for war. Furthermore, British agents were suspected 

of stirring up Indian tribes to attack. In addition, many Americans believed that some 

Canadians really wanted to be Americans. As noted by Berton in his book, The Invasion 

of Canada: 1812–1813,6

 aside from the old Loyalists and the British in residence, most 

Canadians were “at best apathetic or at worst disaffected.”6(p24) He points out that some 

500 Canadians were identified as supporting the “enemy” (the United States). Berton 

notes there were probably more as witnessed by the reluctance of the Canadian militia to 
3 6 • FORWARD SURGERY

do battle.6(pp24–25) As in the Revolutionary War, Americans attempted to lure the French 

Canadians of Quebec Province into the American camp and, as in the Revolutionary War 

with Arnold’s and Montgomery’s attempt to take Quebec, pursuing this same idea on the 

battlefield some four decades later would also end in failure.6(pp24–25)

Lieutenant General (LTG) Sir George Prevost was appointed Governor-in-Chief of 

Upper and Lower Canada in September 1811. Prevost’s defensive strategy was to hold on 

to the territory until help could come from England. He was aware that to take Quebec 

City, the Americans would need to first take Montreal, where he decided to concentrate 

his troops. Prevost could not expect much help from Britain because the war with the 

French was of paramount importance on the European continent, and thus consumed both 

manpower and resources.5(pp43–44) When war was finally declared in June of 1812, Prevost 

cancelled the planned return to England of the 41st and 49th Regiments, and the relocation 

of the 100th Regiment to Halifax.5(p49) Local volunteers, known as “fencibles” (who could 

only serve in Canada) and commanded by Regular Army officers, were established to augment the regulars. Prevost and General Sir Issac Brock also had 13,000 militia and variable 

Indian adjunct forces. 

American troop strength consisted of 17 infantry regiments, four artillery regiments, two regiments of dragoons (cavalry), one regiment of riflemen, and a Corps of 

Engineers.7(p131) On 26 June 1812, a few weeks after war was declared, the regiment size 

was standardized at 900 soldiers and the authorized regiment number was increased to 25. 

By January of 1813, 20 more regiments had been authorized.7(p131) In addition, the American states in 1811 had over 700,000 troops on the militia rolls. In practice, the Federalist 

governors in Massachusetts, Rhode Island, and Connecticut refused a request by General 

Henry Dearborn, the regional commander, to call out militia companies that would have 

allowed Regulars to serve at the front. American planning and operations were complicated 

by such domestic opposition.5(pp57–58)

The early American campaigns included the infamous invasion of Canada in July 1812 

that failed. In the envisioned three-prong invasion, General William Hull was to attack 

Canada from the village of Detroit in one phase, with General Henry Dearborn attacking 

in the east, and General Stephen Van Rensselaer attacking in the Niagara region.3(pp6,157) All 

three incursions would be unsuccessful by the end of 1812.3(p157)

It appears that the US military leadership initially was not adequately briefed on political war plans. For instance, Secretary of War William Eustis had sent orders to Brigadier 

General (BG) Hull only hours before war was declared, but he did not tell Hull of this war 

declaration. He ordered Major General (MG) Henry Dearborn to command the North 

forces, but did not specifically assign Detroit to his command. Dearborn assumed Detroit 

wasn’t his responsibility due to this failure of communication. This lack of preparedness 

and leadership resulted in John Armstrong Jr replacing William Eustis on 13 January 1813 

as the Secretary of War.7(p148) Armstrong served from 1813 to 1814 and supervised the 

Canadian campaigns.

At the start of the Canadian invasion, the three American armies were poised to take 

the border strongpoints of Montreal, Kingston, Queenston, and Amherstburg. It appeared 

that Upper Canada would fall, to be followed by the collapse of Quebec. Berton points 

out that three out of every five settlers in Upper Canada were actually Americans who had 
CHAPTER TWO • 3 7

come in response to the lure of cheap land. Some of these may have had familial loyalist 

sympathies for the Crown dating back to the Revolutionary War. Berton spoke of three 

factors leading to American failure in the invasion of Canada: (1) the British troops were 

better disciplined, although fewer in number; (2) America’s lack of military aptitude; and 

(3) the military alliance between the British and the Indians.6(pp26–27)

Dr James Mann was placed in charge of the upstate New York medical services, and 

later the forces under MG Henry Dearborn assembled at Greenburgh (in the Albany area), 

New York. The forces were largely militia, which returned home after being repulsed 

in their Canadian invasion attempt. Mann attended the sick there; in addition, he was 

required to distribute supplies to Niagara and Plattsburgh. Mann observed the diseases 

that soldiers suffered and opined that rheumatism impacted men over 40 years of age the 

most.7(pp157–159) Dr William Beaumont, of later international fame for his work in digestion, 

served under Dr Mann as a surgeon’s mate in New York. Dr Beaumont saw respiratory diseases as his soldiers’ main health problem. He favored bleeding as a treatment for respiratory issues, to be followed by “raising of blisters” in more extreme cases.7(pp159–160) Dr Mann 

toured the hospitals at Plattsburgh and Burlington, Vermont, where he was pleased with 

the work of Dr James Lovell (later Surgeon General of the Army). Lovell was in charge of 

the hospital at Burlington. Drs Mann and Lovell were both Regular Army surgeons.7(p160)

Many of the American forces along the frontier were in poor health.5(pp81–83) Indeed, 

in 1812, the situation in Buffalo was not good; the 100 wounded held by the British 

at Queenston had died. The prisoners had fought in the Buffalo, Lewiston, and Erie 

areas.7(pp161–162) Mann found that measles and dysentery were the most common illnesses 

suffered by the men.7(p161)

When Secretary of War John Armstrong took office in January 1813, he found the logistical supply infrastructure in dire shape, chronic shortages of Regular troops with training, and a major financial shortfall.5(p115) To address this, Congress doubled import tariffs in 

1813, but otherwise taxes were not raised, due to Republican opposition.5(pp120–121) 

Albert Gallatin, Secretary of the Treasury, encouraged Congress to authorize a war 

loan to be raised by nonconventional means to stave off insolvency. Subsequently, Congress 

authorized a war loan with the help of three wealthy merchants. The merchants included 

John Jacob Astor (of fur trading fame), Stephen Girard, and the financier David Parish. 

Their collective experience as financiers helped Congress arrange a $16 million war loan, 

with higher interest rates than normal (highlighting the need for increased taxes). Thirteen 

million dollars of the loan proceeds were given to the War Department. Gallatin directed 

Armstrong to use no more than $1,480,000 each month, which necessarily meant that 

there would be shortfalls in supplies and manpower.5(p121) Armstrong used some of the 

funds to appoint a number of Regular brigadier and major generals and to reorganize the 

Army into nine military districts.

5(p121) 

The shortages of supplies and trained personnel were evident in the medical arena as 

well. For example, Dr William Beaumont described 300 casualties from an ammunition 

dump explosion in Toronto.8(p16) Because of the shortage of Army doctors, he operated on 50 

of those injured over a 2-day period. He also described working for 48 hours straight in the 

spring of 1813. Some of the surgeons with Beaumont later worked on ships of the American Great Lakes Squadron.7(p170) Beaumont continued as a surgeon’s mate and participated 
3 8 • FORWARD SURGERY

in the September 1814 Battle of 

Plattsburgh. He drew the praise of 

Surgeon Mann and Surgeon General Tilton for his work there.8(pxiii)

Interestingly, Beaumont had only 

obtained his license to practice 

medicine in June 1812.

From June 1812, when war 

was declared, until June 1813 

and the appointment of Surgeon 

James Tilton (Figure 2-1) to the 

newly created office of Physician 

and Surgeon General, the Army’s 

medical care was relegated to 

the individual physician/surgeon. 

Changes were over a year in 

coming. Tilton’s appointment as 

the Physician and Surgeon General 

allowed him to assign and then 

move surgeons, surgeon mates, 

and hospital steward personnel as 

needed.7(pp169–170)

In the 13 October 1812 Battle 

of Queenston Heights (across the 

Niagara River from Lewiston, 

New York), Sir Isaac Brock was killed. The British prevailed in the battle, with General Sir 

Roger Sheaffe assuming command after Brock’s death. American MG Van Rensselaer negotiated a ceasefire with the British, which was extended several times. It was reported that 

it took three attempts to find someone in authority to bring about a truce.5(p82) The British 

listed 20 killed, 85 wounded, and 22 taken prisoner; the American casualties were not officially recorded. MG Van Rensselaer, however, stated in correspondence that 60 Americans 

were killed and 170 wounded. The British reported taking 925 American prisoners.5(pp82–83)

In 1813 in the South, Andrew Jackson had success in actions against the Creek Indians 

in Mississippi Territory. Jackson later became aware that the British were planning to attack Mobile and New Orleans in 1813 from their location at Pensacola, Florida. Jackson 

sent 160 Regulars and a few artillery pieces under the command of Major William Lawrence to garrison at Fort Bowyer at the beginning of Mobile Bay.5(p370)

In the North, Navy Master Commandant Oliver Hazard Perry won a seminal victory on Lake Erie. This brought that entire region around Lake Erie under American 

control.7(p164) The Battle of Lake Erie also made Perry a national hero.5(p184) The Battle of 

the Thames near present-day Chatham, Ontario, in October 1813 resulted in the death of 

Tecumseh and the end of the Indian Confederacy, an alliance between the Indian tribes and 

the British, and thus the threat from the British Native American allies was alleviated.5(p191) 

FIGURE 2-1. Surgeon James Tilton was appointed to the newly 

created office of Physician and Surgeon General in June of 

1813. Tilton’s appointment allowed him to manage medical 

personnel as needed, which had not been the case up until 

that time. Artwork courtesy of the National Library of Medicine, Image #B08882.
CHAPTER TWO • 3 9

The American campaign’s move toward Montreal ultimately failed when the British 

were victorious at the Battle of Crysler’s Farm (11 November 1813)5(p210) in Ontario and 

the Battle of Chateauguay (26 October 1813)5(p202) in Quebec province.4(p21) The Battle of 

Lundy’s Lane at Niagara Falls on 25 July 1814 was one of the war’s bloodiest encounters. 

The Americans lost 173 killed, 571 wounded, and 117 missing in action. The British losses 

were stated to be 84 killed, 559 wounded, and 193 missing. The missing could include deserters and casualties not recovered. The American casualties amounted to 45% of troops 

engaged and 30% for the British.5(pp296–297) 

Winfield Scott, as a brigade commander, received great praise for his command at 

Lundy’s Lane. General Brown sent for Scott, who arrived in the afternoon of 25 July 1814. 

When he saw the number of British facing him, Scott considered withdrawal, but instead 

attacked. Scott was credited with being one of the few aggressive and decisive American 

young generals in the war.5(p289) The American wounded were sent to a hospital made up 

of tents at Williamsville, near Buffalo, New York. The British wounded were taken to Fort 

George, the westernmost of the British fortified posts on Lake Ontario, Upper Canada, 

where only a single surgeon and a sergeant attended 320 of the wounded. The Americans 

were transferred to an inadequate hospital at York (the provincial capital of Upper Canada)—the general hospital was so small that other buildings, including a church, were utilized. The wounded were typically carried on litters made from blankets slung between two 

poles as opposed to being transported on an available wagon. The dead were so numerous 

after the engagement that burning of the dead had to be used instead of burial.5(p298)

The British perfected their version of power projection by sea landings, such as the 

raid on Essex, Connecticut, in 1814, which only lasted 24 hours. This tale of the raid was 

recast in Roberts’ The British Raid on Essex: The Forgotten Battle.9(p1) The British sent 136 

Royal marines and sailors (rowing 6 miles), launched from two warships in the Long Island 

Sound, to attack the American privateers of the village of Pettipaug, Connecticut. The British burned 27 American vessels, which was the most American vessels lost in a single event 

in the war.9(pp1–5) The British also used these sea-borne raids, raised to an art form, in the 

Chesapeake. Vogel presents as a theme of his book, Through the Perilous Fight,4 that in the 

context of the larger war as a whole, the Chesapeake operations were an intended British diversion from American operations in the North, where the land armies were mainly 

concentrated.4(p20) British Admiral George Cockburn told the communities in the region 

that they would be spared if no resistance was offered but that severe retribution would 

come if they did resist. Some communities, such as Havre de Grace,5(p160) offered no resistance, while Georgetown and Fredericktown (on the Sassafras River) resisted and suffered 

destruction of the towns. No more resistance ensued for the next 12 days of Cockburn’s 

incursions.5(pp161–162) In a continuation of the landings from the sea, the British threatened 

Washington, DC, in 1813.4(p21) Cockburn came within 25 miles of the city in mid-March 

1813, but he felt that his strength was not sufficient at the time to attack the American 

capitol.5(p156) In May 1813, the British attacked Havre de Grace in Maryland.4(p25)

Although the Americans knew that the British had threatened Washington in 1813, 

they took no serious actions to defend the capital from attack.5(p303) Howard, in his Mr and 

Mrs Madison’s War; America’s First Couple and the Second War of Independence,10 stated 

that Madison failed to exercise his role as Commander-in-Chief when Washington was 
4 0 • FORWARD SURGERY

threatened. There were many clues as to the threat to the city.10(p196) Indeed, British prisoners had already told the military and Secretary John Armstrong Jr of coming plans for the 

invasion.5(p303) Unfortunately, Armstrong believed that Baltimore was actually the intended 

British target, and Madison did not want to overrule his Secretary of War. Furthermore, 

both Armstrong and Madison overlooked the psychological and morale benefits that 

would accrue to the British from an attack on Washington. Cockburn, the British admiral 

who led the coming attack, was thus certain that Washington would not resist an attack. 

Cockburn was an experienced commander who had amassed 1 year of coastal operations. 

Due to the lack of resistance to date and his awareness of the state of things in Washington, 

he felt resistance would not amount to much.5(p311)

By 1814, Washington, DC, had been the country’s capital for 14 years. The city was 

becoming increasingly important to the United States as the seat of power, making it more 

attractive as a symbolic target. The population of the city and neighboring Georgetown 

was listed as 13,156 (including 2,559 slaves).5(p316)

The British attack resulting in the destruction of Washington on 24 August 1814 

caused outrage among Americans; even some British considered it to be excessive. The British used a force of only 4,000, which advanced 50 miles, to defeat an American force three 

times larger, before burning the public buildings, including the White House, with property 

loss given as $1.5 million.5(p322) The defenders of the city were defeated soundly by the British outside the city.9(p196) The Americans set fire to the Washington Naval Yard on the night 

of the attack, under the orders of the Yard Commandant, Captain Thomas Tingey of the 

US Navy. The Commandant ordered the fire to deny the Naval Yard’s stores from falling 

into British hands. The fire spared only the Marine Corps Commandant’s house.5(pp316–317)

Howard suggests that Madison was able to survive politically only by the popularity of his 

wife Dolly, who early on had become the leader of Washington’s social scene.10(p223)

The subsequent defiance of Baltimore, Maryland (September 1814), and the victory at 

Plattsburgh, New York (11 September 1814), offered some solace for the Americans. After 

the ruin of Washington, there was some resolve to move the capital. However, influential 

lawmakers and businessmen interested in the status quo resisted the move.11(p1)

In September 1814, the British had taken the eastern part of Maine with 100 miles 

of the coast.5(p347) By the end of the war, the British had captured or destroyed 55% of 

America’s naval forces. The Battle of Plattsburgh on 11 September 1814 was won by the 

Americans, as was the naval action on adjacent Lake Champlain, which helped precipitate 

the British loss on land. British General Sir George Prevost blamed the loss by his troops 

on land to the success of the American naval action. Latimer makes the point that it is 

possible a more confident commander could have prevailed against the smaller American 

force.5(p359) Prevost led 11,000 troops against an American force of 1,500 Regulars and 

500 militia.5(p359) The losses of the battle reported for the Americans were 38 killed, 64 

wounded, and 20 missing. The British reported 37 killed, 150 wounded, and 55 missing, 

although more may have deserted to the Americans, attracted by the American offer of 

higher pay than they received from the British side. Indeed, BG Alexander Macomb, the 

American ground commander, reported that over 300 British troops came over to the 

American side in part because they were upset at the British retreat and in part because of 

the American offer of higher pay for their services.5(p358)
CHAPTER TWO • 4 1

As mentioned previously, the British also had Indian allies in the War of 1812. The 

conflict with the Creek Indians ended with General Andrew Jackson’s assault against a 

Creek group at Tohopeka (Horseshoe Bend) on the Tallapossa River in Alabama. Eight 

hundred Indians were killed, compared to the loss of only 45 Americans. The Creek power 

was broken, ending the war with the Indians.5(pp220–221) Andrew Jackson’s victories over the 

Creek Indians resulted in the Treaty of Fort Jackson, which was signed at Fort Jackson, 

near Wetumpka, Alabama, on 9 August 1814. The Creeks were required to give up claim 

to 23 million acres and to move west beyond the Mississippi River. (The British later 

maintained that the treaty was a violation of the Treaty of Ghent [ending the war], which 

had a clause protecting the Indians.5(pp369–370)) Jackson then recruited a militia force, a small 

force of several hundred, and proceeded to Mobile, Alabama. Jackson was promoted to 

the regular rank of major general and took command of Military District No. 7 based at 

Mobile.5(p221) He had received reports that the British were set to invade New Orleans or 

Mobile because they were interested in securing control of the Mississippi River.5(p370)

Later, on 16 September 1814, the British attacked Fort Bowyer with two English ships 

and two sloops. The naval craft carried 60 Royal Marines, 12 Royal Artillerymen, and 

130 Indians. The forces were defeated with the British suffering 32 killed and 37 wounded, 

in contrast to the Americans’ 4 killed and 5 wounded.5(p372) Meanwhile, the British were 

trying to enlist the help of the pirates under Jean Lafitte at Barataria, some 60 miles away 

from New Orleans. The Lafitte pirate group eventually sided with the Americans at New 

Orleans.5(p371)

In preparation for the British advance at New Orleans, Jackson held a fortified line 

with 3,500 men and 100 more in reserve. The Battle of New Orleans extended from 24 

December 1814 until 8 January 1815. The battle took place some 10 miles south of New 

Orleans on the east bank of the Mississippi on the Plains of Chalmette. The 8,000-man 

strong British Army had a plan to take New Orleans and to meet up with troops from 

Canada coming down the Mississippi River. The opposing Army of Americans, by then 

numbering around 4,000, was made up of militia, Regulars, Indians, and pirates.12(pp5–6)

Many of the British troops came directly from the battles of Europe with the defeat of the 

French.5(p383) The end result was that the British sustained a humiliating defeat at the hands 

of a ragtag American force, which proved to be unnecessary given that the peace treaty 

(the Treaty of Ghent) had been concluded on Christmas Eve, 24 December 1814.5(p388)

Total American casualties at New Orleans were reported as 13 killed, 39 wounded, and 

19 missing,5(p387) as opposed to the greater British losses of 289 killed, 1,262 wounded, and 

484 missing (some of which are presumed to have deserted).5(p386)

The Treaty of Ghent was concluded to ensure no further cause for war by either 

side. America was not able to take Canada5(p402); the war ended in a stalemate. The two 

countries were to take their argument of which side owned the islands in Passamaquoddy 

Bay, the northeast boundary between the United States and Canada, to the commissioners 

appointed from each country. The clause inserted by the British to protect native Indian 

lands from encroachment became inoperable due to the pressure of growing American 

populations anxious for new farmlands. Nationalism of the Canadians was increased as a 

result of the War of 1812.5(pp401–408)
4 2 • FORWARD SURGERY

State of Medicine and Surgery in the War of 1812

By the War of 1812, there had been little change in the art of surgery since the 

Revolutionary War. As in the previous conflict, field surgery was a very crude attempt 

to extract a bullet or a piece of shell fragment. The wound would be cleaned and 

dressed. Extremity wounds often resulted in amputation, particularly if the fracture was 

complicated, although simple fractures could be splinted. Mortality rates were 9% for 

simple fractures, 42% for compound or complicated fractures, and 50% for gunshot 

wounds.13(p1071) As in the Revolutionary War, most of the surgeon’s attention was directed to 

the many diseases, although smallpox played a lesser role in this conflict due to vaccination 

(available since 1798 with Jenner’s work).13(pp1071–1073)

Howard, in Wellington’s Doctors,14 provides a view of contemporary war surgery from 

a British perspective. Amputation was deemed to be required to save the life of the soldier 

in certain circumstances, such as compound fractures and uncontrolled bleeding.14(p130) They 

cautioned, however, to let the soldier first recover from the shock of the wounding before 

proceeding to amputation.14(p136)

The French impact on America’s Army, both tactically and medically, began years 

before the War of 1812. In the period preceding the war, General Winfield Scott bought 

French textbooks on war, which he studied carefully. Scott’s use of French techniques 

allowed him to win the only land war victories of the War of 1812.15(p8) Hence it would be 

appropriate for significant regard to also be given to French military surgery greats such 

as Napoleon’s surgeon, Dominique Jean Larrey, Surgeon-in-Chief of the forces. In the 

Napoleonic Wars, Larrey spoke to the need to recover from the initial wounding before 

carrying out definitive surgery, such as amputation.7(p130)

The need for a professional Army, including the medical component, was recognized 

by leaders following the end of the War of 1812. It would be several years later before a 

permanent Medical Department was established in 1818. However, before that happened, 

a Congressional legislative move in 1815 reduced the size of the military to 10,000 

men and eliminated the position of Physician and Surgeon General.7(p186) Curiously, the 

Apothecary General position, with two assistants, was left. In 1816, further legislation 

attempted to deal with medical support to the military and made the position of 

Apothecary General permanent.7(p187) The Apothecary General was tasked with a number 

of functions, such as purchasing and handling all medicines, surgical equipment, and 

dressings. He was to handle the pay of stewards, ward masters, and nurses of the hospitals. 

The Apothecary General was also charged with preparing medicines under the direction of 

physicians.7(Appendix J)

STATUS OF DISEASE AND MEDICATIONS AT THE 

END OF THE WAR OF 1812

Following the War of 1812, much of the attention of the surgeons was directed to 

patients with illnesses/wounds resulting from the conflict, although some new patients 

came from existing forces. The surgeon had to sign a certificate for a soldier to receive a 

pension.7(p190) Nevertheless, most of the practice of military surgeons in this time frame was 
CHAPTER TWO • 4 3

directed at disease, rather than surgery. Vaccination was not practiced as hoped within 

the Army. The Apothecary General appointed a team of six surgeon mates to act as a 

“vaccinating team.” However, he had no command authority to require immunization. 

Materials for vaccination were sent to the commanding officers, who did have the authority 

but often neglected the use of it. Despite this inability to ensure that the commanders or 

the “vaccinating team” did meet success, there were no recorded smallpox epidemics in the 

War of 1812.7(pp191–192)

Dysentery and other related disorders caused the so-called “camp diseases” of the 

War of 1812. Purges and emetics, baths, and medicines such as “Dover’s powder” (a 

combination of opium and ipecac) were used. Many physicians held that diseases of 

“diarrhea and dysentery” were to be treated by increasing perspiration, often by using 

Dover’s powder.7(p192) Some confusion was caused by physicians such as Dr John Warren 

of Revolutionary War service, who in 1813 opined that typhus and yellow fever were the 

same disease.7(p193) There were some reservations about bleeding as a therapy and the use 

of certain medicines such as mercurials, arsenicals, and opiates, but these practices were 

slow to die.7(pp193–194)

 Purges and emetics were standard fare for the physician in the first quarter of the 

19th century. Purges containing mercury were favored. Calomel (also known as mercurous 

chloride) was another purgative that had its advocates. As time passed, the side effects 

of the mercurial purge were recognized and it was slowly discontinued.16(pp6,13) Mercury 

toxicity can cause many side effects that can be appreciated today in retrospect. However, 

even in the early 19th century, toxicities such as these were noticed. Long-term exposure 

may cause numbness, pain, tremor, memory problems, seizures, and death. Mercury can 

also cause vomiting, diarrhea, and kidney failure.17 Purges and emetics remained popular 

in the war period, however. Emetics were seen effective to treat fever and inflammatory 

issues.16(p8)

There were only a few apothecary shops at the turn of the century. Most medications 

were dispensed by the physician after his apprentice put the medication together. Some 

physicians did cross between being a doctor and an apothecary. Apothecaries and druggists 

in the early 19th century often branched into chemical manufacturing. The War of 1812, 

with the loss of English medicines, spurred the domestic development of drug preparations. 

After the war, the quinine alkaloid was isolated in 1820 by Pierre Pelletier and Joseph 

Caventou.18(p10) They started work on the bark of the cinchona tree from which they 

isolated a yellow gum, which the two termed quinine. By 1821, a treatment guide for the 

use of quinine was set. The listing of medicines took a significant step forward with the 

publication of James Thacher’s 1810 The American New Dispensary and with the more 

definitive 1820 Pharmacopoeia of the United States of America (USP).18(pp10–11) In England, 

the Society of Apothecaries was founded in 1790, but its educational mandate was not 

established until the Apothecaries Act of 1815.19(p6) Poor quality medicines were a problem 

in the War of 1812. However, in the 1840s, as European standards increased, poor quality 

drugs became an increasing problem in America. There were no universal standards in 

America; most drug preparation was simply left to the apothecaries. (Quality started to 

improve with the formation of the American Pharmaceutical Association in 1852 and the 

creation of pharmaceutical industries.18(pp12–13))
4 4 • FORWARD SURGERY

Quinine had previously been used in the form of bark of the cinchona tree in the 

treatment of fevers. After 1820, quinine sulfate was extracted from the bark with greater 

dosage accuracy and predictability due to the work of Pelletier and Caventou.18(p10),20

Surgeons were using higher doses (20–30 gms at a time) than previously, with good result. 

They found that the quinine sulfate was better tolerated from a gastrointestinal standpoint 

than the bark of the cinchona tree. Physician/surgeons often used it for other fevers than 

malaria, including typhus, typhoid fever, cholera, and pneumonia, among the many 

diseases causing fever.16(pp6–8) (A survey of Army surgeons in 1843 found that the majority 

of them were using a few larger doses rather than numerous smaller doses. The survey also 

found that the majority of physicians did not relate the gastrointestinal symptoms due to 

the higher doses and confirmed that physicians were indeed using quinine for all types of 

fevers in addition to malaria.16(p7))

Opium had been used for dysentery or severe pain, but its constipation side effects 

were undesirable. Morphine and codeine were refined from opium products in the first part 

of the 19th century. The newly refined drugs were popular and their use was increased. 

The addictive properties were often overlooked and not condemned. Gillet points out that 

even active Army officers might indulge without censure. The opiates were usually taken by 

mouth. However, some physicians applied the drugs directly to exposed skin that had been 

scraped or abraded.16(p7) 

Malaria became less common in the East but was nonetheless a nationwide problem. 

Interestingly, malaria was prominent in the Midwest. Malaria was thought to be spread by 

evil vapors and was felt to be largely a disease of the rural areas. In the writings of the time, 

malaria was called many names, such as intermittent fever, marsh fever, and ague, to name 

a few.16(p8) Relapses with malaria were common in the day. A combination of tuberculosis 

with malaria was often fatal. Malaria could also be fatal in men already debilitated with 

wounds, other diseases, or poor diet. Prior to the refinement of quinine sulfate, bleeding 

still remained the treatment for malaria in addition to emetics, purges, and cinchona 

bark.16(pp9–10)

Venesection for bleeding became less prevalent during this time period. However, some 

physicians still used leeches or vacuum cups to extract blood. (Even in the Civil War some 

bleeding was practiced for the appropriate “relaxation” of the body, which would imply 

weakening of the patient secondary to blood loss.16(p8)) Bleeding had been the treatment of 

choice for malaria before quinine’s use.16(p9)

Typhoid fever was a widespread problem. The etiology was not clear and the treatment 

even less so. Quinine was used to deal with the fever. Dengue fever, yellow fever, and 

cholera were additional diseases for the surgeon to contend with. These diseases were also 

not understood and no effective treatment was entertained. Because there were no methods 

of rehydration available to the cholera patient, death from that disease was cruel.16(pp10–12)

Cholera was endemic in India, the Near East, Russia, and Asia in 1814 to 1815. It became 

periodically present in America after 1832.16(pp10–11) The rapid mortality and the therapies, 

such as bleeding, which didn’t work, brought panic.21(p1)

Scurvy was still a problem for the troops despite the British Navy’s use of fruits to 

prevent the disease. Indeed, the understanding of the role of fruits and vegetables to 
CHAPTER TWO • 4 5

prevent scurvy and to treat the disease was limited. Vinegar was thought, incorrectly, to 

help, although doctors of the period found potatoes worked. The isolated posts often had 

potatoes available, which helped somewhat. Army surgeons came to learn that native 

plants such as maguey, wild onions, prickly pears, and poke weed seemed to work as 

antiscorbutics.16(p14)

POST-WAR OF 1812: 

THE MEDICAL DEPARTMENT GOING FORWARD

The Medical Department had been created after the War of 1812 started, and its 

organization was ended with the end of the war. The office of the Physician and Surgeon 

General was no longer in existence after the legislation of 3 March 1815. The Army was 

reduced to 10,000 effectives at the time by this legislation. While the office of the Physician 

and Surgeon General was eliminated, Congress did retain the office of Apothecary General, 

along with two assistants. These positions were created by a Congressional order on 

17 May 1815. The Apothecary General and his assistants were retained to ensure some 

economy and efficiency in the procurements of medicines.7(pp186–187) Only one surgeon and 

two surgeon mates per regiment were allowed, which caused many otherwise experienced 

surgeons and mates to be dropped from the rolls as the overall numbers were reduced.7(p186) 

In April 1816, the War Department established regulations for the Army that actually 

delineated the duties of medical officers in detail. The position of Apothecary General (and 

his assistants) was made permanent. The regulations discussed roles of the hospital surgeon 

and surgeon mates, as well as allowances for food and quarters. The Army was organized 

into a Northern and a Southern Division. A ratio of four surgeons and eight mates for 

each division was established. There was still no single medical superior to coordinate the 

surgeons and to provide medicine needs to the Apothecary General.7(pp186–187)

On 14 May 1818, the new regulations were approved, establishing the post of Surgeon 

General as well as slots for two Assistant Surgeons. The Surgeon General reported directly 

to the Secretary of War.16(p27) The Apothecary General reported to the Surgeon General 

now.16(p27) The Apothecary General post was also approved, along with two Assistant 

Apothecary Generals. Forty post surgeons were mentioned. One regimental surgeon 

and two mates were to be assigned to each regiment specifically.22(p107) There were four 

regiments of artillery, seven regiments of infantry, a Corps of Engineers, and topographical 

engineers.22(pp126–127)

From the establishment of the Army Medical Department in 1818, Wintermute points 

out that those medical officers faced many challenges, including that of exercising their 

authority. Doctors struggled to get legitimacy and social status. Wintermute uses the term 

“marginalized subordinates” to describe their status.23(p22) He points out that the Regular 

line officer often saw the doctors as interlopers, not deserving of recognition.23(p21) He notes 

that some Regular officers did not always implement the surgeon’s recommendations, 

instead seeing the surgeon as a “contractor.” The Regular officer could say that command 

was his sole concern.23(p6) (As late as 1840, Surgeon General Lawson still had to fight for 

the privilege of wearing epaulettes on the surgeon’s uniform.16(p79))
4 6 • FORWARD SURGERY

Congress again reduced the size of the Army in legislation dated March 1821. The 

Apothecary General position was removed. The Surgeon General appointed a physician 

to be the purchasing officer, but he had the authority to appoint any qualified person 

to the position.22(p126) The surgeons were all now to be classified as surgeons or assistant 

surgeons.16(p28)

In 1832, four more surgeon positions were added to the active roster, along with 10 

more assistant surgeons. At this time, Secretary of War John Eaton proposed abolishing 

the Surgeon General’s office, but Surgeon General Lovell fought the proposal and was 

successful.16(p30) However, in 1834, Congress raised the pay levels for all physicians, except 

for the Surgeon General. The Surgeon General received $2,500 per year, which was lower 

than comparable salaries paid to other Army branch chiefs. Although the record is silent 

on the failure to increase Lovell’s pay, some “payback” may have been in play. The senior 

surgeon received pay of a major, that is, $50 per month. The assistant surgeon would 

receive the pay of a captain. The lowest assistant surgeon would receive the pay of a first 

lieutenant. The surgeons still had no actual military rank. The assistant surgeon who had 

more than 10 years of service would get double rations.16(pp30–31)

THE MEDICAL DEPARTMENT IN THE INDIAN WARS

First Seminole War (1814–1819)

The Seminoles were an aggregate of Indians (mostly Creeks) and runaway slaves. The 

Indians had sided with the British in the War of 1812. Andrew Jackson was sent with 3,000 

troops to deal with the Seminoles. Jackson was successful in defeating the Seminoles and 

captured several forts in Florida. The Adams-Onis Treaty of 1819 with Spain gave America 

possession of Florida in exchange for cancelling Spain’s $5 million debt.24 The treaty was 

signed by the US Secretary of State John Quincy Adams and Spain’s Minister Luis de Onis. 

Florida was subsequently divided into two counties and an infrastructure was established. 

Florida became an official territory 3 years later in 1822. Settlers from the North “invaded” 

Seminole territory. The result was that the Indians and former runaway slaves were pushed 

farther into the Everglades.24

Black Hawk War (1832–1833) 

Andrew Jackson became President in 1829; the Indian Removal Act was passed in 

1830. The Black Hawk War of 1832 to 1833 evolved because the Sac and Fox Indian 

tribes (led by Black Hawk) were attempting to return from Iowa (where they had been sent 

by the Indian Removal Act) to their former lands, east of the Mississippi River in Illinois. 

General Winfield Scott was the commander of the forces opposing the Indian move.16(p50)

Scott had 1,000 men that came from the east and 200 men at Jefferson Barracks in Saint 

Louis. Surgeon General Lovell appointed Josiah Everett as the Medical Director for the 

campaign. Other surgeons from other posts were ordered to join Everett. Two additional 

battles were fought successfully against the Indians, with minor American casualties.16(pp50–51)

The Black Hawk War was known at the time as the “Cholera Campaign,” reflecting the 
CHAPTER TWO • 4 7

high incidence of the disease among the troops in the Army. Cholera spread to many forts 

despite the attempts by Lovell and his surgeons to limit its extent.16(p52),22(pp149–150)

Second Seminole War 1835–1842 

The exploits of the Indian chief Osceola, who led his people to a number of victories, 

were historic as recorded in Hatch’s Osceola and the Great Seminole War: A Struggle for 

Justice and Freedom.25 In a December 1835 attack on the troops of Major Francis Dade, 

who was on his way to Fort King with his detachment (in the area of Tampa Bay, Florida), 

over 100 troops were killed in an event known later as “Dade’s Massacre.” Three soldiers 

survived but two of them died later of their wounds.25(pp321–323) Such a complete massacre 

had not previously been known in Indian warfare.25(p324) BG Duncan Clinch had been in 

charge until General Winfield Scott took over as the Commanding General. Scott was 

called away to wage another campaign against the Creeks.24(p350) Osceola came to negotiate 

a treaty, but was instead captured and imprisoned in September 1837. He became ill with 

fever and died a few months later in 1838 in prison at Fort Moultrie in Charleston, South 

Carolina.25(p452) The conflict, however, didn’t end with Osceola’s death.25(p453)

The Second Seminole War was the only major conflict during the period starting in 

1835 but extending to 1842. The conflict centered on the removal of the “Five Civilized 

Tribes”—the Creeks, Cherokees, Chickasaws, Choctaws, and Seminoles—to lands west of 

the Mississippi River. Attempts to remove the Creeks, and especially the Seminoles, brought 

troops into territories where malaria was endemic, complicating the work of the Army 

Medical Department.16(p53)

Malaria and cholera were the major diseases in this period. Cholera was a major 

problem on the Henry Clay, a steamer transport chartered to move the tribes. It was 

thought that rats infected the steamer before its charter.22(pp150–152) Even Surgeon Josiah 

Everett, who had played an important role as Winfield Scott’s Medical Director in the Black 

Hawk War, died of cholera in 1832. At the time, Everett and the ill troops had just been 

landed from the transport Henry Clay. After Everett died, Assistant Surgeon Robert E Kerr 

was the remaining medical officer.22(p150) Kerr took care of the survivors unassisted.22(p151)

Of a force of 400 soldiers, approximately 250 soldiers were lost (27 died and the rest as 

desertions); 150 effective soldiers remained.16(pp50–51)

The 7-year Seminole conflict alone accounted for 1,200 of 1,500 deaths in the Army 

in the 1835 to 1842 period. Over 75% of the Army deaths in Florida were due to disease. 

The small-unit type warfare was best geared to the Army due to its reduced troop size. 

However, the smaller size could mean no medical support on deployment.16(p58)

Third Seminole War (1855–1858) 

There was a Third Seminole War from 1855 to 1858. The third conflict was between 

the few remaining Seminoles in Florida (who had withdrawn to the Everglades) and the 

white settler population. The Seminole population was reduced to 200 by the end of the 

conflict in 1858.26
4 8 • FORWARD SURGERY

SURGEONS GENERAL DURING THE INTERWAR PERIOD

Joseph Lovell (1818–1836)

Before 1818, there was no position of Surgeon General in the US Army. In May 

1818, Congress established the post of Surgeon General, appointing Dr Joseph Lovell to 

the position (Figure 2-2). He had graduated from Harvard College and Harvard Medical 

School, and then studied medicine with Dr William Ingalls of Boston.22(pp107–108) Lovell 

had previously served as the surgeon of the 9th Infantry and served as a hospital surgeon 

on the Northern frontier.16(p28) He was the head of the hospital at Burlington, Vermont, 

with the forces of General Winfield Scott and General Jacob J Brown.22(pp108–109) Lovell had 

occupied progressively superior positions despite his youthful 30 years of age. Lovell was 

concerned about physician quality and the level of care provided by them. He had to hire 

civilian physicians at various times and locations, with varying quality. Lovell was able to 

modify the regulations to allow for competitive examinations both for appointment and 

promotion. Only two attempts were allowed to pass the test. An assistant surgeon had to 

take an examination within 5 years of initiating military service to remain in the Army. 

However, Lovell allowed the medical officer to refuse a promotion because it usually 

brought with it a transfer. Apparently refusals of promotion for this reason were not that 

uncommon. Lovell tried to accommodate requests for postings. As a result, surgeons and 

assistant surgeons were known to have stayed at one post as long as 20 years. However, 

because some surgeons were quick to request a new post if they were not happy with 

their lot, Lovell required they stay at least 2 years in one post before moving to another 

post.16(pp31–33)

Surgeon General Lovell died on 17 October 1836; the cause of his death was not 

specified. After Lovell’s death, Assistant Surgeon Benjamin King was appointed the 

interim replacement.22(p157) King continued in the office while President Jackson considered 

suggested successors. Thomas Lawson was the favored candidate from the Army medical 

staff.22(p159) There was a movement to appoint a civilian Surgeon General, but this was 

successfully resisted by the military doctors.27

Thomas Lawson (1836–1861)

Lawson (Figure 2-3) began his medical career in the US Navy as a surgeon’s mate, 

but became an Army garrison surgeon in 1811. There is little information about Lawson’s 

early education or even of his medical training; although it is assumed he had been trained 

through a preceptor arrangement. He participated in the War of 1812 and was commended 

for his work at Plattsburgh, New York.27 Prior to his medical appointment as Surgeon 

General, Lawson served as a volunteer Army line officer at the rank of lieutenant colonel. 

He was second in command of a Louisiana volunteer infantry regiment during the Second 

Seminole War, from February 1836 to May 1836. Lawson served later as the medical 

director of troops engaged in the Second Seminole War.16(p53)

Lawson became the Surgeon General in May 1836. He delayed taking over the duties 

of the office while he accompanied the retiring President Jackson to Tennessee. Upon his 

return to Washington, Lawson left again to assume command of a volunteer unit in late 
CHAPTER TWO • 4 9

FIGURE 2-2. James Lovell, Surgeon General (1818–1836). Lovell was the first official Surgeon General, 

appointed to the post in May 1818. He was concerned about the provision of medical care during the 

Mexican-American War. Of the more than 100,000 troops that went into Mexico for the war, about one 

in nine died, the majority of diseases of the time. Artwork courtesy of the National Library of Medicine, 

Image #B18125.
5 0 • FORWARD SURGERY

1837.16(p53) He was the serving Surgeon General during most of the Second Seminole War 

(1835–1842). Lawson had to deal with severe doctor shortages, particularly in Florida 

where many soldiers became ill. A number of the surgeons themselves came down with 

diseases. Lawson had few resources with which to remedy the shortages, but he had little 

tolerance for surgeons who did not do their duty.16(pp58–60) Lawson faced innumerable 

challenges in supporting the Second Seminole War as well as the other scattered Army posts 

nationally, due to an inadequate staff and supply/transportation issues.16(p94) Lawson had to 

supply medical support for many temporary forts—indeed, there were 31 forts in the 1838 

to 1839 period alone.16(p66) In 1838, Lawson had 15 surgeons and 60 assistant surgeons 

but only one clerk in his office. 

In 1842, a few more surgeon 

positions were added by Congress. 

The medical examinations 

for recruits were a problem for 

Surgeon General Lawson because 

many potential soldiers failed the 

basic standards.16(p74) Standards for 

recruits had evolved slowly since 

the Revolutionary War. In that 

war, Congress spoke only of men 

ages 16 to 50. The first specific 

standards were set in 1814 and 

spoke of able-bodied men ages 

18 to 35, whose healthiness had 

to be demonstrated. Examination 

went to showing use of joints 

and limbs and the absence of 

tumors, sore legs, and rupture 

and disease enlargement of 

bones or joints. Admission of 

physically unqualified men was 

recognized as leading to discharges 

for preexisting problems. 

Examination practices for newly 

recruited soldiers up to and 

including the Civil War were very 

lax.28(p148)

During Lawson’s tenure, sick 

troops were evacuated from Florida to East Coast posts such as Fort Monroe (Virginia) 

and Fort Hamilton (New York City Harbor), with the idea that in these locations the 

climate would be healthier. In fall 1840, an additional evacuation point was added, with 

Fort Columbus becoming the second New York City Harbor evacuation point.16(p64)

FIGURE 2-3. Thomas Lawson, Surgeon General (1836–1861). 

Lawson was the second physician appointed to the post of 

Surgeon General. Like some other physicians of the era, he 

had previously served as a volunteer Army line officer at the 

rank of lieutenant colonel. Lawson served later as the medical director of troops engaged in the Second Seminole War, 

where he faced many challenges in supporting the action in 

Florida, as well as the other scattered Army posts nationally, 

due to staffing and supply issues. Artwork courtesy of the 

National Library of Medicine, Image #B16886.
CHAPTER TWO • 51

WILLIAM BEAUMONT, PROMINENT ARMY PHYSICIAN

The international fame of William Beaumont (Figure 2-4) was in recognition of his 

pioneering work in gastric physiology due to a fortuitous encounter with a wounded 

18-year-old French Canadian. This fame brought great credit to Army medicine. While 

Beaumont’s career started out in a traditional manner, the move to a basic research topic 

was not typical. 

Beaumont’s Army career spanned the period from 1812 until his resignation in 1839. 

He served well in the War of 1812, but his star began to rise with his assignment in 1820 to 

Fort Mackinac at the northern point of Michigan. Fort Mackinac, with its island location 

overlooking the Great Lakes, was one of the healthiest posts from the standpoint of 

absence of disease.16(p42) When he arrived in 1820 at the fort, Beaumont had responsibilities 

for a garrison of 50 to 100 soldiers. Because his duties were not that rigorous, he had 

permission to also treat civilians, as long as the private patients did not take away from his 

official duties.16(p42)

Beaumont’s path became famously intertwined with that of Alexis St Martin, an 

18-year-old Canadian who experienced an accidental wounding on 6 June 1822 with a 

musket loaded with “duck shot.” He developed a wound on the left side, which healed 

as an opening 7 inches in circumference. The gastric contents could be viewed through 

the fistula. Beaumont initially had to keep a bandage over the wound to keep the gastric 

contents inside the fistula. However, a fold of the stomach eventually created a type of 

valve.22(p161) Beaumont used this eventful accident as an opportunity to study gastric 

digestion. He placed scraps of various foods into the stomach attached to a silk string 

through the fistula hole directly. He established that digestion was due to a chemical 

process rather than mechanical process.16(pp23–25) Beaumont encouraged St Martin to stay 

with him so that these studies could continue. At one point, he enrolled St Martin as an 

Army orderly to help defray St Martin’s personal expenses.16(p25) In 1834, St Martin left for 

Canada for a proposed short family visit, but he never returned. Beaumont was unable to 

entice his return after that point.16(p25)

Beaumont published a book in 1833 titled Experiments and Observations on the 

Gastric Flora and Physiology of Digestion,27 which recorded his unique observations. The 

book was translated into French and German, which helped facilitate the dissemination of 

his work.22(p162) He was displeased that he could not get chemists to provide analysis of the 

gastric contents to an acceptable level.22(p161)

Brown provided an interesting report on Beaumont’s 1825 participation in a courtsmartial. A lieutenant at Fort Niagara saw Surgeon Beaumont for a sore arm. Beaumont 

thought he was malingering and gave him a compound of calomel and a tartar emetic. 

Beaumont also reported him to his commanding officer, who pressed charges, and the 

lieutenant was dismissed from the service. The lieutenant appealed his dismissal and the 

details came to the President’s attention because he was the final authority in such actions. 

The President disapproved the verdict, and was critical of Beaumont’s testimony and 

conduct. Beaumont applied for a Court of Inquiry, which was refused. Beaumont wrote a 

pamphlet to be circulated in the Army in which he set out the facts of the case. Apparently 

the matter rested after the pamphlet’s publication.22(pp131–132)
5 2 • FORWARD SURGERY

FIGURE 2-4. William Beaumont, Army Surgeon (1812–1839). While Beaumont’s career started out in a 

traditional manner, the move to a basic research topic was unusual. Beaumont’s Army career spanned the 

period from 1812 until his resignation in 1839. Artwork courtesy of the National Library of Medicine, Image 

#B29606.
CHAPTER TWO • 5 3

Beaumont had issues with Surgeon General Lawson, who had succeeded Lovell. 

Lawson did not like the attention that the prior Surgeon General gave to Beaumont, who 

by this time was internationally famous. In particular, the two of them had a conflict 

over leave. Beaumont applied for leave in 1839, with the request that his replacement be 

supplied by the Army at its own cost. (At the time, the officer seeking leave had to make 

arrangements for a replacement and defer some of the costs.) Beaumont gave “personal 

reasons” as the rationale for the leave. Lawson denied the leave. Furthermore, Lawson 

planned to transfer Beaumont to Florida to serve on a medical examining board. Because 

the St Martin experiments were over, Beaumont didn’t have as strong a case to remain in 

Michigan. Beaumont offered his resignation in an attempt to pressure Lawson to rescind 

his actions. Beaumont was not expecting Lawson to accept the resignation because he felt 

he would not be replaceable, given his celebrity. The acceptance of his resignation by the 

Surgeon General effectively ended Beaumont’s Army career, which spanned the period of 

the War of 1812 until 1839.16(p80)

STATUS OF MEDICAL CARE PRIOR TO THE 

MEXICAN-AMERICAN WAR

Diseases and Treatment

A number of diseases, such as cholera and scurvy, continued to be a problem in the 

lead up to the Mexican-American War. Cholera was epidemic in 1832 and again in 1849. 

Scurvy continued to be a problem because authorities were slow to recognize the value of 

fruits and vegetables as prevention aids, despite Lind’s work in the prior century. Slowly, the 

destructive effects of mercury used to treat scurvy were acknowledged.16(pp12–13)

Lead poisoning was also a significant medical problem. For example, a lead-covered 

roof could contaminate the cistern water running off the roof. Lead was also often found in 

utensils associated with cooking and eating—pots, pans, and drinking cups. A form of lead 

was used to clean boots. Paint usually contained lead constituents as well.16(p15)

Alcohol abuse continued to be a problem for both officers and enlisted, in garrison 

and in the field. The Army supplied whiskey, brandy, and/or rum until 1838 as a ration to 

its troops. Additional alcohol was available for purchase. In 1838, the Army substituted a 

ration of coffee and sugar for the alcohol ration. Temperance societies certainly played a 

role in reducing alcohol use, at least officially.16(pp15,84)

Poor diet was a problem that Surgeon General Lovell tried to alleviate. He issued 

instructions calling for less meat and more diverse foods, including grains, vegetables, and 

fruits as available. He discussed beer and the use of molasses and water to make whiskey. 

He liked pickles for the diet because Lovell felt they worked to prevent too much bile 

production.16(p16)

Anesthesia and Surgery

In surgery, ether had been demonstrated in 1846 in Boston. However, ether was not 

popular among medical personnel due to its explosive nature. Ether was used only for a 
5 4 • FORWARD SURGERY

short time in the Mexican-American War (1846–1848) but was discontinued because of 

its flammability. Indeed, often no anesthesia, other than alcohol spirits, was used. Ether 

was first sanctioned for use by the Army in 1849. Chloroform, which had enjoyed more 

popularity in the South, was also approved for Army use in 1849. Sulfuric ether (a more 

stable form) and chloroform, or a combination of the two, was the anesthetic of choice 

before 1861. Army surgeons used anesthetics routinely during operations after 1852.16(pp17–19)

Surgery would typically be necessary for compound fractures, as well as in the cases 

of extensive damage to joints or blood vessels.16(p20) Typical instruments that were standard 

issue for the surgeon’s case would include the following: tourniquets, saws, bone cutters, 

silver catheters, artery forceps, tenaculum (a type of forceps), and a stomach pump (used as 

now for removing stomach contents in overdoses and for operations).

Transportation

Transportation of the wounded had been largely an ad hoc arrangement up to 

the Mexican-American War. Typically wagons, carts, or horses were used to move 

the wounded. In the Seminole and Black Hawk wars, there was no organized method 

of transport. The Mexican-American War featured a two-horse litter system or a 

nondedicated wheeled wagon. The two-horse litter system consisted of two poles with a 

blanket carried between two horses. The wagon was any available wheeled vehicle that 

could be utilized.16(p22) It was not until 1859 that an organized Army Board considered an 

approved wagon of conveyance. They evaluated both a two- and a four-wheeled vehicle. 

The idea of a dedicated ambulance was finally established in 1860. A four-wheeled 

ambulance was first tried out at Fort Leavenworth, Kansas, in 1861 prior to the Civil 

War onset because troopers there would be close to Indian hostilities. The two-wheeled 

ambulance was also evaluated at the fort for the same reason.16(pp132–133)

Medical Education

The state of medical education was not impressive in the years prior to the MexicanAmerican War and, for that matter, up to the Civil War. Many medical students who 

could afford to travel continued to go to the major medical training schools in Europe. 

English, Scottish, and German schools were most popular, with French and Italian schools 

following. In America, there was a proliferation of for-profit schools of varying quality. 

Preceptor training was still common, especially in the first half of the 19th century, and 

could be the whole or part of the training. As in the late 18th century and early 19th 

century, most apprenticeships in the trades lasted 7 years, as was the case for medicine. 

Often the for-profit medical schools required a 3-year apprenticeship in addition to 

attending several sessions of medical lectures.16(p22) Unfortunately, many people just put out 

signs without any real training. During this period, licensing by the states also declined. 

After the Army instituted competitive examinations in 1832, only 50% of candidates 

qualified.16(pp31–31) The examinations were required even for former Army surgeons who 

were trying to return to active duty. The examining boards consisted of three surgeons or 

assistant surgeons who conducted 3-day examinations and traveled to locations near the 

examinees.16(p32)
CHAPTER TWO • 5 5

THE MEXICAN-AMERICAN WAR (1846–1848)

Contemporary Views of the War

A number of current books provide a good understanding of the Mexican-American 

War, which was a complex conflict. A sense of the times can be gathered from these books. 

Greenberg’s book, A Wicked War: Polk, Clay, Lincoln and the 1846 Invasion of Mexico,29

tells the story of the Mexican War from the perspective of five men—John Hardin, 

Nicholas Trist, James K Polk, Henry Clay, and Abraham Lincoln. Hardin was an Illinois 

congressman who was the first to volunteer for the war from Illinois. Trist successfully 

negotiated peace in a manner against the desires of his party and the president. President 

Polk was so identified with the war that it has been called “Mr Polk’s War.” Clay was 

the most famous politician of his time but he did not become president. His role in the 

prosecution of the war was central to the war effort. Lincoln was noted for his opposition 

to the Mexican conflict during his term in Congress.29(pviii)

Merry’s book, Country of Vast Designs: James K Polk, the Mexican War and the 

Conquest of the American Continent,30 provides a view of the war from the perspective of 

President Polk’s actions. It is worthy of note that future presidents Lincoln and Grant did 

not favor the Mexican War, Lincoln serving in his only term in Congress and Grant serving 

as a first lieutenant in the war.30(p474)

Henderson’s book, A Glorious Defeat: Mexico and Its War With the United States,31

seeks to provide the Mexican perspective as to why it went to war with the United States 

in 1846. Mexico had only gained its independence from Spain in 1821. Mexico had many 

internal problems to deal with, given its recent independence. Finances were always a 

problem for a poor country and the political instability as to control of the country added 

to the problems. The relative instability helps explain some of the Mexican decisions in 

the conflict. The book explores the complex societal and hierarchical structure defining the 

Mexican state at the time.31(pp6–8) Henderson points out that Mexico made halting attempts 

to overcome obstacles such as the many different races, regions, cultures, and classes that 

made up the nation. He identified these obstacles as preventing a common identity and 

cause.31(ppxviii-xix) 

Background

As noted, Mexico had gained independence from Spain in 1821. BG Antonio Lopez 

de Santa Anna proclaimed a republican regime in 1822.32(p14) The presence of American 

settlers (called Texians) in Texas caused instability for the Mexicans because the Americans 

did not follow Mexican rules and, furthermore, were independent in nature. The fall of 

the Alamo (6 March 1836) and the Battle of San Jacinto (a signal victory for Texas on 21 

April 1836) were all part of the history of Texas.32(p12) In the ensuing years, new migrants to 

Texas established their own independent Lone Star Republic in 1836. The Mexicans were 

displeased with the outcome but did not move against the new republic due to their own 

internal issues.

The Texans were largely in favor of annexation by the United States, which happened 

in February 1845. War with Mexico seemed very certain with the annexation.16(p95) War on 
5 6 • FORWARD SURGERY

Mexico was declared 15 months later by the United States on 13 May 1846.22(p177) Mexican 

forces had crossed the Rio Grande River while attacking an American patrol. Zachary 

Taylor had stationed an army of 3,500 in preparation at Corpus Christi in late 1845.33(p150)

The many factors leading to war made it controversial even then. President Polk personified 

the energy of the country that created a political need for expansion. Henry Clay and 

Martin Van Buren (among others) opposed this idea, but the populace of America chose to 

go along with Polk.30(p476) In essence, the war caused conflict between those favoring growth 

and those satisfied with the status quo.

President Polk, a Democrat, was a driving force in the war. His two main generals 

were Winfield Scott and Zachary Taylor, who were both Whig Party members with 

political aspirations. President Polk liked the idea of volunteer soldiers, while General Scott 

favored Regular Army troops.33(p78) General Taylor’s Army was not typical; it was a regular 

organization with disciplined troops, as opposed to the more typical militia troops of past 

military ventures. Over one-half of Taylor’s Army was made up of recent immigrants, 

largely from Germany, Poland, and Ireland.22(p60)

Goals and Strategies 

Polk held that the Rio Grande was the border with Mexico, while the Mexicans 

held that the Nueces River was the southern Texan border.33(p149) Polk hoped to secure 

his idea of a border with Mexico and to encourage Mexico to sell the territories of New 

Mexico and California. As the war progressed, the purchase approach was not pursued 

due to Mexican opposition.34(p57) Polk’s military strategy was to have the Navy enforce 

a blockade of Mexico’s ports (in the Gulf of Mexico) and Taylor’s Army to proceed 

from Corpus Christi in a southwestern direction into Mexico to occupy it. A second 

force, composed of Missouri volunteers and commanded by Colonel (COL) Alexander 

Doniphan, was to take New Mexico and California.22(p78) Taylor’s forces would occupy 

northeastern Mexico.22(p88) General Stephen Kearny conquered New Mexico before 

proceeding to California.34(p111),35(p196) COL Doniphan’s Missouri volunteers then captured 

Chihuahua.34(p142) General Scott was to take half of Taylor’s forces and proceed against 

Mexico City. Polk decided that Scott, if victorious, would be less of a political threat 

than Taylor. Taylor was mentioned in political circles as the favored Whig candidate for 

president in 1848.33(p160) Hence, using this political calculus, Winfield Scott was selected for 

the attack on Mexico City.34(p141)

Taylor’s Forces

BG Zachary Taylor was ordered to move his troops from Louisiana to Texas in 

summer 1845. In August 1845, he had set up near Corpus Christi, Texas. General Taylor’s 

forces, including his medical assets, landed at Corpus Christi where President Polk wanted 

his force in the area where he could react to Mexican provocations. Regimental hospitals 

were quickly set up in tents, while general hospitals were incorporated into existing 

buildings. Taylor’s troops soon became ill, with 90 officers and 118 enlisted out of every 

1,000 soldiers sick with various diseases.16(pp98–99)

Taylor was then ordered to move south to Point Isabel (where he set up Fort Texas). 

Taylor’s surgeons received casualties from the Mexican bombardment of Fort Texas (and 
CHAPTER TWO • 5 7

subsequent battles of Palo Alto and Resaca de la Palma). Point Isabel and Fort Texas 

were located directly opposite from Matamoros, Mexico.16(p99) Taylor ‘s forces consisted 

of 3,000 troops, who had marched the several hundred miles from Corpus Christi to Fort 

Texas.34(p58) The first wounded were received from hostilities in May 1846, with 50 killed 

and 130 wounded. The Mexican wounded were turned over to Mexican surgeons by 

Taylor’s forces.16(p99)

Taylor established general hospitals as his troops moved further into Mexico. Hospitals 

were set up at Mier, Camargo, Cerralvo, and at Matamoros (this one for smallpox isolation 

patients). These hospitals were set up in tents or existing buildings, when available. Some of 

these hospitals stayed open until the time when Americans started to leave Mexico in late 

spring 1848.16(pp101–102)

Matamoros was evacuated by the Mexicans; the Americans then occupied the city, 

but malaria increased due to heavy rains. In June 1846, as Taylor moved his Army further 

into Mexico, malaria and scurvy were problems.16(pp100–101) Taylor made it to Monterrey in 

September 1846. Surgeon General Lawson did not increase the ranks of the 20 surgeons 

with Taylor’s Army, resulting in the surgeons working tirelessly. Monterrey capitulated after 

a 5-day battle. The Americans lost 120 killed and 368 wounded; the Mexican losses were 

not known.16(p102) The wounded were transported by litter or wagon to one of three Army 

hospitals set up in existing buildings in the city of Monterrey.16(p102) Wound infections were 

common. Malaria afflicted the wounded as well as complicating any recovery. At Saltillo, 

which the American forces took next, shortage of medicines required their local purchase. 

Malaria and a measles epidemic plagued the troops.16(p104) The Battle of Buena Vista was 

the end of Taylor’s active campaign.16(p105)

Doniphan and His Missouri Volunteers

Although much attention has been directed to the Regular forces, the success of COL 

Doniphan and his Missouri Volunteers reflects the contribution of the citizen-soldier and 

of the natural citizen leader. Doniphan was a small town Missouri lawyer who enlisted as 

a private in 1846, but in a month was elected the colonel of the 1st Regiment of Missouri 

Mounted Volunteers (consisting of 800 soldiers). The volunteers were formed to protect 

Texas, a newly admitted state of the United States.35(p1) President Polk had selected COL 

Kearny, a regular officer, to lead a force consisting of 300 Regulars, 400 other volunteers, 

and Doniphan’s regiment to invade the area that is now New Mexico (but was then part 

of Mexico). Doniphan’s regiment played a key role in the capitulation of New Mexico. 

Doniphan led his regiment in the Battles of Buena Vista (a General Taylor victory) and 

Chihuahua.35(pp193–194) Doniphan placed emphasis on the contribution that the Regular 

Army troops made to the volunteers. After the war, Doniphan gave credit for his military 

success to the 3-month time his troops served with Kearny (who was later promoted to 

general).35(p202)

Kearny’s forces in the “Army of the West” continued to California with a difficult 

journey from Fort Leavenworth, Kansas, to Santa Fe, New Mexico. Doniphan’s volunteer 

forces were split off to remain in Santa Fe. None of Doniphan’s physicians were from the 

Army Medical Department. His volunteer physicians included a civilian contractor that 

Doniphan hired. Doniphan’s troops had a high sick rate, approaching one-third of the 
5 8 • FORWARD SURGERY

force at times, while showing a high death rate from disease (not specified). Measles, fevers, 

and diarrhea were all mentioned as involving the command. In their Chihuahua fight, 

Doniphan lost one killed and five wounded. His surgeons also cared for wounded and ill 

Mexicans.16(p106)

Scott’s Move Toward Mexico City

Johnson, in his book Winfield Scott: The Quest for Military Glory,

33 felt that General 

Scott was very well qualified to lead the American Army to Mexico City. He developed 

what Johnson terms “an astute strategy” and had become in this time of his life “the 

consummate field commander.”33(p208) Scott was a student of history who had studied the 

French experience in the Iberian Peninsula during the Napoleonic Wars. The French, due 

to their poor treatment of the Spanish peasants and soldiers, had a guerilla action on their 

hands.33(pp166–167) Scott had firsthand experience with guerilla action in the Florida Seminole 

Wars during his inability to cancel out an 1836 Indian guerilla action.33(p169) Scott was able 

to use politics and diplomacy in support of his military action.33(p170) 

Scott’s 9 March 1847 assault upon Veracruz was the largest American amphibious 

operation until World War II. Scott landed 8,600 men in 5 hours without any losses.33(p174)

The Veracruz operations were completed by 29 March 1847. Casualties included 13 

Americans killed and 55 wounded. The Mexican casualties were unknown but estimated 

to be about 200 killed.33(p178) After Scott took Veracruz, he imposed martial law. He paroled 

enemy prisoners, distributed food to the city, and provided clean-up funds for the streets. 

Scott’s measures led the people of Veracruz to accept the occupation by his troops.33(p179) 

Veracruz was Scott’s valued supply base (especially for medical supplies) as the troops 

moved into Mexico.33(p180) Veracruz became an important general hospital site due to its 

location. The fear of yellow fever was, however, a reality at Veracruz; at least two surgeons 

died of yellow fever.16(p117) Yellow fever treatments at Veracruz included quinine (for fever), 

mustard plasters (to even the temperature and circulation), mercurials (to promote bowel 

movements), and cupping to draw off blood.16(p117)

Surgeon General Lawson traveled with General Scott’s army, joining him at Veracruz 

in December 1846 and remaining until early spring 1848. He did not exercise direct control 

of Scott’s medical staff, but rather acted as the senior surgeon on the field. The duties of the 

Surgeon General in Washington, DC, were assumed by the very competent Surgeon Henry 

Heiskell.16(p111) One consequence of Lawson being in Mexico dealt with supplies, in that 

the New York supply officer did not receive reports from Lawson in the field and incorrect 

quantities were shipped.16(p114)

Scott sent BG David E Twiggs with his division to capture Jalapa (60 miles away) 

while MG William Worth was ordered to stay in Veracruz.33(p181) As the troops moved 

inland from Veracruz in March 1847, they were plagued with intestinal disturbances 

(diarrhea) from “bad water.”16(p118) Along the march route, the Battle of Cerro Gordo 

was an American victory. The subsequent battle for Cerro Gordo Pass resulted in 64 

Americans killed and 353 wounded. (Mexican figures are not available).16(p118) Jalapa fell to 

the Americans and, again, Scott’s civil pacification strategy kept the citizens quiet.33(p188) At 

Jalapa, Scott had to send home several regiments whose terms of enlistment were soon to 

expire.33(p189) The hospital at Jalapa was located in a church. The facility had few amenities 
CHAPTER TWO • 5 9

and sustained a 20% mortality of the 1,000 estimated patients to pass through it.16(p119) A 

hospital was set up San Augustin and later at Mixcoac within 10 miles of Mexico City. On 

8 September 1847, the Americans battled the Mexicans at Molino del Ray. One surgeon 

was killed leading troops after their officers were killed.16(p120) The surrender of Mexico City 

ended the active prosecution of the war. (As an interesting side note, Robert E Lee had been 

assigned to the US Engineers starting in 1831. He was assigned to the staff of General Scott. 

Lee’s engineering background helped in locating an unused trail at Chapultepec, Mexico 

that allowed the American troops to come behind the defending Mexican forces.36(p41)) 

Disease continued to be a health problem in Mexico City. Diarrhea was the major 

problem for troops there.16(pp121–122) Evacuation of the ill and wounded took 18 days in 

a wagon to reach Veracruz. The evacuated were then taken to New Orleans and Baton 

Rouge. Overcrowding led the Army to send patients as far north as Jefferson Barracks 

near St Louis, Missouri.16(p123) Fort Monroe, Virginia, was the stopping point for other 

evacuees.16(p124)

Medical Care During the Mexican-American War

As the war progressed, some changes were made to the medical side of the Army. 

In 1846, the volunteer surgeons were accorded the same professional status as Regulars. 

In February 1847, ranks were accorded to medical officers, although they were not to 

command outside of medical channels. The Surgeon General was to be a colonel, surgeons 

were to be majors, and assistant surgeons were to be captains.16(pp97–98) The Medical 

Department leaders serving on site in Mexico included a medical director and the director 

of a general hospital. There was also an office of purveyor. The purveyor was a surgeon 

who served as a purchasing officer as well.16(p97)

As noted above, an act of Congress had instructed that medical officers would have 

official rank. Congress ruled that medical officers would have equal remuneration to that 

of other officers for allowances and housing. However, the US Army Adjutant General 

mandated that the old rules would remain in effect because in his view the new law was 

deemed to be inconclusive. In effect, medical officers would still be expected to obey orders 

from the most junior officer. Indeed, medical officers could be brought before courtsmartial for refusing orders, as was the case with Major (Surgeon) Clement Finley, who 

would later become Surgeon General. Finley refused an order from Brevet Lieutenant 

Colonel (LTC) Braxton Bragg (of later Confederate Civil War fame). LTC Bragg had a 

Regular rank of Captain, which Finley held to be Bragg’s true rank, and Finley, as a major, 

therefore refused his order. Finley was convicted by courts-martial. President Millard 

Fillmore upheld the conviction, but remitted Finley’s dismissal from the Army.16(p129) (A 

senior medical officer could lead a Court of Inquiry if he were the most senior in rank, but 

even such a role was not applied consistently.) Thus, the exact status of the medical officer 

remained to be clarified in the future.16(p129) 

The volunteer surgeons and the contract surgeons did not have to pass examinations, 

as did the Regular Army surgeons. The volunteer surgeons, in particular, were not familiar 

with military discipline and the need to adhere to accepted medical standards of sanitation 

planning in the military environment. The surgeon was required to advise the line command as to the placement of latrines and water supplies and to pick a “healthy” site for 
6 0 • FORWARD SURGERY

the camp (if possible, not in an area known for yellow fever or malaria). In the MexicanAmerican War, Surgeon General Lawson did not make the most in all situations of the 

surgeons and staff that he had on hand, because he did not plan to staff both regimental 

and general hospitals at the same time.16(p97) At the start of the conflict, Congress allowed 

only three surgeons per regiment. In 1846, Congress authorized the call-up of two surgeons 

per volunteer regiment. In February 1847, Congress increased the size of the medical staffs. 

One surgeon and two assistant surgeons could be appointed for new regular regiments. 

However, the difficult examination for Regular surgeons still remained. Hence, the hiring of 

civilian surgeons was necessary to staff Army posts and to provide care in Mexico.16(p96)

As part of the logistical planning for the Mexican-American War, Surgeon General 

Lawson favored procuring supplies from New York City, where he wished to set up a 

medical supply depot. He believed that better prices could be obtained in a larger city. 

Supplies were to then be stockpiled in New Orleans because this would be a large port 

closer to the points of conflict. Not surprisingly, there were losses of materials and supplies 

due to pilfering along the supply chain, as well as shipwrecks at sea.16(p98) 

Although disease seemed to be the major focus of medical care, there were wounds 

to deal with in the war. The Mexicans used old musket smoothbore pieces, which fired 

round projectiles. They could be superficial and could be more easily removed than the 

Minié ball, which would be used extensively in the Civil War. Artillery fire from cannons 

was more lethal but, due to the relative lack of Mexican field pieces, was used infrequently. 

Wounds could be more serious, especially if shot or metallic pieces were fired into massed 

troops.16(p118)

During the time of the Mexican-American War, the deaths from disease were 10 

times greater in the Army than at home in the civilian communities.16(p124) Out of 100,000 

soldiers who served in Mexico, Gillet reports 1,500 killed and 10,000 dying of disease. 

(Nevertheless, the ratio of battle deaths to disease deaths for the Mexican-American War 

was improved from the approximate figures for the Revolutionary War.16(pp124–125),35,37) Total 

battle deaths for the Mexican-American War (as listed on the Congressional Research 

Service site) are reported as 1,733, with total deaths largely due to disease of 11,550. 

Woundings not leading to death were listed as 4,152.37

The Treaty of Guadalupe Hidalgo ended the war after it was signed on 2 February 

1848. The treaty was ratified by the US Congress on 30 May 1848 and by the Mexican 

Congress on 15 July 1848. The treaty provided for the use of the Rio Grande River as 

the boundary between Texas and Mexico. The United States paid $15 million to Mexico 

and would settle the claims of United States citizens against Mexico. Mexicans could 

be United States citizens if they lived within the new boundaries. In bringing about this 

settlement, Nicholas Trist represented the United States in negotiations with a special 

commission.31(ppxv,172–178) The treaty also specified that the Indians residing in the newly 

acquired territories would be restrained by the United States from entering Mexico.34(p221)

The successful prosecution of the war launched several political careers. General 

Taylor, a hero of the Mexican-American War, and a slaveholder, became the Whig 

candidate opposing President Polk, a Democrat. General Scott had previously been a 

candidate for the Whig nomination. Scott in a later election became the Whig candidate 
CHAPTER TWO • 61

for president but he lost to Franklin Pierce. Taylor won easily due to his wartime 

prestige.34(p222) President Taylor died on 4 July 1850 of a gastrointestinal ailment. (The 

symptoms suggest to the modern physician reader a recurrence of amebic dysentery or 

cholera.) His death illustrated how diseases of the time could afflict even the most powerful 

person.16(p143),34(p222)

The Mexican-American War outcome promoted the need for a professional military. 

The graduates of West Point brought their engineering and military strategy education 

to the conflict. Their professionalism and the need for a standing army to deal with the 

country’s expanded territory retired the notion of an all-volunteer force.34(p222)

MEDICAL DEPARTMENT INVOLVEMENT 

OUTSIDE MEDICINE

In the same tradition of Generals Ainsworth and Wood, who would later move to 

areas outside medicine in the Army, Assistant Surgeon Albert Meyer became very interested 

in new signal techniques. He would later become the head of the newly created Signal 

Corps in 1863.16(p148) In 1852, Surgeon General Lawson asked for the Army surgeons to 

collect meteorological data for scientific completeness and to report statistics for sickness 

and wounds. (It was later in the 1870s that Dr John Shaw Billings pushed for the collection 

of mortality statistics. He, too, asked for meteorological statistics. He also collected 

examples of unique medical anatomical specimens.22(p210))

THE APPROACH OF THE CIVIL WAR

Army surgeons had generally dealt with the health issues of small and often isolated 

posts. The scale of casualties to be had in the coming Civil War would not be even 

imagined by veteran surgeons of the War of 1812 (1812–1814) or the Mexican-American 

War (1846–1848).

 Surgeon General Lawson died on 15 May 1861. Clement Finley would become the 

next Surgeon General. It was said that only his 40 years of service would be a qualification 

for office because he was not felt to be otherwise qualified by his subordinates.16(pp153–154)

In peacetime prior to the Civil War, the Army Medical Department had to contend 

with limited budgets, isolated posts, and bureaucratic rules. Army medicine and its practice 

were largely as it was prior to the Mexican-American War. Medical practice remained 

more art than science. There were no central plans in the Army for medical supply and 

evacuation so needed in the coming large conflict.16(p149)
6 2 • FORWARD SURGERY

REFERENCES

1. Hickey DR. The War of 1812: A Forgotten Conflict. Urbana, Ill: University of Illinois Press; 

2012.

2. Taylor A. The Civil War of 1812: American Citizens, British Subjects, Irish Rebels, & Indian 

Allies. New York, NY: Alfred A Knopf; 2010.

3. Sheads SS. The Chesapeake Campaigns 1813–15; Middle Ground of the War of 1812. London, 

England: Osprey Publishing Company; 2014.

4. Vogel S. Through the Perilous Fight: From the Burning of Washington to the Star Spangled 

Banner: The Six Weeks That Saved the Nation. New York, NY: Random House; 2013.

5. Latimer J. 1812: War With America. Cambridge, Mass: The Belknap Press of Harvard 

University Press; 2007.

6. Berton P. The Invasion of Canada: 1812–1813. Toronto, Canada: Anchor Canada (Division of 

Random House of Canada Ltd); 1980.

7. Gillet MC. The Army Medical Department: 1775–1818. Washington, DC: US Government 

Printing Office; 1981.

8. Beaumont W, Miller G, eds. William Beaumont’s Formative Years: Two Early Notebooks 1811–

1821. Whitefish, Mont: Kessinger Publishing Company; 2007.

9. Roberts J. The British Raid on Essex: The Forgotten Battle of the War of 1812. Middleton, 

Conn: Wesleyan University Press; 2014.

10. Howard H. Mr and Mrs Madison’s War. America’s First Couple and the Second War of 

Independence. New York, NY: Bloomsbury Press; 2012.

11. Pitch AS. The Burning of Washington: The British Invasion of 1814. Annapolis, Md: The Naval 

Institute Press; 1998.

12. Remini RV. The Battle of New Orleans: Andrew Jackson and America’s First Military Victory. 

New York, NY: Penguin Books; 2001. 

13. Phalen J. Landmarks in surgery: Surgeon James Mann, US Army: observations on battlefield

amputations. Surgery. 1938;(66):1071–1073.

14. Howard M. Wellington’s Doctors: The British Army Medical Services in the Napoleonic Wars. 

New York, NY: History Press; 2008.

15. Bonura MA. Under the Shadow of Napoleon: French Influence on the American Way of 

Warfare From the War of 1812 to the Outbreak of WWII. New York, NY: NYU Press; 2012.

16. Gillet MC. The Army Medical Department 1818–1865. Washington, DC: Center for Military 

History United States Army; 1987.

17. Medline Plus. Mercury. http://www.nlm.nih.gov/medlineplus/ency/article/002476.htm. Accessed 

19 March 2015.

18. Higby GJ. Chemistry and the 19th century American pharmacist. Bull Hist Chem. 2003;(28):10.

19. Bynum WF. Science and the Practice of Medicine in the 19th Century. Cambridge, England: 

Cambridge University Press; 1994.

20. Royal Society of Chemistry. Quinine. http://www.rsc.org/chemistryworld/podcast/

CIIEcompounds/transcripts/Quinine.asp?playpodcastlinkuri=%2Fchemistryworld%2Fpodcast

%2FCIIEcompound%2Easp%3Fcompound%3DQuinine. Accessed 19 March 2015.

21. Whooley O. Knowledge in the Time of Cholera: The Struggle Over American Medicine in the 

Nineteenth Century. Chicago, Ill: University of Chicago Press; 2013.

22. Brown HE. The Medical Department of the United States Army From 1775 to 1873.

Washington, DC: Surgeon General’s Office; 1873.

23. Wintermute BA. Public Health and the US Military: A History of the Army Medical 

Department, 1818–1917. New York, NY: Routledge (Taylor and Francis Group); 2011.
CHAPTER TWO • 6 3

24. Exploring Florida. The Seminole Wars. http://fcit.usf.edu/florida/lessons/sem_war/sem_war1.

htm. Accessed 19 March 2015.

25. Hatch T. Osceola and the Great Seminole War: A Struggle for Justice and Freedom. New York, 

NY; St Martin’s Press; 2012.

26. US Army Medical Department. Office of Medical History. Surgeons General. Thomas Lawson. 

http://history.amedd.army.mil/surgeongenerals/T_Lawson.html. Accessed 19 March 2015.

27. Beaumont W. Experiments and Observations on the Gastric Juice and the Physiology of 

Digestion. Plattsburgh, NY: Maclachlan and Stewart; 1833.

28. Mahmoud RA, Clark KL, May L. Military Preventive Medicine: Mobilization and Deployment. 

Vol 1. Chapter 7. Evolution of military recruit accession standards. https://ke.army.mil/

bordeninstitute/published_volumes/mpmVol1/PM1ch7.pdf. Accessed 19 March 2015.

29. Greenberg AS. A Wicked War: Polk, Clay, Lincoln, and the 1846 US Invasion of Mexico. New 

York, NY: Alfred A Knopf; 2012.

30. Merry RW. A Country of Vast Designs: James K. Polk, the Mexican War and the Conquest of 

the American Continent. New York, NY: Simon and Schuster; 2009.

31. Henderson JJ. A Glorious Defeat: Mexico and Its War With the United States. New York, NY: 

Hill and Wang (Division of Farrar, Strauss, and Giroux); 2007.

32. Nofi AA. The Alamo and the Texas War for Independence; Heroes, Myths and History. San 

Antonio, Tex: De Capo Press; 1992.

33. Johnson TD. Winfield Scott: The Quest for Military Glory. Lawrence, Kans: University Press of 

Kansas; 1998.

34. Christensen C, Christensen T. The US-Mexican War. San Francisco, Calif: Bay Books; 1998.

35. Dawson JC. Doniphan’s Epic March: The 1st Missouri Volunteers in the Mexican War. 

Lawrence, Kans: University Press of Kansas; 1999. 

36. Lee F. General Lee: A Biography of Robert E Lee. Wilmington, NC: Broadfoot Publishing, Inc; 

1989. (Original publication 1894 by D Appleton and Company, New York, NY.)

37. Congressional Research Service. American War and Military Operations Casualties: Lists and 

Statistics. http://fas.org/sgp/crs/natsec/RL32492.pdf. Accessed 19 March 2015.
‘‘The Civil War was an epic conflict 

involving forces engaged in large-scale 

battles. The military’s medical resources 

were stretched almost to the breaking 

in the early phases of the fighting. The 

Confederacy was limited in its medical 

response by lack of resources due to the 

blockade of many of its ports. Because the 

statistics and records of the Confederate 

Medical Department are limited, most 

of the discussion in this chapter will be 

focused on the Union Army. It was a time 

of ‘forward surgery’ in its simplest form.”
INTRODUCTION

THE CIVIL WAR WAS AN EPIC CONFLICT involving forces engaged in large-scale 

battles. The military’s medical resources were stretched almost to the breaking in the early 

phases of the fighting. The skills of men such as William Hammond, Jonathan Letterman, 

and John Shaw Billings helped the Union meet the challenge. The Confederacy was limited 

in its medical response by lack of resources due to the blockade of many of its ports. Because the statistics and records of the Confederate Medical Department are limited, most of 

the discussion in this chapter will be focused on the Union Army. Prior to the Civil War, the 

“action” in Army medicine was centered in the military outposts in the West. It was a time 

of “forward surgery” in its simplest form. In the West, the Army surgeon treated broken 

bones, the occasional arrow wound, and the many illnesses of the time. The postwar transition to peace signaled a return to many features of prewar medicine. The late-1860s to the 

mid-1890s were characterized by small-unit Indian conflicts with just the bare essentials of 

“forward surgery.” The Spanish-American War in 1898 showed the inadequacies of preparation for large-scale conflicts. However, the brevity of the conflict meant that the inadequacies of supplies and personnel did not affect the outcome. After the Spanish-American War, 

new national responsibilities in Cuba, Puerto Rico, Panama, and the Philippines highlighted 

the importance of public health advances (control of yellow fever, malaria, immunization 

programs, and sanitary reforms) for Army medicine. 

THE COMING OF WAR 

In the decade before the onset of the Civil War, there were fundamental changes that 

had impact on the coming conflict. In the 1850s, most people in the North and the South 

were living in rural areas. A large influx of immigrants in that decade brought many Irish 

Chapter Three

The Civil War: 

Military Medical Care in the 

War Between the States 

LANCE P. STEAHLY, MD
6 6 • FORWARD SURGERY

and Germans to the United States. (Many of these same immigrants would enlist in the 

Union Army in the conflict ahead.) Most of these new immigrants settled in urban areas. 

The North, especially, developed a large manufacturing infrastructure; the South had some 

manufacturing gains, but it remained largely focused on agriculture. Cotton was the main 

economic engine in the South.

The slavery question was heavily tied to the agrarian economy of the South. Over the 

years, the US Congress had taken up the issue of slavery. The Northwest Ordnance of 1787 

originally stipulated that states north of the Ohio River were to be free, while those states 

to the south were to be slave. The states were balanced until 1819, when Missouri sought 

admission as a slave state. Maine came in as a free state to balance the number again, 

which was codified in the Missouri Compromise of 1820. Further accommodation had to 

be made in the Compromise of 1850. In the Congress, Henry Clay of Kentucky was the 

central manager of the agreement, with aid from Daniel Webster of Massachusetts. The 

Compromise admitted California as a free state and prohibited slavery in the District of 

Columbia. However, it allowed new states that were to be admitted henceforth to decide 

the slavery issue for themselves.1(p6) At issue here, as a common thread, was the concern 

about “state’s rights.”1(pp5–6)

The election of Lincoln in 1860 added weight to the South’s perception that the federal 

government would seek to abolish slavery. The secession of the Southern states, starting 

with South Carolina, was a point of no return. The 12 April 1861 4:30 am firing upon Fort 

Sumter, South Carolina, was the opening volley in a civil war that would last several years 

and affect almost every family in both the North and the South. Major Robert Anderson, 

the commander of Fort Sumter, surrendered on 13 April 1861 because the fort lacked 

adequate supplies and manpower to withstand the ongoing attack.2(p166),3(p5)

Lieutenant General (LTG) Winfield Scott, the aging Army Chief of Staff who played 

such a prominent role in the War of 1812, the Indian Wars, and the Mexican-American 

War of 1848, devised the Anaconda Plan of 1861 to deal with the insurrection. The plan 

envisioned blockade of the entire 3,000 mile southern coastal line (both Atlantic and 

Gulf ports) and the capture of the Mississippi River, which bisected the Confederacy. The 

plan required an expedition of 84,000 troops, supported by gunboats, to go down the 

Mississippi and capture New Orleans, Louisiana.2(pp168–169) LTG Scott was replaced as the 

Army Commander because of his health, obesity, and advanced age (74 years old) by 

Major General (MG) George McClellan on the orders of President Lincoln (Figure 3-1). 

Nonetheless, the Anaconda Plan devised by General Scott was basically the strategy for the 

military and economic offense that was followed going forward.1(p41),3(p5)

OVERVIEW OF THE 

MAIN BATTLES OF THE CIVIL WAR

To set the stage for this discussion of the Civil War, a brief review of the timelines 

involved and the subsequent important battles follows:

• An Ordinance of Secession was passed by South Carolina on 20 December 1860,
CHAPTER THREE • 6 7

FIGURE 3-1. President Abraham Lincoln, in his familiar top hat, with his commander, Major General George 

B McClellan and other officers, Antietam, Maryland, October 1862. Photograph courtesy of the Library of 

Congress, Image #04352.

making it the first state to secede. Over a 6-month period, it was followed by 11 other 

states, with Tennessee joining the last of the states on 8 June 1861.1(p31)

• The Confederate attack on Fort Sumter (Charleston Harbor, South Carolina) was 

carried out on 12–13 April 1861. On 15 April 1861, President Lincoln proclaimed a 

state of insurrection. He issued a call for 75,000 Union volunteers.1(pp85–87)

• The First Battle of Bull Run was fought; both the North and the South were hoping

for a quick victory and to rapidly occupy their respective opposing capitals. The 

battle began on 21 July 1861. The Confederates gained victory while the Union had a 

disaster as their forces retreated in a chaotic manner. The Union fielded some 35,000 

troops in the Army of the Potomac, of which 2,896 were killed. The Confederates had 

1,982 killed, out of a force of 21,000 Confederate troops.1(pp87–90)

• The Battle of Shiloh, fought at Pittsburg Landing on the Tennessee River in Tennessee 

during the period of 6–7 April 1861, was considered a Union victory, although much 

criticism was leveled at Grant for his losses. The Union lost approximately 13,000 

wounded and killed (of the 30,000 troops in the Army of the Potomac) compared with 

the Confederacy’s 10,694 casualties (out of 21,000 troops).1(pp91–93)

• The Battle of Antietam was preceded by the Confederate victory at the Second Battle

of Bull Run. The Antietam Battle on 17 September 1862 was a signal Union victory 
6 8 • FORWARD SURGERY

and the premiere McClellan triumph.1(pp95–96) Only 40,000 Confederates faced more 

than 75,000 Union troops. Antietam had the distinction of being the battle with the 

most casualties in a single day, amounting to approximately 12,400 for the Union and 

10,300 for the Confederates.1(p94) (Gettysburg had more casualties overall but it was 

a 3-day engagement.) The Army of the Potomac (Union) tried to keep Lee’s Army of 

Northern Virginia from entering Maryland at Frederick, Maryland.

• Chancellorsville was one of General Lee’s greatest victories. Union MG Joseph Hooker 

had replaced MG Ambrose Burnside as the Commander of the Army of the Potomac. 

General Lee and his forces were able to severely defeat Hooker’s Union forces. The 

battle lasted from 1–3 May 1862. The Union sustained 17,000 casualties, while the 

South had 13,000 casualties. The South had some 60,000 troops involved under 

the command of General Robert E Lee. The Union had 134,000 troops under the 

command of MG Hooker.1(pp97–98)

• The Battle of Gettysburg lasted from 1–3 July 1863. It was the Confederate’s last 

major incursion (Frederick, Maryland, at Antietam was the first) into the North. It was 

a costly encounter for both sides but the Confederates withdrew, without pursuit, to 

safety. In a 3-day battle, the losses were so great that 50,000 combined casualties were 

noted. MG Hooker’s Army of the Potomac fielded over 90,000 men to oppose Lee’s 

75,000 men.1(pp99–100)

• The Battle of Chickamauga was from 19–20 September 1863. The battle, named for a

Georgia creek, provided a victory for the Confederacy.1(pp102–103) The Union Army of the 

Cumberland, commanded by MG William Rosecrans, had taken areas in Tennessee 

including Chattanooga, an important transportation and supply hub. The Confederate 

Army of Tennessee was commanded by the Confederate General Braxton Bragg. 

Union MG George Thomas’ performance was credited with keeping the Union losses 

controlled. Fortunately for the North, Bragg did not provide decisive leadership that 

could have resulted in a crippling blow to the Union.1(pp101–103)

• Chattanooga, Tennessee, was a victory for the North in October and November 1863. 

Chattanooga was the South’s important regional supply and communication center. 

The loss of such a center was impossible to mitigate.1(pp105–106) The Union forces had 

seized Chattanooga in November 1863 and had fended off attempts to retake the 

center. MG Braxton Bragg and his Confederate forces besieged the city. MG (later 

LTG) Ulysses S Grant came to the rescue, using MG William T Sherman’s and MG 

Hooker’s troops.1(pp104–106)

• The Battle of the Wilderness transpired from 5–7 May 1864, but was indecisive for 

either side. It was followed by the 8–21 May 1864 Battle of Spotsylvania, which had 

Lee and Grant in play. The losses were great: 17,500 Union casualties and 10,000 

Confederate casualties. The Union fielded approximately 119,000 troops, poised 

against the undermanned Confederates (64,000 strong) of Lee’s Army of Northern 

Virginia.1(pp110–112)

• Atlanta, an important Southern manufacturing and communication center, fell 

to Sherman’s troops after a 4-month long campaign from 1 May to 2 September 

1864.1(pp112–113)
CHAPTER THREE • 6 9

• The Battle of Nashville, 15–16 December 1864, brought about the defeat of

Confederate General John Bell Hood and the Army of Tennessee. It would be the last 

major battle in the West.

• The Battle of Petersburg, Virginia, ran from 15 June 1864 until 3 April 1865. The 

10-month siege of Petersburg ended in a Confederate defeat, despite their victory 

earlier at the Battle of Cold Harbor, Virginia, on 3 June 1864. 

• General Lee surrendered his Army to General Grant at Appomattox Court House on

9 April 1865, which is usually perceived as the war’s end. However, other Confederate 

commands continued the war for another 10 weeks.1(p217) LTG Kirby Smith fought 

on 12–13 May 1865 in Texas. LTG Simon Buckner surrendered in New Orleans, 

Louisiana, on 25 May 1865. The last to surrender was the Cherokee force headed 

by Confederate Brigadier General (BG) Stand Watie, which quit fighting on 23 June 

1865.1(p218)

BATTLEFIELD SURGERY: 

THE RUN-UP TO THE CIVIL WAR

French Influence on Western Medicine

During the Napoleonic Wars, the French Surgeon Dominique Jean Larrey described 

“temporary hospital establishments, organized near the divisions of an army.”4(p1) Larrey 

started out as a young surgeon from Beaudeau in the Pyrenees Mountains,4(p13) and later 

became the medical chief of the French Army of the Rhine. Larrey was appointed to his 

position in the Army of the Rhine only 13 months after the start of the Reign of Terror 

during the French Revolution.4(p14) He developed two- and four-wheeled light wagons, 

which he organized as a “flying ambulance,” that carried surgeons and their assistants to 

the front and then brought the wounded to the surgeons.4(p14) The surgeons could then do 

amputations, remove bullets, and dress wounds. There was some tradition for regimental 

surgeons treating soldiers on the line already in England and with multiple Continental 

armies at Fontenoy, Belgium, in the mid-18th century.4(pp14–15) Yet another French surgeon, 

Pierre Francois Percy, organized a trained corps of ambulance litter-bearers to gather the 

wounded and to carry them to a surgical support station.4(p15) He created the Percy surgical 

wagon, similar in concept to that devised by Larrey.

In the Crimean War (1854–1856), the French, unlike the English and Russians, were 

prepared with a complete system of army hospitals, including the “flying ambulances” 

(and the ordinary ambulance).4(p17) The flying ambulance consisted of a light cart with one 

officer, two surgeons, and two attendants. The ambulance was posted near the battle to 

treat and evacuate the wounded. The ordinary ambulance consisted of five wagons carrying 

more extensive dressings and material. Five officers, six surgeons, 25 attendants, several 

apothecaries, and an instrument maker made up the ambulance staff.4(p17) Most surgeons 

followed the wisdom of Pare and Larrey that immediate amputation was desirable. 

Chloroform became popular in the Crimean conflict as the anesthetic of choice. 
7 0 • FORWARD SURGERY

The Beginnings of the Nursing Profession

In the Crimea, Florence Nightingale was appointed the superintendent of the Female 

Nursing Establishment of the Eighth General Hospital in Turkey. She set up for business 

with 38 women trained as nurses just 4 days after the “Charge of the Light Brigade” 

at Balaclava in October 1854. The British (unlike the French) were not able to care for 

their wounded and had a poorly organized evacuation system.4(pp19–20) The advances to 

come from the Crimean conflict included improved amputation techniques, the use of 

prefabricated wooden buildings along the pavilion system lines, and the care brought 

forth by Nightingale.4(p17) Florence Nightingale and her recruited nurses were not initially 

appreciated by the medical establishment and many of the surgeons, despite the fact 

that the nurses were appreciated by the wounded troops. However, their hard work 

and dedication won the belated respect of the surgeons and more so of the international 

community.4(p21)

Contributions of the Prussians

The Prussians first introduced a system of dedicated litter bearers to bring the wounded 

off the field in 1855. The Prussians learned much from Larrey (and later Letterman) in 

setting up specialized and dedicated wartime surgical treatment.4(p69) The Prussians made 

a significant advance in their armaments with the advent of the breech-loading Dreyse 

needle-fire rifle. The rifle’s cartridge was set off by a steel pin pushed by the hammer into 

the base of the cartridge. This firearms advance resulted in more casualties to be treated for 

the opponents of the Prussians. On the field of battle the dedicated litter carriers helped to 

evacuate the enemy casualties, in addition to their own troops.4(p96)

It was with this introduction that the medical and surgical needs of the US Civil War 

were to be met.4(p21) In the Civil War, the medical establishments were as unprepared as 

was the military for the soon-to-erupt carnage. Years of fighting in small engagements, 

or quickly won small wars, would soon be replaced by the need to field massive armies. 

The medical support necessary to tend to the needs of the casualties would overwhelm the 

initially inadequate medical establishment.

WAR FOR AMATEURS—LINE AND MEDICAL

For both the North and the South, despite the small cadre of military academy 

graduates (West Point, the Citadel, Virginia Military Institute, and the Military College 

of Vermont), the armies were populated by amateurs. In the same way, the small number 

of professional military surgeons would be joined by a majority of military medical 

“amateurs.” These inadequacies were soon tested in the First Battle of Bull Run, which 

failed to be the easy victory that many in the Union sought. They had hoped it would 

bring an early end to the rebellion, but instead the South was the victor. The Confederate 

victory led to the South’s expectations that the rest of the war could be prosecuted just 

as efficiently and successfully. It was unfortunate that the South’s expectations were 

unrealistically elevated so early. In their enthusiasm, it led to the perspective that the South 
CHAPTER THREE • 7 1

could be victorious, while ignoring their inadequate resources necessary for victory in the 

long term.1(p88)

Just before the start of the Civil War, the US Army Medical Corps had only 30 

surgeons and 83 assistant surgeons. Of these, three surgeons and 21 assistant surgeons 

resigned to join the Confederate States of America (CSA). Another three assistant surgeons 

were dismissed because they would not sign loyalty oaths.4(p23) The 80-year-old and dying 

Surgeon General, Thomas Lawson, a veteran of the War of 1812, cut budgets because 

he was frugal; furthermore, he denied his surgeons leave. He also cut the medical supply 

inventory to a minimum.5(p2) Additionally, only 62 new surgeons were appointed out of 

116 applicants.6(p9) Surgeon General Lawson’s 1860 budget request for appropriations 

was a mere $90,000 ($27,000 of the total would be paid for contract surgeons). Lawson’s 

frugal obsession was aided by Congress, which appropriated only $115,000 in March 

1861.6(p5) Lawson had become the Surgeon General only because of seniority at the time 

of the administration of John Quincy Adams. He stayed in office for the period up to the 

Civil War because there was no retirement law.6(p4) Thus, the US Army Medical Corps was 

woefully unprepared for the massive casualties it would soon be called on to care for in the 

war. The coming of the Sanitary Commission would put additional pressure on the Medical 

Department and Congress to spend at more appropriate levels.6(p5)

THE CIVIL WAR: ITS IMPORTANCE TO 

MILITARY MEDICINE

The number of Civil War deaths had been believed to be 360,000 Union dead (and 

281,000 wounded) and 285,000 Confederate dead (and 194,000 wounded) ever since an 

1889 report, based on imprecise after-action reports for the South compiled by William F 

Fox, who served as a lieutenant colonel of USA Volunteers, and had served at Antietam, 

Chancellorsville, and Gettysburg.7 Fox wrote that of 2.3 million enrolled Union troops, an 

additional 199,970 died of disease. Confederate figures are not as accurate, but are in the 

range of 150,000 died of disease.7 In a recent book, Young explores the murky Confederate 

casualty numbers in the Overland Campaign, a series of battles fought in Virginia during 

May and June 1864. He studied letters, diaries, and, best of all, Confederate newspapers, 

which were often the most accurate sources for reliable statistics.8(ppix–x) Young found 

that Lee’s numbers at the start of the campaign were larger than reported. Furthermore, 

Confederate losses were greater than previously held to be the case.8(px) In a 2011 article, 

Hacker revised the number of deaths upward by 20%, based upon recently digitalized 

19th-century census data. He noted that the data are not final because the number of 

civilian dead can only be estimated.9 Blaisdell points out that these casualties exceeded 

the total of all proceding or subsequent US wars. He further notes that the losses affected, 

directly or indirectly, nearly every family in the North and the South.10 These casualties 

occurred at the more than 10,000 battles and combat encounters that took place during 

the 4 years of the Civil War. 
7 2 • FORWARD SURGERY

The history of Civil War medicine for Union forces has been thoroughly reported 

in several volumes, including The Army Medical Department 1818–186511 and Medical 

Recollections of the Army of the Potomac.12 There was no comparable reporting of Civil 

War medicine for the Confederate forces. Yet there are glimpses of Confederate military 

medicine. As one example, the second CSA Surgeon General, Dr Samuel Preston Moore 

(replacing the inept David C Deleon), had been a US Army surgeon until 1861. He is 

credited with reform of Southern hospitals and creation of an ambulance corps. His work 

included efforts to find substitutes from the Southern flora for pharmaceuticals (which were 

affected by the Northern blockade). Interestingly, he was the editor of the Confederate State 

Medical and Surgical Journal, which is available (in DVD [digital video diskette] format) 

from the Francis A Countway Library of Medicine at Harvard University in Boston.13

The enormous battlefield carnage, infection, and disease sorely tested the US Army 

Medical Department in the Civil War. Viewing it from a 21st-century perspective, the 

medicine practiced in the 1860s seems primitive. However, as Schroeder-Lein commented, 

a sense of context and humility is needed to evaluate the medicine and surgery of the 

time. Schroeder-Lein wrote that surgeons were trying to do their best generally, with the 

equipment and techniques available, and trying to learn from their experience.14(p2)

The Sanitary Commission

The Sanitary Commission was formed to assist in the massive undertaking of caring 

for the wounded and sick of the North. The Sanitary Commission could be thought of as a 

combination of today’s American Red Cross and the United Service Organizations (USO). 

It was actually more in practice, assuming many of the roles that the military/government 

would have today. The Sanitary Commission was to play a unique role in relation to the 

Army Medical Department, acting as a “‘gadfly’ in ‘stinging’ the moribund department into 

more effective activity.”6(p5)

The Sanitary Commission was established in New York in 1861 by a combination 

of physicians, ministers, and women interested in improving the life of the soldier.6(p5) It 

was said to have resulted from a happenstance New York City curbside meeting of the 

Reverend Henry W Bellows and Doctor (Dr) Elisha Harris. Hoping to avoid the medical 

disaster of the Crimea, the two, supported by a number of prominent New York women, 

formed the Women’s Central Association of Relief. The society’s organization was carried 

out at a meeting at the Cooper Union.6(p5) This organization asked the Army Medical 

Department about its needs, to which the Surgeon General responded that they didn’t need 

help.6(p6),15(p42)

A delegation representing these groups then went to Washington with a view that a 

sanitary commission like the one formed in the Crimea should be created.6(p7) The original 

document sent to the War Department (with a supporting letter from Army Surgeon 

General Lawson’s office) on 18 May 1861 outlining the mission and intent of the Sanitary 

Commission was signed by Henry W Bellows, DD; WH Van Buren, MD; J Hansen, MD; 

and Elisha Harris, MD. The document listed three organizations from New York that 

would participate in the proposed commission.15(pp63–64) These were the Women’s Central 

Association of Relief for the Sick and Wounded of the Army, the New York Medical 
CHAPTER THREE • 7 3

Association for Furnishing Hospital Supplies in Aid of the Army, and the Advisory 

Committee of the Boards of Physicians and Surgeons of the Hospitals of New York. The 

letter also pointed out that commissions in the Crimean War followed the war. The signers 

proposed that this commission should be established immediately because the war had 

already begun.15(pp45–47,53)

A delegation met with General Winfield Scott, the Army Chief of Staff, which resulted 

in the order being given for series of “preventive measures,” such as increased attention 

to sanitary matters in the layout of troop camps. The delegation met next with the Army 

Acting Surgeon General Robert C Wood.15(pp47–48) Wood, although very polite, was not 

inclined to have interference from an outside agency.15(p49)

The official 9 June 1861 order for the establishment of the Sanitary Commission came 

from the War Department and was signed 4 days later by President Abraham Lincoln (13 

June 1861).15(pp63–65) The Women’s Central Association of Relief offered to train and provide 

cooks. The association also offered the use of several hundred women who had registered 

as nurses with the group.6(p7) In addition, the proposal called for the association to select 

100 female volunteers. The document further proposed that a group of “volunteer dressers 

[male volunteer nurses who would apply and change bandages among other duties], 

composed of young medical men, drilled for this purpose by the hospital physicians and 

surgeons of New York . . . [would be made available to come] to the aid of the regular 

medical forces.”15(p65) While awaiting the final approval, Surgeon General Lawson died and 

was succeeded by Clement A Finley, who had been an Army surgeon since 1818. Finley 

was skeptical of the Sanitary Commission, but yielded to public pressure and signed off on 

the proposal. He added a stipulation that the commission concern itself only with volunteer 

troops rather than Regular Army soldiers.16(p8) 

Frederick Law Olmsted, who would later design Central Park in New York City, was 

the organization’s General Secretary.15(p106) Olmsted was one of the original members of 

the US Sanitary Commission appointed on 20 June 1861.15(p64) Olmsted, assisted by Dr 

Harris representing the Sanitary Commission, wrote a report in 1861 on the conditions 

of 20 Army camps in the Washington area that found many deficiencies. Olmsted put 

the root of the problems to the lack of experience on the part of the officers and the 

consequent poor discipline of the soldiers.15(p86) When General George McClellan assumed 

command of the Army of the Potomac, he was receptive to the Sanitary Commission’s 

recommendations.15(p93) The commission pushed to build a model hospital system based 

on the “pavilion system.” The system envisioned separate wards in the form of detached 

buildings.15(p84) The Sanitary Commission had searched among the medical officers for 

someone to recommend for Surgeon General. They identified Dr William A Hammond, 

who had a career as an Army officer and had been Professor of Physiology and Anatomy at 

the University of Maryland.15(p130) The commission’s members put their considerable weight 

behind his ultimately successful candidacy.15(p134)

The Sanitary Commission provided inspections, supplies, hospitals, and transportation 

for the wounded. Commission members inspected Army hospitals and camps to make 

sure they were as healthy as possible. Clean Army facilities were shown to have less disease 

than dirty ones, even though the role of bacteria was not yet known. In many facilities, 
7 4 • FORWARD SURGERY

the Army officers were unhappy with the commission finding that they failed to adhere 

to Army regulations, especially concerning sanitation. The Sanitary Commission also 

transported supplies and maintained its own organic transportation systems, including river 

steamboats, wagons, and ambulances. Although chartered by Congress, its operation and 

finances were solely from private sources. 

Among the Sanitary Commission volunteers was Walt Whitman, best known for 

his poetic works.17(pp85,87) Whitman was also a war correspondent who wrote about 

war from behind the lines. He came to Washington seeking his brother who had been 

wounded in the Battle of Fredericksburg in Virginia. He finally found him recovering near 

Fredericksburg. Whitman stayed in Washington until the end of the war. He made over 

600 hospital visits while speaking to an estimated 100,000 wounded soldiers.18(pp52,59) His 

humanitarian work brought much comfort to the wounded and ill soldiers, as well as to 

their families.6(p89),18(pp52,59)

Women were significantly involved in the 7,000 regional and local offices of the 

Sanitary Commission. Although the top leaders of the commission were men, women 

assumed public roles that were uncommon before the time by becoming involved with 

providing local and regional leadership.19(p62) The commission established Soldiers Homes 

to provide housing while soldiers were on furlough.16(pp291,292) It also provided long-term 

care convalescent centers.19(p62)

The local chapters (branches) raised $15 million in supplies and $5 million in cash 

for the Sanitary Commission.19(p62) Much of the fundraising came from special events. 

Contributions large and small came from people anxious to help relieve the suffering 

of the wounded and ill troops. The commission’s fundraising received especially 

large contributions from “Sanitary Fair” events. Indeed, the fairs in New York and 

Philadelphia were compared to international expositions on the order of the Great 

Crystal Palace exposition in England. Various celebrities also donated items for sale. At 

one Sanitary Fair, for example, President Lincoln provided a handwritten copy of the 

Emancipation Proclamation, which brought a $3,000 bid.19(p63) The actual contributions 

and disbursements for supplies and expenses are listed in detail in the 1864 The United 

States Sanitary Commission, which has been digitally reproduced by the Cornell University 

Library in Ithaca, New York.20(pp539–549)

The Sanitary Commission was vitally important to the Army Medical Department. 

For instance, after the Battle of Antietam, the commission delivered to the area hospitals, 

independently of the Army, a variety of items in quantity including dry goods, condensed 

milk, beef stock and beef, farina (a cereal), bottles of wine, and various beverages such 

as tea and coffee along with sugar.21(pp120–121) The commission also set up an overall 

hospital directory that allowed family members to find where their soldiers were situated. 

Surprisingly, the War Department did not keep such records on an official basis.19(p62) After 

the Civil War, the Sanitary Commission also helped veterans file claims for pensions.19(p62)

Other charitable organizations, like the US Christian Association, sent personal items to 

soldiers such as socks, stamps, paper for letters, soap, and canned foods. It was associated 

with the Young Men’s Christian Association.22(p78)
CHAPTER THREE • 7 5

Surgeons and Their Training

Many surgeons of the era learned their profession as apprentices, although there were 

formal medical schools in operation. As an example, William Henry Corbusier, who served 

as an acting assistant surgeon for the 6th Illinois Cavalry, didn’t receive his Medicinae 

Doctor degree from the Bellevue Hospital Medical College in New York until 1867 after 

“having attended lectures and clinics. I had also received instruction in a special class 

under Dr Stephen Smith . . . . and a course in auscultation and percussion and diseases 

of the heart and lungs, under Dr Austin Flint.”23(p62) The sparse nature of the curriculum 

can be seen as Corbusier found it necessary to supplement his training with “special” 

classes (requiring fees) under the direction of New York specialists. His path in medicine 

was typical of many of his Civil War colleagues. Corbusier started to study medicine 

and surgery with a Dr JJ Braman of Gilroy, who “wanted a helper who could speak 

Spanish.”23(p36) He studied “[p]harmacy and made all of the tinctures, syrups, mixtures, 

powders, pills, etc.”23(p39) He later met an English surgeon in the area who “was well 

educated and had had much experience, some of which he imparted to me.”23(p39) In 1864, 

with this limited training, Corbusier gained his position as an acting assistant surgeon with 

the 6th Illinois Cavalry. “The Army needed surgeons and I had no difficulty in getting a 

position.”23(p47)

The quality of the surgeons certainly varied from the very good to the poorest excuse 

for a surgeon. The Army surgeons that were initially recruited were young, inexperienced, 

and frequently not of good quality. The best medical recruits were said to take the Surgeon 

General’s Office examination for “surgeons of volunteers” and, if successful, were 

generally assigned to staff positions in general hospitals rather than field duty.6(p46) Many 

of these newly acquired surgeons refused assignment to Washington hospitals, preferring 

to ply their trade in the field.6(p73) The lack of the “best” surgeons on the battlefield had 

consequences for the Army. At the Second Battle of Bull Run, for example, the medical 

situation was worse than at the first battle. Letterman had worked in July and August 1862 

on the preliminary start to what would be an effective medical plan, but the confusion and 

disarray of troops during the battle precluded its effectiveness. The Union alone sustained 

10,000 casualties (killed and wounded) out of 62,000 Union troops, while the victorious 

Confederates had 8,300 casualties (killed and wounded) out of 50,000 troops.6(p73) The 

medical side had poor coordination with other departments in the matters of transportation 

and supply. Furthermore, the volunteer surgeons were said to have displayed ignorance 

of military order and procedure and showed no teamwork.6(p63) It was reported that the 

Surgeon General dismissed 2,000 volunteer surgeons, paying their way home, believing that 

they would not obey orders and would be more trouble than their value.6(p57)

The extremes of care are illustrated in the following case. As a Private Chase was 

quoted after his wounding in the Overland Campaign and transport to Fredericksburg: 

“The worst treatment I received in all my Army service was from the brute that called 

himself an Army surgeon. He appeared to be void of all feeling for humanity, and seemed 

to delight in torturing the wounded men as much [as] a savage.”24(p188) Yet the next day, the 

same private was attended by a Dr William Sawin of the 2nd Vermont. Chase said, “It was 

his kind hands that fixed me up, gave me a quieting powder, and spoke cheerful words to 

me . . . . He said to me . . . . ‘I am very tired. I have amputated 100 limbs today.’”24(p188)
7 6 • FORWARD SURGERY

How did it come to be that there was such a range of skills among Army surgeons? 

Many of the medical schools in the United States were little more than “diploma mills.”6(p50)

(It would take the Flexner Report of 1906 to close down many of these schools.) Even 

Harvard Medical School, one of the leading schools of the time, had no stethoscope until 

1868, which was 30 years after its invention. Corbusier, in his memoirs, said that in 1864 

his unit had “a wooden tube about four inches long with a trumpet shaped piece at one 

end and a flat disk at the other, as a stethoscope to listen to the sounds of the heart and 

lungs.”23(p47) Harvard had no microscope until 1869, even though the microscope had been 

devised by Anton van Leeuwenhoek in 1674.6(p50) By contrast, the achromatic microscope 

(no distortion), developed in the early 1860s, did find its way to the headquarters of the 

Army Medical Department in a matter of a few years (1863).6(p51)

Many medical schools started to appear in the late 18th and early 19th centuries. 

However, many surgeons still gained their training by working with a preceptor. The 

preceptor was a surgeon who took on an assistant to learn the trade, usually over a 7-year 

period. The preceptorship could be augmented by medical courses or even attendance at 

a traditional school of medicine. It was the medical equivalent of “reading the law” at the 

side of a practicing lawyer, rather than attending a law school. 

At first, most medical schools were in the North and the southern students trained 

there. Transylvania University (1799) in Kentucky and the University of Maryland (1807) 

were early schools. Transylvania University was the first university west of the Allegheny 

Mountains. The medical department was formed by the trustees in 1799. Harvard, in 

Massachusetts, and the University of Pennsylvania were very highly regarded. The Jefferson 

Medical College in Philadelphia, Pennsylvania, opened its doors in 1825. This tendency 

toward a Northern education is reflected in the fact that the membership of an 1830 North 

Carolina medical society had a majority graduating from three Northern schools.25(p10)

The South was soon to follow with medical schools. The Medical College of South 

Carolina in Charleston (1824) became a leading center. The University of Virginia had 

a medical department in 1828. In the next decade medical schools were established in 

Richmond, Virginia; New Orleans, Louisiana; and Augusta, Georgia.25(p10) However, most 

physicians studied at these Northern and Southern institutions for a period of only 4 to 5 

months of lectures. Virginia expanded its lecture schedule to 9 months in 1837, allowing 

more anatomical instruction. The Medical College of Georgia in 1837 proposed the 

extension of its 6-month course, started in 1832.25(p11) The numbers of faculty employed by 

the medical schools were limited; eight was a typical number. 

Some surgical advances were made in the first part of the 19th century. For instance, 

a Danville, Kentucky, surgeon (Dr Ephraim McDowell, from Virginia originally) in 1809 

performed a successful ovariotomy that he later repeated a number of times (with no 

patient deaths). In 1849, Dr James Marion Sims completed a successful repair of a vesicovaginal fistula. Of course, Dr Crawford Long of Georgia, a rural surgeon, first used ether 

in 1837 as an anesthetic prior to the Boston use in 1848.25(p18) Dr Benjamin W Dudley, who 

was a professor at Transylvania University (Kentucky) from 1817 until 1850, did impart in 

his teachings to medical students from the South the value of boiled water and cleansing of 

the surgical field. He felt that dirt and impure water could somehow lead to disease.25(p19)
CHAPTER THREE • 7 7

The Contributions of Jonathan Letterman

Jonathan Letterman became the medical director of the Army of the Potomac (Figure 

3-2) following the failure of Charles Tripler to deal with the disastrous Peninsula Campaign 

casualties. During this campaign (March–June 1862), the Union suffered defeat and many 

casualties received delayed and substandard care, attributed to Tripler’s lack of planning 

and direction. As detailed in his memoirs, on 1 July 1862, Letterman reported to MG 

George McClellan, Commanding 

General, for duty as the Medical 

Director of the Army of the 

Potomac. McClellan was then at 

Harrison’s Landing on the James 

River in Virginia, following the 

Peninsula Campaign.

Letterman then received orders 

on the 23rd of July to report to 

the White House, but didn’t get 

there until the 28th where he met 

with Frederick Law Olmsted and 

other members of the Sanitary 

Commission.12(pp6–10) Letterman 

recorded in his memoirs that the 

greatest need of the troops then 

was for proper food. Slowly the 

situation improved but not without 

much suffering of the troops. 

At the instigation of Letterman, 

McClellan issued orders for the 

organization of an Ambulance 

Corps (Special Orders No. 147, 

dated 2 August 1862).12(p24) He 

later issued an order discussing the 

use of the Ambulance Corps and 

that of Ambulance Trains (General 

Order No. 85, dated 24 August 1862). Congress passed an “Ambulance Corps Act of 

1864,” enacted on 11 March 1864, that codified its operation.12

Letterman was born in Washington County, Pennsylvania, on 11 December 1824. 

His father was a well-regarded physician and surgeon in western Pennsylvania in his own 

right. He engaged a private tutor to educate his son. Jonathan Letterman graduated from 

the Jefferson Medical College in Philadelphia, in March 1849. He passed a comprehensive 

medical examination after which he was appointed as an Army assistant surgeon. 

Letterman served in Florida where he took part in the Seminole Indian campaigns until 

March 1853. He then was assigned to Fort Defiance in New Mexico. As a young Army 

assistant surgeon, Letterman participated in campaigns against the Indians, treating disease 

FIGURE 3-2A. Jonathan Letterman. Letterman became the 

medical director of the Army of the Potomac in 1862 following 

the failure of Dr Charles Tripler to deal with the disastrous 

Peninsula Campaign casualties. His ambulance evacuation 

system revolutionized Army medical care. He served in his 

post until 1864, at which time he resigned from the US Army. 

Photograph courtesy of the National Library of Medicine, 

Image #B011098
7 8 • FORWARD SURGERY

and inflicted arrow wounds that might later become infected. By 1859, he was assigned 

to Fort Monroe, Virginia. In 1860, he was posted to California where he participated in 

a campaign against the Pah Ute Indians. In 1861, Letterman was assigned to the Army of 

the Potomac. In May 1862, he was appointed as the Medical Director of the Department 

of West Virginia.12(p1) Letterman was then ordered to the position as Medical Director of 

the Army of the Potomac. He was later promoted to the rank of surgeon on 2 July 1862 

(effective date 16 April 1862). William Hammond, the Army Surgeon General, requested 

in July 1862 that the position as Medical Director further be enhanced by appointing 

the Director as an aide-de-camp to the Commanding General and be afforded the rank 

of colonel. Secretary of War Edwin Stanton denied the request. It finally took an act of 

Congress in February 1865 to provide the extra rank.26(pp227–228)

In the position of Medical Director of the Army of the Potomac, Letterman followed 

Charles Tripler, who was faulted for the poor handling of the casualties of the Peninsula 

Campaign. Tripler was then offered other posts and he selected the position as chief 

surgeon of the Department of the Lakes in Detroit. The office later moved to Columbus, 

Ohio, and then to Cincinnati, Ohio. Tripler received brevet promotions to colonel (1864) 

and to brigadier general (1865). While still on duty at Cincinnati in 1865 Tripler died, 

secondary to neck cancer. Tripler’s past accomplishments are worth noting. He was born 

in 1806 and graduated from the College of Physicians and Surgeons in New York in 

1827. Tripler worked for several months in New York’s Bellevue Hospital. He spent time 

FIGURE 3-2B. Dr Jonathan Letterman (seated, left) with his medical staff. Warrenton, Virginia, 1863. 

Photograph courtesy of the Library of Congress, Image #03769v. 
CHAPTER THREE • 7 9

in Florida in the Seminole War and later in the Mexican-American War, where he served 

under General Twiggs. He organized and supervised a variety of hospitals. In those days, 

disease put more troops out of action than wounding. He later spent time in Michigan, 

New York, and California. On 12 August 1861, he was assigned as the first Medical 

Director of the Army of the Potomac. Paradoxically, Tripler had been chosen for this 

position to bring order after the poor showing by the medical assets after the Second Battle 

of Bull Run.6(pp60,73,245) He probably performed better than he was credited in the Peninsula 

Campaign fiasco. Tripler’s own assessment in his final report of the campaign was that he 

neither was “a complete success nor a very decided failure.”6(p73) He listed many mitigating 

issues (described below) that he was not able to affect.6(p73–74)

The Peninsula Campaign, which was Tripler’s downfall, was designated such as 

fighting took place on the York Peninsula on the Virginia coast near Richmond.6(p61)

McClellan’s Peninsula Campaign was designed to capture Richmond; however, it had 

ultimately failed by July 1863. McClellan had envisioned an offensive strategy featuring the 

largest US Army fielded thus far in the war. The Army of the Potomac made an amphibious 

landing at Fort Monroe, Virginia. A temporary camp was established there with many 

supplies and a temporary tent city housing 100,000 Union troops.21(p69) The Union 

ultimately had some 105,000 troops, while the Confederates fielded only 60,000. The 

Union sustained 5,031 casualties including 790 killed, 3,594 wounded, and 647 missing. 

The Confederates, on the other hand, had 6,134 casualties including 980 killed, 4,749 

wounded, and 405 missing.27(p147)

The Confederates had established three lines of defense from the York River to the 

James River. The first line of defense at Yorktown stalled McClellan’s Army in a siege that 

lasted a month.21(p70) The Confederates later attacked the Union troops at Seven Pines. 

After only 2 days’ fighting, the Union had 3,600 wounded.21(p71) The wounded number 

had expanded to 8,000 by the end of the engagement.21(p72) McClellan halted his offensive. 

General Robert E Lee attacked the forces on 25 June 1862, at the start of the Seven Days 

Battle. McClellan withdrew then to the James River.21(p70)

The Peninsula Campaign’s medical efforts were characterized by lack of supplies 

(which became exhausted), medical tents missing or in need of repair, and the lack of 

surgeons. The extensive outbreak of dysentery in the Union Army has been cited as 

one of the reasons for McClellan’s withdrawal from the peninsula. The soldiers called 

the dysentery the “Tennessee trots” or the “Virginia quick-step.”2(p232) The Sanitary 

Commission provided significant criticism of the medical operations. Although Tripler did 

not receive the logistical support requested, the outrage at the extent of the casualties and 

their poor management doomed any chance that he could have remained at his post.21(p72)

A unique perspective of the scale of the Peninsula Campaign medical disaster comes 

from several eyewitnesses as recalled 68 years later.29(p27) In May 1862, Union troops were 

advancing through Virginia’s lower peninsula as part of the campaign. The Confederate 

rear guard action, as part of a delaying tactic, resulted in the Battle of Williamsburg, which 

took place east of the historic town. In 1930, the Reverend Dr WAR Goodwin shared on 

“recording discs” the oral history of what transpired as recalled by two then-teenagers. 

One said: 
8 0 • FORWARD SURGERY

I went on the battlefield the next day . . . . and there wasn’t a hospital or anything 

of the kind to take care of the wounded. And the Confederates and the Yankees, 

the Federals were all in a barn . . . My father . . . heard the suffering . . . he went 

down [and brought] . . . up some of the Confederate soldiers [to his home.] The 

Federals . . . . took care of their men as well as they could. They took care in fact 

of both sides. But there was nothing, no hospitals, or anything of that kind.29(p28)

The people of Williamsburg nursed soldiers in their own homes and turned the 

town church into a basic hospital. “A Baptist church visitor chanced upon a pile of limbs 

amputated by Yankee surgeons operating there.”29(p30)

Letterman provided his views of the eastern campaigns through 1864 in his Medical 

Recollections of the Army of the Potomac, published in 1866.

12 Letterman resources also 

include for review here Clements’ Memoir of Letterman30 and Tripler’s brief biography 

(regarding the Peninsula Campaign).31 Letterman began his book12 with the “Aftermath 

of Seven Days” in the wake of the peninsula disaster when Letterman became the Medical 

Director for the Army of the Potomac. He details how he tried to improve the diet and 

provide sanitary disposition of the encampment. Letterman reported that he examined 

the hospitals (under the Army of the Potomac) at Point Lookout, Fortress Monroe, 

FIGURE 3-3. Design of an improved ambulance to upgrade the basic Letterman Ambulance, November 

1864. The Letterman ambulance made possible the rapid and potentially life-saving evacuation of the 

Civil War wounded. Letterman’s ambulance system greatly improved the treatment of the Civil War soldier. At the instigation of Letterman, McClellan issued orders for the organization of an Ambulance Corps. 

Photograph courtesy of the National Archives and Records Administration, Image #16652. 
CHAPTER THREE • 81

FIGURE 3-4. Views of the 

Letterman ambulance. The 

ambulance formed the 

centerpiece of the Ambulance Corps organized by 

Jonathan Letterman. The 

ambulances featured springs 

in their suspension that were 

much more comfortable for 

the occupants than a regular 

wagon. They were drawn by 

horse or mule with canvas 

roofs and sides of canvas. 

Two-wheel ambulances were 

followed by the four-wheel 

ambulance pictured here. 

Photograph courtesy of the 

National Library of Medicine, 

Image #19999137-2.
8 2 • FORWARD SURGERY

Portsmouth, and Newport News, all in Virginia. There he found more than 7,000 patients, 

66 surgeons, 500 nurses, and miscellaneous medical cadets, stewards, and cooks. The 

numbers found there highlight the scale of care that was needed.12(p33)

Letterman organized the Ambulance Corps with two-horse and four-horse 

ambulances12(p27) (Figures 3-3 and 3-4). McClellan had issued an order establishing the 

corps on 2 August 1862.11(pp190–191) The system was tested at the Battle of Fredericksburg 

on 13 December 1862, with good results. The Maryland campaigns were even more of 

a test for the Medical Director because the trains were a problem for medical evacuation 

(as described in the section in this chapter on transportation). The trains were boarded at 

Frederick, Maryland, for transport of the wounded to Washington, DC, and Baltimore, 

Maryland. There were other problems facing Letterman. He described the loss of surgeons 

at the Battle of Antietam. Some contract surgeons just deserted the battlefield because they 

were not bound by Army regulations. He also described a Dr CR Agnew of New York, 

representing the Sanitary Commission, coming to Maryland and distributing much needed 

medical supplies. Letterman, seeking to avoid supply issues in the future, reported that in 

October 1862 he instituted a system of “brigade supplies” with accountability.12(pp50–53)

The battles of Antietam Creek and Sharpsburg, both in Maryland, accounted for 

11,600 Union troops killed or wounded (of approximately 50,000) in contrast to the 9,000 

that were killed or wounded among the Confederates (of approximately 33,000). The rate 

of soldiers being killed or wounded was put at 2,000 per hour of engagement.21(p114) Thus, 

the medical resources of both sides were strained to handle such casualty flows.21(pp114–115)

Letterman’s preparation was beneficial to the forthcoming Fredericksburg Campaign. 

Specifically, he made certain that all aspects of the Ambulance Corps were ready, including 

inspection of horses, harnesses, stretchers, lanterns, and related equipment.12(pp65–66) By 

then McClellan had been relieved of duty and it was to be MG Ambrose Burnside who 

would lead the Fredericksburg Campaign in Virginia. (McClellan was relieved by President 

Lincoln who felt that the general had been too slow to pursue Lee after Antietam.2(pp242,262)) 

Letterman had had a good relationship with McClellan, who gave him wide latitude and 

support, which was not the case with his successor.

 The Union’s plan of execution at Fredericksburg was complicated by a delay in 

erecting a pontoon bridge, which resulted in high casualty lists, to which Letterman had to 

respond. The Union plan had been to build a bridge to cross the Rappahannock River to 

engage the Confederates in Fredericksburg. However, Confederate sharpshooters continued 

to pick off Union troops attempting to complete the bridge. The approximate combined 

casualties included 2,000 dead, with 13,000 wounded and 2,500 missing.21(p146) The Union 

casualties (total forces engaged of 114,000) included 1,284 killed, 9,605 wounded, and 

1,769 missing. The Confederate casualties (total forces engaged of 72,500) included 608 

killed, 4,116 wounded, and 653 missing.32(p405)

The Sanitary Commission again supplied many needs of the wounded because the 

Army did not have sufficient supplies. Despite the need to supplement Union medical 

supplies due to shortages, the Sanitary Commission gave Letterman a good review for 

preparation. The commission was, in fact, evaluating how the Medical Department 

functioned in various battles.21(pp147–148)
CHAPTER THREE • 8 3

MEDICAL CARE AT THE TIME OF THE 

BATTLE OF GETTYSBURG

In the lead up to the Battle of Gettysburg (in Pennsylvania), the extreme carnage of the 

Civil War was exemplified by the Antietam casualties for both the North and the South.4(p94)

The surgical performances of both sides at Antietam had been criticized in public talk of 

“butcher surgery.”6(p115) During the Chancellorsville fighting, despite the South’s victory, 

Letterman was proud of the Union medical response and, in particular, cited a successful 

amputation at the hip joint of a private who was struck in the upper thigh by a conical ball, 

creating a comminuted fracture. The surgery was done in a field hospital without loss of 

much blood. The private survived despite being captured (while he was recuperating) and 

being moved to Richmond.12(pp117–119)

As pointed out in the book Doctors in Blue: The Medical History of the Union Army 

in the Civil War,6 there was a great deal of controversy regarding the issue of when and 

how to amputate. One faction advocated “conservative” measures that might preserve the 

injured extremity. The other faction favored prompt, speedy surgery/amputation.6(pp131–132)

The latter faction favored speed due to the enormous workloads in battle. They termed 

the amputation as “primary” in this situation6(p134) (Figures 3-5A and 3-5B). The risk 

of infection after amputation was ever present. Civil War surgeons, such as John Shaw 

Billings, considered that the surgeon’s hands might spread infection, which had already 

been demonstrated in obstetrical circles in the case of puerperal fever.6(p140)

In his memoirs, Letterman described the actions and medical care in the Union Army 

in significant detail in the period leading up to the battle at Gettysburg. As an example, in 

describing the Battle of Chancellorsville, Virginia, Letterman noted that 1,200 of the Union 

wounded fell into Confederate control. Letterman organized a relief column of 26 medical 

officers and five wagons loaded with supplies. Nineteen Union surgeons had remained with 

the wounded and were augmented by the 26 medical officers in the column. Also of interest 

is that General Lee offered free passage to the Union ambulance trains to Chancellorsville 

and, as Letterman put it, “to avoid the suffering that would be endured if our wounded 

were carried in the enemy’s transportation, and transferred to our ambulances.”12(pp139–140)

The 1863 Gettysburg Campaign was the second attempt by the Confederates under 

Lee to invade the North. The first was the 1862 push into Antietam. After Antietam 

resulted in a Union victory, Lee viewed an invasion of the North as a way of forcing a 

political settlement. Gettysburg was a 3-day battle that resulted in huge casualties for 

both sides (a combined total of 46,386 killed, wounded, or missing out of a total force 

of approximately 160,000 men). The Union (94,000 total troops) had casualties of 

23,055 (3,151 killed, 14,531 wounded, and 5,369 missing). The Confederates (66,000 

total troops) had casualties of 23,231 (4,708 killed, 12,693 wounded, and 5,830 

missing).21(pp186-187) The last day of the engagement ended with the Confederate charge (led 

by MG George Pickett) at Cemetery Ridge that netted only a small part of the Union line 

that could not be secured.4(pp99–100) It would take until 14 July 1863 for the Confederates to 

be across the Potomac marking the end of the Gettysburg Campaign. Lee remarked to the 

officer escorting the wounded: “Too bad! Too bad!” in reference to the battle.32(p25)
8 4 • FORWARD SURGERY

During the Gettysburg Campaign, Letterman remarked that the Ambulance Corps 

performed well and that he was able to remove the wounded from the battlefield within 6 

hours.12(pp158–159) Letterman requested that the Surgeon General send 20 more surgeons. The 

surgeons that came included some that worked well, but the majority were poorly trained 

and of little use. Letterman used the occasion to remark to Surgeon General Hammond 

that three surgeons per regiment must accompany the Army into the field.12(p159)

The Union medical organization under Letterman during the Gettysburg Campaign 

consisted of 650 medical officers, 1,000 ambulances, and 3,000 ambulance drivers and 

litter carriers to service the 94,000 Union troops.6(p91) Many Northern women came to Gettysburg after the fighting ended to serve as nurses and attendants. The Union forces even 

allowed Southern women to come to Gettysburg to perform the same functions for wounded Confederate forces.6(p70) Letterman used hospital tents and “nearly every house formed 

a hospital ward”6(p92) in the small town. Letterman moved the wounded from the houses 

and other points to Camp Letterman, a central medical facility composed of 400 tents of 

varying size and capacity.6(p214) The wounded at Gettysburg were then sent to hospitals outside the area as soon as possible. The main tent hospital in Gettysburg closed more than 4 

FIGURE 3-5A. Amputation, Gettysburg, July 1863. Civil War surgeon in a posed scene preparing to 

amputate a wounded soldier’s leg. Amputation was the method of choice for compound fractures and 

vascular injuries of the extremities. The speed of the surgeon was judged to be a point of pride. The Minié 

ball wound was responsible for many amputations because the bone was often shattered. A flap method 

of amputation left more tissue to cover the stump (the preferred Union method). Chloroform and ether 

were readily available anesthetics, with chloroform being the preferred agent. Ether’s explosive nature 

made its use dangerous. Photograph courtesy of the National Archives and Records Administration, 

Image #520203.
CHAPTER THREE • 8 5

FIGURE 3-5B. Civil War era amputation kits and implements. Photograph courtesy of Army Medical Department Center of History and Heritage.

FIGURE 3-5C. Minié ball, .58 caliber. From the Battle of Fredericksburg, Virginia. Minié ball wounds were 

responsible for the majority of the amputations. Photographs courtesy of Ronald Sparacino. 
8 6 • FORWARD SURGERY

months after the battle ended, on 

20 November 1863, the day following Lincoln’s Gettysburg Address dedicating the new military 

cemetery.22(p79)

The Sanitary Commission came to Gettysburg on 4 

July 1863, the day after Pickett’s Charge. The Commission 

raised large amounts of money 

to respond to the needs of the 

wounded, bringing in over 40 tons 

of food and supplies.22(p78) The 

Sanitary Commission and the US 

Christian Commission (an outgrowth of the Young Men’s Christian Association) supply wagons 

that came from Frederick to Gettysburg had avoided most of the 

fighting in the region and brought 

much needed materials to the various Union hospitals.6(p184) The US 

Christian Commission sent along 

soap, towels, paper, stamps, and 

food as well.22(p78)

The Confederate Medical 

Director at Gettysburg, Lafayette 

Guild, said that the Confederates 

left behind 6,000 wounded and 

100 surgeons to provide care 

for them in 24 hospitals within a 12-mile radius of Gettysburg.21(p188) Letterman’s medical 

troops already were dealing with their own 15,000 wounded at Gettysburg.21(pp188–189)

Regardless of the tremendous burden resulting from such horrific casualties, Letterman 

received criticism for the care of the wounded, despite how well he performed. In response 

to criticism from the press and Congressional members, Secretary of War Stanton sent 

Surgeon General Hammond to inspect. Hammond put the blame for medical supply 

shortages in General Meade’s line of responsibility.21(p196) Letterman left surgeons and 

resources at Gettysburg and a hospital named for him (Camp Letterman), which continued 

to operate until November 1863, although the responsibility for operations had been 

transferred to another surgeon.21(pp196–197),33(p15)

Lafayette Guild, the Medical Director for the Army of Northern Virginia, had also 

graduated from the Jefferson Medical College 1 year before Letterman. He had served in 

the Union Army in western posts, including California. Guild and Letterman met in person 

at Gettysburg to deal with the wounded.21(pp290–291)

FIGURE 3-6. Surgeon General William A. Hammond (1862–

1864). Surgeon Hammond came to the attention of the 

Sanitary Commission members as a replacement for Surgeon 

General Finley. Hammond was appointed over the acting Surgeon General (Colonel Wood) and over a candidate backed 

by Secretary of War Stanton. Hammond was the catalyst for 

Letterman’s reforms and ambulance organization. Hammond’s 

courts-martial for alleged irregular procurement of medical 

supplies resulted in his dismissal in 1864. He subsequently 

went on to academic success in New York. Congress restored 

his brigadier general rank in 1878. Photograph courtesy of the 

National Library of Medicine, Image #B08356. 
CHAPTER THREE • 8 7

There was also combat activity, and thus medical activity, in the “western” part 

of the theater of operations during this time. To Letterman’s credit, the “Letterman 

system” was more integrated in the West, in the Army of Tennessee for the 1863 to 1865 

campaigns.6(p106) In contrast, the South had a confused and disorganized medical activity 

in the West. The hospitals were makeshift at Magnolia, Mississippi, and Ringgold, 

Georgia.25(p49) Also in the West during the Civil War, some of the Indian tribes saw an 

opportunity to cause trouble while the armies were otherwise engaged. For instance, 

the Dakota War of 1862 left several hundred settlers dead. BG Henry Sibley brought 

revenge for these killings in the summer of 1863 in the present North Dakota when 

he located a large encampment of Sioux. The later Sand Creek Massacre had further 

repercussions.34(pp241–242) BG Alfred Sully’s own punitive expedition in 1864 followed, 

with further loss of life for all involved.34(p177) It is important to note that the Dakota War 

brought much more destruction to the people of Minnesota than did the Civil War.34(pxi)

These campaigns took place during the time of the Civil War, although their campaigns and 

medical/surgical response were more typical of the Plains wars to follow in the upcoming 

decades. 

Surgeon General William Hammond (Figure 3-6) was the catalyst for Letterman’s 

reforms. The tier-hospital system and the effective Ambulance Corps were the highlights of 

the advances. When Hammond became the Union Army Surgeon General, he worked with 

Letterman to implement pavilion-style hospital design, which featured open ventilation 

and efficient operation.11(pp66,67) Unfortunately, Hammond ran into political difficulties 

with Secretary of War Stanton. Hammond was arrested on 17 January 1864 and charged 

with malfeasance and fraud. The core of the charges was that he allowed medical supply 

purchases without going through the standard channels. There were also allegations of 

substandard supply quality. His trial lasted 4 months and ended with Hammond’s dismissal 

from the Army on 18 August 1864.21(pp216–220),28(p234) Hammond campaigned to seek 

vindication of his courts-martial in 1878. An Act of Congress in 1878 restored him to the 

Army (retired) with a rank of brigadier general, but with no back pay.35

By the second year of the Civil War, the two-wheeled ambulances were replaced by the 

four-wheeled model. The four-wheeled model came in two variations: one was drawn by a 

two-horse team and the other by a four-horse team. Most came with springs, which was a 

blessing for the injured. The larger ambulances could carry four to six stretcher cases.14(p8)

Until Letterman’s implementation of his Ambulance Corps, the Army Quartermaster had 

control of hospital and ambulance procurement and disposition. Ambulances were often 

diverted to other purposes before Medical Department control.6(p34)

Letterman was subsequently appointed as the Medical Inspector of the hospitals in 

the Department of the Susquehanna, where he stayed until 1864. This appointment was 

important because the Department of the Susquehanna was responsible for the entirety of 

the Virginia operations. Although he could not truly be replaced, Letterman was succeeded 

as Medical Director of the Army of the Potomac by Surgeon Thomas A McParlin.4(p57)

In his new position, Letterman inspected the Department of the Susquehanna’s 18 

hospitals, which accounted for 10% of the Union hospitals at the time.21(pp217–219) He also 

involved himself in the Congressional proposals to create an Army-wide Ambulance Corps, 

which passed and became law on 11 March 1864. It was noted that it was largely the 
8 8 • FORWARD SURGERY

same as McClellan’s General Order No. 147 of 1862.21(p218) One of the provisions of the 

Ambulance Corps creation was that only Corps personnel could help the wounded from 

the field, rather than random troops.6(p97)

When Letterman learned that he was slated to receive new orders assigning him to 

the Department of the Missouri, he declined the position; he submitted his resignation 

from the Army on 22 December 1864. After 15 years in the Army, Letterman departed to 

take up private business opportunities in California. He had been married for only a year 

when he made this decision. Thus, despite his significant contributions to the war effort, 

Letterman left the Army before the end of the war because of increasing frustrations in his 

position and continued problems in procurement and supply. Unfortunately, the promising 

opportunities in California didn’t work out; Letterman then started a medical practice and 

later became the coroner in San Francisco, California.21(pp224,238,247–258) The coroner’s job 

provided a steady source of income and a prestigious position. Letterman retired from his 

coroner’s position in 1871; he died on 15 March 1872 of what may have been chronic 

dysentery.21(pp260–261)

SURGEONS GENERAL DURING THE CIVIL WAR

Thomas Lawson (30 November 1836–15 May 1861)

Thomas Lawson served for almost 25 years as the Surgeon General. His period in 

office was during conflicts such as the Seminole Wars, the Mexican-American War, the preCivil War Indian conflicts, and finally the start of the Civil War. His signal accomplishment 

while in his long tenure was his fight for rank and recognition of his surgeons. His tenure 

was marked by conflicts with superiors and subordinates. He doggedly pursued medical 

officers who he felt were not a credit to the Army. However, he was unable to respond to 

the fall of Fort Sumter because he was quite ill. Lawson died on 15 May 1861.36

Clement Finley (15 May 1861–14 April 1862)

The next Surgeon General was Clement Finley, who was 64 at the time of his appointment. He had also served in the Seminole Wars and the Mexican-American War. The rank 

of the Surgeon General had been that of colonel. An act was passed by Congress on 16 

April 1862 that made the Surgeon General a brigadier general and provided for an assistant 

surgeon general and a medical inspector, who were to be colonels. Finley was not promoted 

to the rank of brigadier general because he retired on 14 April 1862, 2 days before the act 

was passed. Assistant Surgeon General Robert C Wood was the interim office holder until 

the appointment of William Hammond, who took over on 25 April 1862.37 Finley received 

praise for his dedication to the care of his patients. General Winfield Scott praised him for 

his care of cholera patients in the Black Hawk War. His tenure in office was characterized by 

efficient operation, although his assistant garnered some of the credit there.37

William Hammond (25 April 1862–18 August 1864)

William Hammond and Jonathan Letterman were both classmates at the Jefferson 

Medical College.21(p285) William Hammond was appointed an assistant surgeon in 1849, just 
CHAPTER THREE • 8 9

missing the Mexican-American War. He served in a variety of posts and participated in a 

campaign against the Sioux Indians. Hammond was interested in physiology and botanical 

studies, which he pursued in his off-duty time. In fact, he won an 1857 award from the 

American Medical Association for his essay dealing with the nutritional and physiologic 

effects of albumin and gum used as a food.35 In 1860, he resigned from the Army to accept 

a teaching position in Baltimore, Maryland. On 28 May 1861, Hammond reentered the US 

Army as an assistant surgeon. He served in a number of positions after the start of the Civil 

War but came to the favorable attention of the Sanitary Commission members, who were 

not happy with Surgeon General Finley. Hammond was appointed over the acting Surgeon 

General (Colonel Wood) and over a candidate backed by Secretary of War Stanton.35

Hammond’s courts-martial for conduct unbecoming to an officer and alleged irregular 

procurement of medical supplies resulted in his dismissal in 1864.21(p285) He subsequently 

went on to academic success in New York as a neurologist (a newly evolving specialty). 

He held a series of academic appointments subsequently.21(p285) Although he did not 

return to active duty, Congress restored his brigadier general rank in 1878 and placed 

him on the retired list as surgeon general. He published extensively and established a 

sanatorium.21(p285),35

Joseph Barnes (22 August 1864–30 June 1882)

Joseph Barnes followed Hammond in 1864 as the next Surgeon General. He had also 

served in the Seminole conflict and later in the Mexican-American War. He was serving in 

the West at the onset of the Civil War. He was ordered back to the Surgeon General’s Office 

where he was designated the surgeon for Washington. While in this position, he made a 

favorable impression upon Secretary of War Stanton. Indeed, Stanton was influential in 

Barnes being chosen to replace Hammond. Barnes became the Surgeon General in August 

1864 and remained in office for almost 18 years.38 Barnes assigned officers to compile the 

Medical and Surgical History of the War of the Rebellion, which was an exhaustive record 

of the conflict and the main achievement of his long tenure as Surgeon General.21(p264)

CONFEDERATE MEDICAL SERVICES

The primary focus in this chapter is on the Union Army as a continuation of the US 

Army. The book entitled Doctors in Gray: The Confederate Medical Service,25 authored 

by Horace H Cunningham, was first published in 1958. It is one of the best descriptions 

of the Confederate Medical Service organization.25 The Confederate’s problems in 1861 

included lack of medical personnel, food, and supplies. These problems increased as the 

war endured, in part due to the effective blockade of all Confederate ports.

Many of the South’s physicians had received training in the North before the war 

began. Cunningham states that in 1860 the majority of the members of the North Carolina 

Medical Society received their training in the North. As time went by, more schools 

developed in the South, including the Medical College of South Carolina (1824) and the 

University of Virginia (1828); other institutions were established in the 1830s.25(pp10,12)
9 0 • FORWARD SURGERY

Dr Joseph Jones is quoted as saying that he believed there were 600,000 Confederate 

troops mobilized and 200,000 of these died as a result of action, wounding, or disease 

during the conflict.25(p3) Only 50,000 deaths were directly attributable to battle as described 

by Jones.25(p5) (Cunningham, quoting other authorities, concluded that deaths from disease 

may be understated for the South.25(pp5–6)) Dr Jones was a graduate of the University 

of Pennsylvania School of Medicine and taught at the Savannah Medical College, the 

University of Georgia, and the Medical College of Georgia before the war. He became a 

Confederate surgeon of note.25(p3) Disease was very prevalent in both armies. Even General 

Robert E Lee was afflicted with an unspecific illness in May 1864 during the Battle of the 

Wilderness. Indeed, illness affected outcomes for both the North and the South.25(p8)

The Confederate medical system also had to contend with the prisoner-of-war sick 

and wounded at Southern prisons. Andersonville, Libby, Belle Isle, and Salisbury Prison 

were the most famous of the Confederate prisons.25(p7) The prison hospital at Andersonville 

recorded 15,987 cases of illness, of which 11,086 died, which would confirm a frightful 

mortality rate.25(pp7–8) Cunningham reported 42,686 deaths from disease or wounds in 

the prisons for 6 months in 1864 alone.25(p7) Records for the Danville, Virginia, prison 

hospital for the period November 1864 to March 1865 reflected a 30% mortality for 

sickness. However, records were incomplete in the Confederacy; even the number of overall 

prisoners of war is vague.25(p8)

At the start in 1861, the Surgeon General of the Confederacy was to have a rank 

of colonel, while surgeons and assistant surgeons would rank as majors and captains, 

respectively.25(p21) The Confederate Medical Department had on its rolls one Surgeon 

General, 1,242 surgeons, and 1,994 assistant surgeons.25(p37) The Confederate Surgeon 

General received pay of 3,000 Confederate dollars per year. The pay rates listed were 162 

to 200 Confederate dollars per month for a surgeon, while an assistant surgeon received 

110 to 150 Confederate dollars per month25(p21) (the Confederate dollar declined in value 

as the war proceeded). (By comparison, the Union surgeon was paid only $80 to $100 per 

month until the rates were raised in 1864.6(p175))

The first CSA Surgeon General was Dr David C Deleon, who lasted only a few 

months. He was named the Acting Surgeon General on 6 May 1861. His tenure was ended 

on 12 July 1861 due to perceived incompetence. Dr Charles H Smith served for a few 

weeks as an interim Surgeon General. He was followed by Dr Samuel Preston Moore, who 

served until the end of the war.25(p28) Dr Moore prevailed upon the CSA Secretary of the 

Treasury, who controlled office assignment, that his office could not operate out of the one 

room assigned to the Surgeon General’s Office. He received a larger space.25(p28)

Moore was an 1834 graduate of the Medical College of South Carolina. In 1835, 

he became an assistant surgeon in the US Army. He served at many posts and his service 

included the Mexican-American War, after which he became a full surgeon. Moore was the 

medical purveyor in New Orleans (managing the purchase and distribution of medicines 

and supplies), but left for private practice when the Civil War broke out. He was then 

selected to become the Confederate Surgeon General.25(p28)

The arrival of German immigrants who were trained as pharmacists enhanced 

possibilities of formulating medicines from indigenous sources to offset the effects of the 

North’s blockade.25(p16) In the South, almost all of the surgeons were allopathic physicians 
CHAPTER THREE • 9 1

who had graduated from a medical school. However, because the type of school was not 

specifically stated, technically a homeopathic physician could be appointed.14(p5) Moore 

implemented medical examining boards, which generally provided thorough examinations. 

Some criticisms were inevitable, but the results were usually fair.25(pp34–35) The Medical 

College of Virginia was the only Southern medical school to keep its doors open during 

the Civil War. Hence, the supply of new surgeons was affected.25(p35) Some 3,000 medical 

officers served in the Confederate Army and Navy.25(p36)

Confederate surgeons made great efforts to prevent surgical fevers in the hospitals. 

They separated infected patients and called for disinfection and whitewashing of hospital 

walls to slow the spread of disease.25(p242) Surgeon General Moore spoke of the value of 

surgical records, in which many surgeons were remiss.25(p242) Indeed, Moore was quite 

critical of hospitals and surgeons that did not keep accurate records. In fact, many of 

his facilities kept such minimal records that they were of no value.25(p257) Moore had his 

critics, but Jefferson Davis in a speech recognized the value of his hospital organization 

in 1863.25(p251) Moore is credited with the concept of a one-story hospital pavilion, which 

became the preferred model even after the war.25(p267) Moore had good relations with the 

Confederate Congress, which paid close attention to his estimates of medical needs. The 

Confederate Congress increased the amounts for medical services as needed, eventually 

reaching 74 million Confederate dollars.25(p43)

Confederate hospitals came to have good ventilation and light for their patients with 

infectious disease and “surgical fever.” Because the blockade precluded the use of many 

medications, the new use of natural remedies, including no medications, had a beneficial 

effect. Without the ingredients of many “quack” medications, perhaps the public was better 

off also.25(p268)

Richmond, Virginia, became the hub of medical care for the sick and wounded in the 

region, with 11 hospitals situated there. Chimborazo, named after a Mexican War battle 

site, was the most recognized and the largest of the purpose-built hospitals. (Both the North 

and the South found that purpose-built hospitals meant better recovery rates.19(p60)) It could 

serve as many as 8,000 patients with its more than 150 buildings. The hospital bakery 

produced approximately 10,000 loaves of bread per day. It also had five ice houses and 200 

cows on the nearby grounds to provide milk and butter.19(p60) Other Richmond Confederate 

hospitals included Camp Lee and Howard Grove.25(p286) Twenty hospitals were ultimately 

located in the Richmond area.25(p53)

Another of the hospitals in Richmond was the Winder Hospital; it was similar in 

design to the Chimborazo Hospital. The Winder Hospital had grounds of 125 acres and 

had a capacity of 5,000 patients.25(p52) The Jackson Hospital, another main Richmond 

hospital, had wooden barracks, which housed approximately 2,500 patients. It had two 

water closets, two icehouses, a bakery, a garden, and 60 cows.25(p52) Gardens were attended 

by recovering patients. Canal boats brought food from Lexington and Lynchburg for 

the patients. The Confederates had ambulances, although (aside from captured Union 

ambulances) they were difficult to acquire. Regular wagons generally had to suffice. The 

Richmond Ambulance Committee was formed from volunteers in 1862 and provided 

service to the Army of Northern Virginia. The regular Confederate Ambulance Corps, in 

theory, had two ambulances per regiment.14(p6)
9 2 • FORWARD SURGERY

The Confederate Medical Department recognized the value of professional dentists and 

ensured the availability of dentists to the troops. (The Union was not as proactive.25(p273)) 

The skills developed by CSA surgeons provided for advances when Lister’s concepts and 

improved anesthesia were available. It was the lancet for blood letting that was not used 

further as the popularity of that therapy declined.25(p268) Confederate surgeons used the 

Smith anterior splint (as did the North) for fractures of the lower extremity, unless the 

fracture was more complicated, thus requiring pulley and weight. The Smith anterior splint 

had been designed by a University of Maryland surgeon before the war. The South used 

maggots to clean wounds. The North, with its copious medical supplies, did not utilize this 

technique, while the South had to improvise often. The practice had been forgotten after 

the Napoleonic Wars. It was again forgotten after the Civil War.25(pp268–269)

CIVIL WAR DIET, VACCINATIONS AND 

MEDICATIONS, AND TRANSPORTATION

Diet

By the time Letterman left the service in 1864, the Army’s diet and hygiene had 

improved greatly over the previous 3 years, due in large part to his efforts. It was apparent 

that dietary additions, such as fresh vegetables and fruits, reduced the risk/rate of scurvy. 

In the Civil War, the Union soldier used considerable hardtack, which was a form of a 

cracker that had to be soaked or broken up to eat. A soldier was said to consume up to 

10 crackers a day. Bakeries cut the dough into 3-inch squares and perforated them with 

16 holes. Typically, soldiers of both sides would carry 3 days’ rations before going into 

combat.39(pp45,47) The Southern soldier used ground corn as his staple because corn was 

plentiful in the South. Pork was more commonly available than would be beef or chicken. 

Fresh meats, vegetables, and fruits were only periodically available.19(pp20–22)

Vaccinations and Medications

Smallpox vaccinations (used first in the Revolutionary War) were required for 

Confederate soldiers.40 Corbusier commented that smallpox was “very fatal to the 

Negroes,”23(p60) while the whites and the soldiers were protected by “vaccination from 

scabs.”23(p59) However, the source of the smallpox material was “not always well selected 

when there was so great a demand for them at the beginning of war [resulting in] very sore 

arms [and that the] persons were not always rendered immune.”23(pp59–60)

Most of the medications then used by physicians were not particularly useful, with 

the exception of quinine for the treatment and prevention of malaria. Opium had its use 

as a pain medication; it could also help in some diarrhea cases by slowing the digestive 

system.19(p57) Many drugs that were used included harmful contents such as mercury, 

lead, and strychnine. Thus, the South’s inability to get many of these medicines due to the 

blockade may have been beneficial to the Confederate troops.19(p56)

Quinine was the closest thing to a “miracle drug” in the Civil War because it provided 

an effective treatment for malaria. Quinine was obtained from the bark of the Peruvian 

cinchona tree and was bitter in taste; indeed, whiskey was often used as an inducement to 
CHAPTER THREE • 9 3

take the medicine. Whiskey didn’t always work, as noted by Dr Corbusier in his Memoirs,23

who said that his first time on tour with his regiment, “I took several barrels of whiskey 

along to issue with quinine for malarial fevers.”23(p50) Corbusier found that the whiskey was 

unnecessary for the drug to work and that the alcohol tended to “evaporate.” Alcohol was 

a key feature of medicines in both the North and the South. Alcohol was used in whatever 

form to help with surgery and its aftermath. It was a key ingredient in medicines such as 

quinine and opium. It was also used to preserve specimens of tissue.

Alcohol was always in short supply, especially in the South. Theft for recreational 

use was a significant problem.14(p3) Quinine was used as a “stimulant drug,” along with 

dilute sulphuric acid.6(p140) Ipecac (a plant) and calomel had been used for diarrhea. 

Ipecac, generally used as an emetic, had become more popular again in the Civil War 

following British experience with it in India. (Ipecac has some bactericidal action in 

bacterial dysentery cases.) It was noted to be useful in amebic dysentery (apparently 

having amoebicidal components) but no one knew why it worked.19(p57) Quinine was 

used by some surgeons for diarrhea because they believed the diarrhea might be due to 

malaria.6(p218) Alcohol was used in the war as an antiseptic and as a remedy (alcohol was a 

main ingredient in many remedies in the Civil War and continuing into the 20th century). 

Alcohol was appreciated by soldiers for its obvious benefit.6(pp128,140,144) 

In the context of medications in the Civil War, there was a conflict between the 

allopathic or “regular physicians” and the homeopathic physician. The homeopathic view 

was begun by Dr Hahnemann, who advised against bloodletting and use of “heroic” 

medications. The allopathic physicians stemmed from the teachings of Dr Benjamin Rush 

of Revolutionary War fame. The allopathic physicians formed the American Medical 

Association and controlled the medical boards appointing surgeons in the North. The 

surgeons in the South had a more lenient attitude toward the use of botanical drugs.14(p5) Dr 

Oliver Wendell Holmes said in an 1860 talk before the Massachusetts Medical Society that 

the populace was “overdosed” with medications. While he gave the medical profession part 

of the blame, he also said that the public “insisted on being poisoned.”25(p16)

Trains and Ambulances: Medical Evacuation

Letterman’s ambulance system greatly speeded treatment for the Civil War soldier. The 

ambulance system and the use of trains improved the care of the Union soldier, although 

transportation remained a problem in the West. The ambulances featured springs in 

their suspension; they were so much more comfortable than a regular wagon that they 

were often requisitioned for the use of officers and their wives. They were horse or mule 

drawn with canvas roofs and sides of canvas that could be raised or lowered depending 

on the weather.6 Letterman’s organization of the Ambulance Corps via General Order 

No. 85, issued on 24 August 1863, initially detailed the use of two-wheeled ambulances 

(to be followed later by four-wheeled vehicles) and described the details of ambulance 

organization, parking, and order of march. For instance, medicine wagons were to follow 

the ambulances. Letterman’s organization prohibited the ambulances to be used for other 

purposes as they had in the past.26(pp162–178)

The “travelling general hospitals” were an interesting use of the railroads utilized 

by the Army of the Cumberland to follow its march when rail lines were in proximity. 
9 4 • FORWARD SURGERY

Transportation to a convenient rail head would be the alternative. The railroads were 

used to move the wounded to larger hospitals in a safer and more expedient manner. 

Corbusier describes being in charge of a “railroad train of sick and wounded in freight 

cars.”23(p57) The wounded had to travel on the “bare floor, having only one or two blankets 

as bedding.”23(p57) Dedicated ambulance trains that were purpose designed would come in 

much later conflicts.

The Civil War was the first American conflict in which the military made great use of 

railroads to transport troops, move supplies, and transport the wounded.19(pp50–54) Getting 

the wounded onto a train, however, did not always mean a convenient or comfortable trip 

to a hospital. For instance, railroads were generally local or regional in operation, although 

a few larger operations existed, such as the Pennsylvania Railroad. There were often no 

through trains, as in the case of Baltimore, where travelers would come in at one station 

and have to go to another station to continue. Even when lines were linked, the companies 

might unload and reload their cargo as the route changed to a different company. At the 

start of the war, the North had a transportation advantage with 21,000 miles of track, 

compared to the South’s 9,000 miles. In addition, the South had not spent money in the 

decade before to improve its infrastructure. Furthermore, the locomotives were largely 

built in the North. The Richmond-based Tredegar Iron Works built some engines, but not 

enough to meet the demands of the war.19(p50) Also, due to the poor state of the tracks in 

the South, most trains were limited to 15 to 20 mph. The engines burned wood largely and 

required significant supplies of water along the rails for steam. 

The railroad hospital transportation of the Medical Department in the East “continued 

to be crude down to the end of the war.”6(p105) The trains (Union Army) running from 

Nashville to the front were painted a “glaring scarlet while at night three red lanterns were 

hung beneath the headlight”6(p108) to distinguish them from regular trains. Often the rail 

routes were threatened by enemy troops. In the Overland Campaign, for example, General 

Grant had planned to move the wounded across the Rapidan River for evacuation by train 

to Washington. However, the threat of raiders caused the plan to be modified, eventually 

transporting the wounded by boat from various points along the Potomac River.24(p186) The 

wounded had first been transported to Fredericksburg in “spring less wagons.” 

CSA evacuation trains also had problems. Confederate surgeon Frank M Dennis, in 

charge of Confederate ambulance trains in 1863, described the day train, in which the 

worst cases were placed in bunks, while another 200 sat in the seats. The night mail train 

had no bunks. Only the wounded were to be on the evacuation train, whose schedules were 

irregular due to equipment failures and poor scheduling. The train surgeons were described 

as a disciplined group whose main problem was getting the wounded off to the hospitals. 

Many of the wounded were reported to have travelled 20 to 25 miles to get to the railhead. 

Fortunately, the destination hospitals were generally located close to the transportation 

railheads.25(p282) The North and the South both had some designated ambulance trains. 

Union General John Fremont was credited with setting up such a train in 1861.

Union hospital ships were used along the Western rivers. The medical evacuation in 

the first part of the war was irregular and confused at times. Oftentimes civilian captains 

of the vessels would not set off until the ship was filled. Early in the war, riverboats were 
CHAPTER THREE • 9 5

dedicated to the sick and the wounded, with the leased City of Memphis being the first in 

1862. The Western Sanitary Commission, operating on the Mississippi River and west of 

it, arranged to outfit the captured Red Rover as a hospital ship that same year.41(p62) (The 

Western Sanitary Commission was independent from the main Sanitary Commission.) The 

USS Red Rover became the first US Navy hospital ship and transported 1,697 wounded in 

its first two and a half years. Both sanitary commissions ran hospital ships, with the Army 

supplying the doctors, while the nurses were employed by the Sanitary Commission.41(p64)

The main Sanitary Commission controlled all hospital vessels in the East.41(p70)

ADVANCES IN MEDICAL CARE 

Writing in the Archives of Surgery,

10 Dr William Blaisdell described a number 

of medical advances that he viewed as important during the Civil War. He identified 

recordkeeping; management of mass casualties in a timely fashion (including Letterman’s 

ambulances); and the improved design of hospitals, sanitation/hygiene, and use of female 

nurses. The pavilion-style hospital construction (Figure 3-7), featuring open ventilation and 

clean details, was championed by Surgeon General Hammond, Letterman, and John Shaw 

Billings. Blaisdell viewed as most important the physician lessons learned in management, 

surgery, and anesthesia.10(p1045) The Civil War surgeon also acquired invaluable experience 

in the management of infectious disease and the rapid treatment of fractures and 

wounds.10(pp1045–1050)

An interesting addition to the Union Army Medical Service was the attempted 

introduction of the Autenrieth Wagon to carry surgical instruments and supplies into the 

field. An earlier 1862 attempt was directed at building a light wagon to carry medications, 

which would travel with ambulances. The wagon proved impracticable.42(p244) It was to be a 

dedicated special supply source that could be targeted in the direction or area needed. The 

wagon would go to wherever surgery was being done, whether in makeshift hospitals in the 

field or in homes or churches. The idea was to get surgical needs to the surgeons quickly. 

It had one storage case specifically for major operations, such as amputations, readily 

available. Unfortunately, the Autenrieth Wagon was not of interest to the Union medical 

authorities during the war because it was too complex and costly to manufacture.42(pp244–245)

Wounds and Diseases

In addition to the wounds from bullets and artillery, the Civil War is notable in that 

more soldiers died of camp diseases, such as pneumonia, typhus, and dysentery, than 

from battle wounds. In the era before germ theory, deaths could come from outbreaks of 

typhoid fever, yellow fever, smallpox, dysentery, and cholera. Typhoid, typhus, and the 

so-called “continued fevers” were common in both armies. Various fevers that could not 

be diagnosed seemed to be placed into the “continued fevers” category.25(p194) Unsanitary 

camp conditions certainly didn’t help limit diseases. It was not uncommon to locate latrines 

near water sources. Childhood diseases, such as measles, also took their toll, especially in 

the crowded camps. Soldiers from rural areas, who had often lived in relative isolation, 
9 6 • FORWARD SURGERY

suffered more than those from urban centers. Population dislocations had their impact as 

well. Jim Downs, writing in the Lancet, points out the dire effect of disease upon freed slave 

populations of the Civil War era.43(pp1640–1641)

Pneumonia had been treated in the period before the war with antimony and the lancet 

for bleeding. During the war, opium, rest, and “snakeroot” (a low-growing perennial 

found in central and southern climates) were utilized. Snakeroot was considered a remedy 

to produce “expectoration.” Snakeroot was also used as a cure for snakebites. It had been 

used since colonial times for fevers and malaria.25(p203) For both the North and the South, 

scurvy was undoubtedly underreported or was misdiagnosed. Scurvy was reported as early 

as 1862 in the Army of the Potomac. Scurvy was likely unreported in Southern hospital 

records. As an example, only 110 cases of scurvy were reported in records at Chimborazo 

Hospital in Richmond, Virginia, among Confederate patients.25(pp206–208)

Smallpox was both endemic and epidemic despite attempted vaccinations, which 

featured often ineffective vaccines and failure to vaccinate enough of the nonvaccinated 

FIGURE 3-7. Convalescing soldiers at Carver Hospital, 1865, one of the Washington area’s hospitals. The 

pavilion-style hospital construction was utilized. Walt Whitman, a Sanitary Commission volunteer, made 

over 600 visits to military hospitals in the Washington area for the purpose of visiting the wounded. The 

pavilion style of hospital construction featured open ventilation and light. Photograph courtesy of the 

National Archives and Records Administration, Image #524592a.
CHAPTER THREE • 9 7

troops in both the North and the South.25(p199) As an example, The Smallpox Hospital 

in Richmond had 250 cases resulting in 110 deaths in 1 week in December 1862.25(p196)

Smallpox patients at Army camps were isolated in remote buildings.25(p198) Smallpox was a 

problem for prisoner of war camps in both the North and the South. It was medical policy 

for both the North and the South to vaccinate all prisoners who did not have vaccination 

scars. However, there were ineffective vaccines that did not prevent the disease.42(p294)

Smallpox also was an issue among Freedmen (freed slaves) who had not been vaccinated, 

and caused the majority of deaths in this group.42(p291) The attempts by physicians on both 

sides to treat smallpox once it developed were largely ineffective.42(p296)

Meier wrote an interesting book, published in 2013, that presents a unique thesis 

that the healthy soldier was distanced from the infirm by what she terms as “self-care.”44

Healthy soldiers bathed more often, washed their clothes, sought out good footwear as 

available, and sought better shelter. They would seek to supplement their camp diets with 

fruits and vegetables. To meet these ends, these soldiers might “straggle” behind their 

formations to forage for what they could along the route of the march.44(pp1–7)

Anesthesia

In the period leading up to the Civil War, anesthesia was not universally employed 

in the United States in either civilian or military settings. Of note, ether was utilized in a 

few cases in the Mexican-American War (1846–1848).45(pxii) Anesthetic agents had been 

available since the 1840s after the early use (1842) by Crawford Long, a surgeon.45(pp2–5)

Several men were involved in the introduction of ether as an anesthetic: Horace Wells, a 

Boston dentist; Charles Jackson, a Boston surgeon (who fought with Morton over claims 

for its use); and William Morton, a dentist (1846). An Edinburgh physician discovered 

chloroform’s use as an anesthetic in 1847. Indeed, Queen Victoria had used chloroform in 

1853 for the birth of one of her children.45(pxii) However, in the aftermath of the Crimean 

War, the British Surgeon General believed general anesthetics were dangerous in serious 

cases.6(p120) Even some medical journals in 1861 enunciated the belief that the patient’s 

excitement might carry them through and that anesthetics should be avoided.6(p120)

Nevertheless, the surgical use of anesthesia accelerated during the Civil War in response to 

the sheer numbers of wounded. Chloroform and ether were both available as anesthetics, 

but chloroform was the preferred agent when available, due to ether’s explosive nature. 

Alcohol (ie, liquor) was used to supplement these agents or to substitute for them when 

supplies were exhausted. 

During the Civil War, Union forces had no difficulty obtaining anesthetic agents. ER 

Squibb and other companies made both ether and chloroform. Squibb had been a Navy 

surgeon who later became a pharmaceutical manufacturer.46(p46) In fact, more than 1 

million ounces of each agent were purchased by the North during the conflict.46(p46) The 

South attempted to obtain adequate supplies of anesthetics through various methods. 

For example, some supplies were obtained by blockade running and the use of supplies 

captured from Northern troops.14(p9) Also, small amounts of ether and chloroform were 

manufactured in the South during the Civil War.46(p46) The South generally used chloroform 

anesthesia, which had been discovered in 1847 by Dr Simpson and used almost exclusively 
9 8 • FORWARD SURGERY

by the British in the Crimean War.25(pp225–226) WTG Morton, who had given one of the first 

anesthetics in Boston (1846), later gave many anesthetics during the Battles of Spotsylvania 

and the Wilderness, both in Virginia.46(p46),47(pp1068–1078)

Surgery 

Surgeons had antiseptics and disinfectants available, but they often didn’t use them 

effectively. For example, antiseptics might not be used until a wound was infected. 

Disinfectants were often used to get rid of odors associated with infections, but instruments 

and dressings were not routinely disinfected. Carbolic acid as an antiseptic had use in the 

Civil War, but it would not be used as a standard agent until Lister published his work with 

carbolic acid in 1867. 

Antiseptics included potassium iodide; potassium permanganate; carbolic acid; 

bromine; chloride; turpentine; and the nitric, sulfuric, and hydrochloric acids. The US 

Sanitary Commission published a pamphlet in 1863 on the use of disinfectants.6(p128) The 

Commission favored quicklime, chloride, bromine, and sulfate of lime.6(pp126–127) Some 

surgeons even washed their hands in chlorinated soda, which was shown in the 1840s to 

reduce childbirth fever.14(p9)

Dressings and bandages were a priority in medical supply. Bandages were often rolled. 

Dressings were termed wet or dry. Dry dressings, without added ointments or liquids, often 

resulted in improved healing. Wet dressings might involve placing a beeswax ointment 

(cerate). There was a further distinction between the cold and the warm dressing. The cold 

version might involve applying water continuously to the wound.14(p34) The warm version 

was associated with obtaining suppuration as a result of infection.6(p233)

The most common surgery involved bullet removal and wound cleaning, although 

amputations, with the images of piles of limbs, seem more common. The Minié ball wound 

was the responsible agent for many amputations. The Confederates preferred the circular 

method of amputation, while the North preferred a flap approach. The South considered 

the circular approach more efficient; in this method the skin and tissues were rolled over 

the stump and then closed. The flap method involved two strips of skin and tissue that were 

tied together and closed. The flap method left more tissue to cover the stump, in the view of 

those favoring the technique. 

Surgeons used scalpels, hemostats, and saws that would be familiar today. Instruments 

were kept in lined cases and were usually just washed off with stream or well water, or 

just wiped off before replacing in the case. Some instruments passed into history, such as 

the “Nelaton’s probe,” which had a ceramic knob that would show scratches when it was 

passed close to a bullet.19(p57)

Introduction of Female Nurses and Physicians

During the Civil War, the use of female nurses was a signal event. As Keegan pointed 

out in his article, “Reinventing the Battlefield,” combat of the Civil War period involved 

heavy and extensive rifle fire with entrenched soldiers, leading to more casualties, 

which made the role of nurses immediate.49 In 1862, the Secretary of War, upon the 

recommendation of Surgeon General Hammond, authorized a squad of 11 nurses to take 

care of 100 patients. The use of female nurses followed the precedent set in the Crimean 
CHAPTER THREE • 9 9

War. Dorothea Dix was appointed Superintendent of Female Nurses for the Union.50(p40)

The Catholic religious orders supplied many well-trained nurses, although Dix was not in 

favor because she (like many of her time) was suspicious of Catholic institutions.6(pp176–179)

In the nursing heritage, the name of Florence Nightingale stands out. She established a 

nursing training program at St Thomas’ Hospital in London during 1862. In America, 

nurses were often referred to as “Nightingales” because of her work.51(p408) Nurses during 

the Civil War performed many duties, including dispensing medications, changing dressings 

and bandages, and washing the wounded. They often cooked food for the wounded or ill. 

The role of the friend, the confidante, the letter writer, and the purveyor of hope were all 

extremely valuable.51(p424)

Clara Barton was one of the most famous of women involved in the Civil War. Barton 

started as a teacher but gained a position as a clerk in the US Patent Office (in Washington, 

DC). She worked there from 1854 to 1857 and then again from 1860 to 1865, which 

provided support for her Civil War pursuits. She obtained influential backers, which 

allowed her to operate independently of The Sanitary Commission and Dorothea Dix and 

her nurses.14(p37)

Barton provided care in 1861 for wounded soldiers injured by Baltimore mobs. She 

gathered donated supplies and took them to Culpeper and Fairfax Station, Virginia. 

Barton attended the wounded at Fredericksburg in 1864. She set up an office in Annapolis, 

Maryland, that would help families find their soldier relatives. She went to the infamous 

Confederate prison at Andersonville, Georgia. She made a list of all that had died the past 

year and where they were buried. She continued her important work running her missing 

person office, receiving only a small amount of government aid in 1866.14(p39)

Dr Elizabeth Blackwell, the first female American graduate in medicine, established 

a nurses’ training program to provide skilled individuals.43(p424) There were always issues 

about the nurses, including concerns about the baggage accompanying them. There was 

criticism that the nurses were too interested in carrying clothes, and personal items such as 

brushes and combs.6(p183)

Dorothea Dix’s organization supplied nurses to Army field hospitals. The exasperated 

reaction of the medical director, Dr John Brinton, of the large facility at Cairo, Illinois, 

was not unusual for the time. The doctors were most upset with the fact that the nurses 

did not understand military order. Dr Brinton was quoted as saying of the nurses: “They 

defied all military law.”41(p54) Mary A Bickerdyke (known as Mother Bickerdyke) openly 

challenged the authorities in Union Hospitals. She told them she received her authority 

from the Creator.41(p57) The attitudes of both the physicians and the nurses softened as the 

war progressed. 

In the Confederate hospitals, good nursing was recognized early and the best nurses 

were deemed by the patients to be women. A number of women were employed in military 

hospitals, although the role was not generally supported in public thought.25(pp267–268) In the 

South, local women’s organizations provided assistance. Mrs Opie Hopkins, for instance, 

was sent to Richmond with food and clothing for the wounded by the Ladies Aid Society 

of Montgomery (and later the Ladies Aid Society of Alabama). They continued their 

growing assistance until they aided the Alabama section of the noted Chimborazo Hospital 

in Richmond.41(p54)
100 • FORWARD SURGERY

Another interesting personage is that of Dr Mary Walker, who graduated in 1855 

from Geneva Medical College. Dr Walker worked to become an official assistant surgeon, 

even to the point of showing up for duty in a uniform she had created herself. She was first 

allowed to work only as a nurse; then in late 1861 to work as a volunteer field surgeon. In 

1863, she was hired as a civilian contract assistant surgeon, finally quietly being integrated 

into the ranks of medical professionals.41(p60) In the Confederacy, Jefferson Davis gave a 

commission (as a captain) in the Confederate States of America to nurse Sally Tompkins 

so she could continue her work after all Confederate hospitals were placed under military 

control.41(p58)

WEAPONS AND WOUNDS OF THE CIVIL WAR

Rifles

Captains Claude-Etienne Minié and Henri-Gustave Delvigne of the French Army 

devised a rifle, the Minié rifle, in 1849 that would fire a conical hollow-base projectile with 

three ring bands that would deform when fired and create a good seal in the chamber to 

prevent the loss of gases. The bands expanded into the rifling of the barrel after firing. The 

ball could be easily and quickly inserted down the muzzle loader’s barrel.39(p8) By 1851 the 

British had equipped their forces with the Minié rifle, firing the feared Minié ball projectile.

By contrast, smooth-bore muskets required actively ramming the ball down the muzzle 

with a rod, which took extra time and effort. Interestingly, Jefferson Davis (later the 

President of the Confederate States of America), while serving as the US Secretary of War, 

held tests of the rifle in 1854 that led to the direct production of the 1861 Springfield rifle. 

The Springfield, using the Minié ball ammunition, was accurate out to 1,000 yards.17(p191)

Davis standardized the .58mm caliber Minié ball as the Federal ammunition. The shorterlength barrel of the Harpers Ferry .58 caliber rifle was a limiting factor in terms of range, 

but the Confederates came into possession of many of these weapons when they took 

the Federal Armory at Harpers Ferry, West Virginia, in October 1859.39(p6) The Englishmanufactured Enfield was respected and used by both sides for its quality of manufacture. 

It was held almost to the standard of the 1861 Springfield rifle. Other foreign weapons 

were used, especially by the Confederates, including the .54 caliber Austrian Lorenz rifle 

musket and a .71 caliber Belgian rifle musket.39(p6) The Confederates manufactured copies 

of the Springfield rifle for their troops, such as the “Richmond” rifle.

By 1860, percussion cap and Minié ball rifles were the standard infantry weapon of 

the Union forces. The Spencer and Henry breech-loading repeating rifles were introduced 

soon thereafter, although not widely used until later in the war. Breech-loading and 

relatively rapid-firing percussion weapons such as the Henry (featuring an elegant brass 

receiver) were expensive because they required critical machining. The Henry rifle was the 

forerunner of the 1873 Winchester repeating rifle. All of the small arms used black powder, 

which added to the haze over a battlefield, hindering accuracy.50(pp94–95),51(pp56–62)

Bilby calls 1863 the “year of the rifle-musket”50(p95) because both sides were finally 

equipped with the standard weapon for the conflict, which was a single-shot rifled weapon
CHAPTER THREE • 101

such as the weapons produced at the Springfield Armory.2 However, he terms 1864 the 

“year of the repeating rifle”52(p95) because increasing numbers of Spencer rifles, and to a 

lesser extent the Henry rifle, started to be seen more.50(pp94–95) These breech-loading rifles 

used copper rim-fire cartridges that contained the powder and the primer.50(p95)

Corbusier explained that his 6th Illinois Cavalry of 1,000 men were armed with 

“sabres and Spencer carbines, having one shot in the chamber and six in the breech.”23(p50)

He further describes the carbines having “cartridges [that] were metallic . . . unlike the 

paper cartridges used in standard weapons . . . which required good teeth to tear”23(p50) the 

packets open to load the weapon. Corbusier speculated that the use of the Spencer carbine 

with its metallic cartridges allowed men with few or no teeth to be recruited. The carbines 

had issues that he described in his writings of a soldier using a carbine that had mechanical 

loading problems or, as Corbusier described, “the cartridges soon gave out on the advanced 

line”23(p50) and he came back carrying his “hat full of cartridges.”23(p50) Despite glitches in the 

weapon as noted by Corbusier, the Spencer used .56-.56 caliber cartridges; the rifle could be 

very effective in combat.

The Union in 1864 contracted with the Spencer factory to buy every Spencer rifle it 

could manufacture. Many units clamored to be equipped with the new rifle. The Henry 

rifle (the 16-shot rifle) was usually obtained as a private purchase item; however, the 

Ordnance Department provided the ammunition for the Henry. The South came into 

possession of some captured repeating rifles, but ammunition was always a problem, unless 

it was also captured.50(p116) Union units used the Henry repeating rifle as an enlistment 

inducement.51(p62) The Spencer repeating rifle made a considerable contribution to Union 

firepower, especially the cavalry. The rifle was not manufactured beyond 1865 because the 

Army had a need for a large-caliber round, which could be accommodated only with a 

single-shot rifle at that stage of technology.51(p62)

Handguns

Handguns were the favorite of cavalry troops. The Union purchased over 370,000 

pistols in the war. The weapons of choice included the .44 caliber Army Colt and the 

.36 caliber Navy Colt pistols. The Union purchased approximately 12,000 Lefaucheux 

French pistols, which fired a unique .41 caliber pin-fired self-exploding cartridge.1(pp136–137)

Revolvers were issued to cavalry and officers, but not to the enlisted men. However, the 

enlisted men managed to equip themselves. Oftentimes, infantry troops found the revolvers 

were not as useful as they thought they would be and frequently sold or simply disposed 

of them. The Confederates, when faced with a shortage of handguns for the cavalry, 

confiscated such guns from the infantry. Handguns used in the South came from captured 

stocks and imported weapons. The British-made Adams and Deane, and the Kerr revolvers, 

were imported in quantity. The Colt revolvers of the Army and Navy versions were also 

sought-after weapons.1(p137)

Projectiles

The infamous Minié ball, a low-velocity projectile, caused severe wounds. The bullet 

could shatter bone and tear soft tissue, while bringing fragments of clothing and other 
102 • FORWARD SURGERY

forms of contamination into the wound. Infection would often follow. The fractures 

resulting from the ball were complex enough to challenge surgeons today.11(p282) The 

Minié ball was said to have caused 108,000 wounds (where the type of projectile could 

be determined), as opposed to only 16,000 for the older round ball.6(p114) Most of the 

Confederate rifle wounds were caused by the Minié ball.25(p220) There were some explosive 

Minié balls that embedded copper, lead, and pewter into the wound.11(p282)

Artillery

Artillery weapons were common on the battlefield. The “Napoleon” was used most 

commonly by both the North and the South. It was a smooth-bore muzzle-loading cannon 

that used a 12-pound ball projectile. It was developed in France during the Napoleonic 

years, but it was only introduced into the United States in 1856. The rifled artillery pieces 

were used somewhat less frequently and included the Parrot and the 3-inch ordnance. The 

rifled weapons had longer range but were best against fortifications because the accuracy 

depended on line-of-sight visualization. These weapons were all muzzle loading. Breechloading weapons were starting to be used, but were troublesome. The early breech-loading 

artillery had problems with the breech seal (to prevent escaping gases) and the seating of 

the shell.1(pp140–141)

John Keegan noted that “[u]ltimately, Civil War battles came to be characterized by 

heavy rifle fire, by the [relative] absence of artillery, and the prevalence of earthworks.”49(p87)

Keegan felt that artillery and the cavalry were comparatively insignificant in Civil War 

encounters. He went on to note that heavy casualties were typical of Civil War battles, 

which he attributed to local terrain making it difficult to maneuver or escape. He would 

include such a situation as those at Antietam and parts of Gettysburg’s battlefield.48(p87) Of 

special note, there were few bayonet or edge weapon (sword) wounds, despite the popular 

image of forces charging each other with fixed bayonets and drawn swords.6(pp113–114) 

THE WAR CONTINUES

In September 1863, the Battle of Chickamauga (named for a creek in northern 

Georgia) proved to be a bloody affair. Despite being a Confederate victory, General 

Braxton Bragg failed to deliver a decisive defeat to the Union. However, the South did get 

a morale lift in Chickamauga after its defeats at Vicksburg and Gettysburg.52(pp101–102) By 

the midpoint in the war, both sides had shortages of physicians, treatment facilities, and 

medical supplies.52(p106) Rubenstein points out that the Medical Directors for the North (the 

Army of the Cumberland) and the South (the Army of Tennessee) had treatment schemes in 

place at the Battle of Chickamauga that proved to be inadequate, which resulted in needless 

deaths.52(p110) For example, the Union hospitals were not placed well. The location of the 

hospitals was said to have been poor as they were exposed to artillery and assault. The 

main hospital was located at Crawfish Springs, which at least did offer water for the Union. 

(The entire area had sustained a drought.52(p74)) The wounded were evacuated by the Union 

by scheduled day and mail trains to the general hospitals, while an equal number were sent 
CHAPTER THREE • 103

by troop transport trains on the backhaul route (trains returned empty after off-loading 

cargo, hence they were available for carrying wounded).52(p109)

The Confederates, led by General Bragg, assaulted Union forces at Chattanooga, 

Tennessee. Ulysses Grant had recently been appointed commander of the Military 

Division of the Mississippi. The Confederates in the end were defeated in their combat 

attempts; more importantly, their defeat opened the way for Sherman’s advances into the 

South.1(pp105–106)

Lee and Grant faced each other as adversaries for the first time at the Battle of the 

Wilderness in Virginia. It is of note that in 1864 the Confederate Surgeon General directed 

that a Reserve Surgical Corps be set up so that the reserve could be used in emergencies. 

However, Lafayette Guild, the Confederate Medical head at the Battle of the Wilderness, 

was unable to get as many of the reserve members as needed.25(pp116–117) Despite heavy losses 

for both sides, the Wilderness Campaign ended in a stalemate, which was followed by the 

May 1864 Battle of Spotsylvania, also in Virginia. This latter battle also resulted in huge 

losses for both sides, but the casualties could be better absorbed by the North with its 

greater overall population.1(pp11–12)

At the start of the war, captured medical officers were held as prisoners of war in 

the same manner as regular line officers. Generally, surgeons would be left to attend the 

wounded when the forces of either side retreated. However, an agreement of 31 May 1862 

between medical officers of both sides was followed by a General Order from McClellan’s 

headquarters and copied to General Lee that medical officers would be exchanged.25(pp130–131)

The ready exchange worked well, despite an 1863 issue concerning a Union surgeon who 

was sought for civil charges by the Richmond authorities.25(p132)

THE WAR ENDS 

As the Confederate defeats continued, Lee was given overall command of the 

Confederate armies in 1864. However, the South continued to experience shortages of 

almost everything. A string of defeats at Petersburg, the fall of Richmond, Sherman’s wins 

(Atlanta, Georgia; the Carolinas; and Savannah, Georgia), and Sheridan’s victories in the 

Shenandoah region in Virginia all led up to the final events. The end was signaled by Lee’s 

surrender to Grant at the Appomattox Court House. America’s greatest battle carnage was 

finally over.

MEDICAL OUTCOMES

The implementation of an effective ambulance evacuation scheme was perhaps the 

signal advance of the Civil War. Limb immobilization, using splints such as the Hodgen 

Splint, provided improvement in the handling of orthopedic injuries. The beginnings of 

specialty division care started in the war, with reconstructive surgery and neurological 

surgery being first. Dr S Weir Mitchell was a neurologist to whom Surgeon General 
104 • FORWARD SURGERY

Hammond dedicated a hospital for Mitchell to study neurological disease. Mitchell and his 

associates looked at the relief of phantom limb problems and various nerve injuries (among 

many areas of interest).11(p283)

 Considerable progress was made in the creation of artificial limbs for those soldiers 

with lost extremities. Mobility in the ankle of the prosthesis was a new advance. Surgeon 

General Hammond appointed a committee of physicians to approve the dispensation of an 

artificial limb. The soldier could then choose a prosthesis from a number of manufacturers 

that cost $50 or less.11(p287)

Many surgeons gained improvement in their skill set, which would benefit future 

patients. The following surgeons are examples of the later successes of the many surgeons 

who served during the Civil War. Dr William W Kean, a veteran of Gettysburg and other 

campaigns, went to Europe for additional training after the war and became one of the 

first American surgeons to adopt Lister’s antiseptic techniques. John Shaw Billings helped 

establish the Army Medical Museum and went on to design the new Johns Hopkins 

Hospital.21(pp289–290) Dr William Corbusier continued to serve in the Army and served 

through World War I. Many other less famous surgeons were to serve their country in 

myriad ways after this terrible war. 

REFERENCES 

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Essential Facts About the War That Divided America. Avon, Mass: Adams Media; 2007. 

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America’s Greatest Conflict But Never Learned. New York, NY: William Morrow and 

Company, Inc; 1996. 

3. Jensen LD. Johnny Reb: The Uniform of the Confederate Army, 1861–1865. Mechanicsburg, 

Penn: Stackpole Books; 1996. 

4. Haller JS. Battlefield Medicine: A History of the Military Ambulance From the Napoleonic Wars 

Through World War I. Carbondale and Edwardsville, Ill: Southern Illinois University Press; 2011.

5. Straubing HE. In Hospital and Camp: The Civil War Through the Eyes of Its Doctors and 

Nurses. Harrisburg, Penn: Stackpole Books; 1993.

6. Adams GW. Doctors in Blue: The Medical History of the Union Army in the Civil War. 

Shreveport, La: Louisiana State University Press; 1996.

7. Fox WF. Regimental Losses in the American Civil War, 1861–1865. Albany, NY: Albany 

Publishing Company; 1869. Available online as an e-book at https://archive.org/stream/

regimentallosses00foxw#page/n9/mode/2up. Accessed 23 March 2015.

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University Press; 2013. 

9. Hacker JD. A Census-based count of the Civil War dead. Civil War Hist. 2011;57(4):307–348. 

10. Blaisdell FW. Medical advances during the Civil War: presidential address. Arch Surg.

1988;123(9):1045–1050.

11. Gillet M. The Army Medical Department 1818–1865. Washington, DC: Center of Military 

History, United States Army; 1987. 

12. Letterman J. Medical Recollections of the Army of the Potomac. New York, NY: D Appleton 

and Company; 1866.

13. Medical Heritage Library. Internet Archive. Confederate States Medical and Surgical Journal. 

https://archive.org/details/confederatestate12conf. Accessed 23 March 2015.
CHAPTER THREE • 105

14. Schroeder-Lein G. The Encyclopedia of Civil War Medicine. Armonk, NY: ME Sharpe, Inc; 

2008: Introduction.

15. Stille CJ. History of the United States Sanitary Commission Being the General Report of Its 

Work During the War of the Rebellion. Philadelphia, Penn: JB Lippincott and Company; 1866.

16. The Sanitary Commission of the United States: A Succinct Narrative of Its Works and Purposes. 

Ithaca, NY: Cornell University Library; 1864. 

17. Naythons M. The Face of Mercy: A Photographic History of Medicine at War. New York, NY: 

Random House; 1993.

18. Morris R. The soldier’s missionary. Civil War Q. 2014;Spring:52, 59. 

19. Norris DA. Life during the Civil War. History Magazine (Toronto, Can: Moorshead Magazine, 

Ltd.); 2009. 

20. Howe SG. The United States Sanitary Commission. Ithaca, NY: Cornell University Library; 1864. 

21. McGaugh S. Surgeon in Blue. New York, NY: Arcade Publishing Company; 2013. 

22. Schultz D. A strange and blighted land. MHQ: Q J Mil Hist. 2013;25(4):78. 

23. Corbusier WH, Wooster R (ed). Soldier, Surgeon, Scholar: The Memoirs of William Henry 

Corbusier 1844–1930. Norman, Okla: University of Oklahoma Press; 2003.

24. Coffin H. The Battered Stars: One State’s Civil War Ordeal During Grant’s Overland 

Campaign. Montpelier, Ver: Country Man Press; 2002.

25. Cunningham HH. Doctors in Gray: The Confederate Medical Service. Shreveport, La: Louisiana 

State University Press; 1958. 

26. Garrison FH. John Shaw Billings: A Memoir. New York, NY: GP Putnam’s; 1915.

27. Sears SS. To the Gates of Richmond: The Peninsula Campaign. New York, NY: Ticknor and 

Fields; 1992. 

28. Brown HE. The Medical Department of the United States Army From 1775 to 1873. 

Washington, DC: Surgeon General’s Office; 1873.

29. Barbour JH. And now a few words on the battle of Williamsburg. Colonial Williamsburg. 

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30. Clements BA. Memoir of Jonathan Letterman, MD, Surgeon United States Army and Medical 

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32. Eicher D. The Longest Night: A Military History of the Civil War. New York, NY: Simon and 

Schuster; 2001.

33. Trudeau NA. Did Lee doom himself at Gettysburg? Q J Mil Hist. Summer2009;21(4):14–25.

34. Beck PN. Columns of Vengeance: Soldiers, Sioux, and the Punitive Expedition, 1863–1864. 

Norman, Okla: University of Oklahoma Press; 2013. 

35. Office of Medical History. US Army Medical Department. Surgeons General. William 

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March 2015.

36. Office of Medical History. US Army Medical Department. Surgeons General. Thomas Lawson. 

http://history.amedd.army.mil/surgeongenerals/T_Lawson.html. Accessed 23 March 2015.

37. Office of Medical History. US Army Medical Department. Surgeons General. Clement A Finley. 

http://history.amedd.army.mil/surgeongenerals/C_Finley.html. Accessed 23 March 2015.

38. Office of Medical History. US Army Medical Department. Surgeons General. Joseph K Barnes.

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39. Field R. Eastern Theater 1861–1865: Union Infantryman Versus Confederate Infantryman.

Botley, Oxford, United Kingdom: Osprey Publishing Ltd; 2013.
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40. Army Heritage Center. A Deadly Scourge: Smallpox During the Revolutionary War. https://

www.armyheritage.org/education-and-programs/educational-resources/education-materialsindex/50-information/soldier-stories/282-smallpoxver. Accessed 23 March 2015.

41. Freemont F. Gangrene and Glory: Medical Care During the Civil War. Carbondale, Ill: 

University of Illinois Press; 2001. 

42. Bollet AJ. Civil War Medicine: Challenges and Triumphs. Tucson, Ariz: Galen Press; 2002.

43. Downs J. Emancipation, sickness, and death in the American Civil War. Lancet. 

2012;380(9854):1640–1641.

44. Meier KS. Nature’s Civil War: Common Soldiers and the Environment in 1862 Virginia. Chapel 

Hill, NC: University of North Carolina Press; 2013. 

45. Snow SJ. Blessed Days of Anaesthesia: How Anaesthetics Changed the World. Oxford, England: 

Oxford University Press; 2008.

46. Wright AJ. The merciful magic of ether-anesthetics in the Civil War. Anaesth News. 

2013;393. http://www.anesthesiologynews.com/ViewArticle.aspx?d=Ad+Lib&d_

id=384&i=March+2013&i_id=937&a_id=22708. Accessed 23 March 2015.

47. Morton WTG. The first use of ether as an anesthetic at the Battle of the Wilderness in the Civil 

War. JAMA. 1904;42(18):1153. 

48. Keegan J. Reinventing the battlefield. Q J Mil Hist. 2009;22(1):80–87. 

49. Beller SP. Medical Practices in the Civil War. Cincinnati, Oh: Betterway Books; 1992.

50. Bilby JG. The guns of 1864. Am Rifleman. 2014;162(5):94–95. 

51. Bilby JG. The guns of 1865. Am Rifleman. 2015;163(3):56–62.

52. Rubenstein DA. Thesis: A Study of the Medical Support to the Union and Confederate Armies 

During the Battle of Chickamauga: Lessons and Implications for Today’s US Army Medical 

Department Leaders. Submitted to the Faculty of the US Army Command and General Staff 

College. Fort Leavenworth, Kans: US Army; 1990. http://history.amedd.army.mil/booksdocs/

civil/ThesisRubenstein/rubenstein.html. Accessed 23 March 2015. 
INTRODUCTION

AT THE END OF THE CIVIL WAR, the size of the US Army was reduced to prewar 

levels and its missions were redirected. The Army reverted to its prewar model of 

dealing with Indian irregular warfare, with a limited role as an occupation force in the 

reconstruction of the South. Years later, the Army had to quickly gear up for a more 

modern conflict in the Spanish-American War. The Army also saw action in China (the 

Boxer Rebellion), the Philippines (the Philippine Insurrection), and in Mexico, all in the 

prelude to World War I. 

In the Civil War, the Regular Army became less attractive as a destination for recruits 

as the war progressed due to the popularity of the volunteer units. This was because the 

volunteer units of the states had more favorable terms of service and bounties than did the 

Regulars.1(p381) The whole issue became more of an academic topic once peace came and the 

separate militaries of the North and the South melted away. 

The Civil War resulted in casualties of a magnitude not seen in warfare up to that time. 

However, largely due to medical innovations introduced during the Civil War, the mortality 

rate was reduced significantly as the war went on. As an example, the mortality rate 

sustained by soldiers at Gettysburg was only one-third of the mortality experienced during 

the Peninsula Campaign just one year earlier.2(p214) However, as the war ended, the lessons 

learned about mass casualty management were not applied because monies became scarce 

and the once great Army was reduced to a fraction of its previous size. 

As a detractor from the aftermath of the Civil War, the Army’s attention was focused 

again on the international stage with potential changes for both the North and the newly 

defeated South. The French intervention in Mexico was guided by Napoleon III; the 

French government also established the Austrian Maximillian as Emperor of Mexico. 

This incursion of a European power literally in the backyard of both the North and the 

South represented an additional threat as the Civil War ended. One of the agendas of the 

Chapter Four

Transitions: Army Medicine 

in the Post-Civil War Period 

to the Start of World War I

LANCE P. STEAHLY, MD
108 • FORWARD SURGERY

Confederacy at the 1865 Hampton Roads Conference dealt with this Mexican/French 

issue. Prior to the end of the Civil War, on 3 February 1865, President Abraham Lincoln 

and Secretary of State William Seward met with representatives of the Confederacy aboard 

a steamboat in the James River at Hampton Roads, Virginia. The Confederate delegates 

included the Confederate Vice President Alexander Hamilton Stephens and two others. The 

Confederates hoped that the Union could be persuaded to work with the South in dealing 

with the French incursion.3(pp210–211) However, the Mexicans dealt with Maximillian after the 

French abandoned the venture. After the end of the French adventure in 1867, the Army 

did not plan for any larger conflicts.

IMMEDIATE POST-CIVIL WAR PERIOD

A monumental effort by the Army Surgeon General’s Office, under the guidance of 

Surgeon General Joseph Barnes, resulted in the publishing of six volumes between 1870 

and 1888. The Medical and Surgical History of the War of the Rebellion, 1861–1865 was 

the result of that effort using much data from the Provost Marshal General’s Bureau.4 This 

compilation of the statistics and experience of the US Army Medical Department should 

have been an aid to planning for conflicts of the future. Unfortunately, as in many wars, the 

lessons learned were forgotten and had to be relearned for future conflicts.

The volunteers were rapidly and completely released from duty while Congress 

reduced the number of Regular troops from 54,000 in 1867 to 26,000 in the 1870s.5(p218)

Immediately following the Civil War, the Medical Department, like the Army as a whole, 

spent much of its energy reducing personnel and hospitals. Contract surgeons were reduced 

to 187 by 1870 from the many thousands used in wartime.6(pp4,7,8) A peacetime Medical 

Corps was established in 1866 by Congress. It featured a Surgeon General at the rank 

of brigadier general and an Assistant Surgeon General as a colonel. Field surgeons were 

continued as a surgeon (ranked as a major) and an assistant surgeon (ranked as either a 

lieutenant or a captain).4(p901) The Regular surgeons and assistant surgeons who remained 

in the Army had to meet high standards. While these positions might look good to a 

young physician without prospects, the slow promotions and low pay that characterized 

the peacetime Army had a negative effect on recruiting the best physicians for these 

positions.7(p106) It was not until 1876 that Congress increased the number of colonels to 

three and doubled the number of lieutenant colonels, potentially benefiting recruitment by 

freeing up more spaces at the top of the pyramid. Otherwise, Congress did not address the 

recruitment issue.8(pp250–251)

As mentioned above, the post-Civil War Army reverted to its prewar Indian fighting 

model but gained a role as a limited occupation force enforcing Reconstruction in the 

South. The many physicians, the large general hospitals, and the hospital trains and 

ships were no longer needed. The medical service in the South involved dealing with the 

inevitable diseases and with the health of troops and Freedman’s Bureau clients. The Indian 

war fighting role involved frontier post medicine and surgery, punctuated by various 

campaigns to deal with irregular warfare.
CHAPTER FOUR • 109

Dr William Henry Corbusier actually experienced both roles in his career. In 1864, 

Dr Corbusier accepted a contract offer as an Acting Assistant Surgeon in the US Army 

for 1 year. He was ordered to Amite, Louisiana, where he was stationed with the 1st 

US Infantry under Brevet Major Offley. His book, titled Soldier, Surgeon, Scholar: The 

Memoirs of William Henry Corbusier,

9

 provides a uniquely personal experience of that 

time in Louisiana.9(pp62–63) He requested that his contract end early on 14 June 1865 because 

he wished to earn a medical degree. Although he was a surgeon in the war, he didn’t receive 

his medical degree until 1867 from the Bellevue Medical College, after attending lectures 

and clinics. 

As in the case of Corbusier’s commanding officer, brevet ranks were used in several 

ways. Brevet rank could be conferred when a position called for a higher rank, much as 

services may “frock” someone with a command requiring a higher rank. Brevet ranks 

were conferred, as were substantive regular ranks, by a nominating process requiring 

Senate confirmation. Eicher and Eicher note that in the period of rapid demobilization and 

military occupation of the South during Reconstruction, brevet ranks conferred during the 

Civil War were all given the “omnibus” date of rank of 13 March 1865.10(p34) However, for 

medical officers the rank situation remained murky. The formal ranks granted in 1847 were 

not clarified so the rank equivalents in the form of the titles of “surgeon” and “assistant 

surgeon” continued. However, the Surgeon General did have an official brigadier general 

rank and prevailed as one of the all-powerful bureau chiefs. These Army bureau chiefs ran 

their own departments and had direct access to the Secretary of War.11(p4)

Army duty in the period of Reconstruction in the South presented its own medical 

challenges. Disease remained the Army’s major problem in the immediate post-Civil War 

era. Preventive medicine remained the only real defense against disease available to the 

Army surgeon. Unfortunately, the surgeon’s recommendations to the line officer concerning 

preventive medicine measures were often disregarded. However, in 1874, the Army did 

require the surgeon to make sanitary and public health recommendations that had to be 

approved or disapproved by the commander. The commander had to forward his reasons 

for his actions to the territorial/regional commanding general.11(pp39–40)

There were areas in which medical care was inadequate for a variety of reasons. For 

example, smallpox vaccinations were required for Army soldiers, but local communities 

were frequently not protected due to antivaccination movements. Sometimes lax 

enforcement of the vaccination requirement was the problem. For instance, approximately 

600 Black soldiers died of smallpox in 1866, which the authorities attributed to a postwar 

letdown in precautions.11(pp39–40) Other diseases were also prevalent. Yellow fever was 

always a peril in the South. Yellow fever epidemics were reported in Florida in 1867, 

causing the death of one soldier at Key West and 27 at Fort Jefferson. Dr Samuel Mudd, 

of Lincoln conspiracy fame and a prisoner there, was given permission to work at Fort 

Jefferson to deal with the illness. Cholera was also a real threat, although the death rate 

from cholera declined after 1867 due to the implementation of better medical practices, 

while yellow fever rates climbed. In 1869, yellow fever caused 12 soldier deaths in 

Pensacola, Florida. Captain George Sternberg, the future Army Surgeon General, was 

a surgeon at Fort Barrancas (Pensacola). Sternberg came down with yellow fever but 
110 • FORWARD SURGERY

survived, after which he gained a special interest in the disease. After 1869, the death 

rates fell as yellow fever and cholera cases decreased in part due to the isolation of the 

troops from other populations.11(pp40–41) As Gillet notes, the Army moved troops away 

from involved areas, which helped, but the mortality rate with yellow fever cases could 

nonetheless exceed one-third of the total number of cases.11(p41)

A major postwar development for the Army Medical Department was the creation of 

the Hospital Corps in 1886. The Corps would be composed of hospital stewards, acting 

stewards, and privates. Hospital corpsmen still had to be trained for their wartime roles 

as soldiers because they might be called upon for defense, especially in the West. Schools 

of instruction were set up to teach horse care, first aid, anatomy, physiology, nursing, and 

pharmacy. More than 400 hospital corpsmen were trained from 1891 to 1896, but many 

were lost to attrition due to lack of interest or academic failure. Because they were also 

soldiers, those dropping out would serve in the ranks.11(pp100–101) However, random soldiers 

could not be picked to work as nurses in the hospitals—only stewards of the Hospital 

Corps with appropriate training could work there. Especially in the West, stewards were 

dispersed among the posts and did not have the ability to work and train together beyond 

their initial steward course. In the late 1880s, the reduced Indian threat brought some 

attention to the prospect of medical readiness for other threats. In 1883, the Surgeon 

General recommended that the Medical Department’s enlisted soldiers train together.5(p396)

Despite the number of posts declining after the Civil War, the individual medical officer 

had more responsibilities. By the 1890 to 1891 year, the Army had closed more than onefourth of these posts5(p80); the surgeon had little staff and almost no respite. The posts were 

often in remote areas with little to offer in terms of diversions or amenities for a family. 

Families had difficulty obtaining clothing and household goods, which often had to be 

ordered from cities or sent by relatives. The medical officer had to care for the soldiers and 

their families. The doctor trained his stewards and litter carriers to his specific requirements 

beyond any initial school training. There was a professional need to pay more attention 

to antiseptic principles and the consequent need for more skilled surgical interventions, as 

improved techniques became known.

SURGEONS GENERAL CONTRIBUTIONS IN THE 

PERIOD 1865 TO 1917

The period from the end of the Civil War to the start of World War I can be viewed 

through the accomplishments of the respective Army Surgeons General. The Surgeons 

General all faced challenges to provide care at the many widely separated posts with limited 

resources. The expected budget cutting following a major war persisted as a political 

feature up to the Spanish-American War. The Surgeons General from 1865 to 1893 were 

all Civil War veterans; six of the number had served prior to the war. 

Joseph K Barnes (22 August 1864–30 June 1882)

The first of these men was Brigadier General (BG) Joseph K Barnes, who entered office 

in 1864. Barnes attended, but did not graduate from, Harvard College. He received his 
CHAPTER FOUR • 111

medical degree from the University of Pennsylvania in 1838. He served at various Army 

posts and was a participant in the Mexican-American War. After serving in many posts, he 

served in various Civil War commands in Missouri and Kansas. He was then assigned to 

Washington, DC, where he became the attending military surgeon in that city. The duties 

included caring for the ranking military and civilian office holders. Barnes made a favorable 

impression upon Secretary of War Edwin Stanton.12

Barnes’ appointment as the Surgeon General was the result of the court-martial 

conviction of the prior Surgeon General, William Hammond. Barnes was officially 

appointed as a brigadier general, but was given a brevet appointment as a major general 

due to his Civil War service. Stanton was instrumental in Barnes’ appointment. Barnes 

developed the Army Medical School and Medical Museum. He was one of the attending 

physicians for President Garfield during his illness. He left office in mid-1882 due to 

nephritis, which ultimately caused his death in April 1883.13(pp233,247)

Charles H Crane (3 July 1882–10 October 1883)

Barnes was followed by his Assistant Surgeon General, BG Charles Crane, who 

held the position until he died of a hemorrhage from an oral tumor a little over a year 

after becoming Surgeon General. Both Barnes and Crane were involved in the dramatic 

drawdown of forces.14(p52) Crane graduated from Yale College and then Harvard Medical 

School in 1847. He served at Veracruz during the Mexican-American War, and also 

participated in the Seminole Wars for 3 years (1849–1852). Crane went on to serve in 

California and Oregon, and later in Florida. He served in the Civil War as the primary 

assistant to Surgeon General Barnes. Barnes had retired in 1882 because Congress had 

passed legislation in June 1882 mandating retirement for age, and he was a year beyond the 

maximum age. Crane followed Barnes to the Surgeon General post in July 1882.15

Robert Murray (28 November 1883–6 August 1886)

Crane was followed by another Assistant Surgeon General, BG Robert Murray, in 

November 1883. Murray had served in the Army Medical Department since 1846, hence 

providing a long historical perspective ranging to the Mexican-American War.14(pp74–76)

Murray received an MD degree from the University of Pennsylvania in 1843. He became 

an assistant surgeon in 1846. Murray spent the Mexican-American War years in California 

until 1850, when he returned to the East. In 1854, he was again posted to California and 

he remained there until the start of the Civil War. He served with what became the Army 

of the Cumberland and was its medical director until 1862. Murray was then posted to 

Philadelphia, Pennsylvania, as the medical purveyor commanding a depot from which 

he was the principal purchasing agent for medical supplies and medicines. In 1866, he 

became the medical purveyor at San Francisco and remained there until 1876. In 1880, he 

became the medical director of the Division of the Atlantic. As the ranking medical officer, 

he became the Assistant Surgeon General to the newly appointed Surgeon General Crane. 

When Crane died in 1883, President Arthur advanced the senior man, namely Murray, 

to the Surgeon General’s office. Murray recognized advances in surgery and advocated 

antisepsis and antiseptic surgery in reports. He was responsible for a report citing 

contaminated water at posts as a disease source. Murray retired due to age in 1886.16
112 • FORWARD SURGERY

John Moore (18 November 1886–6 August 1890)

After much political maneuvering by the various eligible senior officers, President 

Grover Cleveland appointed BG John Moore, who had been Major General (MG) William 

Sherman’s medical director near the end of the Civil War, to be the next Surgeon General. 

Moore received a medical degree in 1850 from the University of the City of New York. He 

did an internship at Bellevue Hospital and then worked for several years at the New York 

Dispensary. He passed the examination for assistant surgeon in the Army in 1853, receiving 

an appointment in June. Moore was posted at various assignments, including duty at the 

Marine Hospital at Cincinnati, Ohio, where he remained until 1862. In 1862, he was 

assigned to the Army of the Potomac as medical director of the Central Grand Division. 

In 1863, he became the medical director for the Department of Tennessee. Murray then 

became the medical director for the Army of Georgia and Tennessee (the designation for 

a larger command) and later the medical director at Vicksburg, Mississippi. He remained 

in Mississippi until 1866, when he relocated to New York. After 2 years in New York, he 

spent the period from 1868 until 1880 as an attending surgeon at area hospitals (private 

practice) and served on various boards while based in New York City. He became the 

medical purveyor at San Francisco until appointed Surgeon General in 1886. 

Moore was instrumental in having first aid taught throughout the Army. Various 

teaching and training manuals were produced. Under his guidance, Army regulations were 

issued for the conduct and training of the Hospital Corps, which Congress established in 

1887. He encouraged sanitary reports, adding awareness to the sanitation efforts of posts. 

Moore retired in 1890 for reasons of age.17

Jedidiah Baxter, MD (16 August 1890–4 December 1890)

BG Jedidiah Baxter, the chief medical officer in the Provost Marshal’s office,13(p76)

became the next Surgeon General after being involved in political infighting for most of 

his career. Baxter received his medical degree from the University of Vermont in 1860. He 

spent some time providing care at Bellevue and Blackwell’s Island hospitals in New York. 

Following the start of the Civil War, Baxter received an appointment as a surgeon to the 

12th Massachusetts Volunteers in 1861. Following this and a later stint with the Army 

of the Potomac, he was moved to Washington where he became chief medical officer for 

the Provost Marshal General’s Bureau until the end of the war. He served as a medical 

purveyor during some of the time in Washington and he was credited with getting the 

medical supply chain running smoothly. 

Baxter apparently developed a busy medical practice at the White House during the 

Garfield term, treating numerous members of Congress and various influential leaders. 

Baxter even earned a law degree from Columbia during this period while on active duty 

as a military surgeon. After much infighting (which had been building over the years), 

he secured the office of Surgeon General but died 4 months into the term after a severe 

stroke.18 Even with only 4 months in office, Baxter made a contribution inasmuch as he 

was responsible for sending Walter Reed to study bacteriology and pathology with Dr 

Henry Welch at Johns Hopkins School of Medicine in Baltimore, Maryland.13(pp75–78)
CHAPTER FOUR • 113

Charles Sutherland (10 May 1831–10 October 1895)

Sutherland graduated from Jefferson Medical College in Philadelphia, Pennsylvania, in 

1849, and gained his commission in 1852. He served at the following locations: Jefferson 

Barracks, Missouri; Fort Riley, Kansas; and New Mexico. Sutherland was serving in Texas 

on the border when the Civil War started. He was sent to Florida for a year. In 1862, he 

became the medical purveyor for MG Henry Halleck’s command, centered in Mississippi. 

He was credited with setting up and supplying numerous hospitals in the command. He 

later became the medical director for the Department of Virginia and medical purveyor for 

the Army of the Potomac. 

After the Civil War, 

Sutherland became the medical 

purveyor for Washington and 

New York. From 1879 until 1884, 

he was the medical director of 

the Division of the Pacific and 

from 1884 until 1893 he was the 

medical director for the Division 

of the Atlantic.19 In May 1893, 

Sutherland became the next 

Surgeon General. By all accounts, 

he was a capable administrator 

with an amiable disposition. Due 

to his age, he retired in 1893 on a 

mandatory basis. As was the case 

with all of the Surgeons General 

in the post-Civil War period, 

much of his work revolved around 

the continued drawdown after 

the Civil War (closing facilities, 

reducing physician staff, and 

always watching the limited 

budget).5(p218)

George M Sternberg 

(30 May 1893–8 June 1902) 

George M Sternberg followed 

Sutherland in the Surgeon General’s Office in 1893. In view of his relative junior standing 

and his lack of administrative experience, Sternberg (Figure 4-1) would seem an unlikely 

choice. However, he was a scientist rivaling the best European scientists. He had studied 

with Koch in Germany. Sternberg became skilled with the microscope and the camera while 

establishing himself as a serious researcher. He published and developed a prominence 

in scientific circles and he had a serious quest for recognition.20(pp178–179) Sternberg was 

FIGURE 4-1. George Sternberg. Sternberg was a prominent 

scientist in addition to being the Army Surgeon General. 

He was responsible for setting up the Army Medical School 

(1893–1894) and oversaw its evolution into the Army Institute 

of Research. Sternberg encouraged his doctors to seek more 

training. Among his achievements, he obtained early radiograph machines for some post hospitals. He retired in 1902 

and was the recipient of many honors. Photograph courtesy 

of the National Library of Medicine, Image #B03026.
114 • FORWARD SURGERY

responsible for the establishment of the Army Medical School, which functioned in 

conjunction with the established Medical Museum.15(p153) The first class of the Army 

Medical School was held from November 1893 to March 1894. The success of that group 

ensured the school’s continuation and its evolution into the Army Institute of Research. The 

School had four instructors, including Major (MAJ) John Shaw Billings (associated with 

the founding of the Army Medical Museum) and MAJ Walter Reed.11(pp97–100)

Sternberg was instrumental in getting the new radiograph machines for several 

post hospitals. To his credit, he assigned physicians to posts near medical schools and 

encouraged them to become involved in more training. Sternberg also concerned himself 

with the training and organization of the Hospital Corps. He looked at the hospital 

corpsman as having an important role in the future. He worked to improve post sanitation, 

the quality of the water supply, and to implement preventive medicine procedures. Under 

his guidance, Army rations were evaluated and a new emergency 4,100-calorie ration was 

devised for use in the field and in action. Sternberg called for the creation of operating 

rooms to reduce infection and laboratories to help with diagnosis.11(pp100–108)

Surgeon General Sternberg’s 9-year tenure witnessed the entrance of Army medicine 

into an era of modern medicine. However, the department was still geared to medicine 

on the frontier and at posts, rather than to major wartime needs. The department did not 

incorporate any lessons that could have been learned from the casualty management of 

the Franco-Prussian War. For example, the Prussians insured that every German soldier 

carried emergency bandages that a treating medic would use. The Germans started 

using identification cards for the wounded that stated what treatment had been given. 

Furthermore, the Prussians had dedicated litter carriers at all times. The medical casualties 

of the coming Spanish-American War and the invasions of Cuba and the Philippines would 

suffer because of that neglect to incorporate the latest innovations pioneered in Europe.11(p112)

Surgeon General Sternberg retired in 1902 due to mandatory age requirements. 

He received many honors and was at one time the President of the American Medical 

Association, the American Public Health Association, the Military Surgeons of the United 

States, and the Washington Biological Association.21(pp70–74)

William H Forwood (8 June 1902–7 September 1902)

William Henry Forwood served as the Surgeon General from June 1902 until 

September 1902. Of special interest, when he was appointed to the office he had only 3 

months before his age-mandated retirement date.21(pp75–78) Forwood graduated from the 

University of Pennsylvania in 1861. In August 1861, he became an Army assistant surgeon. 

He served in many battles and survived a chest gunshot wound at the Brandy Station Battle 

in Virginia. Forwood served at various stations in the West (Kansas, Texas, and Nebraska), 

as well as in Georgia. He participated in several expeditions, including an exploring 

expedition in the summer of 1883 with Robert Lincoln, the son of the slain president, 

and President Chester A Arthur. Forwood became the Professor of Military Surgery at the 

Army Medical School when it was opened in 1893. He held various positions there until 

1898 when he was appointed the chief medical officer for a hospital and convalescent 

center in Georgia. He was posted to California but returned to the Washington Army 
CHAPTER FOUR • 115

Medical School in 1901. Although a colonel at this point, he was appointed to the rank of 

brigadier general and to the post of Surgeon General (replacing the retiring Sternberg) with 

only 3 months remaining until his own mandatory retirement date. His 41 years of service 

culminated in his being considered one of the great military surgeons of his day.22

Robert M O’Reilly (7 September 1902–14 January 1909)

O’Reilly was Surgeon General from September 1902 until January 1909. Interestingly, 

he served in the Civil War as a medical cadet. The medical cadets were formally recognized 

by the Union Army as medical students who had not graduated but could offer more 

advanced care than a layman. Resuming his studies after the end of the war, he received 

a medical degree from the University of Pennsylvania in 1866. He served at various posts 

until 1870, when he became involved in numerous actions against the Indians. He later 

became the personal physician to President Grover Cleveland. He served in various spots 

including Havana, Cuba, during the Spanish-American War. He was sent to Jamaica to 

study British methods in the tropics. He became the Surgeon General by virtue of a new 

rule that required the candidate to be able to serve 4 years before the mandatory retirement 

age. The three colonels ahead of him were not eligible. His greatest accomplishment 

was the enlargement of the Medical Corps and of the Hospital Corps.23 He was also 

able to create the Medical Reserve Corps. O’Reilly maintained good political relations 

in Washington after his appointment as Surgeon General. Funding for the Walter Reed 

Hospital in Washington was passed during his tenure.23

George H Torney (14 January 1909–27 December 1913)

Torney graduated from the University of Virginia School of Medicine in 1870. He 

started his military career with the Navy in 1871 but resigned in 1875 due to severe 

seasickness. He accepted an Army commission the following day. He served in a variety of 

assignments including field duty in New Mexico and Colorado until 1895, when he was 

posted to Virginia for 4 more years with the start of the Spanish-American War. During 

the years of the Spanish-American War, he was assigned to Hot Springs, Arkansas, until 

1902. He was then sent to Manila, in the Philippines, where he commanded the 1st Reserve 

Hospital. He was the commander of the Presidio Hospital, in San Francisco, California, 

from 1904 to 1908. He was involved in directing and supervising emergency care during 

the 1906 earthquake and fire in San Francisco. His good work there helped the momentum 

for his selection as Surgeon General in 1909. During Tourney’s time as Surgeon General, 

the newly built Walter Reed Army Hospital was opened in 1909. The Dental Corps was 

established in 1911. Laboratories were added to the Army Medical School and typhoid 

immunizations were standardized for the Army.24

William C Gorgas (16 January 1914–3 October 1918) 

Gorgas was appointed Surgeon General in January 1914 and served almost to the end 

of World War I (October 1918). Gorgas (Figure 4-2) was the son of a West Point graduate 

and later brigadier general in the Confederate Army. The young Gorgas was interested in 

a military career but could not get admitted to West Point. He decided to gain a military 
116 • FORWARD SURGERY

career by entering the Army 

through medicine. He graduated 

from Bellevue Medical College 

in New York in 1879. He served 

a year of internship in New 

York and received an Army 

commission in 1880.25

Gorgas started in the Army 

as an assistant surgeon. Like 

Leonard Wood, Gorgas was 

stationed in the West, where he 

had a number of tours, and also 

in Florida. He survived yellow 

fever while in Florida; he also 

survived typhoid fever. After 

being appointed the military 

governor of Cuba in 1899, BG 

Leonard Wood appointed him 

as the chief sanitary officer in 

Havana. Gorgas, as a colonel, 

worked on the health aspects of 

the Panama Canal project until 

1913. Gorgas is credited with 

removing the mosquitoes, all but 

eliminating malaria and yellow 

fever from the Canal Zone. 

He was appointed the Surgeon 

General in 1914 and was later promoted to the rank of major general in 1915. Although he 

had planned to retire in 1917, the onset of World War I and all of the needed mobilization 

planning kept him on until his mandatory age retirement just short of the armistice.25

Gorgas is best known for his sanitary efforts in Cuba and the Panama Canal Zone. 

His work in eradicating yellow fever brought major acclaim. The canal could not have been 

built had diseases not been curtailed. During his Surgeon General tenure, Fitzsimons Army 

Hospital in Colorado opened in 1918 under his direction and the Army School of Nursing 

in Washington, DC. Gorgas was involved in the many facets of World War I care and the 

early phases of the influenza pandemic, which became more pronounced in late 1918 

and 1919.25

Meritte Ireland (5 October 1918–31 May 1931)

Ireland succeeded Gorgas as the next Surgeon General in October 1918.11(pp88–93)

Ireland became an assistant Army surgeon in 1901 by examination after graduating from 

the Detroit College of Medicine and then the Jefferson Medical College. He served in Cuba 

and later in the Philippines. In the immediate lead up to World War I, General Pershing 

selected him as the American Expeditionary Forces (AEF) Medical Director. However, 

FIGURE 4-2. William C Gorgas. Gorgas was an 1879 graduate 

of New York’s Bellevue Medical College. He began his Army 

career as an assistant surgeon in 1880, serving at posts in the 

West and in Florida. General Leonard Wood later appointed 

him to be the chief sanitary officer in Havana, Cuba. Gorgas 

was credited with all but eliminating malaria and yellow fever 

(by mosquito control) during the building and operation 

of the Panama Canal. Photograph courtesy of the National 

Library of Medicine, Image #B13204.
CHAPTER FOUR • 117

Surgeon General Gorgas appointed another colonel for whom Ireland served as deputy. 

He deployed to France with General Pershing as the deputy to the AEF Medical Director, 

Colonel Bradley. He was quickly promoted to colonel, then brigadier general, and finally 

major general, Assistant Surgeon General, AEF, in 1918. He was recommended for Surgeon 

General following Gorgas’ retirement. He was to remain in this office until 1931.11(pp94–100)

MG Ireland will be discussed further in the chapter on forward surgery in World War I.

THE DOCTOR BECOMES A SOLDIER: THE ROLE OF 

LEONARD WOOD IN THE INTERWAR YEARS

The study of the career of Dr 

Leonard Wood (Figure 4-3) is an 

effective vehicle to illustrate the life 

and times of a physician in the Indian 

Wars, the Spanish-American War, the 

Philippine Insurrection, and the lead 

up to World War I. Although other 

physicians had many similar medical 

experiences (Exhibit 4-1), Wood was 

unique in his combination of medical 

and nonmedical assignments. While 

Leonard Wood reached the military 

pinnacle of becoming the Army’s Chief 

of Staff, and later became a near-run 

candidate for president, it should be 

remembered that he started as an 

Army contract surgeon. Even though 

he later switched roles and became a 

line officer, he always paid attention to 

the medical needs of his commands. 

As his career progressed, the role of 

Army medicine is highlighted through 

his actions. 

His medical training arguably 

enhanced his future commands by 

increasing his awareness of public 

health, preventive medicine, and the 

handling and disposition of casualties. 

In his governing roles in Cuba and the 

Philippines, his attention to public health and disease control greatly enhanced his role as 

commander.26(p30) Wood’s experience nicely highlights the events leading to a transition of 

the Army from an Indian fighting force to an Army preparing for overseas conflicts. 

EXHIBIT 4-1. WILLIAM CORBUSIER, ARMY 

SURGEON SPANNING MANY ERAS

In addition to Leonard Wood, another interesting figure from the era was Dr William Corbusier. 

His career was different from Wood’s in that he 

stayed with Army medicine. His career ran from 

1877 to World War I. Dr Corbusier and his wife both 

wrote separate books detailing their frontier and 

later experiences. Fanny Corbusier wrote from the 

perspective of an Army officer’s wife raising her 

children in often rather primitive posts.1

 William Corbusier described being in the field in 1885 in pursuit 

of Geronimo. Corbusier was unique in that he took a 

leave of absence to study advances in surgery from 

November 1881 until March 1882. In the SpanishAmerican War, Dr Corbusier was sent to the Philippines for the first of two tours. He described being 

in charge of the wounded sent by rail from the front 

at Caloocan, which was the main railroad terminus in 

central Luzon located north of Manila.2(p130) Corbusier 

was involved in evacuation of the wounded by boat 

following an attack on Malolos by General Arthur 

MacArthur.2(pp130,202)

References: (1) Corbusier FD. Fanny Dunbar Corbusier: Recollections of Her Army Life, 1869–1908. 

Norman, Okla: University of Oklahoma Press; 2003; 

(2) Wooster R, ed. Corbusier WH. Soldier, Surgeon, 

Scholar: The Memoirs of William Henry Corbusier 

1844–1930. Norman, Okla: University of Oklahoma 

Press; 2003.
118 • FORWARD SURGERY

FIGURE 4-3. Leonard Wood. Wood began his Army career as an Army assistant contract surgeon after 

graduating from Harvard Medical School. His career was aided by Generals Miles and Crook. Wood 

belatedly received the Medal of Honor for his efforts in the capture of Geronimo. He made a transition to 

become a line Army officer and also served as the physician to the White House and particularly to President McKinley’s wife, Ida Sexton McKinley. He commanded the Rough Riders in the Spanish-American 

War with Theodore Roosevelt. Wood became the Army Chief of Staff before the start of World War I. 

(A). General Leonard Wood as Chief of Staff (Wood is in uniform). Photograph courtesy of the Library of 

Congress, Image #11338V. (B) Theodore Roosevelt, Leonard Wood, and Alexander Brodie in 1898, in San 

Antonio, Texas. Photograph courtesy of the Library of Congress, Image #37599V. 
CHAPTER FOUR • 119

Leonard Wood’s father had attended the Massachusetts Medical School (a precursor of 

Harvard Medical School) and Dartmouth Medical School, but exhausted his funds before 

he could complete his studies. He obtained a diploma from the Eclectic Medical College 

of Pennsylvania (a version of a homeopathic school), but was unable to earn a satisfactory 

living from his practice.27(p11) Due to his incomplete training, Wood’s father could not get an 

appointment as a physician in the Union Army. Instead, he became a hospital steward and 

was an enlisted soldier, rather than an officer, for an 11-month tour in Louisiana.27(p12) 

Leonard Wood’s Medical Training

Leonard Wood was able to enroll at the Harvard Medical School in 1880. His 

enrollment was made possible by the loan of money by HH Hunnewell, a prominent 

Wellesley businessman. At the start of his second year, he received a scholarship. The 

Harvard course at that time was 3 years in length. As part of his training, he received 

an appointment as an intern at Boston City Hospital. In the hospital setting, the interns 

were largely to be observers while senior staff surgeons carried out procedures. Wood, 

however, did not adhere to the requirement that he only observe surgery. He was placed 

on probation for operating without supervision. One month later, he was released from 

his internship for continuing to operate without supervision (the episode didn’t surface 

until much later in Wood’s life [during his quest for promotion to major general] when 

the mayor of Boston got access to the records of the Boston City Hospital and used this 

information against Wood). There was little recourse for him but to find a type of limited 

practice opportunity that did not require some type of hospital connection.26(p30)

Wood took over the practice of a classmate who had not done well with it. He had 

patients but most could not afford to pay, so he mentored medical students to supplement 

his income. Wood decided to take the examinations for an Army medical appointment; 

he wasn’t sure he wanted to be an Army medical doctor but he needed the security and 

the money of the position. Wood placed second in the examination out of a field of 59 

applicants.27(p12) Because there was only one commission available at the time, he was 

offered a 1-year stint as an assistant contract surgeon with pay of $100 per month.28(p20)

The $1,200 to $1,500 per year paid to assistant and contract surgeons (contract surgeons 

were paid slightly more money than the assistant) equaled or exceeded the average 

civilian doctor’s income at the time. The contract surgeons wore officer’s uniforms, were 

treated as officers, and were included in officer functions and entertainment as a courtesy. 

The two ranks at the time were an assistant contract surgeon and the (full) contract 

surgeon.26(pp30,31),29 The contract surgeon and the assistant surgeon were required to reapply 

each year for a renewal of the appointment; the contract was subject to cancellation at 

any time by the Surgeon General (often related to budget problems). There is still some 

confusion among historians as to the status of the contract surgeon. For instance, in a 

recent book about Dr Henry Porter, who was a contract surgeon with Custer’s 7th Cavalry, 

the author uses the term “non-commissioned contract surgeons,”29(p11) which creates the 

false impression that they were noncommissioned officers (enlisted sergeants).

Wood took the job of assistant contract surgeon and reported to Fort Whipple in 

Arizona. Interestingly, he met Fred Ainsworth, another fellow contract surgeon, at Fort 

Whipple; both Wood and Ainsworth would ultimately decide to leave the Medical Corps 
120 • FORWARD SURGERY

after they had later become commissioned Medical Department officers. Ainsworth, an 

industrious bureaucrat, rose to become the Adjutant General of the Army, while Wood 

picked a route that led him to become the Army Chief of Staff. Ainsworth was to become a 

nemesis to Wood when they both achieved high positions. It is an interesting note of history 

that these two men, who both started as contract surgeons at the same time, should end up 

in conflict when they had both reached a high point in their respective careers.28(p252) Wood, 

with the help of Secretary of War Stimson, ultimately won the bureaucratic battle between 

the two of them when Stimson sided with Leonard Wood.28(p252) Ainsworth essentially 

wanted to continue acting independently of the Chief of Staff’s direction as a bureau chief. 

Ainsworth, despite his position, power, and ability to block many actions, was forced to 

retire. As McCallum points out, Ainsworth and Wood shared the same beginnings and 

demonstrated many of the same assets and flaws that would cause them to become bitter 

antagonists. They both were very intelligent, motivated, hard working, and believed in 

their own vision. Neither man could really bring himself to readily compromise, but saw 

conflicts as power and control issues.28(pp250–251),30(p178)

Wood’s Early Military Career: The Frontier Indian Wars

Two generals, George Crook and Nelson Miles, played an important role in Wood’s 

early military career and in the frontier Indian wars. General Crook was an 1852 graduate 

from West Point. Assigned to frontier duty before the Civil War, Crook survived being shot 

with a poisoned arrow during the Oregon Rogue River War. Crook later had the dubious 

distinction of being the highest-ranking Union officer (Major General of Volunteers) 

captured by the Confederates. His capture occurred while he was staying at a hotel in 

Cumberland, Maryland. He was imprisoned at Richmond’s Libby Prison for 2 weeks 

before being released in a prisoner exchange.31(p135) Secretary of War Stanton wanted to fire 

Crook for allowing himself to be captured, but General Grant intervened on his behalf.32(p15)

In the Civil War, Crook was awarded a brevet major general rank. After the Civil War, 

he made a mark in the Indian conflicts in the Pacific Northwest. Crook was transferred to 

command the Department of Arizona in 1871. He fought successfully against the Apaches 

and was promoted to brigadier general in 1875. He then commanded the Department of 

the Platte and dealt with the Sioux. He returned to the Arizona command in 1882 and 

obtained some success using Indian scouts and irregulars to fight and track Geronimo. 

He had conflicts with his commanding officer, General Philip Sheridan, about the conduct 

of the Geronimo pursuit. When Crook lost Geronimo (actually on several occasions), his 

request for transfer was quickly accepted. He was later promoted to major general, but 

died 2 years afterward in Chicago. Crook thought highly of Wood and used his influence 

while he held office to promote Wood’s career.28(p25)

Nelson A Miles was the other general who had a long-term impact on Wood’s career. 

Miles had little formal military training but raised a company of Massachusetts Volunteers 

after the First Battle of Bull Run in Virginia. Miles emerged from the Civil War as a Major 

General of Volunteers.33(pp1,144,195) Because he was not a West Point graduate, he was selected 

to serve as the commander of Fort Monroe, which held the former Confederate President 

Jefferson Davis as a prisoner. The powers-to-be thought he would be less likely to offer 
CHAPTER FOUR • 121

Davis special consideration than a fellow West Pointer.28(p45) After the Civil War, he was 

successful in battle at the Red River War, the Great Sioux War, and the Nez Percé conflict 

and the Geronimo campaign. Miles was considered by many to be one of the Army’s 

best commanders against the Indians.9(p200) Miles became the commanding general of 

the US Army in 1895 and the mentor of Leonard Wood while advancing his career (and 

later recommending him for the Medal of Honor28(pp27–44)). Miles trusted Wood’s medical 

judgment implicitly, but he also supported Wood’s interest in the regular business of being 

a soldier.

In July 1885, Wood was ordered to Fort Huachuca in Arizona where he established a 

long-term relationship with Captain Henry Lawton. Lawton was a dedicated soldier who 

would be Wood’s good friend until his death 15 years later.28(p20) In Arizona, Wood spent 

much time outdoors with the troops chasing Apaches. In the difficult pursuit of Geronimo, 

Wood rode and walked countless miles in the desert and mountains and volunteered 

to carry dispatches.28(pp34–40) Although he was only a contract physician awaiting a 

commission, he became a functioning officer with Captain Lawton by default. Wood 

served as a medical officer, and an assistant surgeon with Lawton and under the ultimate 

command of General Miles. 

True to the situation experienced by many Army surgeons, the pursuit of a highly 

mobile Indian force over nearly impassable terrain allowed for only the minimum in 

carried supplies. The surgeon would transport all of his instruments and supplies on his 

own horse and perhaps one or two other animals. As antiseptic surgery was not practiced, 

only the barest of equipment was needed. Fortunately, the number of wounded was 

generally limited. Fractures and medical problems were the main stay of the mobile Army 

surgeon. For transport of the wounded or seriously ill, the surgeon had to rely on a horse 

or mule litter.11(pp64,65) Transportation of supplies always complicated the need to evacuate 

the wounded. During the Indian campaigns, wagons had to be utilized if other means of 

transporting the evacuees (rail or boats on waterways) were unavailable.11(p64) 

Arrow wounds were not all that common after the end of the Civil War, presumably 

because the Indians were now universally armed with guns. Skilled surgeons devised 

various techniques to remove the arrows that they did encounter. The sinews used to 

hold the arrowhead on the arrow shaft would soon break down due to the humidity and 

enzymes in bodily fluids. Thus an arrowhead could remain behind, embedded, if the shaft 

were just grasped. Hence, an instrument or a wire placed behind the arrowhead to retract 

the head, with shaft and all, was preferred.11(p67)

Surgeons sometimes had to improvise evacuation techniques. At times a “travois,” 

a litter-like device with one end attached to the horse and the other end dragged on the 

ground (based on the Indian model), was used to evacuate the wounded. The “travois” 

could be made with any materials at hand such as tree limbs, teepee poles, or small trees. 

Some surgeons preferred this device when transporting the wounded over rough country. 

(While any pack animal could be used, the pack animals tended to weaken if they were on 

limited rations themselves.11(pp65–66)) If the evacuation was in haste, the wounded would have 

to be slung over a horse or mule if no wagon was available or if a wagon couldn’t be used 

because the terrain would not allow a rapid retreat by that means.
122 • FORWARD SURGERY

Gillet noted that in the Modoc Wars in the Northwest (Oregon and Northern 

California) in 1872 to 1873 (also called the Lava Bed Wars) conducted over uneven lavaorigin terrain, a chair-like device was fashioned by a carpenter that could be used with a 

single mule to evacuate the wounded. The wounded of the Indian wars were evacuated to a 

post hospital or to a field set-up if a post hospital was not possible. Usually tents were used 

for a field set-up, although other temporary structures could be used.11(pp65–67)

Frostbite was always an issue for the military surgeon in cold weather; the surgeon had 

no effective treatment for such an injury. Amputation of toes and feet were too often the 

outcome lest gangrene/infection gain a hold.11(p67) While in pursuit of hostiles, the surgeon 

still had to contend with disease, including typhoid, malaria, and scurvy (especially in cold 

times when rations could not be supplemented with fresh fruits and vegetables).

General Miles and Captain Lawton pushed the recommendation that Leonard Wood 

be awarded the Medal of Honor, which he finally received in 1898.28(pp4,45) The Medal of 

Honor was essentially the only award for heroism and such an honor would not be justified 

by today’s standards. The award was used rather more commonly then. (General Arthur 

MacArthur, for example, didn’t receive his Medal of Honor for Civil War service until 

the early 1900s.) General Miles thought highly of Wood’s medical experience. Wood was 

clearly Miles’ protégé and his influence in gaining the Medal of Honor and countless later 

professional opportunities helped the surgeon move toward a nonmedical Army career.28(p45)

At one point, Miles had suffered a complex compound fracture of his leg in an accident. 

The attending surgeons wished to amputate but Miles insisted that Wood be summoned. 

Wood was able to get the fracture to heal, ensuring Miles’ lasting gratitude.28(p47) Until 1892 

(after the Battle of Wounded Knee in 1890), the Army surgeons were also encouraged to 

help treat the civilians. After that time, the surgeons were to concentrate on their military 

charges only. 

Surgeons like Wood and Ainsworth participated in many diverse Indian conflicts. The 

Great Sioux War of 1876 to 1877 featured the great effort of the Sioux and Cheyenne 

at the Little Big Horn. As mentioned earlier, Dr Henry Porter, a contract surgeon also, 

served with Major Reno, who Custer designated to command a section of his force. Porter 

handled horrific casualties, as high as 50 injured at one time.29(p112) Despite setbacks at the 

Powder River country of Montana, the Army was the ultimate victor. Hedren, in a book 

about the Great Sioux War, lists the Army and a contract surgeon involved in the clashes 

and provides an accurate accounting of the casualties sustained by Army soldiers as well as 

those of the Indians.34(Appendices D–F)

Leading up to the events in which Wood would participate, General Sheridan, who 

was one of Grant’s favorite Civil War commanders, became the commander handling 

forces in the West and was based in Chicago. Sheridan waged winter campaigns and 

actively sought out hostiles and their villages with converging troop deployments. In the 

1874 to 1875 Red River War, Sheridan’s strategy resulted in the defeat of the Comanche 

and Kiowa. While the Battle of the Little Bighorn was the high point of the Indian’s success, 

their traditional style of war would lead to their ultimate downfall. The Indians did not use 

cohesive coordinated plans. Each warrior acted on his own, seeking personal combat and 

triumph. In the end, the constant encroachment of farms, ranches, and towns, coupled with 
CHAPTER FOUR • 123

the wholesale decline of the buffalo population, all contributed to the final defeat of the 

Indian nations.35(p472)

Sherman had success in the Indian conflicts of the Southern Plains. The railroads 

were then able to extend their lines, at which time the conflict shifted to the Northern 

Plains.36(p37) During the 1880s, the Indian expeditions and battles became more rare. The 

last major engagement of the Indian conflicts occurred at Wounded Knee in South Dakota 

on 29 December 1890. Army troops were sent to disarm the Lakota Indians. The ensuing 

events led to the deaths of 150 Indians and 25 soldiers. The events and outcome have been 

obscured.37

In December 1890 during the Battle at Wounded Knee, trains were used to transport 

medical supplies and men. A 25-bed hospital was expanded to a 60-bed facility. Most 

of the surgery involved setting fractures and providing homeostasis of wounds. Some 

triage was done and trained Hospital Corps personnel were first used in this major 

encounter. Two years later, Captain Charles B Ewing, who was an Assistant Surgeon of the 

Department of the Platte, gave an address to the Association of Military Surgeons of the 

National Guard at St Louis on 19 April 1892. He described the various wounds that were 

attended there. His address was titled: “The Wounded of the Wounded Knee Battlefield, 

With Remarks on Wounds Produced by Large and Small Caliber Bullets.”37

After 8 years of frontier medicine, Leonard Wood felt underemployed. He asked 

General Miles for a line assignment but without success. He sought and received 

assignment to Washington, which was complicated by political considerations. When 

he finally arrived in Washington, William McKinley had been elected President. Wood 

became the attentive doctor for the wife of the President, Ida McKinley. Wood proved a 

sympathetic ear for Mrs McKinley, who sought his consultation daily. She had a seizure 

disorder, which may have been a petit mal variant. Because people knew little of epilepsy, 

the disorder was kept quiet. McKinley was very attentive to her needs and adjusted his 

schedule and plans to meet her situation.38(pp267–271) Mrs McKinley had had a difficult 

several years. Her first daughter died at age four. Her second daughter died a few months 

after birth. The death of her mother also added to her precarious mental state. Doctors of 

the period, including Wood, would have been able to offer only sedatives to alleviate the 

severity of the seizures. Wood’s famous patient provided significant access to the President 

and other influential people.39(pp347–361) During this time, Wood became the strong friend and 

companion to Theodore Roosevelt, the new Assistant Secretary of the Navy. Roosevelt’s 

influence was to prove to be a definite asset for Wood.40(p105)

Coming of the Spanish-American War

The 1898 explosion of the US battleship Maine in the harbor in Havana, Cuba, 

provided the fuse that ignited the Spanish-American War. Surgeon General Sternberg had 

to change his thinking from that of a scientist to that of a wartime medical leader. Congress 

provided for the expansion of regular and contract surgeons. Sternberg appointed Colonel 

(COL) Charles Greenleaf as the chief surgeon in the field.41 The assigned physicians 

reported to the line commanders of their units while answering to Greenleaf for their 

professional work. The states picked the volunteer surgeons with varying success both in 
124 • FORWARD SURGERY

inducing physicians to serve and to the fact that the physician quality varied greatly. The 

rapid expansion of the forces required the Medical Department to select contract surgeons 

largely by references rather than by examination.11(pp117–120)

Sternberg pointed out that sufficient supplies were on hand for the 27,000 deployed 

troops. Despite being allowed to handle bids and to even buy directly on the open market, 

the need for speedy acquisitions of instruments and medical supplies was frustrated by 

the bureaucracy. In addition, the Quartermaster Department failed in its responsibility to 

furnish larger items such as tents.11(p121)

Fortunately, Sternberg had the authority to control hospitals and medical trains. He 

moved to establish hospitals at the division level and away from the previous regimental 

system. Sternberg established 10 general hospitals specifically for the Spanish-American 

War within the United States and organized medical trains coming inland from Tampa, 

Florida. Tampa was a War Department chosen site for deployment due to the proximity 

to Cuba. Roads and railroads were sparse in the Florida area and the port medical 

facilities were not developed (Figure 4-4). During his tenure, the Medical Department 

had continued challenges with the invasions of Cuba and the Philippines. Items such as 

bandages, medicines, and instruments were always in short supply. (Sternberg came in for 

major criticism from many quarters for the perceived failures of medical care in the early 

FIGURE 4-4. Operation in a tent during the Spanish-American War. Note absence of surgical gloves even 

though Halsted had introduced them to Johns Hopkins Hospital in 1871. Photograph courtesy of the 

National Library of Medicine, Image #A022370.
CHAPTER FOUR • 125

period of the Spanish-American War in 1898, although the Dodge Commission [appointed 

to investigate war issues] placed no major blame on the Medical Department.11(p314)) The 

long journey to reach the Philippines added to the dimension of the problems. Because San 

Francisco was a major supply depot with excellent transportation, the wounded and sick in 

the Philippines received better care than those in Cuba.42(p386) Despite the fact that Cuba and 

Puerto Rico were closer to the United States, the ports and infrastructure in Florida were 

not up to the standards and state of infrastructure on the West Coast.

With the Spanish-American War on the horizon, Wood and Roosevelt worked to 

obtain a volunteer command. Success came finally with the interest in forming “cowboy 

regiments” and the creation of the United States Volunteer Cavalry. Theodore Roosevelt 

was offered the command of the First Volunteer Cavalry. Roosevelt agreed to take the 

second in command slot if Wood would be named the commander.41,42(pp386–387) President 

McKinley was certainly reluctant to have his wife’s favorite doctor away from Washington 

but Wood was able to persuade Ida, and thereby the president, of his strong desire to be 

a line officer in the war. When Wood’s immediate superior became ill with malaria, Wood 

was promoted to brigadier general (to take over the position) and Roosevelt became the 

commander of the Rough Riders. (As an aside, Wood and Roosevelt were interested in 

taking control of Santiago [held by the Spanish] but they needed to get by blockhouses 

on top of San Juan Hill, Kettle Hill, and El Caney. It appears that the Rough Riders 

captured Kettle Hill while Lieutenant John Parker’s Gatling guns provided excellent 

covering fire. Lawton and his Second Infantry secured El Carney. Kent held San Juan Hill. 

However, the hills were contiguous, so it is of little consequence as to who took which 

hill.43(pp113,125–129,142–147)) 

Tropical Diseases and Sanitation in Cuba

Wood’s medical training was to be of assistance to him throughout his career. In 

Cuba in 1900 to 1902, as military governor, he dealt with a large number of sick and 

undernourished individuals and a lack of hospitals and medical facilities. Wood created 

large temporary hospitals in Cuba and supplemented the few Cuban doctors with military 

surgeons. He built nursing schools and even opened an asylum for the mentally ill in 

Cuba.40 In his book Theodore Rex,40 Morris comments that Wood, “A trained surgeon, 

he . . . transformed Cuba from one of the world’s most pestilential countries into one of its 

healthiest.”40(p105) During the Spanish-American War, the Cuban hospitals were occupied 

and utilized fully by the Spanish. The Spanish used the facilities for their troops and civilian 

dependents, employees, and officials, who used up the limited resources. The work of 

Leonard Wood and his staff aggressively dealt with the problems of the Havana hospitals 

and Cuban sanitation.

For decades yellow fever had been a constant problem in Cuba. Army Surgeon 

General Sternberg, a microbiologist by training, appointed Major (MAJ) Walter Reed to 

head the Yellow Fever Commission that would investigate infectious diseases in Cuba. 

The mosquito was identified as the vector of the disease. Wood then ordered mosquito 

control measures, which his chief medical officer, William Gorgas, successfully applied. By 

1901, yellow fever and malaria had been significantly reduced. The famed Johns Hopkins 
126 • FORWARD SURGERY

gynecologist Howard A Kelly, in his 1906 book Walter Reed and Yellow Fever,

44 spoke of 

the need to recognize Leonard Wood for “his active and intelligent interest in the work of 

the Army Commission.”44(p172) Kelly further credited Wood for his “permission to conduct 

experiments on non-immune people.”44(p172) Kelly noted that Wood granted money and 

authority “to be expended in rewarding volunteers.”44(p172) Kelly quotes Walter Reed as 

saying about Wood: “without his approval and assistance their [Yellow Fever Commission] 

observation could not be counted.”44(p172) Leonard Wood said of Walter Reed that he 

knew of no one man “who has done so much for humanity.”44(p232) Due to the American 

intervention, “Cuba was free from yellow fever for the first time in two centuries.”40(p105)

Three medical officers were dispatched by Surgeon General Sternberg to deal with the 

fevers. They were under the direction of MAJ Walter Reed, who was the microbiologist 

(officially the professor of bacteriology and clinical microscopy44(p238)) of the Army Medical 

School. The other members of the Yellow Fever Commission included Dr James Carroll, 

who first met Reed after they were both assigned to the Army Medical School.44(p255)

Dr Jesse Lazear, another member of the Commission, allowed himself to be bitten by 

a mosquito, and died of yellow fever at age 34.44(pp267–268) Dr Aristides Agramonte, the 

son of a prominent general in the Cuban insurgency, was a graduate of the Columbia 

College of Medicine.44(pp271–272) Agramonte did the autopsies and pathology work for the 

Commission.44(p273) Wood supplied Reed with $10,000 for his research, with the promise 

of additional funds as needed.45(pp2–3)

In 1902, Harvard University granted Walter Reed an honorary MA degree in 

recognition of his work in eradicating yellow fever.44(p242) In the same year, Reed received 

a honorary LLD from the University of Michigan.44(p244) Reed was also appointed as a 

professor of pathology and bacteriology at Columbia University in New York at the 

time he received the Army Medical School appointment.44(p238) Sadly, MAJ Walter Reed 

developed appendicitis, which at operation was found to be infected and perforated. Reed 

died of peritonitis 6 days after the surgery, on 22 November 1902.44(p248)

Wintermute presents the interesting idea that it was during this period that the Army 

Medical Department sought to reinvent itself as the nation’s public health and sanitation 

resource. The addition of the newly acquired territories of Cuba, Puerto Rico, and the 

Philippines was a timely catalyst to this reinvention.46(p4) However, little progress was noted 

in combat medicine and surgery until the next great conflict.

Leonard Wood and Army Medicine in the Philippines

During his tenure in the Philippines prior to his becoming the Army Chief of Staff 

in 1910 (appointed in 1909), Wood preferred to be a line commander, but he applied his 

medical knowledge in disease prevention for his troops and the local population. Wood 

was a good administrator who had an interest in efficiency. (Just as Wood had used his 

medical training to great benefit in Cuba and the Philippines, this skill set was again put 

to use in World War I while he was sidelined to Fort Riley, Kansas, training divisions for 

European service. Influenza broke out in October 1918. He recognized that the disease was 

airborne in its spread. Wood eliminated large assemblies of men, separated dining tables 

with screens, and dispersed the men in camp. This outbreak quickly subsided in his Kansas 

station but had worldwide scope.28(p274))
CHAPTER FOUR • 127

In 1899, all of the volunteers and one-third of the regular troops returned from the 

Philippines to the United States. As the conflict escalated against the Filipino rebels, fresh 

volunteer and regular troops were sent in the autumn of 1899. The Philippine Insurrection 

was a guerilla war in a tropical environment. The conflict became an insurgent effort, 

which resulted in dispersion of forces and medical assets. The military medical officers had 

to deal with dysentery, malaria, and venereal disease among the troops. Medical officers 

even had to deal with smallpox among the native population. The doctors had to rely on 

prevention as they had little with which to treat the diseases.47(p185) The lack of surgeons 

and hospital corpsmen was always a challenge.48(pp202–210) Placement of facilities was also 

an important factor in maintaining manpower. Small facilities that were close to the front 

lines could get soldiers back to duty sooner and lightened the load of the larger facilities. 

Evacuation to larger cities, such as Manila, could be done by waterways, if needed.48(p213)

A large facility, the Sternberg Hospital (Figure 4-5), was established in Manila. Initially, 

as already noted, the Army in the Philippines provided better care for the wounded and 

ill than provided in Cuba due to the resources available in San Francisco. However, as the 

Philippine conflict spread to more islands there, the problems mounted. These included 

more conflict-related casualties and greater requirements for medicines, supplies, and 

medical personnel.9(p201),48(pp133–134) The Army Medical Department maintained a large 

hospital on each coast of the United States even after the shuttering of the modern hospital 

at Fort Monroe, Virginia. In 1900, the general hospital in San Francisco (to be named 

FIGURE 4-5. Sternberg Hospital, Manila, Philippines. In the Philippine campaign, the placement of hospital 

facilities was very central to the provision of adequate care. Larger facilities, such as the Sternberg Hospital, were designed to receive evacuated wounded and the sick. Photograph courtesy of the National 

Library of Medicine, Image #19999162.
128 • FORWARD SURGERY

Letterman General Hospital in 1911) was the receiving point for evacuated Army patients 

from the Philippine conflict.48(p337) In 1901, roughly half of the patients there were from 

the Philippines. The East Coast facility was initially housed in buildings of the Washington 

Barracks. When the new hospital, named after MAJ Walter Reed for his contributions in 

yellow fever research, opened in 1909, it housed only 80 patients.48(p338)

The fact that the Filipinos did not accept the American occupation led to a prolonged 

guerilla war. Medicine had to adjust to a war of small-unit operations in remote isolated 

areas, often without outside support. The Philippine conflict was controversial in the 

public view. Linn, in his book about the 1899 to 1902 Philippine War, suggests that US 

involvement in that country was incremental and accidental.48(p5)

The Boxer Rebellion, which occurred in China in 1898 to 1900, was antiforeigner 

and anti-Christian in its scope. It involved conventional forces and combat. US medical 

officers had to work with physicians of the other European forces and of Japan. The Boxer 

Rebellion was like the Philippine conflict in that disease was always a threat to the welfare 

of the troops.48(p224)

The Army Medical Department was also involved in the response to the devastating 

San Francisco earthquake and fire in 1906. The Army set up hospitals in the Deer Park 

section of the Golden Gate Park. The Medical Department was instrumental in helping 

with sanitation, treatment of casualties, and preventive medicine.49 Dr Henry du R Phelan 

published an account of his personal experiences as a contract Army surgeon in the 

earthquake and subsequent fires. It highlighted the good work of the Army and its medical 

assets in dealing with the tragedy. The Army troops were led by Frederick Funston, who 

had been promoted to Regular Army brigadier general. Funston declared martial law in 

San Francisco in the aftermath of the earthquake, fires, and looting.50(p95)

ADVANCES IN CIVILIAN MEDICINE

Lister and Germ Theory

A defining event in medicine, which had ramifications for the military, was the English 

publication in 1867 of Joseph Lister’s work titled On the Antiseptic Principle in the 

Practice of Surgery.51,52(pp326–329) Lister used carbolic acid in the treatment of a compound 

fracture in an 11-year-old Scottish boy in 1865. He applied carbolic acid to the wound and 

found healing later without infection. He gave a lecture describing his techniques before 

the British Medical Association in London. Lister later published the lecture as an article in 

the British Medical Journal.53(pp245–260) Lister’s fundamental concept was the germ theory in 

association with infection. He applied the concepts of Pasteur’s 1864 work.54(pp327–329)

Lister believed it was important to fill the air with antiseptic, in addition to its use in the 

wound. He developed a carbolic acid spray apparatus, which he termed a “carbolizer.”46(p17)

It took some time for his principles and practice to become accepted and used, even in 

Scotland where he was a professor. In fact, physicians in Germany showed more interest in 

antiseptic surgery than did those in England or Scotland. The United States had resistance 

to germ theory among some leading surgeons, which persisted until the late 1880s, almost 
CHAPTER FOUR • 129

20 years after Lister published his article. For example, an American Army medical officer, 

Captain Alfred C Girard, made a visit to observe Lister’s techniques in England in 1877. 

He recommended the techniques highly to Surgeon General Barnes. Barnes then circulated 

the information to the medical officers, but he did not specifically recommend its adoption. 

The subsequent Surgeon General Robert Murray (November 1882–August 1886) finally 

endorsed antiseptic techniques in his 1884 annual report.55(pp588–591)

Pasteur and Koch

Louis Pasteur is best known for his work on what came to be known as 

“pasteurization” and the development of a rabies vaccine (also a military benefit). Pasteur 

did work that suggested the future use of heat sterilization in surgery, which was given 

in a paper written in 1878.56(pp166–167) Robert Koch, a German physician, did work that 

correlated disease with disease-causing organisms, resulting in what is known as Koch’s 

postulates. Koch devised four postulates, which briefly were that: (1) the microorganism 

must be found in the infected host but not in healthy ones, (2) the microorganism must be 

found in the diseased host and grown in culture, (3) the microorganism will cause disease 

when introduced into a healthy organism, and (4) the microorganism must be cultured 

from the original and identified as the organism’s causative agent.57(p19) Koch presented his 

findings at the 10th International Congress of Medicine in Berlin in 1890 to formalize the 

cause and effect of microbes and disease.57(p20)

Despite the work of Lister and his followers, the principles of antisepsis were often 

ignored. For example, after President Garfield was shot by an assassin on 2 July 1885, 

the wound in his back was repeatedly probed with unsterile instruments and fingers in an 

attempt to locate the bullet. He died 11 weeks later. (As a side note, Alexander Graham Bell 

had made available an early “foreign body localizer,” which failed due to the overlooked 

metal in the bedsprings under President Garfield.11(p50))

Halsted and Antiseptic Surgery

In the United States a rising star in surgery, William Halsted, had embraced the 

principles of antiseptic surgery at an early point in his career. He entered the College of 

Physicians and Surgeons in New York in 1874. It had a 3-year curriculum and was one 

of the better medical schools at the time. Halsted would become the Professor of Surgery 

at the newly formed Johns Hopkins School of Medicine.58(p299) William Henry Welch, the 

famed Hopkins pathology professor and Halsted’s friend, had spent time with Koch’s 

students and even spent a month with Koch himself in Germany. Hence, Welch provided 

support for antiseptic techniques.59(pp72,73) Halsted (Figure 4-6) became a leader and 

innovator in American surgery; many of his innovations would also impact Army surgery. 

For instance, he popularized surgical gloves; the use of surgical shirts and trousers; and 

rigid attention to surgical detail, homeostasis (prevention of blood loss), and the application 

of surgical pathology techniques to the operating room. Halsted’s clinical interests were 

in hernia repair (he had perfected a careful and precise herniorrhaphy operation), thyroid 

surgery (Halsted had performed thyroidectomies regularly), and mastectomy for breast 

cancer.59(pp221,222)
130 • FORWARD SURGERY

Military Adaptation of 

Civilian Advances

Many of these advances 

in the civilian world were 

adopted in the military in an 

attempt to keep Army medicine 

current. Medical officers tried an 

increasing number of operations 

including abdominal surgery. Dr 

Halsted’s interest in hernia repair 

was appreciated in the Army 

because Surgeon General George 

Sternberg placed emphasis on 

herniorrhaphy to reduce the 

numbers of disabled soldiers. In 

1895, the Army gave soldiers 

the option of undergoing hernia 

surgery or being boarded out 

on disability. After a successful 

operation and a “cure” to the 

hernia disability, they would 

remain in service. Hernia repair 

and appendectomy operations 

were the norm in the later 

1890s. Surgeons were even doing 

hysterectomy, nephrectomy, and 

cholecystectomy procedures.59(p111)

Rubber surgical gloves were originally obtained for the hands of the future Mrs Halsted, 

who had a severe dermatological reaction to the antiseptic soaps of the time. The use 

of gloves facilitated her continuing as Dr Halsted’s surgical nurse, although the gloves 

obviously also had a role in infection control. Dr Halsted used gloves that were made 

finely and withstood frequent heat sterilization.59(p309) The Army adopted surgical gloves 

in 1889.59(p476) However, they were not universally adopted by the Army surgeons because 

their use was not mandated. In addition, many surgeons preferred to have improved “feel” 

and dexterity without the perceived inconvenience of gloves.

Johns Hopkins was at the forefront of medical advancement, in fact being the only 

school initially approved by the Flexner Report, which evaluated medical schools in key 

admissions and curricula areas.59 The report by Abraham Flexner revolutionized medical 

education quickly, resulting in the closure of most substandard institutions. Johns Hopkins 

then became the “gold standard” for the schools going forward.59(pp199–200)

President Cleveland: Beneficiary of Medical Advances

The surgery performed on President Cleveland was a marked contrast to that for 

President Garfield. Cleveland underwent the successful removal of a tumor in the roof 

FIGURE 4-6. William Halsted of the Johns Hopkins Hospital, 

Baltimore, Maryland. Dr Halsted was the first Professor of 

Surgery at the newly opened Johns Hopkins Hospital. He 

trained in New York and Europe, and introduced attention to 

detail in surgery. Halsted also introduced innovations in hernia 

repair, thyroid surgery, breast surgery, and cholecystectomy. 

Photograph courtesy of National Library of Medicine, Image 

#B08313. 
CHAPTER FOUR • 131

of his mouth. The 1893 surgery resulted in no infection, the removal of a portion of his 

mandible, and the fitting of a prosthetic. Dr Welch, from Johns Hopkins, participated in the 

evaluation of the mass with indeterminate conclusions as to malignancy. (The pathology 

was reconsidered as late as 1980 with tissue obtained from the Mutter Museum of the 

College of Physicians and Surgeons of Philadelphia, Pennsylvania. The study by Brooks 

and Enterline, published in the Journal of the American Medical Association in 1980, was 

of interest because they reevaluated the Mutter Museum tissue because the fact that the 

president survived the operation for 15 years spoke to a more benign lesion, rather than the 

generally suspected sarcoma or oral carcinoma. Brooks and Enterline noted that various 

more benign diagnoses had been entertained. In their study they concluded that the lesion 

was a lower-grade malignancy.60(p2729))

MEDICAL CHALLENGES AND NEW TECHNOLOGY IN THE 

SPANISH-AMERICAN WAR AND OTHER MILITARY ACTIONS

Surgeon General Sternberg had ordered supplies in anticipation for war, although the 

amounts were enough only for a conflict of short duration. Indeed, Congress had not even 

provided funds sufficient for peacetime stockpiling.11(p124) Sternberg took personal charge 

in many of the details of supply. Despite the Surgeon General’s involvement, depots were 

inadequate to handle the quantities of supplies needed.11(pp125–126)

In the mobilization for the Spanish-American War, a great deal of confusion occurred 

at the embarkation ports for the Army Medical Department, as well as for the troop 

supplies. At Tampa, for example, medical supplies and ambulances were often left behind 

in the rush to load troops and munitions. (Similar problems in the shipment of medical 

supplies were experienced in the invasion of Puerto Rico.11(pp131,132))

In the period since the Civil War, the peacetime Army had been centered on post 

facilities, which ultimately received the wounded and ill from the field in the Indian 

wars. The size of the Army being formed for the Spanish-American War called for a new 

approach to care, incorporating Letterman’s plans in the Civil War, as opposed to the smallunit Indian wars’ approach. The Surgeon General’s decision was to base care on a division 

level with a field hospital following the division in combat.11(p127) At the time, the decision to 

move to a divisional organization was unpopular because most of the regiments reporting 

had some basic medical facilities organic to their organization. Inasmuch as they were to 

pool the equipment beyond their needs to the divisional medical facility, parochial concerns 

were present.11(p128)

Fortunately the combat phases of both the Spanish-American War and the invasion 

of Puerto Rico were short. In the invasion of Cuba in the Spanish-American War, division 

hospitals could not be landed due to lack of smaller landing craft and the fact that there 

were problems in unloading from ships, so hospitals were set up on ships. After the Spanish 

surrender at Santiago, the medical needs switched from dealing with wounds, fractures, 

and infections (Figures 4-7 through 4-10) to working on public health matters.11(p142) 

 The role of disease in the Spanish-American War follows the military experience as far 

back as the loss of many men to typhoid fever at Camp Thomas on the site of the Civil War 
132 • FORWARD SURGERY

FIGURE 4-7. Sternberg Hospital (distinct from the Sternberg Hospital in the Philippine Islands), 3rd Army 

Corps, Camp Thomas, August 1898. During the Spanish-American War, many men were lost to typhoid 

fever at Camp Thomas on the site of the Civil War Chickamauga Battlefield. Diseases such as malaria and 

yellow fever continued to plague the war effort in the Spanish-American War and were treated at facilities such as the one at Camp Thomas, Georgia. Photograph courtesy of the National Library of Medicine, 

Image #19999178-2. 

FIGURE 4-8. Soldiers loading a patient into an Army ambulance—little changed since the Letterman 

ambulance of the Civil War. Photograph courtesy of the National Library of Medicine, Image #9999190. 
CHAPTER FOUR • 133

FIGURE 4-9. Casualties of the invasion of Puerto Rico, 1898. The ambulances used in this photograph 

were rather similar to the Letterman ambulances of the Civil War. In this scene, medics are unloading 

patients from such an ambulance at a hospital converted from a school. Oftentimes, any shelter available 

was used as a hospital. Photograph courtesy of the Spanish-American War Photographic Collection, Otis 

Historical Archive, National Museum of Health and Medicine, Item #8002-28. 
134 • FORWARD SURGERY

Chickamauga Battlefield. Diseases such as malaria and yellow fever continued to plague the 

war effort in the Spanish-American War as in prior conflicts.61(p283) 

New technology was available to assist the military doctor during this period. 

Radiographs were developed in 1895. The only radiograph capability in theater was two 

units on US Army hospital ships and at the general hospitals back in the United States. The 

use of radiograph technology allowed bullets and shrapnel to be located without manual 

probing, thus decreasing the likelihood of infection. On the important date of 8 November 

1895, Wilhelm Roentgen had taken a radiograph of his wife’s hand. The device was shown 

publicly in Germany during a December 1895 demonstration. Other militaries also took 

advantage of the new technology. For example, radiographs were used by the British in the 

medical care of the wounded in the South African War.62(pp15–20) Surgeon General Sternberg’s 

Army Medical Museum was the site for early Army experimentation with radiographs. 

MAJ Walter Reed’s initial request to buy a unit was denied, but in 1896 he had obtained a 

radiograph. He used it to localize a bullet in the thigh of a wounded person.44(p177)

Harvey Cushing immediately began using the new technology and brought his own 

apparatus when he came to Johns Hopkins. Cushing used the radiograph tube energized 

by a hand-cranked static generator to show a bullet lodged in a woman’s spine.59(pp231,232)

It is noteworthy that the Army embraced this early technology in time for the SpanishAmerican War. 

FIGURE 4-10. Carrying wounded to a hospital after action in Santa Mesa, Puerto Rico, 1898. Because dedicated litter bearers were not always available, the scene of armed American soldiers carrying wounded 

to a field hospital was not uncommon. Photograph courtesy of the Spanish-American War Photographic 

Collection, Otis Historical Archive, National Museum of Health and Medicine, Item #8002-9.
CHAPTER FOUR • 135

At the time, the hazards of radiation exposure were yet to be learned, so consequent 

patient burns due to prolonged exposure were not uncommon. The hazards to the 

physicians and other personnel were also not recognized, leading to illnesses and loss of 

digits. For example, at the Johns Hopkins Hospital, Frederick Henry Baetjer had worked 

with Cushing in the use of the apparatus Cushing brought from Boston. Subsequently, he 

was selected to take over the work when Cushing finished his residency. In 1902, Baetjer 

became the radiologist for the hospital. Although he developed the specialty of radiology, 

he paid a steep price, developing cancer and losing one eye and some of his fingers as a 

result of radiation exposure.59(p265)

In addition to shortages of equipment and supplies, the Army Medical Department 

also experienced staffing shortfalls. For example, in the Philippines there were shortages of 

medical personnel. To deal with the shortages and to enhance the skills of the surgeons, the 

Army opened the new Army Medical School in November 1901 in the Washington Army 

Medical Museum buildings. Surgeon General William C Gorgas (January 1914–October 

1918) encouraged contract and volunteer surgeons to take the examinations for entrance 

to regular service to expand the core of the Regular Army Medical Department.11(p319) In 

the area of nursing staff, the Secretary of War allowed female nurses to be sent overseas 

to help with the shortages in combat theaters. While large and small hospitals were 

established, the medical and surgical care came to resemble that of the Indian wars. The 

battles seldom were large operations, but rather a series of low-intensity conflicts and 

counterinsurgencies. The majority of first-line care resembled that of the Indian wars with 

surgeons embedded with their troops providing most of the care in the field. In general, the 

Philippine Insurrection and the Boxer Rebellion highlighted the need to deal with tropical 

diseases, a multiplicity of diseases of vitamin and nutritional disorders, and the problems of 

long supply lines. 

PRELUDE TO THE “WORLD WAR” 

There would be many challenges in preparing the healthcare system for the coming 

large-scale conflict even though there had been many overall technological advances in the 

provision of care. Army healthcare for troops had been evolving since its inception, but the 

coming events in Mexico, in the run-up to World War I, further highlighted the need for 

additional preparation. The incursion into Mexico demonstrated the early use of motor 

transportation, airplanes, and improved supply methods, but the medical side was not as 

advanced. The medical equipment that was supplied to regiments was minimal, with the 

plan being to pass the injured on to dressing stations. The only forward surgery capacity 

was designed to prepare patients for evacuation.

The Regular Army was organized at the time only on a regimental basis. The regiment 

consisted of 1,887 men supported by four medical officers and 24 medically trained enlisted 

men.11(p400) Band members and line troops would have to carry litters, if needed. The medical 

support for the mission had to be organized for the moment and it was felt to be adequate 

for the smaller number of expected casualties. Although considered forward medicine, the 
136 • FORWARD SURGERY

medical support that accompanied the troops was reminiscent of Indian war days. At the 

peak of manpower, Pershing was backed up by two field hospitals organized as a camp 

hospital. The field hospitals were described as meagerly equipped shelters. Camp hospitals 

were 100- to 350-bed sized—smaller than a base hospital but equipped for surgery and 

related procedures.11(pp400–401) They were viewed as semimobile. The National Guard had 

difficulty with its medical support along the border because it had not been prepared to 

expand its operations and the Army had not planned adequately for its support.63(p287)

Before the US incursion into Mexico, the Germans had been active there since 1910 

when the Diaz regime was replaced by that of Francisco Madero in a revolution. Only 

3 years later, Victoriano Huerta seized power and killed Madero. Huerta established a 

military dictatorship, which drew the opposition of President Woodrow Wilson. In 1914, 

a Hamburg-Amerika ship had landed munitions at Veracruz intended for Huerta. Already 

calling for the restoration of a democratically elected Mexican government and hostile to 

the Huerta regime, President Wilson dispatched US Marines to Veracruz. The Marines 

were directed to occupy the Veracruz port to keep the ship from unloading the guns and 

ammunition, which they did with 19 American and 100 Mexican casualties. Huerta was 

subsequently overthrown by Venustiano Carranza, one of the leaders of the rival factions. 

German intelligence transferred its support to Carranza.64(p254)

The Army joined forces with the Marines at Veracruz in 1914. Because the military 

action in Veracruz was quickly over, the Army medical units had time to take on the care of 

civilians. The Army medical staff provided immunizations, including smallpox, for the local 

population. The military required mostly routine sick-call duty from the Army and Navy 

medical units there.11(pp394–395)

Because hostilities also threatened the US-Mexico border, the US Army established 

a post called Camp Furlong at Columbus, New Mexico. Francisco “Pancho” Villa and 

500 men attacked the town of Columbus and Camp Furlong on 9 March 1915. The 

troops at Camp Furlong defended the camp and drove the invaders from Columbus into 

Mexico. Ten US soldiers and 8 townspeople were killed in the raid.65(pp26–29) President 

Wilson’s Administration responded with the formation of a “Punitive Expedition” 

under the command of Brigadier General John J Pershing (of later fame as the American 

Expeditionary Forces’ commander of World War I). German agents were suspected of 

encouraging Pancho Villa to raid the United States. (For example, the Germans were 

mentioned as being the source of munitions supplying Villa in the various ciphers 

intercepted by British Captain “Blinker” Hall and his “Room 40 operation.”64(p189))

Pershing moved into Mexico with two cavalry columns; one infantry column and the 

logistical supply formation followed. Rail transport was only useful to a point due to the 

lack of rail infrastructure, which then required movement of supplies by wagon and truck. 

Pershing’s troops were all Regular Army troops. He moved 516 miles into Mexico before 

doing battle with Mexican troops at Parral. The battle did not yield significant results. After 

the first encounter, the troops then withdrew about 250 miles and at that point set up an 

occupation line. The troops withdrew from Mexico in February 1917 after engaging some 

of Villa’s forces but without capturing him. The Texas National Guard was then mobilized 

to protect the border.11(p400)
CHAPTER FOUR • 137

By August 1916, the peak number of National Guard members called to meet the 

Mexican threat numbered some 128,000 troops, and included 59 field hospitals, along 

with assorted ambulance companies and sanitary detachments.11(p400) Only 60,000 of the 

128,000 troops had actual prior military service. These were all federalized but problems of 

men not reporting, and others resigning once there, added to a poor medical support. The 

regular troops in the campaign numbered only 42,000.11(p400)

A NEW TYPE OF WAR?

As a large-scale conflict for the United States, the Civil War clearly was the closest thing 

to the coming World War I experience. However, the Europeans had experienced larger 

scale wars by World War I that included the Crimean War, the Franco-Prussian War, the 

Boer War, and the Russian-Japanese conflict (among others) in the lead up to World War I. 

The US experience in the latter decades of the 19th century was, however, limited 

in conflicts of any magnitude. Following the Civil War, the Army reverted to small-unit 

operations conducting a counterinsurgency type of campaign against the Indians. The 

Army mounted operations from forts that were scattered in the West. Although it had 

potential for a broader conflict, the Spanish-American War was almost over before it 

began, so that large-scale mobilizations and a war economy were not required. The Boxer 

and Philippine insurrections were largely small-unit operations. The Mexican border 

encounters were small and not particularly successful. The Army did have a chance to use 

newer technology such as trucks, motorcars, and airplanes on a limited basis. Hence, the 

learning curve was even greater for the United States as it was on the verge of entering 

World War I. The Army Medical Department had not been called on to prepare for and 

treat mass casualties prior to World War I. 

Fortunately, visionaries such as Drs Harvey Cushing and George Crile were there to 

help the country prepare to get into a position to provide emergent medical care in the 

future conflict.

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138 • FORWARD SURGERY

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CHAPTER FOUR • 139

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55. Garrison FH. Notes on the History of Military Medicine. Washington, DC: Association of 

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Columbus, NM. J Am Mil Past. 2012;37:26–29.
THE LEAD UP TO WORLD WAR I

AS THE PREVIOUS CHAPTER DISCUSSED, the Army Medical Department’s healthcare 

system had evolved considerably since the US Civil War, the Indian wars, the SpanishAmerican War, and the “Punitive Expedition” into Mexico. By the time the US Army entered the World War in April 1917, a great many changes had occurred in the organization 

and deployment of Army medical assets, but many more needed to be made to address the 

coming significant medical and logistical needs.

Before discussing these needed changes, it is worthwhile to briefly recap the sizable casualties of this global conflict to lend context to the magnitude of the problem confronting 

the belligerents. If one considers that the war lasted from 1 August 1914 until 11 November 1918, it is difficult to grasp the magnitude of suffering sustained by the participants. In 

just one battle—the Battle of the Somme—1 million or more men were casualties. Some 

14,000 British soldiers died in the first 10 minutes of the battle.1(p5)

In the Great War, as it was called then, some 60 million men were mobilized by all 

belligerents. Of that number, approximately 19 million were wounded and 7 million were 

killed.2(p239) The exact number of dead listed, however, varies depending on the source. 

Hastings cites figures showing 2 million military deaths for the Germans, 1 million for 

the British Empire (including 800,000 British), and 1.7 million for the French.3(p561) Jukes 

and associates list 325,000 casualties for the United States with 115,000 killed.4(p346) These 

authors cite 4 million wounded for Germany, 5 million wounded for the French, and 3.2 

million wounded for the British Empire. However, the influenza epidemic of this period was 

estimated to have had 50 million worldwide deaths by contrast. Hence, the deaths from the 

influenza pandemic were more numerous than the deaths from the World War.4(p346)

After the opening maneuvers of 1914, the Western Front became an immobile battlefield, populated with artillery and trenches. Opposing sides used incessant artillery barrages, 

followed by desperate infantry actions, to gain little advance. The wounds sustained were 

largely due to artillery shells and shrapnel. The Eastern Front was a mobile front where 

maneuver for terrain was the characteristic. Gunshot wounds were most common there. 

Chapter Five

Forward Surgery in the Great War: 

 A War of New Technologies

LANCE P. STEAHLY, MD
142 • FORWARD SURGERY

CHRONOLOGY OF THE WAR 

The events precipitating World War I have been attributed to the assassination of the 

heir to the Austrian-Hungarian throne (and nephew to the Emperor), Archduke Franz 

Ferdinand, and his wife, Sophie Chotek. They were shot at Sarajevo by a 19-year-old 

Serbian on 28 June 1914.5(p46) As Clark points out, the Serbian organizations that were 

incriminated in the archduke’s assassination were very secretive. Indeed, the head of the 

Serbian military intelligence regularly burned his papers.6(p47) Clark states that the murders 

of the archduke and his wife were “a transformative event, charged with real and symbolic 

menace.”6(p367) Clark would argue that the events leading to war were so complicated 

with the myriad entanglements that the postwar blame apportioned to Germany and the 

Austrian-Hungarian empire was flawed.6(p559) As an example, Clark speaks of the Balkan 

Wars as causing changes in the relationships of the greater versus lesser powers. The French 

and Russian alliance caused the powers there to interpret the Sarajevo events in a way that 

moved the war footing forward. The assassinations did not allow the Austrian-Hungarian 

empire to reasonably negotiate with Serbia. As viewed by Clark, the Germans were not the 

only state to give in to hysteria as events moved forward. Clark sees the crisis bringing the 

war in 1914 to a reality was due to a shared flawed political culture.6(p561) Europe erupted 

into war 37 days later. As Clark pointed out in his book, The Sleepwalkers: How Europe 

Went to War in 1914,

6

 the resulting war mobilized 65 million soldiers with over 20 million 

civilian and military deaths and 21 million wounded worldwide.6(pxxiii) Clark posits that no 

one country could be singled out as causing the war, but rather it was a result of a “shared 

political culture [which was] also multipolar and genuinely interactive.”6(p561)

The British became involved in the war because of Germany’s invasion of Belgium, 

which Britain was bound to defend by treaty. However, McMeekin in his book, July 1914: 

Countdown to War,7 has a theme that the Treaty of Versailles accusations of war guilt 

unfairly single out Germany as the main warmonger. The placing of guilt had ramifications 

in terms of postwar reparations, territorial changes, and unilateral disarmament. He further 

argues that England would have eventually been involved due to its naval arrangements 

with France to protect the North Sea. He maintains that the invasion of Belgium just made 

it happen sooner.7

Germany’s role in the conflict was only a part of the overall picture. McMeekin further 

argues that Germany’s strategic position to prosecute a war in 1914 was not favorable.7(p387)

He traces the regional instability involving Serbia, Austria-Hungary, and Russia as being 

a large factor leading to conflict. The Germans and the French were involved due to the 

understandings with Austria-Hungary and Russia, respectively, produced by the two 

Balkan Wars of 1912 to 1913, which could have erupted into a larger conflict.3(p558),7(p388)

Russia had enough reason to start a war over Serbia in the Balkan Wars and at other 

times.7(p384) McMeekin points out that Germany had no interest in the Balkans in 1912 

to 1913 or even 1914. He observes that the Austrians had an interest in curbing Serbia’s 

influence in those years.7(p385)

The German High Command determined that France had to be beaten before the 

Russians could mobilize. The Germans believed that Russia would take an unusually long 
CHAPTER FIVE • 143

time to accomplish full mobilization due to poor transportation infrastructure and the huge 

size of the country.5(p59) However, the Russians had implemented the “Period Preparatory 

to War” before either Serbia or Austria had mobilized. This was a secret preliminary 

mobilization to give Russia more time to respond. Russia did not want its potential 

adversaries to know of the earlier mobilization plans because Germany and AustriaHungary would expect a slow Russian mobilization in the war plans. The Russians’ 

mobilization would be longer than, for example, Germany’s, which had planned everything 

to the ultimate degree. 

The Germans had planned for mobilization since the time of Bismarck by developing 

well-coordinated railroad infrastructure and excellent training of regular and reserve 

forces. The German Schlieffen Plan was a bold plan to defeat the French that seemed to 

work for a period of time. The plan anticipated Austria-Hungary and Italy as allies of 

the Germans. Further, the plan did not include Russian involvement. Soon, however, the 

warfare became more of a siege, rather than a war of maneuver.5(p60) McMeekin points out 

that recent research calls into question whether there was an inflexible Schlieffen Plan, or 

whether the invasion of Belgium was decided by General Helmuth von Moltke (the nephew 

of Moltke the Elder) in his role as Chief of the German General Staff.7(p401) Moltke the 

Younger probably modified any preexisting plan by a combination of planning and taking 

opportunities as they presented. Helmuth von Moltke the Younger replaced Schlieffen 

in 1906 and saw the fallacy of not planning for Russian involvement based upon his 

assessment of French and Russian cooperation. He also did not think Italy would side with 

Germany due to territorial issues with Austria-Hungary.7(p401)

McMeekin views as a mistake the German decision to invade Belgium 2 weeks before 

the German Army would be ready.7(p401) This decision did not follow even the modified 

Schlieffen Plan. Hastings in his book, Catastrophe 1914: Europe Goes to War,3 notes that 

von Molkte (the less-than-talented nephew of the Elder) felt that Schlieffen’s concept would 

be the key to German dominance over Europe.3(p27) Helmuth von Moltke the Elder wanted 

to deal decisively with France after the fall of Paris in the 1870 to 1871 War, but he was 

overruled by Bismarck.3(p25–26) General Alfred von Schlieffen devised his plan in 1905 after 

he became the Chief of the General Staff in 1892. The plan underwent modifications with 

various iterations up to the war’s start.8(pp15–16)

After a series of mobilizations and declarations, Germany invaded Belgium on 4 

August 1914. Britain, France, and Germany were in battle along the French borders in 

the last open movement of the war. In the Battle of Mons on 23 August 1914, the French 

and British were defeated. The Battle of the Marne stopped the German advance on Paris 

in September 1914. In September 1914, both sides moved to entrenchment with lines 

extending to the English Channel. The First Battle of Ypres lasted from 12 October until 

22 November with heavy losses on each side (approximate casualties: British with 58,000, 

the French with 86,000, and the Germans with 134,000).9(p259) The Western Front became 

established. The Germans used poison gas on the Eastern Front on 3 January 1915.9(p260)

Gas was used in the West by the Germans at the Second Battle of Ypres on 25 May 

1915.9(p260) The Battle of the Somme began on 1 July 1916 and lasted until 19 November 

1916. The Battle of Verdun ended on 18 December 1916 with the Germans pushed 
144 • FORWARD SURGERY

back.9(p262) The United States came to the conflict late for many reasons but the resumption 

of unrestricted submarine warfare by Germany was certainly a catalyst. America declared 

war on Germany on 6 April 1917.9(p263)

The Allies were mainly interested in having fresh American troops enter their lines to 

replace French and British casualties. General John Pershing, appointed as the American 

Expeditionary Forces (AEF) commander stubbornly held to the Americans serving under 

their own command. Pershing had the British and French help with the training of the new 

troops to prepare them for trench warfare. Pershing insisted that the American soldier be 

a marksman and participate in battles of movement. Pershing felt that a war of maneuver 

was the preferred route and that marksmanship was the most important skill.10

The American divisions were set up on the standard square pattern with two brigades 

each consisting of two regiments (each with three battalions of 1,200 men apiece). The 

American divisions were supplemented with an artillery brigade and three machine-gun 

battalions. The total division strength was 28,000 men per division.8(p17) Grotelueschen 

points out in his book, The AEF Way of War: The American Army and Combat in World 

War I,11 that the American AEF division included two large infantry brigades, an artillery 

brigade of 5,000, and many support troops. The division at 28,000 officers and men would 

be twice the size of most German or Allied divisions.11(p27)

The German units were organized along the triangular pattern with three regiments 

(each with three battalions). The division had an artillery regiment (three or four battalions) 

and supporting units. The German divisions were smaller than the American division, 

having just 14,000 men in the German division. The Germans also had some specialized 

troops. In 1918, they had organized special elite units called Stosstruppen that could 

infiltrate trench systems in raids.12(p9)

British divisions officially numbered 13,000 men.8(p12) The British also had special 

troops for raiding, but they were not as well known as the German raiding troops. The 

French entered the war with a square 18,000-man division of four regiments. The German 

Army configuration was of two brigades (of two regiments each) of 12,000 men by the end 

of the conflict.12(p18)

On 26 October 1917, the Russians withdrew from the war after the Communist 

Revolution. German troops were then free to be sent to the Western Front. The Germans 

were anxious to use these extra forces before American manpower could affect the war 

situation.

Americans fought at such places as Belleau Wood, the Meuse-Argonne offensive, 

Chateau-Thierry, and Soissons. The Belleau Wood engagement was not well executed, 

unlike Soissons, which was well done. Pershing’s emphasis on marksmanship paid off 

whenever the battles became fluid and out of the trenches. The Americans launched a 

successful 4-day offensive at St Mihiel on 12 September 1918. On 26 September 1918, 

the Americans started a successful offensive in the Meuse-Argonne.10p33) The US Army had 

evolved into an effective force that tipped the scale against the Germans. 

On 11 November 1918, an armistice was signed by the Allies and Germany, bringing 

hostilities to a close.9(p264) At the time of signing the armistice, the Germans assumed 

Wilson’s Fourteen Points would form the subsequent treaty. The Treaty of Versailles was 

presented by the Allies for Germany to sign on 28 June 1919, but it incorporated none of 
CHAPTER FIVE • 145

Wilson’s points and instead imposed difficult obligations upon Germany. The reparations 

were especially harsh financially. The Germans were restricted to a small military force 

without submarines or air assets. In August and September 1919, Wilson brought the issue 

of ratification of the treaty and the League of Nations to the American people. The Senate 

did not ratify the treaty nor approve of the League of Nations.5(p4)

PIONEERING LEADERS OF THE WORLD WAR I 

MEDICAL EFFORT 

The medical community stateside was keenly aware of the war in Europe and the 

looming possibility, indeed probability, of American involvement at some future time. In 

response to this awareness, many in this community began exploring what could be done 

to assist. Two physicians—Harvey Cushing and George Crile—were at the forefront of 

these efforts; their careers began in the decades leading up to an active American role in the 

global conflict. Their experiences prior to and after America’s entry into the war parallel 

the gradual US involvement in the European conflict. The American people slowly came to 

support medical help for the Allies. Cushing and Crile helped immensely in calling attention 

to the need for military medical preparedness, which was not a popular stance.

Harvey Cushing 

Cushing’s life and accomplishments are chronicled in the detailed diaries from which 

he published selected excerptions, first in 1919 in his book The Story of US Army Base 

Hospital No. 5.13 His 1936 book, From a Surgeon’s Journal 1915–1918,14 was a more 

complete work, drawing from nine bound volumes of personal diary. (Perhaps because 

Cushing’s comments about the war are so descriptive, Peter Englund selected passages

from his journal to mark Cushing’s role as one of the 20 characters in The Beauty and the 

Sorrow: An Intimate History of the First World War.15(p3)) 

Cushing (Figure 5-1) spent 17 years at the Johns Hopkins Hospital in Baltimore, 

Maryland, under the direction of William Stewart Halsted (Figure 5-2), the Chief Surgeon 

at the Johns Hopkins Hospital and Professor of Surgery at the innovative Johns Hopkins 

University School of Medicine. Cushing initially came to Baltimore after a year as a surgical 

intern at the Massachusetts General Hospital in Boston. He started as Halsted’s assistant 

resident. Cushing served as a resident physician from 1896 until 1900. He then studied in 

Europe in the 1900 to 1901 academic year. He was a faculty member at Johns Hopkins 

from 1900 until 1912, when he assumed a Harvard appointment.16(p245) Cushing was 

recognized as perhaps the most talented of Halsted’s 17 chief residents. These talented 

men became Halsted’s chief resident after years progressing through a complex pyramidal 

system to become the single leader of the house staff and a junior faculty member. Twelve 

of these men became professors, associate professors, or assistant professors of surgery in 

their own right.16(p348)

As Cushing progressed under Halsted, he essentially invented the neurosurgery 

specialty with the permission of Halsted. Halsted was interested in his residents taking over 

certain specialties. For example, he had an interest in the pituitary gland and encouraged 
146 • FORWARD SURGERY

Cushing to study it. Cushing devised many of the procedures and instruments while largely 

limiting his work to neurosurgical concerns. He was known to typically spend many hours 

with his thorough operative notes, recapturing every detail of his surgeries, with particular 

focus on his failures.17(p270) As Imber discusses, Cushing was able to develop his skills 

while caring for most of Halsted’s patients and taking responsibility for his teaching load 

because of Halsted’s addictions (first to cocaine and then to morphine—both drugs were 

not illegal at the time) and long periods of absence.16(pp229–241) The situation with Halsted 

gave Cushing arguably more experience, but resulted in friction that became more of an 

issue as Cushing’s stature advanced. A boost to his stature came in 1910, when he removed 

an intracranial meningioma from General Leonard Wood, then the Army Chief of Staff, 

with good recovery. Cushing’s success with the case, in part, brought an offer of the Chair 

of Neurosurgery at the new Peter Bent Brigham Hospital and the Moseley Professorship 

in Surgery at Harvard. He left for Boston in 1912 when he was unable to get a clear 

commitment for his academic future from Halsted. Cushing felt that he had suffered under 

Halsted’s erratic leadership and frequent absences.16(p245)

George Crile

George Crile’s experiences were addressed in his 1947 two-volume set, George Crile, 

an Autobiography.18 Crile graduated from Wooster Medical College (which later merged 

to form the Case Western University School of Medicine, located in Cleveland, Ohio) 

in 1887. He had joined the US Army Medical Reserve Corps in the Spanish-American 

War and served in Puerto Rico. Crile made valuable contributions to military medicine 

with his work that started in the Spanish-American War but continued through World 

War I. Indeed, Crile actually headed the first university Ambulance unit (which basically 

was a hospital unit in French terms), sailing in January 1915 for its 3-month service. 

By comparison, the Harvard unit was organized by Cushing and RB Greenough, and 

FIGURE 5-1. Harvey Cushing. 

Cushing was William Halsted’s 

resident and later faculty associate 

(at Johns Hopkins Hospital in Baltimore, Maryland) who developed 

the specialty of neurosurgery 

with his mentor’s encouragement. Cushing left to become 

the Professor of Neurosurgery at 

Harvard University in 1912, in part 

because Halsted would not give 

him a firm future commitment. 

Cushing’s appointment came as a 

result of his success with General 

Leonard Wood’s meningioma 

removal. Photograph courtesy of 

the National Library of Medicine, 

Image #B05024.
CHAPTER FIVE • 147

financed by William Lindsey of Boston.14(p3) The Harvard unit worked at the American 

Ambulance at the Lycee Pasteur in Neuilly, France.19 Unlike Crile, Cushing did not actually 

head the Harvard unit (sailing in March 1915).20(p418) While Crile was the leader and 

the innovator, Cushing chose a passive role as a consultant with the 1915 Harvard unit 

traveling to various British hospitals (as part of the British Expeditionary Force [BEF])14(p51)

to allow time to observe surgical techniques. At this point, Cushing was not interested in 

command per se. As an observer, Cushing only occasionally performed neurosurgery.21

In 1917, Cushing was assigned to British Hospital No. 13, under the command of a 

British surgeon.14(pp56–57) He was later assigned to the No. 11 General (BEF) Hospital in 

May 1917.14(p111) When America entered the War, Cushing was assigned to Base Hospital 

No. 5. However, Roger I Lee, a Harvard colleague of Cushing’s, was appointed as the 

Commander of Base Hospital No. 5.14(p129)

In contrast to Cushing, George Crile, a professor of clinical surgery at Case Western 

Reserve, held a reputation as a prominent surgeon with an interest in surgical research. His 

work with nitrous oxide-oxygen anesthesia reduced dependence on ether as an anesthetic 

agent. He also promoted the use of whole blood to treat shock. Crile described human 

FIGURE 5-2. William Halsted. Halsted, the Johns Hopkins Hospital’s famous Surgeon in Chief, is performing surgery in a hospital amphitheater ably assisted by his chief resident, Harvey Cushing, and his 

assistant resident Hugh Hampton Young. The operation is being observed by physicians and/or students 

seated in the background. There are also three nurses and two student attendants. Halsted introduced 

surgical gloves (shown in the photograph), originally intended to protect the delicate hands of his operating nurse, Miss Hampton (later Halsted’s wife). Photograph courtesy of the National Library of Medicine, 

Image #A030435. 
148 • FORWARD SURGERY

direct artery-to-vein transfusion in an Annals of Surgery article in 1907.22 He authored a 

1909 book, titled Hemorrhage and Transfusion: An Experimental and Clinical Research,23

discussing transfusion and shock. Crile became one of the founders of the Cleveland Clinic 

in 1921.20 In recognition of his service, he was appointed as a Brigadier General in the 

Medical Reserve Corps after World War I.24(p379)

TREATMENT PHILOSOPHY 

During World War I, the underlying philosophy of battle wound treatment differed 

among the various Allies. The British and the French gave preference in treatment to 

the wounded that had the best prospect of returning to combat. The Americans gave 

preference to the more seriously wounded; they also held that experience demonstrated that 

removal of traumatized tissues and fragments could wait as long as 12 hours. Hence the 

less severe wounds could wait.25(p159) The frequent artillery wounds received in the French 

farming countryside almost always resulted in infection with gas-forming bacteria.25(pp159–160)

The British and French were convinced that early surgery was essential to deal with gas 

gangrene. Because of their awareness of the serious adverse potential of gas gangrene, 

the Royal Army Medical Corps placed emphasis upon a practice that made it a priority 

at the casualty clearing station to treat shock and to prevent infection.26(p196) This practice 

stabilized the patient before proceeding to any other treatment.

The difference in the Allies’ underlying treatment philosophy had ramifications for 

hospital size, mobility, and location. Although originally mobile in concept, the British 

casualty clearing stations became located in groups to expand their capacity, thereby 

reducing their mobility. The French made their hospitals large and immobile, despite their 

role in developing mobile hospitals. The large size and immobility worked with static trench 

warfare, but not with battles of movement. The need for mobility of the hospitals highlights 

the need to protect the staff and patients from a mobile front and to position the care facility 

near the wounded to reduce transport distance and time, and thus expedite care.

The French had created the triage system of sorting patients based on their injuries 

and prognosis. To facilitate triage, the aid station moved with its battalions, although it 

had few medical supplies. At the battalion aid station, severely injured soldiers had their 

wounds lightly covered with iodine before the dressings were applied. Tetanus antitoxin 

was administered here and morphine was given for pain. The use of splints effectively 

reduced the amputation rates, which had previously been viewed as necessary in severe 

compound fractures, not unlike the situation dating back to the US Civil War.9(pp240–241)

Compound fractures were immobilized with Thomas splints. (This is a long leg splint 

extending beyond the foot, consisting of rigid rods located on the lateral and medial aspect 

of the leg with a stabilizing ring that circumscribes the thigh. It can be adjusted to provide 

traction; it immobilizes the bones of the leg and makes transportation possible.) The splints 

were readjusted at the battalion aid station if they had been already placed in the field.27(p105)

The amputation rate greatly declined with better splinting techniques for compound 

fractures.9(pp240–241),27(p106) Triage was adapted by the American Army from the French. 
CHAPTER FIVE • 149

However, as already noted, the British and the French (unlike the Americans) placed the 

most emphasis on treating cases that could be returned to combat.28(p1610) 

ORGANIZATION OF MEDICAL ASSETS IN THEATER

Ambulance Americaine Concept

American medical involvement in World War I began long before the United States 

officially entered the war on 6 April 1917. In March 1910, a group of American expatriates 

in Paris formed the American Hospital, a small facility located near the Boulevard 

Victor Hugo. There had been precedent established in the Franco-Prussian War of 1870 

when a group of Americans living in Paris had solicited donations to establish a field 

hospital that became known as the American Ambulance (ambulance being a French 

military hospital).21(pp678–685) When World War I started in Europe in 1914, the American 

“colony” increased its support of the American Hospital Board—the administration of 

the Ambulance Americaine. Robert Bacon was the president of the Hospital Board and, 

fortuitously, was also the American Ambassador to France. Because there was historical 

precedent for American hospital help in the Franco-Prussian War, French approval for 

the role of the American hospital came with less delay than it had in the Franco-Prussian 

War.21(p677)

Because the Americans’ intent was to treat wounded French soldiers, the French 

government offered the use of an unfinished school, named the Lycee Pasteur, for its 

Ambulance Americaine (or military hospital).29(pp3–4) The large school building was equipped 

to have a bed capacity of approximately 500 to 600 patients.17(p270) Physicians from 

American teaching hospitals volunteered to serve as the clinical faculty on a short-term 

rotating basis. In planned 3-month rotations, the Ambulance three wards were to be staffed 

by surgical personnel who were skimmed from the top American medical schools. These 

civilian medical units provided proactive preparation 2 years before the arrival of American 

military units.21(p678) A second Ambulance Americaine was established close to the front. It 

was financed by prominent New Yorkers and care was provided by physicians and staff 

rotating from the Columbia University College of Physicians and Surgeons in New York.15(p3)

In 1914, as already noted, the French government had offered to the American 

Hospital the use of the Lycee Pasteur (an unfinished French school) as its treatment facility. 

The new facility received its first patients on 6 September 1914. An ambulance unit was 

formed on 14 September 1914 to serve the original American Hospital in Paris, using Ford 

Model T cars converted to ambulances, each capable of carrying four patients.29(pp4–5) Later 

groups included the American Ambulance Field Service (formed by A Piatt Andrew, a prior 

Director of the US Mint and an Assistant Secretary of the Treasury).24(p39) Another group, 

formed by Richard Norton, an archeologist, was named the American Volunteer MotorAmbulance Corps.24(pp22–37) A fourth group was formed by H Herman Harjes, an official of 

the Morgan-Harjes Bank in Paris. This group was termed the Morgan-Harjes Ambulance 

Mobile de Premiers Secours.24(p14) The Harjes group later came under the organization of 

the American Red Cross.29(p45)
150 • FORWARD SURGERY

All of these groups were financed through private donations. No American 

government funds were allocated prior to the 6 April 1917 Declaration of War. The success 

of the fundraising was attributed to the unique American flavor to the ambulance groups 

and the influence of upper class wealthy patrons, especially women.21(p680) The Ambulance 

Americaine hospital was also financed by private donations. The Ambulance held a 

popular position in the American press, which helped promote military medical awareness 

and started the idea of America’s military medical preparedness.21(p679) The Cleveland unit, 

headed by Crile, was financed by Samuel Mather of Cleveland; the Harvard unit was 

financed by William Lindsay of Boston.21(p679)

During the 3-month rotation, Cushing visited with other units (French and British) 

and performed some neurosurgery. There were three university units rotating in the 

3-month rotations. Cushing later visited the British No. 13 General Hospital in the middle 

of the Second Ypres combat.14(p61) The Second Battle of Ypres was the only major front 

launched by the Germans for the Flemish town of Ypres in Belgium’s west. There had 

been the surprise German use of poison gas, the collapse of the Ypres Salient (a salient is 

a battlefield that extends into enemy territory), and the Germans’ advance, accompanied 

by tremendous artillery barrages as they crossed the Yser River.29(pp64–65) Because he acted 

only as a consultant and not as the chief surgeon, per his own request, Cushing had this 

time available to visit these other units. Crile had selected and recruited Cushing and the 

Harvard unit to follow his Cleveland unit.18(pp247–252) Cushing took over the Lycee Pasteur

from Crile’s unit on 1 April 1915. Cushing also spent time with the French 2nd Army, 

where he visited with the French surgeon Alexis Carrel. Carrel was a major with the 2nd 

French Army at the time, but he had already helped devise the Carrel-Dakin treatment 

of wounds. The treatment involved the use of an antiseptic solution containing sodium 

hypochlorite. The wound was irrigated periodically with this solution for antisepsis.14(p18)

Carrel and Cushing visited a British facility nearby, but Cushing was not impressed with 

how the medical care was provided because the emphasis was placed on treatment of 

patients who could return to duty first.14(p19)

When Cushing visited the British No. 13 General Hospital Royal Army Medical Corps 

during the Second Ypres combat, he also visited the No. 8 Field Ambulance, which was 

located in the area. It was at this time that Cushing had his first encounter with a British 

medical evacuation train.14(p79) In Cushing’s description, the hospital train was made up of 

23 cars carrying 250 stretcher cases and an additional 150 sitting cases. The trains carried 

45 attendants, three doctors, and three nurses with an attached kitchen car.14(p61)

These medical hospital trains continued to evolve and by 1917, in British hands, 

the trains carried pharmacies, sterilization equipment, food units, and operating rooms 

that could rival a casualty clearing station. Serving on trains for surgeons, nurses, and 

attendants required some getting used to because of the delays (munitions and troops 

were given priority) and the movement of the trains, especially if doing surgery or another 

procedure. The nurses had to keep the wounded calm and even entertained during the 

delays, requiring some talent.9(pp252–253)

Cushing also traveled to England, where he stayed with Sir William Osler and Lady 

Osler at Oxford. Osler invited Sir Walter Morley-Fletcher, Secretary of the British Medical 

Research Committee, to discuss blood transfusions and plans for the project to send 
CHAPTER FIVE • 151

physicians and medical staff from 20 to 22 American medical schools to France to replace 

the original Harvard and Cleveland units.30(p126) During his time in England, Cushing 

described to his associates a French case in which he used a large magnet to remove a 

metallic foreign body from the brain, a process that was then relatively new in concept.15(p50)

After his time in Europe, Cushing returned to the United States on a ship that traveled 

through the debris field where the Lusitania had recently been torpedoed by a German 

U-boat.14(p77),15(p30)

These American hospital units were officially neutral in their attitude, as outlined by 

George Crile in an article he wrote for the Cleveland Medical Journal in 1915.31 This stance 

befitted America’s status as a neutral country. During service in the Ambulance Americaine, 

treatment afforded to German prisoners was complicated by the requirement to guard 

them.28 Allied sympathy became more apparent as the war progressed. Twenty-five United 

States Army medical personnel were placed with British units following the Balfour 

Mission to the United States in April 1917.29(p38) Lord Arthur Balfour had been sent by the 

British War Ministry to meet with the Council of National Defense in Washington. Balfour 

requested six base hospitals and 116 American surgeons from the War Department’s 

medical assets.30(p97) The British had insufficient numbers of doctors in the military at the 

start of the war (before the civilian doctor population could be brought into the military) 

and by 1915 they had a shortage of surgeons, which impacted the staffing of the casualty 

clearing stations. The British subsequently had a marked shortage of civilian physicians at 

home due to the expanding military needs.26(p43) Ultimately, 1,649 American Army doctors 

would serve with the British Royal Army Medical Corps (RAMC).32(p32)

In response to the British requests of the Balfour Mission, Army Surgeon General 

William Gorgas sought the involvement of the American Red Cross in organizing base 

hospitals in France modeled upon military facilities. The Medical Reserve Corps was 

the first branch of the Army to be a reserve component. The Army had established the 

Medical Reserve Corps in 1910 to be better prepared for future conflicts and to avoid 

the mobilization problems of the Spanish-American War (where inadequately trained 

contract physicians and volunteer surgeons had to be used due to shortages of Regular 

Army surgeons).33(p2) No military training was required of the Medical Reserve Corps 

members. Few members opted to transfer to active duty because the opportunities were 

limited, in contrast to the opportunities available in the civilian world. Correspondence 

courses and joint training camps were established for Medical Reserve Corps officers. The 

correspondence courses were popular with the officers. The Medical Reserve Corps was 

ended in 1917 with the creation of the Officer Reserve Corps. Surgeon General Gorgas 

opposed this transition because the new corps included reserve officers of all branches, 

rather than just the medical officers, but Gorgas was not successful in his opposition.26(p382)

Originally a government body was formed in the United States by the National 

Academy of Sciences called the National Research Council (NRC). The NRC was 

succeeded by the Council on National Defense (CND). A rider to the Defense 

Appropriations Act of 1916 created the CND, which allowed Surgeon General Gorgas 

to be appointed as the member for medicine.26(p379) The CND oversaw the nation’s 

preparations for the coming conflict.26(p379)
152 • FORWARD SURGERY

The National Defense Act of 1916 also helped the Army’s Medical Department with 

the authorized expansion of the number of medical corps officers by 1,107 and also the 

authorized ratio of seven medical officers per 1,000 soldiers. Furthermore, it established a 

Veterinary Corps and allowed five Medical Corps officers to work with the Red Cross in 

preparation and planning for the coming war.26(pp379–380)

French Medical Assets

The French developed a mobile surgical hospital (called an auto-chir) and a mobile 

surgical unit (termed a groupe complementaire). The early models in 1917 had no 

hospital beds of their own so they functioned with evacuation hospitals. They added the 

needed bed capacity to their auto-chir Plisson-Proust model (type 1917), which normally 

occupied wooden troop barracks, when these were available, but could use their own 

tents (large and small Bessonneau models). They could use other buildings when they were 

available.25(pp184–185) Cushing wrote in his journal that he and Dr Alexis Carrel inspected an 

auto-chir in 1917.14(p52)

The auto-chir included an operating room truck, a radiography truck, a sterilizing 

truck, a truck for tents and bedding, and a kitchen truck. The radiography truck carried 

a gas-powered generator for lighting and other needs, while the operating truck carried 

operating tables and equipment. The trucks gave the unit the ability to follow the troops; 

they could be ready for service in only a few hours. The idea was that the auto-chir would 

use buildings as available and expand to 400 patients, at which time another auto-chir

would start its tour. The auto-chir would have a staff of four surgeons and four assistants, 

four anesthetists (as they were then called), one bacteriologist and an assistant, a staff 

quartermaster, one radiologist, one pharmacist, 10 nurses, and 35 orderlies. The groupe 

complimentaire was a smaller unit carrying operating and radiography equipment used for 

specialized surgery, such as neurosurgery or orthopedics.25(p186)

British Medical Assets

American medical officers assigned to the British were placed in regimental aid 

posts and in casualty clearing stations (CCSs). If assigned to a CCS, they would be only 

a few miles away from the aid posts. As noted, the aid posts were the most dangerous 

assignments for the surgeons. Advanced aid posts were set up even closer to the action.

The British CCS was originally intended as a mobile hospital, which would be an 

intermediate between field ambulance units and the base hospitals. The Royal Army 

Medical Corps (RAMC) established three functions: (1) treat the sick and wounded not 

fit for transport, (2) evacuate patients that could travel, and (3) retain those who would be 

fit for duty in a few days.26(pp195–196) The CCS system ultimately performed more surgical 

operations than the stationary general hospitals. CCSs were often located a few miles 

behind the front lines on the Western Front as the war evolved from one of movement to 

one of static trench warfare. The Americans were part of a supplemental rotation. The CCS 

teams were often multinational, including teams from Canada, Australia, New Zealand, 

and South Africa, in addition to the British and the Americans.26(p201) Cushing said of his 

time at a CCS: “Life at a CCS alternates between pressure of work and no work at all. 

Both are killing.”14(p336)
CHAPTER FIVE • 153

In 1916, the British sent surgical instructor teams to CCSs to impart new surgical 

techniques, including the use of the Dakins-Carrel antiseptic irrigating solution. In this 

tradition, the British also set up a training school (the British Service School in Leeds) 

specifically for American doctors assigned to the British Expeditionary Forces. The RAMC 

had an additional basic training school at Blackpool, England.26(pp43,202) After each major 

battle, the British would have need for more American medical staff due to their own 

medical staff casualties. (British doctors assigned to duty as regimental medical officers had 

a 1917 mortality rate of 40/1,000/per month.25(p184)) Thus, Americans would find increasing 

numbers attached to the CCSs.32(p19)

The British field organization started with the regimental aid post. The 16 stretcherbearers were under the command of the regimental medical officer. They collected the 

wounded from the battle and brought them to the regimental aid post, which had been 

set up in some form of shelter close to the action. The next stop was the field ambulance, 

which included an advanced dressing station and the main dressing station. However, the 

field ambulance was seen by many as unnecessary because they felt the wounded should be 

taken directly to a CCS from the regimental aid post.25(pp189–190,193)

Over time, the CCS evolved in its functions. As previously noted, the CCS was 

designed to be a mobile hospital. A high incidence of gas gangrene spoke to the need for 

immediate surgery. As the war became static, the CCSs enlarged to become hospitals that 

handled most of the surgery on the Western Front. The surgeons in the CCS performed 

all types of procedures, as needed, using modern techniques and anesthesia.9(p238) There 

was, nevertheless, much argument as to the location near the action. Should the CCS 

be close in to the battle or further back to provide for safety? The CCS, in fact, was no 

longer mobile and was usually located near railheads. (The previous locations of CCSs are 

often marked now by proximity to military cemeteries.25(pp198,278) A list of CSSs in Flanders 

and France can be accessed online at http:// www.1914-1918.net/ccs.htm.) By 1917, the 

British had allowed for an exchange of surgeons between general hospitals and CCSs, so 

that the consultant surgeons in the general hospitals could provide advanced surgical care 

and teaching at the CCS. Also in 1917, the use of Carrel-Dakin (a hypochlorite solution) 

in surgical wound cleaning helped reduce infection rates. Most of the RAMC medical 

officers at the CCSs were not regular officers, although their commanders were often 

careerists.26(pp129,165)

American Medical Assets

Prior to US entry into World War I, much of the pharmaceuticals and surgical 

equipment came from Germany. In America, the drug and medical manufacturing 

resources were mobilized to meet the demand for medical and pharmaceutical equipment 

in the field and at home. Supplies such as bandages, tape, and disinfectants were produced 

and stockpiled as rapidly as possible.27(p41)

Medical care for the American soldier started with buddy or self-care, using the 

individually carried aid packet. Each soldier was issued a regulation first aid packet or a 

front aid pack. The first aid packet was a metal box containing several compresses, gauze 

bandages, and several safety pins with instructions. The front packs were used by medical 

units, but came in various types depending on the size of the dressings: Packet No. 1, red 
154 • FORWARD SURGERY

label (small-sized wounds); Packet No. 2, white label (medium-sized wounds); and Packet 

No. 3, blue label (large-sized wounds).27(p117)

The risk of tetanus was mitigated by a protocol that called for antitoxin treatment with 

even minor wounds. The antitoxin was usually given before reaching the field hospital. The 

battalion aid station was the usual place to give the tetanus antitoxin, but the field hospital 

gave it if not already administered.

Sanitary detachments carried the injured to the regimental aid station/battalion aid 

station after the sanitary troops applied bandages and splints. Company aid stations were 

more commonly used in trench warfare. The regimental aid station functioned mainly 

as a triage station. As battalion size was increased, the battalion aid station became 

essentially the same as the regimental aid station. The regimental aid station persisted in 

some situations, mainly as the location of the regimental surgeon with an administrative 

function.28(p117)

It was at the battalion aid station that sorting patients by the severity of their wounds 

(“triage”) first transpired. And it was there that the first rudimentary treatment was 

given.25(pp105,106) The American battalion aid station’s personnel performing this early 

treatment consisted of a medical officer (sometimes a dental officer), four to six enlisted 

Medical Department soldiers, two runners, and one or more litter-carrying squads supplied 

by the ambulance company.25(p113)

Dressing stations took patients from the aid station. Ambulance dressing stations were 

located at the point where ambulances could travel with some safety. Dressing stations 

(Figure 5-3) were located in a trench or any building in static trench warfare, although in 

FIGURE 5-3. Dressing Station in American sector trenches. Initial treatment was rendered in the 

trenches at the dressing station. Photograph from the Army Nurse Corps Photograph Collection, Image 

#1999.91.191, courtesy of the Office of Medical History Research Collection, Army Medical Department 

Center of History and Heritage, Fort Sam Houston, Texas.
CHAPTER FIVE • 155

more fluid combat they would be located in a tent. The dressing station’s purpose was to 

give emergency treatment to casualties and ship them on to field hospitals. According to 

medical directives, surgery was to be confined to hospitals. Treatment elsewhere was to be 

limited to treating shock, hemorrhage, and the splinting of fractures. Probing of wounds for 

fragments or bullets was expressly forbidden.25(p106) 

The evacuation hospital was the first surgical facility reached by the wounded. It 

operated alone or in conjunction with one or more mobile hospitals. The wounded were 

stabilized until they could be evacuated. The evacuation hospital did initial operations and 

also revised procedures done at forward facilities. The evacuation hospitals were usually 

located near rail lines. The evacuation hospital, the mobile surgical unit, and the mobile 

hospital were the main surgical resources.34(pp111–112)

The duration of time that postsurgical patients remained in the evacuation hospital 

depended on the situation and the nature of the wounds. It was policy that neurosurgical 

cases were kept 10 days to 2 weeks, while abdominal, knee, and thoracic injuries were kept 

up to 2 weeks. If the beds were needed, these patients would be evacuated sooner. It was 

estimated that 10% of the patients would be retained, while the rest would be moved.34(p114)

Evacuation hospital equipment assignments were modified in the period between 

1912 and 1916. The modification involved increasing the amounts of equipment that had 

been previously intended for a field hospital. In the review of equipment, changes were 

made to place emphasis on equipment being durable, simple in design and function, and, 

especially, portable. The bed capacity was expanded from 324 to 450 by 1916. However, 

the changes were not sufficient to meet the challenge of the World War. The evacuation 

hospitals in 1917 were infrequently moved and the changes designed to ensure portability 

were not needed. The designated bed capacities were to prove inadequate in combat. The 

hospitals were enlarged in size and their equipment types were expanded and were of the 

more stationary design.35(p290) Field hospitals were increased in size to handle 216 patients in 

1916. However, the equipment was reduced for the sake of transport.35

There were 21 American ambulance companies (of the 82 that were organized) in 

France by November 1918.36(pp296–297) The ambulance companies were now an integral part 

of the US Army under the direction of Colonel Jefferson Kean. Kean was a military officer 

assigned at the war’s start to the American Red Cross. In 1917, he returned to the Army 

with the job of militarizing the American ambulance units. Unfortunately, not all of the 

drivers and units wished to be brought into the Army. Many wanted to remain in civilian 

capacities. After “converting” the units, the Army organized training facilities in the United 

States for Army drivers.29(pp164–165)

The Americans “discovered” the auto-chir amid their need for mobility. In 1918, 

the Chief Surgeon of the Allied Expeditionary Forces placed an order with the French 

manufacturer for 20 auto-chir units and a like number of the lighter complementary 

groups. The auto-chir was obtained from the French at Fort De Vavnes, located near Paris. 

Some of the hospitals were assembled on a polo ground near Paris (Hospitals No. 1, 2, 3, 

and 4) and later at the Parc des Princes, Port St Cloud (only 5 miles from Fort De Vavnes).

The Americans planned to use the auto-chir to augment the surgical capability of the field 

and evacuation hospitals. Twelve mobile surgical hospital units were set up at the Paris 

Auto-Park. Mobile Hospital No. 5 (left for duty 20 September 1918) through Mobile 
156 • FORWARD SURGERY

Hospital No. 12 (left for duty 23 January 1919 to provide care for occupation troops) were 

established for American use. The AEF had operational units numbered 1 through 11 and 

39 (Base Hospital No. 39 provided the basis for the No. 39 Mobile Surgical unit and it was 

so named).25(p187)

The Army authorized a larger staff complement for the mobile hospitals than that of the 

French. A major of the Medical Department was to command. There were 10 captains or 

lieutenants, Medical Corps, authorized. One Sanitary Corps captain or lieutenant rounded 

out the commissioned complement. The senior NCO was a sergeant first class in charge of 

17 sergeants (all Medical Department) and 62 privates or privates first class. There were 22 

female nurses listed. The mobile surgical unit (corresponding to the groupe complimentaire) 

had a captain or lieutenant, Medical Corps, in charge. The enlisted group was headed by 

one sergeant first class leading three sergeants and eight privates or privates first class.25(p187)

Five of the first six mobile hospitals obtained their medical staff from base hospitals 

managed by the British. Base Hospital No. 2 (Presbyterian unit) supplied the staff for 

Mobile Hospital No. 2. Base Hospital No. 4 staffed Mobile Hospital No. 5. Base Hospital 

No. 5 (Cleveland, Ohio) staffed Mobile Hospital No. 6. The No. 10 Base Hospital supplied 

personnel for Mobile Hospital No. 8, while Base Hospital No. 21 (St Louis, Missouri) 

furnished operating staff for Mobile Hospital No. 4.14(p66) The mobile hospitals were run by 

the Americans, but were initially staffed in part by British personnel. 

The mobile hospitals operated with evacuation hospitals or field hospitals, or operated 

independently. As an example, Mobile Hospital No. 39 (which had been a Red Cross base 

hospital, staffed by Yale personnel) was the first mobile hospital in action with American 

forces. It had tents and French-designed Adrian barracks to supplement the basic mobile 

unit. It participated in the area of the St Mihiel Battle of 1918 (involving the AEF, the 

French, and the Germans) with an expanded size of 524 beds.25(pp191–193) In his journal, 

Cushing described the first three mobile units planned along the lines of the French autochir, organized by Colonel (COL) JM Flint, of which the first was known as the Yale 

Mobile Unit. Cushing reported that No. 1 and No. 2 units had seen active service in the 

July 1918 offensive.14(p66)

Two operating rooms could provide for six teams. These hospitals were not 

standardized; each unit had flexibility in obtaining additional equipment or supplies 

that the commanding officer might desire. An example would be an ophthalmologist 

commander who wanted ocular equipment. The staff opinions of active unit mobile 

hospitals were gathered to determine what items were really needed. The new standardized 

equipment list items could be hauled on 20 3-ton trucks.25(p189)

The Army approach for mobile hospitals (Figures 5-4 and 5-5) envisioned dealing with 

the wounded along the lines of the French units previously discussed. The mobile hospital 

commander would be a major. The mobile hospital had fixed sterilization, radiology, and 

power generating plants, carried on two trucks. Other trucks carried tents and enough 

supplies to set up a 120-bed unit with six operating teams.37(pp355–356)

The mobile surgical unit also had trucks carrying equipment (such as a portable 

sterilizer and radiology equipment). The mobile operating room would have a portable 

light-generating plant along with supplies mounted on trucks. The mobile units ended up 

supplementing the field hospitals, but they did not carry organic setups for their own beds, 
CHAPTER FIVE • 157

FIGURE 5-4. Operating Room, Mobile Hospital No. 39. Initially designated as Base Hospital No. 39, it was 

later set up as Mobile Hospital No. 39, which operated close to the troops. Photograph from The Medical 

Department of the United States Army in the World War, courtesy of the Army Medical Department Center of History and Heritage, Fort Sam Houston, Texas. 

FIGURE 5-5. Mobile Hospital No. 39 Layout. The mobile hospital was designed to bring surgical care 

to the troops closer to their actual wounding. Photograph from The Medical Department of the United 

States Army in the World War, courtesy of the Army Medical Department Center of History and Heritage, 

Fort Sam Houston, Texas. 
158 • FORWARD SURGERY

as did the mobile hospital. The commander of a mobile surgical unit was a captain. The 

mobile unit drew upon the surgical staff of the field hospital it was to augment.37(p356)

The plans for the mobile surgical units (complementary groups) called for 20 units. 

The equipment for these units was made in France. However, by the time of the Armistice, 

only 16 mobile surgical units were in operation. They were No. 1 through No. 12, and No. 

100 through No. 103.25(p199)

Mobile hospital units provided a way to utilize specialty neurosurgical care. In many 

cases, Cushing noted that neurosurgeons were placed in command of surgical care in 

hospitals performing triage. The rush of patients and the ability to use local anesthesia 

for neurosurgery cases led to incomplete care, which in Cushing’s view would include 

neurosurgery done too rapidly. Over time, the situation changed and he noted that by 

June 1918, only two neurosurgical teams were organized, one at Mobile Hospital No. 

1 and the other at Mobile Hospital No. 2. The only penetrating wound of the head that 

survived in June 1918 came through those mobile hospitals that Cushing managed.38(p755)

Cushing reported that special instruments for neurosurgery, such as rongeurs, drills, and 

“perforators,” had to be obtained from French manufacturers because they were not 

available from Army sources. Most of the cases could be done under local anesthesia with 

morphine as a pain medication supplemental. Cushing felt that the British example of 

collecting several neurosurgical teams in a special hospital for head trauma worked best 

in a static situation. In his view, the use of two teams in the larger evacuation hospitals 

worked best for the Americans in situations such as the Meuse-Argonne operation. The 

patients would be later sent to specialized centers.38(pp750,757)

Originally, when the United States entered the war, the nature of the war had been 

static. It had been initially established that evacuation to a larger remote hospital was 

preferable. Later, such surgery could not be delayed until such rear hospitals could be 

reached. Wounds in this war were more than 80% due to shell fragments; bullet wounds 

were rare, unlike the experience of earlier conflicts.39(p87) The shell fragments were invariably 

accompanied by bacterial contamination, which could quickly lead to fatal infection if early 

forward surgery were not the norm.39(pp87–90)

The base hospital, with a capacity of 500 patients, received its patients from the 

evacuation hospital. The base hospital could function as an evacuation hospital if combat 

was close. It would then send its patients to a base hospital further from the action. 

Specialization of some base hospitals allowed improved care. The care could include 

specialized instrumentation and surgeons familiar with specialized procedures.34(p86) 

As the war progressed, the Americans established more hospitals of their own. The 

Red Cross accounted for the organizing and equipping of 36 of the 42 base hospitals. The 

evacuation hospital was the basic unit to back up the division. However, due to shipping 

problems (troops, equipment, and munitions had shipping priority), no more than 25% 

of the requested evacuation hospitals arrived in France.38(p290) The evacuation hospital size 

was officially 1,000 beds, but it could be expanded as needed. They were planned as being 

mobile in concept but their large size limited that role.35(pp161–163) Eventually, organized 

professional teams, including surgeons and operating room staff from the base hospitals, 

were needed to fill out the professional staff of the evacuation hospital.39(p28)
CHAPTER FIVE • 159

The field hospital was situated 3 to 8 miles from the front. The function and setup of 

the field hospital in static trench warfare could be different from the open warfare model. 

The static situation could mean a field hospital with fixtures and complete equipment. 

In fluid situations, field hospitals might not have the equipment and might be dedicated 

to evacuation. In other fluid situations, they could be found in good quarters and wellequipped.27(pp100–101) The field hospital at times had a mobile surgical unit attached to handle 

surgery for those that could not be evacuated.27(p101) The field hospital was never intended 

for major surgery on a regular basis; the mobile surgical or evacuation hospital was better 

suited for the task. Only the most serious cases were attempted at a field hospital, but 

if evacuation could not be done due to combat, then other cases were done. The field 

hospital sent patients to the mobile hospital and to the evacuation hospital. Base hospitals 

and general hospitals followed in the evacuation chain.27(p81) The evacuation hospital 

was generally located forward, not far from the field hospital, although exceptions were 

numerous depending on the fluidity of combat.27(p107)

FIGURE 5-6. Badly wounded soldier receiving care at the Base Hospital, Johns Hopkins Unit, France. The 

Johns Hopkins unit was organized in Baltimore as Base Hospital No. 18. It set up at Saint Nazaire, France 

in 1917 and treated many patients until closure in 1919. It became Base Hospital No. 1 and later No. 101. 

Photograph from the office files of the Research Collection, US Army Medical Department Center of 

History and Heritage, Fort Sam Houston, Texas.
160 • FORWARD SURGERY

FIGURE 5-7. Operating Room, Base Hospital No. 52. Base Hospital No. 52 was initially organized at Camp 

Greenleaf, Georgia, and further organized at Camp Gordon, Georgia. It arrived at its station at Rimacourt, 

France on 8 August 1918, where it remained until it was closed in January 1919. The setup of the operating 

room was typical of a base hospital. Photograph from the office files of the Research Collection, US Army 

Medical Department Center of History and Heritage, Fort Sam Houston, Texas.

The organization of base hospitals and evacuation hospitals was detailed by the 

Army Surgeon General’s Office. The hospitals that were to go overseas required the most 

careful planning. These plans called for the organization of the hospitals at one of the 

medical training camps. After 6 weeks of training, the hospital units would be moved to a 

cantonment area to be designated for further organization and training. At the conclusion 

of this process, the hospitals could be deployed. In 1918, when the American forces were 

involved in their heaviest fighting, urgent calls for more hospital units came from the AEF 
CHAPTER FIVE • 161

Headquarters. The Surgeon General consolidated some of the units to provide a rapid 

deployment because it was difficult to find adequate personnel at all times.40(pp351–353)

Base hospitals (Figures 5-6 and 5-7) had 1,000 beds, with a colonel in command. The 

evacuation hospital was commanded by a lieutenant colonel, but also had 1,000 beds. 

Before the war, the evacuation hospital and base hospitals were to be 500 beds. During the 

war, however, the base and the evacuation hospital were increased to 1,000 beds, based on 

the expected flow of casualties. Because both hospital types could be expanded as needed, 

hospitals with several thousand beds were not that uncommon. The surgical service for the 

evacuation hospital would include a chief, 11 general surgeons, one orthopedic surgeon, 

one urologist, one neurosurgeon, one otolaryngologist, one ophthalmologist, and one 

oral surgeon. Two radiologists were attached.40(p353) The selection of a commander called 

for a person with “special administrative efficiency and the ability to command.”40(p353)

Following this scheme, 162 base hospitals and 59 evacuation hospitals were created in the 

United States. Of that number, 121 base hospitals and 40 evacuation hospitals were sent 

overseas. The end of hostilities allowed the remaining units still in the United States to be 

demobilized quickly.40(p354)

EQUIPMENT AND HOSPITALS

Ambulances

The first motorized Army ambulance was steam powered and placed at Washington 

Barracks, in Washington, DC, while a second steam unit was placed at the Army 

Military Academy at West Point, New York. The steam units were problematic because 

of operational and maintenance difficulties; animal-pulled ambulances returned until 

gasoline-powered ambulances were available. The Army contracted with the Keeton Motor 

Company for a 6-cylinder unit with special solid puncture-proof tires.2(p362) 

In April 1917, the French requested that the Americans send 100 ambulance groups 

to serve with the French military. The ambulance groups had been militarized by that 

time and were known now as the US Army Ambulance Service. The section or group 

involved 20 ambulances and 45 men. This request was based on the work of the volunteer 

Americaine Ambulance groups with the French forces. The Ford Motor Company 

shipped 2,350 ambulances to France by October 1917. Fifty additional units were sent to 

Pennsylvania for training with the US Army Ambulance Service.35(p363)

Militarization of the American volunteer ambulance companies after America entered 

the war in April 1917 would involve administrative transfer into the US Army Ambulance 

Service. Because these units were taking care of French troops, they were brought into 

the US Army, but then reassigned to the French. The other volunteer organizations were 

assimilated into the military with varying degrees of success.29(pp161–162,179)

The Ford contract first involved the 1917-model body (the ambulance portions were to 

be added later), which was found to have many faults. These problems were redressed with 

the 1918-model body, which featured a wider wheelbase and extended body. The HayDee 15-inch extension was incorporated into the body. The Army utilized the Fords but 
162 • FORWARD SURGERY

later used a longer body type. Although the Army used the Fords, it preferred the General 

Motors Corporation (GMC) ambulances for their larger size.36(pp395–396) However, the Fords 

did move best of the vehicles over rough and destroyed roads; the bigger GMC ambulances 

did best on improved roads.36(pp265,290)

General Motors had had the benefit of supplying vehicles for the 1916 MexicanAmerican conflict. However, the GMC ambulance they had provided was too light for 

Army purposes and a new model, the Model 16—a 3⁄4-ton truck—was designed. A 1917 

contract of 2,000 was expanded to 5,000 for 1918. The war ended before all could be 

assembled. Other companies were also contracted to build the ambulance, but no factories 

were built because the contracts were cancelled due to the end of the war.39(pp337–340)

Deployment of Base Hospitals

Surgeon General William Gorgas and Dr George Crile organized a simulated base 

hospital in Philadelphia, Pennsylvania, at the 1916 American College of Surgeons meeting. 

The simulation was to provide awareness of the need for surgical care in Europe and to 

provide training in setting up an operational facility.2(p248) A series of base hospitals was 

organized following the earlier model. These hospitals included the following units:

BASE HOSPITAL NO. 4

The experience gained in the early years started the formation of university base 

hospitals. Base Hospital No. 4 (Case Western Reserve, Cleveland, Ohio), led by George 

Crile, was the first American military unit in France, arriving on 25 May 1917. Base 

Hospital No. 4 was immediately assigned to help the desperate British manpower shortage 

by taking over the British General Hospital No. 9 in Rouen (1,240 regular beds and 

300 crisis beds). Base Hospital No. 4 operated as the No. 9 General Hospital, British 

Expeditionary Force, for the entire period until it returned to the United States in 1919. 

The Lakeside unit was organized in August 1916 and mobilized in May 1917.41(p2)

BASE HOSPITAL NO. 5

At Boulogne, British General Hospital No. 13 was relieved by Base Hospital No. 

5. Base Hospital No. 5 was organized by Harvey Cushing at Harvard University in 

February 1916 and mobilized in May 1917. It arrived at Boulogne, France, in May 1917, 

approximately a month after the United States formally entered the war. It was assigned 

to the British Expeditionary Force and was designated as British General Hospital No. 

13, housed in a large city building until 1919. (The building had been the home of the 

Boulogne Casino.13(p50)) The Germans bombed Base Hospital No. 5 by plane, killing four 

Americans. Cushing received a message while he traveled to Camiers that among the 

dead was 1st Lieutenant William Fitzsimons, Medical Corps, US Army, the first American 

medical officer killed in action.27(p2)

Harvey Cushing and the Harvard unit sailed to England in 1917 on the SS 

Saxonia.

14(p103) Cushing had previously been assigned to Base Hospital No. 5. Subsequently, 

he was assigned to the No. 46 Casualty Clearing Station at Mendingham from 22 July 

1917 until 1 November 1917.9(p166) CCS No. 46 was one of three casualty clearing stations 
CHAPTER FIVE • 163

at Mendingham. Cushing wrote that the British were surprised by the Americans’ use of 

nurse anesthetists because the standard in England called for physicians in the role.13(p41)

Harvey Cushing was asked to attend to the son of Sir William Osler who had been 

wounded by artillery shrapnel near St Julien. Second Lieutenant Edward Revere Osler 

(known largely by the name Revere) had served with the Royal Artillery since 1916. He 

had been taken to Casualty Clearing Station No. 47 at Dosinghem. Despite the desperate 

surgical intervention of a group of surgeons including Crile, Osler’s son did not survive. 

(Cushing did not actually involve himself in the operation because there was no head 

trauma.15(p197))

Cushing’s time with a British CCS was fruitful. He collected a series of technical 

reports of patients treated during the Passchendaele. (This was actually the Third Battle of 

Ypres, which transpired from 31 July until 6 November 1917. The British carried the Allied 

burden in the Third Battle of Ypres as they attempted to prevail over the Germans strictly 

by attrition rather than any grand tactical maneuver.9(p263)) Cushing perfected his en bloc

bone resection under local anesthesia for his intracranial surgeries. He popularized the use 

of magnets to remove intracranial metal fragments and pioneered the use of dichloramine-T 

as a neurosurgical wound antiseptic.42(pp283–294) Crile recorded in his autobiography a visit 

with Cushing during which his younger subordinates complained that Cushing was too 

slow and deliberate for combat surgery. Crile said he advised them to let Cushing work at 

his own pace on select cases while they handled the larger burden.18(p161) Cushing was noted 

for his methodical pace and great care to detail in his operations and notes throughout his 

career. His style as a perfectionist with slow methodical technique could be attributed to his 

Halsted training.16(p236)

BASE HOSPITAL NO. 21

Also at Rouen, the duties of the British General Hospital No. 12 were assumed by 

Base Hospital No. 21. Base Hospital No. 21 came from Washington University at St Louis, 

Missouri. It was organized in July 1916 and mobilized in April 1917. It remained there 

until January 1919.43

BASE HOSPITAL NO. 12

While at Camiers, No. 18 British General Hospital was replaced by Base Hospital No. 

12. No. 12 (the last to sail) was set up from staff at Northwestern University in Chicago, 

Illinois. It was organized in July 1916 and was mobilized in May 1917. British General 

Hospital No. 18 remained attached to the British Expeditionary Force until March 1919.37

BASE HOSPITAL NO. 10

At Treport, Base Hospital No. 10 replaced British General Hospital No. 16.16(p683) Base 

Hospital No. 10 was organized from the University of Pennsylvania, Pennsylvania Hospital 

(Philadelphia). It was organized in February 1917 and mobilized in May 1917. It was sent 

to Le Treport, where it was assigned to the British Expeditionary Force and operated under 

the auspices of No. 10 General Hospital, British Expeditionary Force. The No. 10 Base 

Hospital remained with the British Expeditionary Force until February 1919. 
164 • FORWARD SURGERY

Initially, the university-anchored base hospital system provided a solid basis for 

excellent care of the Allied Expeditionary Force by utilizing the best available surgeons 

and their staffs. At the end of the war, 50 Red Cross Base Hospitals were set up in 

Europe.25(pp92–93) Cushing noted that the five original base hospitals assigned to the British 

Expeditionary Force treated more wounded than the 78 base hospitals in the American 

Expeditionary Forces, which he viewed as reflecting the more efficient British experience 

and organization. Cushing felt that the Americans did not wish to deal with this implied 

inefficiency of American versus British facilities officially. Unofficially, the senior medical 

officials saw no problem.15(p73 

Other Base Hospitals

Examples of some of the base hospitals to arrive later include the following:

Base Hospital No. 1 was organized at Bellevue Hospital, New York in September 1916 

and was mobilized in November 1917. It eventually set up in Vichy, France where it took 

over a group of hotels used by the French as hospitals. It remained in operation in Vichy 

from March 1918 until March 1919.37(pp629–655)

Base Hospital No. 2 was the Presbyterian Hospital of New York City. It was organized 

in March 1917 and mobilized for duty in May 1917. Base Hospital No. 2 was assigned to 

British Hospital No. 1 at Etretat, France. It was there until February 1919.37(pp629–655)

Base Hospital No. 3 was organized at Mount Sinai, New York, in September 1916 

and mobilized in November 1917. It was posted to Vauclaire, France, where it stayed until 

March 1919. 

Base Hospital No. 6 was organized at the Massachusetts General Hospital, Boston, in 

March 1916 and mobilized in May 1917. It was sent to Bordeaux, France. It took over a 

French hospital, where it remained until March 1919.37(pp629–655)

Base Hospital No. 7 was organized at Boston City Hospital, Boston, Massachusetts, 

in December 1917 and mobilized in February 1918. It was set up at Loire, France, where it 

remained until early 1919. 

Base Hospital No. 8 was organized at the Post-Graduate Hospital, New York, in 

November 1916 and mobilized in July 1917. It was sent to Savenay, France, where it 

functioned until January 1919.37(pp629–655)

The added American medical staffs greatly helped the British. By July 1917, American 

base hospitals sent doctors and staff to British casualty clearing stations. The British 

reported having insufficient surgeons on their own to perform frontline surgery. This 

shortage threatened planned expansion of surgery at the front.33(pp43,202) Many of the 

British surgeons were not surgeons in fact, but only had rudimentary surgical training. The 

Americans brought much needed skills and training to the CCSs.9(p166) The contribution of 

American military medicine was a significant gift to the Allies.

Medical officers were trained additionally at home. Soon after war was declared, the 

Army set up Army Medical Officer Training camps at the following locations: Fort Riley, 

Kansas; Camp Greenleaf, Georgia; and Fort Benjamin Harrison, Indiana, all of which 

operated until the end of the war (with the exception of Fort Benjamin Harrison, which 

closed in 1917 because it was deemed nonessential).40(pp348–349)
CHAPTER FIVE • 165

SIGNATURE WOUND OF WORLD WAR I 

Early on, the surgeons of the Western Front were expecting the relatively 

uncomplicated gunshot wound of earlier conflicts. The woundings in World War I were 

complicated by contamination resulting in infection, gangrene, and shock. The type of 

projectile that caused the most problem came from artillery. Terraine, in his 1982 book

White Heat: The New War 1914–1918,46 gives artillery the credit for being the cause of 

“the greatest loss of life, the most dreadful wounds, the deepest fear.”44(p146)

The German 7.7 cm, the British 18 pounder, and the French 75 mm were the most 

used artillery pieces in the light field gun category. The Americans used the French 75 mm 

field piece, even producing them under license in the United States. The French 75 mm 

threw a shell out to 8,400 meters. (A special dedicated shrapnel shell could travel 9,000 

meters.45(p14)) The use of heavier artillery became more common as the war progressed. 

Artillery ranging from the 90 

mm to the use of large naval 

guns mounted on railcars was 

seen.45p14) Upon impact, the highvelocity shells gave off splinters 

and parts of fuses, casings, or 

other parts that created unusually 

configured wounds.45(pp14–15)

OFFICE OF THE 

SURGEON GENERAL 

AND THE 

ESTABLISHMENT OF 

CONSULTANTS 

William Gorgas (Figure 

5-8) became the Army Surgeon 

General in 1914 after the 

unexpected death of the former 

Surgeon General, George H 

Torney. Gorgas had an illustrious 

background largely grounded 

in epidemiology, especially with 

reference to yellow fever. His 

largest challenge was in the area of administration and expansion of the medical care 

system. Gorgas was Surgeon General for most of the war.39(p154)

Interestingly, Merritte W Ireland (Figure 5-9), the Surgeon General during the latter 

part of World War I, had been assigned to the Fort Sam Houston Hospital, San Antonio, 

Texas, to treat casualties of the Punitive Expedition. He met Brigadier General (BG) John 

FIGURE 5-8. William C Gorgas. Gorgas was the Army Surgeon 

General from January 1914 until October 1918 (covering most 

of World War I). His work eradicating mosquitoes and yellow 

fever from Cuba and later in the Canal Zone brought him 

acclaim as a sanitarian. Photograph courtesy of the National 

Library of Medicine, Image #B029216.
166 • FORWARD SURGERY

Pershing there. Pershing later 

made him the Assistant Chief 

Surgeon of the AEF. He promoted 

him to the Chief Surgeon’s slot 

before recommending Ireland 

as a replacement for Surgeon 

General Gorgas in October 

1918.5 While Gorgas handled 

most of the World War, Ireland 

presided over the last phase of 

the war, the postwar occupation, 

and the influenza crisis.39(p155)

After the war, Ireland’s Army 

Medical Department produced 

a seminal 15-volume series titled 

The Medical Department of 

the United States Army in the 

World War,27 which covered the 

activities of Army medicine in the 

period.

The AEF established a 

consultant system by General 

Order No. 88, on 6 June 

1918. BG John MT Finney 

(Johns Hopkins) was named the Surgical Services Chief Consultant, with COL Harvey 

Cushing as the Neurosurgical Consultant and COL George Crile as the Consultant for 

Surgical Research. Their positions as consultants allowed them to advise the command 

concerning their areas of expertise.42(p385) The Surgical and Medical Consultants reported 

to the Director of Professional Services, who was COL William Keller. Consultants 

were appointed for each of the surgical services and for each of the medical services. 

(Interestingly, the Roentgenology Consultant fell under the Surgical Consultants listing.) 

The headquarters for the Professional Services Division was situated in Neufchateau, 

France.46(pp63–64) In terms of accomplishments, the consultant group arranged for some of 

the base hospitals to specialize in certain cases. This allowed the specialized consultants to 

be co-located with cases of their interest. For example, Base Hospital No. 20 dealt with 

tuberculosis cases while Base Hospitals No. 8 and No. 25 specialized in neuropsychiatric 

cases. Base Hospital No. 46 was devoted to neurosurgery patients. No. 115 concentrated 

on ophthalmic and maxillofacial cases. Finally, Base Hospital No. 9 was reserved for 

orthopedic injuries.46(p65)

Influenza Pandemic

The influenza and pneumonia pandemic of 1918 created havoc for the armies on 

both sides of the conflict, with significant losses of soldiers in a short time. The increased 

FIGURE 5-9. Merritte W Ireland. Ireland followed William C 

Gorgas as the Army Surgeon General. He remained in office 

until May 1931. Ireland had to deal with the drawdown of 

World War I and the influenza pandemic. Photograph courtesy of the National Library of Medicine, Image #B015407. 
CHAPTER FIVE • 167

mortality in Army camps compared to the civilian population was due, in part, to close 

living conditions in military camps and mess hall areas. The Surgeon General’s report 

was favorable in its reporting of the Medical Department’s response and the dedicated 

response of its nurses, doctors, and enlisted members.45(pp1033–1035) Byerly, however, in the 

book Fever of War,44 raises the question of whether the Army did all it could to deal with 

the pandemic.44(pp154–155) The flu infected over 1 million Army soldiers (26% of the Army 

troops). It accounted for 82% of the Army’s deaths from disease.44(p6) Byerly points out that 

military leaders, medical officers, and the Federal Government all tended to downplay the 

significance of the influenza pandemic on the war. Byerly is of the opinion (not necessarily 

shared by others) that such attempts added to the complacency in responding to the crisis. 

Byerly’s sense is that the military did not realize the impact of the pandemic upon warfighting capability in further planning.44(p11)

SUMMARY: ADVANCES 

Each war is said to have its own medical advances. The medical progress of World 

War I built on prior advances. The recognition of germ theory established new sterile 

techniques. Immunizations for tetanus and typhoid became available. New frontiers were 

being advanced in abdominal, thoracic, and neurosurgery that had been previously closed 

to the surgeon.44(p1609) World War I advances to remember include the use of whole blood 

transfusions, advances in shock treatment by transfusion (Crile’s work), debridement (with 

antiseptic solutions) as a standard surgical technique in dealing with wounds, and, finally, 

advances in neurosurgical injury repair.

Orthopedics

A surgeon on the Western Front was required to deal with all types of procedures.

World War I saw advances in orthopedic open reductions with internal and external 

fixation. The Army created a Manual of Splints and Appliances as the result of several 

“splint boards” convened to standardize the use of splints and to reduce the number of 

splints to 10.35(pp554–555) The Thomas splint was the best known of the available splints due 

to its ease of use. Improvements were made in splint application after surgery (considered 

a weak point) by the creation of hospital splint teams, which increased the productivity of 

orthopedic surgeons.39(p584)

Neuropsychiatry

Recognition and treatment advances were made in neuropsychiatric cases termed 

“shell shock.” Much work in the war was directed to “war neurosis.” Artillery was 

considered an important part of the etiology.45(pp373–375) The psychiatrists also described a 

neurasthenic version of the war neurosis, with an antecedent pattern of exhaustion.45(p379)

Drugs were to be used as little as possible. The patient’s morale was to be strengthened, 

always with a view to getting back to duty. The treatment was deemed a success if the 

soldier could be motivated to return to duty.45(pp403–404)
168 • FORWARD SURGERY

Neurosurgery

Cushing learned from his experience with the British that the mortality rate for head 

wounds could be reduced in half if soldiers were operated on in the forward area. He 

describes a 28% mortality rate in a British Casualty Clearing Station for his own cases 

versus a 45% rate in an American base hospital attached to the British Expeditionary 

Force.38(p755) The British adopted a plan to have several teams concentrated in one 

hospital for neurosurgery. The Americans felt it was preferable to have two teams located 

in evacuation hospitals along the lines of evacuation. As the levels of experience in 

neurosurgical procedures increased among specialized neurosurgeons, the Americans came 

to see the best results in larger centers with concentrated expertise.38(p757) 

Neurosurgeons became aware of the impact of helmet design upon head wounds. 

The British helmet was seated too high to afford protection. The French Adrian helmet, 

which was produced quickly, was not adequate to prevent penetration of projectiles. The 

German helmet was better designed and was 30% stronger than the English and American 

helmets.39(pp1–2) Experimental versions of the American interpretation of the German design 

were made, but the war ended before production could be considered. In fact, versions 

of the reengineered World War I helmet were used through 1942 in the US Army. The 

German design also afforded greater protection of more of the head, especially the sides 

and the back of the head.39(pp1–3)

Plastic Surgery

Advances were made in plastic surgery to deal with the huge number of facial 

disfiguring wounds. Facial wounds were not that uncommon, even during the Civil War. 

Facial wounds were to be closed as soon as possible without excision of tissue unless 

necrotic. Mucous membranes were to be closed along with skin closure. Secondary plastic 

repair could be done for reasons such as an unsightly scar. There was collaboration 

between general surgeons, otolaryngologists, oral surgeons, ophthalmologists, and 

neurosurgeons in the development of new approaches to facial plastic surgery.48(pp313–314) 

Radiographic Localization of Foreign Bodies

Radiographic localization of foreign bodies was used during surgical operations in 

World War I to find and remove projectiles and shrapnel. Fluoroscopic control was often 

used to facilitate such extractions.40(pp258–259) 

Transfusions

Transfusion of blood was a truly life-saving innovation. Wright described the use of 

citrates to allow storage of blood in 1894.30(p126) Landsteiner reported blood groups in 

1901. In 1906, George Crile reported direct transfusion from a donor radial artery to a 

donor cephalic elbow vein,22(pp329–332) and Jansky described blood group incompatibility 

in 1907.30(p129) In 1912, the first perioperative blood transfusion was completed at 

Massachusetts General Hospital. A paraffin collection vessel and delivery cannula (to 

discourage blood clotting) was used. The equipment was termed the Harvard Kimpton 

paraffin-coated transfusion apparatus.15(p124) By 1918, the British were providing 
CHAPTER FIVE • 169

transfusions in base hospitals and casualty clearing stations to an average 50 patients per 

day. In that year, all blood was citrated, but not all was typed and stored in blood banks. 

The level of understanding was incomplete in terms of incompatibility and treatment of 

transfusion reactions at this stage of development. As an example, Dr Archibald Lee of 

McGill University served in France from April 1915 until October 1916. In his series of 

eight soldiers receiving transfusions, six died, one had success, and one survived despite 

having a hemolytic reaction. The use of citrated-glucose enhanced blood transfusion, 

followed by the use of preserved blood in 1917 and 1918, reduced morbidity and mortality. 

However, the testing for blood groups and issues of incompatibility had to await future 

improvements after the war.30(p130)

Evacuation

The Army Medical Department used motor ambulance vehicles, trains, and canal 

barges in Europe to evacuate the wounded to treatment sites. Ships were used to transport 

the wounded to America. Trains were obtained from the French and the British. The plan 

to use ordinary modified boxcars was abandoned following the European finding that 

dedicated trains were superior. Nineteen British trains were delivered before the end of 

hostilities. The trains procured were not the more advanced British units featuring surgical 

capabilities. Two French trains converted from passenger units were also used in American 

service. Sixty barges were converted to American medical use. Barges were to be used for 

soldiers with compound fractures, and abdominal or chest wounds who would not be able 

to be transported by train. Ambulances were used extensively. The issue of spare parts for 

these vehicles called for a change in future shipping protocols. All spare parts were to be 

shipped in boxes with the ambulance. It was found that the ambulance should be shipped 

with its frame and body assembled.49(pp317–348)

The events of World War I encouraged many advances in techniques, medications, lifesaving transfusions, and equipment such as motorized ambulances. As Garrison pointed 

out, “the forgotten principle of debridement . . . was revived by Lemaitre and HMW Gray 

and in this way the danger of infection between front and base was effectively bridged 

and thousands of lives were saved.”50(pp201–202) Garrison noted that as the war neared its 

conclusion, evacuation hospitals were pushed closer to the front lines. His book, Notes on 

the History of Military Medicine,

50 summarizes nicely the many contributions of the noted 

military surgeons and the advances in military medical care during the World War.50(pp200–202)

Inasmuch as history is often forgotten, many lessons learned from this great conflict had to 

be relearned for the next worldwide conflict,50(pp283–294) only a little more than 20 years away.

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1919.

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1936.

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NY: Alfred A Knopf; 2011.

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274.

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CHAPTER FIVE • 171

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Military Surgeons; 1921–1922: 201–202.
INTRODUCTION

WORLD WAR II FOLLOWED in one generation after the end of World War I, which 

had been called the “war to end all wars.” The immense scope of the fighting in World 

War II required unparalleled planning, preparation, and execution on the part of the 

military medical community. As Roberts noted in his book, The Storm of War: A New 

History of the Second World War,

1

 World War II (quoting Gilbert) “lasted for 2,174 days, 

cost 1.5 trillion [dollars] and claimed the lives of over 50 million people.”1(p579) The total 

casualty count for all of America’s armed forces in World War II was 1,073,000 (dead and 

wounded). The counts varied by combat theater. For example, the Pacific (including Asia) 

Theater of Operations casualties were 27.6% of that total, of which 106,207 were killed 

in action (KIA) and 253,142 were wounded in action (WIA).2(p675) In the European Theater 

of Operations, the casualties were 52.4% of that total, of which 185,924 were KIA and 

376,000 were WIA.3(p543) The remaining casualties of the war (approximately 150,000 KIA 

and WIA) were from lesser theaters of operation as well as training accidents and the like.

Rather than trying to cover all of the medical and surgical aspects of World War II, this 

chapter will focus on the narrower topic of Army forward surgery and its impact on care. 

As an example of forward surgery, the China-Burma-India (CBI) theater of operations will 

be examined in greater detail throughout this chapter because it required forward surgery 

in its simplest form to deal with the jungles and mountains, and lack of transportation.

Start of World War II 

World War II began in Europe when Germany invaded Poland on 1 September 1939 

in conjunction with the Soviet invasion from the east.1

 The Soviet Union and Germany 

had signed the Molotov-Ribbentrop Pact (a comprehensive nonaggression pact), which 

had a secret aspect dealing with the countries’ respective roles in the coming Polish 

invasion. The Soviets were to invade and control the eastern portion of Poland, while 

the Germans were to invade and control the western part of the conquered nation.1(p29)

The respective forces would meet at agreed upon demarcation points. The Germans (the 

Chapter Six

World War II: Army Forward 

Surgery on a Worldwide Scale 

LANCE P. STEAHLY, MD
174 • FORWARD SURGERY

SD—Scherheitsdienst—and the feared Gestapo) and the Soviets (the NKVD—the People’s 

Commissariat for Internal Affairs [secret police]) quickly set out to arrest classes of people 

that would be “problems” for the respective regimes. These groups included professional 

classes, Jews and Gypsies, military officers, and intelligentsia of all types. The secret accords 

also detailed proposed Soviet advances into Finland and the various Baltic states.1(pp10,29)

France and Britain declared war on Germany on 3 September 1939 in response to the 

invasion of Poland. France and England had signed defense treaties with Poland in 1939. 

There was a lull in the fighting for 6 months until April 1940 (the so-called Phoney War or 

Sitzkreig), when Hitler occupied Denmark (9 April 1940) and invaded Norway. Denmark 

was taken originally as a prelude to the invasion of Norway. The country did offer some 

resistance, but its position was weak. The presumed reason for the lull was that the Axis 

powers were making preparations to expand the conflict to other countries and to stockpile 

more supplies, but required time. The Allies chose to delay any land offensives, although 

operations at sea continued. In rapid succession in 1940, the Germans then took over 

Holland (May), Belgium (May), Luxembourg (May), and France (June). In September 

1940, Germany and Italy signed an agreement of cooperation with Japan. Germany and 

Japan had previously signed an Anti-Comintern Pact (the Comintern was formed by the 

Soviet Union to foster international communist revolution) in 1936, which Italy had joined 

in 1937. A military alliance resulted, first in 1939 between Germany and Italy, and further 

in 1940 with the merging of military goals for the three countries.1(p5),4(p145) Italy declared 

war on the then-Allies (predominantly Britain and France) on 10 June 19401(p70); Mussolini 

had already committed Italian forces to the invasion of Ethiopia and Greece.1(p119)

Although the war in Europe had started in 1939 with the German invasion of Poland, 

the United States did not enter the war then, nor during 1940, nor most of 1941. On 10 

August 1941, in Placentia Bay off the coast of Newfoundland, the Prince of Wales carried 

Winston Churchill to meet Franklin D Roosevelt on the USS Augusta. Churchill had hoped 

that Roosevelt would declare war on Germany at this shipboard meeting. Roosevelt, 

however, did not agree to United States involvement at that point, presumably responding 

instead to America’s isolationist sentiment.5(pp62–68) Hamilton suggests that it was Roosevelt’s 

intent to dissuade the Axis powers from risking war with the United States by increasing 

America’s deterrence through the showing of its military strength.5(p35) Unfortunately, Japan 

felt its endeavor to pursue a policy of expansion in the Pacific Rim area was threatened by 

the existence of the US Navy’s Pacific Fleet, stationed in Hawaii. The United States finally 

entered the war following the Japanese attack on Pearl Harbor on 7 December 1941. 

Congress declared war on Japan on 8 December 1941.4(p365) The vote in Congress had 

only one dissenting member. On 11 December 1941, Germany declared war on the United 

States, as did Italy.1(p193),6(p637)

Army draftees then in service were extended on active duty even if they had completed 

their 1 year of service; Guard units scheduled to return to state control were immediately 

retained under federal control.4(p635) In April 1941, the War Department planned an 

operation, called “Rainbow-5,”7(p46) to station American troops in the British Isles, of which 

a portion were to be stationed in Northern Ireland. The first US Army units arrived in 

Belfast, Ireland, as early as March 1942. The shift of American troops to Northern Ireland 
CHAPTER SIX • 175

would allow the British to move their troops from there to North Africa. By May 1942, the 

contingent included the 5th Corps (1st Armored Division and 34th Infantry Division).8

Start of the War for the Army Medical Department

In 1939 when Germany invaded Poland, the US Army had seven general hospitals 

and 119 station hospitals. The five general hospitals in the continental United States were: 

Walter Reed (Washington, DC), Letterman (San Francisco, California), Fitzsimons (Denver 

Colorado), William Beaumont (El Paso, Texas), and the Army and Navy Hospital (Warm 

Springs, Georgia). The two overseas general hospitals were Tripler General Hospital 

(Honolulu, Hawaii) and Sternberg General Hospital (Luzon, Philippines).9(p2) The Surgeon 

General had determined by 1934 that even the peacetime hospitals were inadequate in 

terms of size and state of the equipment. Little concrete progress was made by 1939, 

despite planning efforts, due to the limitation of Congressionally appropriated funds. The 

amounts of appropriated construction funds were only enough to allow for maintenance 

of existing structures.9(p3) The only medical equipment the Army had as backup was stored 

after World War I and was, at best, of 1918 vintage. Many pieces of equipment were 

obsolete or close to it. The fiscal limitations consistent with the Depression-era constraints 

prevented the Army from incorporating the newest technology.9(p6)

The 119 station hospitals were designed to deal with the less serious cases, referring 

the more complicated ones to one of the seven general hospitals. Based upon the Army’s 

experience in the Civil War, the Spanish-American War, and World War I, the Army 

Surgeon General had a vision of how wartime medicine should be conducted. Hospitals 

in communication zones (ie, “back home”) were designated either station or general 

hospitals and were considered “fixed.” However, in combat zones, there were three classes 

of hospitals, categorized as: (1) the evacuation hospital, (2) the surgical hospital, and (3) 

the convalescent hospital. They were considered “mobile hospitals” because they were 

able to mobilize and physically move; they were to be assigned to field armies.9(p4) The 

surgical hospital could function in the army area much like an evacuation hospital or in the 

division area as an emergency treatment facility. The surgical hospital in the division treated 

shock, gave transfusions, treated complex fractures, and generally stabilized the soldier for 

evacuation to the rear, where the evacuation hospital functioned.9(p5)

Medical Officer Training

Although still considered peacetime (even after the invasion of Poland), the Army’s 

various medical branches began some measures to enlarge their numbers in anticipation 

of a possible mobilization. As an example, the Officer Basic Course for physicians was 

shortened from 5 months to 3 months in 1940 and was to be expanded to be given twice a 

year. This shortened course was designed to increase the physician numbers coming into the 

service and for Regular officers who had not attended the Medical Field Service School, at 

Carlisle Barracks, Pennsylvania. An expanded class of 111 doctors was graduated in 1940 

(the previous largest class had been in 1935 when 81 graduated).10(p36)

In preparing for possible conflicts, the Army could look to manpower from the 

Regulars, the Reserves, and the National Guard. In peacetime, the Army maintained a 
176 • FORWARD SURGERY

small professional element, including physicians assigned to the Medical Corps, dentists 

assigned to the Dental Corps, veterinarians assigned to the Veterinary Corps, and 

administrative staff with the Medical Administrative Corps. The Army had a Medical 

Department Reserve, which had professionals with the same qualifications as the Regular 

group. In the Reserves were many physicians from World War I with military medicine and 

military administrative experience who had stayed in the Reserves. These physicians were 

able to be placed in leadership roles due to their awareness of military ways. The Reserve 

officers performed 2 weeks of duty yearly and took medical extension courses.9(p2) The 

Medical Department of the Army National Guard placed emphasis on field training. In 

1939, physicians numbered 1,098 for the Regular component, 15,198 for the Reserves, and 

1,085 for the National Guard.10(p3)

In 1940, the initial training for the Regular Medical Corps officer was a 4-month Basic 

Graduate Course at the Army Medical Center (Walter Reed, Washington, DC) followed 

by a 5-month course at the Medical Field Service School (MFSS) (Carlisle Barracks, 

Pennsylvania).10(pp5–6) The MFSS trained enlisted and officers in matters of administration 

and field medicine.10(p4) The students of the MFSS also participated in the 1940 spring 

corps and Army maneuvers in Louisiana, termed “The Louisiana Maneuvers.” The corps 

phase was held at Fort Benning, Georgia. Half of the MFSS students were assigned to 

medical battalions and the other half to regimental medical detachments. The students then 

switched their assignments during the Army phase of maneuvers, which was held in the 

Sabine River area of Louisiana. By all accounts, the students showed more interest than 

the assigned physicians. The MFSS staff felt that the time would have been better spent 

doing field work near the Carlisle Barracks, Pennsylvania home base.10(p36) The officers of 

the maneuver units had been pulled from hospitals and were inexperienced in command. 

The Army’s modest assessment of their performance in the maneuvers was described as 

“creditable” in after-action reports.10(p35)

The Army started a partial mobilization as part of the limited emergency in the fall of 

1940, drawing upon its Regular, Reserves, and National Guard constituents. The Selective 

Training and Service Act of 1940, starting in September, made medical personnel subject 

to the draft. Some professionals joined with the threat of being drafted, in many cases to 

proactively deal with the inevitable and also in the hope of gaining some advantage in 

terms of assignment. The act was extended for an additional year after the summer of 

1941. During the year of partial mobilization, Medical Corps officer strength (physicians) 

was expanded from 2,000 to 14,000. A 1-month refresher course for National Guard and 

Reserve officers was begun.10(pp36,39) The Army introduced the Army Specialized Training 

Program to provide training in engineering, science, and medicine for enlisted soldiers. The 

Army used this program to expand the supply of physicians available for military service. 

The supply of trained Reserve physicians was used up by the end of 1941. The Army 

Medical Corps was expanded to 47,000 physicians by August 1945. There were sufficient 

numbers of older physicians (some of whom deferred their retirements) to treat the home 

civilian populations.10(pp42–43)

The new military physician students first participated in the corps phase at Fort 

Benning, Georgia. Eight faculty members from the MFSS came with the students. The 
CHAPTER SIX • 177

Army started a 1-month basic course in December 1940 as a refresher course for Reserve 

and National Guard. Extension courses by mail remained available for Reserve officers, but 

not the Regulars.9(pp36–37)

In an attempt to ensure that it had enough military physicians, the Army also 

contracted (through the efforts of the National Research Council) with civilian institutions 

to provide specialized training for medical officers. In 1942, the Mayo Clinic (Rochester, 

Minnesota) and the Johns Hopkins Hospital (Baltimore, Maryland) were the initial 

training institutions. By late 1942, specialized training was given at 15 institutions in 12 

areas of specialty work. Many courses were cancelled in late 1943 and by June 1944 there 

were only remaining courses in neurosurgery, radiology, physical therapy, anesthesiology, 

and surgery/medicine. The civilian courses were reduced because of shortages in the 

Medical Corps officers needed to staff military facilities rather than being involved in 

training in civilian facilities.10(p60) However, a special course in anesthesiology for portable 

surgical hospitals was held from 7 August to 4 September 1943. This type of instruction 

was critical because the anesthesiology course was designed to train personnel to use the 

limited anesthesia equipment in the portables. The portables seldom had trained anesthesia 

personnel and relied on physicians/surgeons who could do double duty.10(p71)

Deployment of Medical Assets

In 1942, the most immediate need for troops and medical assets was in the South and 

Southwest Pacific. In the aftermath of the Japanese victories in the Pacific at the expense of 

the Allies, urgency was placed on building up American assets in a largely neglected theater. 

Australia was in grave danger and combat augmentation was needed despite the fact that 

Europe would soon claim the most attention. In the first 6 months of 1942, the Surgeon 

General sent to Australia the following: two evacuation hospitals, two surgical hospitals, 

and four general and 14 station hospitals. Two each of evacuation, surgical, and station 

hospitals were sent to other islands in the Pacific. The field hospital was created in early 

1942 to provide for a smaller and more mobile hospital in the Pacific than the smallest 

other type of hospital (the 250-bed station hospital).9(p144)

By the mid-point of 1942, the emphasis began to turn away from the Pacific and 

toward North Africa and later Europe. The British were anxious that Europe become the 

priority because Hitler was the most direct threat for that region.9(p160) Toward the end of 

1942 and the first half of 1943, US Army hospital units were sent to North Africa and 

England. However, the Army Inspector General found that the casualty rates for North 

Africa were less than anticipated and that more than enough beds were available there. 

The planners had estimated that more casualties would result, hence accounting for the 

increased number of beds available.9(p216)

In early 1942, Northern Ireland also received one general and one station hospital. 

To support the deployed troops in Iceland (which had replaced British troops earlier) one 

general hospital was dispatched to Iceland.11(pp8,10) Hospital facilities were established by the 

Army in Greenland, which served all service branch personnel there.11(p18) Medical facilities 

were also established in 1942 in Newfoundland, at Gander and at Fort Pepperrell.11(p23)

American bases were set up in the early war years extending from the Arctic Circle of 

Canada to the Azores.11(p7)
178 • FORWARD SURGERY

Two general and three station hospitals were sent from the continental United States 

to England. Other hospitals were sent to India and to Canada in 1942 to provide care 

for the builders of the Alcan highway, which was seen as a critical defense need to allow 

rapid transport of troops and supplies in the event of a Japanese invasion of the American/

Canadian/Alaskan mainland.12(p143)

American forces were dispatched to Iceland to free up British troops for use elsewhere. 

Six thousand men of the US Army’s 5th Division arrived to supplement 4,100 US Marines. 

Most of the hospital beds were in the Reykjavik (the capital) area. Three station hospitals 

came initially in 1942. Later in that year, six more station hospitals and one general 

hospital arrived in Iceland to deal with the increased number of soldiers.11(p12) (If captured, 

Iceland could be used by the Germans as an additional base to thwart Allied convoys 

bearing arms and supplies to Russian north ports.) By August 1943, troops were moved to 

England and the medical support was reduced in Iceland to reflect the changes. By 1945, 

only the 92nd Station Hospital remained in Iceland.12(pp195–204)

Forces were also sent to Greenland. There were ultimately four station hospitals in 

Greenland. That area was important as a potential German base, which could threaten 

Canada and the United States. It also had a role as an air base and refueling point on the 

Atlantic routes.12(pp190–192)

In Bermuda, the 221st Station Hospital was the main facility. Bermuda was a British 

possession off the American Atlantic coast, which had potential use as a German base close 

to the American mainland. Again, British troops could then be spared for use in the Middle 

East after the American troops arrived.11(p8)

In 1942 there were also discussions under way concerning the proposed invasion of 

France to drive the Germans out. General George Marshall favored an early cross-Channel 

invasion while Prime Minister Churchill and Field Marshall Alan Brooke, Chief of the 

Imperial General Staff, urged caution and delay in such plans. The British view did hold 

as President Roosevelt was also influenced by the force of Churchill’s personality (and 

arguments). Marshall and Admiral King, the Navy’s Chief of Naval Operations, implied 

that a Pacific first approach might be the result of the British position. President Roosevelt 

sided with the caution of the British and a continued Europe first commitment. The 

evolving plan for “Operation Bolero” included sending 30 divisions (1 million soldiers) to 

England by late 1942 or at least by early 1943.9(p150) The Surgeon General estimated at least 

100,000 beds would be needed to support Bolero alone. The timing of an Allied invasion 

proved controversial throughout the war. The Soviets were always pushing for another way 

to take pressure off their own forces on the Eastern Front. The final consensus was to delay, 

with a tentative date of 1 May 1944 (even then the date had to be delayed a month due to 

the shortage of LST [landing ship, tank] landing craft).1(p465)

MAJOR COMBAT THEATERS

The Pacific Theater: Difficult Times 

The Japanese had been involved in China since the 1931 invasion of Manchuria, which 

was part of Japan’s overall plan to expand its domain and acquire additional raw materials. 
CHAPTER SIX • 179

The Japanese seized French Indochina in September 1940. The Japanese then captured the 

oil, tin, and rubber-containing Dutch East Indies (now Indonesia). The attack on Malaya 

began on 8 December 1941. (The Malayan coast is in the South China Sea with Singapore 

lying off the southern tip of the Malay Peninsula.) Singapore was considered the most 

heavily defended British colony. Singapore fell to the Japanese on 15 February 1942. The 

Japanese could utilize the natural resources of its conquests to supplement its own meager 

supplies on its island nation.1(p190)

As previously mentioned, Japan regarded the United States as its main impediment 

in its quest to control the Pacific Rim region. Events heated in the Pacific when the United 

States put an embargo on the sale of scrap metal to Japan, in an attempt to interfere with 

the acquisition of these materials. The Japanese decided that the time was right to strike 

at the Pacific Fleet. The attack on Pearl Harbor on 7 December 1941 started at 0600 and 

was over at 1000. Because the American aircraft carriers were out to sea, the Japanese did 

not launch their third wave attack for fear of the carriers engaging them in battle.1(pp191–192)

Japanese attacks on Malaya, Hong Kong, Guam, the Philippines, Wake, and the Midway 

Islands followed within days.1(p193) Wake Island was first attacked on 11 December and 

a final time on 23 December. Hong Kong was attacked shortly after Pearl Harbor; the 

15,000 Commonwealth troops finally surrendered on 25 December 1941. Thailand was 

taken on 8 December 1941. The fall of Singapore on 15 February 1942 involved the 

surrender of 130,000 troops.1(pp200–205) In the span of just 2 months, the Japanese had made 

inroads in their overall invasion plans.

General Douglas MacArthur had been the US Army Chief of Staff1(p208) until he retired 

in 1935. MacArthur then received an offer to go to the Philippines as its military advisor. 

In 1936, MacArthur was made a field marshal in the Philippine Army, while remaining on 

the US Army retired lists. He was recalled to active duty in the US Army with the coming of 

war. His 130,000-man force, consisting of 22,400 Americans and 107,600 non-Americans 

(Philippine forces and forces of the colonial powers of the British, Dutch, Portuguese, and 

Australians)1(p208) had a formidable task given the Japanese naval, air, and army resources in 

the region.1(p207)

The Japanese successfully destroyed most of MacArthur’s air assets at Clark Field on 

the first day of the invasion on 8 December 1941 (18 of 35 B-17 bombers were destroyed, 

as well as 56 fighters out of 90). By 23 December, MacArthur had abandoned Manila, 

moving to the Bataan Peninsula and later the island fortress of Corregidor. MacArthur faced 

upward of 200,000 Japanese troops,1(p208) including the 43,000 14th Army soldiers landed 

on Lingayen Gulf in the Philippines on 22 December 1941 under General Homma.10(p93)

Following the Japanese conquests in the Far East and the looming loss of the 

Philippines, General George Marshall, who had been appointed as the Army Chief of Staff, 

promoted (with President Roosevelt’s concurrence) MacArthur back to the four-star rank 

(he had returned to his two-star permanent rank in retirement) he had held as the former 

Army Chief of Staff. Furthermore, Marshall suggested to President Roosevelt that he order 

MacArthur’s withdrawal from the Philippines and award him the Medal of Honor as a 

symbolic act for the American people. The troops were not complimentary, referring to 

MacArthur as “Dugout Doug.”13(p82)
180 • FORWARD SURGERY

Subsequently, MacArthur was ordered by Marshall (again for President Roosevelt) to 

Australia on 11 March 1942.4(p711) Bataan, just west of Manila, was surrendered by General 

Jonathan Wainwright (who was left in command by MacArthur) to the Japanese on 9 

April 1942.1(p209) However, some Americans and Filipinos refused the order to surrender 

and instead slipped away into the surrounding terrain to form an impromptu guerilla force 

to continue fighting the Japanese. 

 The infamous “Bataan Death March” began on 10 April 1942. Seventy-eight 

thousand troops (12,000 Americans and 66,000 Filipinos) were marched over 60 miles 

with horrific losses. Of the 78,000 troops who began the march, between 7,000 and 

10,000 Filipinos died, as well as 500 to 700 Americans.1(p209) The exact numbers lost on 

the Bataan Death March vary as some Filipinos were able to escape and blend in to the 

native culture. The Japanese held in contempt the Filipino troops who had been loyal to the 

Americans. Indeed, the Japanese were described as using Filipino troops and civilians for 

bayonet practice, which accounts for their greater losses.1(p209) The Japanese also executed 

many along the way who could not keep up with the 5-day march pace. Some were 

shot execution style while others were bayoneted or shot randomly.9(pp172–173) Many more 

died in the camps to which they were marched. Exact losses at the various prison camps 

maintained by the Japanese are largely approximations based on estimates and prisoner 

information. As documented in postwar trials, the conditions at all Japanese prisoner 

camps were horrific.1(p209)

On 6 May 1942, Lieutenant General (LTG) Jonathan Wainwright surrendered the 

remaining part of the Philippine Islands not already held by the Japanese.1(p209),6(p713) The 

troops had only 3 days’ water supply left when he surrendered. Wainwright, a West Point 

graduate and a friend of MacArthur’s, had been the North Luzon commander and became 

the Philippine commander with the evacuation of MacArthur. Wainwright remained in 

Japanese captivity until the end of the war.9(p87)

Malaria was a problem for the Filipino-American forces well before their capture. 

Malaria was a serious handicap to military operations, with shortages of quinine for 

prophylaxis. It is estimated that 24,000 cases of malaria (among the 130,000 troops) 

afflicted the Filipino and American troops at the time of their surrender in 1942.9(p503)

The battle for the Philippines including Bataan and Corregidor cost the Americans 

2,100 casualties (900 killed and 1,200 wounded) and, of course, the 12,000 captured. 

The Japanese sustained 4,000 casualties (1,900 killed and 2,100 wounded) as well.1(p209)

(General MacArthur and his forces returned to the Philippines with the Leyte invasion on 

20 October 1944 but it was May of 1945 before all Japanese organized resistance had 

stopped.9(p92)) 

By early 1942, the Allied fortunes had fallen in land engagements. The war against the 

Japanese moved to the sea and demonstrated the importance of the aircraft carrier. The 

Battle of the Coral Sea was not a clear victory for the Americans, although the Battle of 

Midway, which followed, was such a victory. The Battle of the Coral Sea, on 7 and 8 May 

1942, was fought some 800 miles to the northeast of Queensland, Australia, in the Coral 

Sea. The Americans lost the aircraft carrier Lexington while the Japanese lost a light cruiser 
CHAPTER SIX • 181

and had two carriers damaged. The Japanese plan to take Port Moresby in New Guinea 

was abandoned as a result of the stalemate during the Battle of the Coral Sea.1(pp251–252)

The Battle of Midway took place 1 month after the Battle of the Coral Sea and 

was a decisive turning point in the effort to control the waters of the Pacific Theater 

of Operations. The naval battle was near the Midway Atoll west of Hawaii—actually 

midway between Japan and the mainland of the United States, between 4 June and 7 June 

1942.1(p256) The Japanese lost four carriers to one for the United States. The American 

carrier Yorktown was also damaged. The US success at the Battle of Midway made the 7 

August 1942 Guadalcanal invasion (the first American land invasion) possible by freeing 

up naval assets from imminent threat. However, the Australian and American ships off 

Guadalcanal were forced to leave when threatened by Japanese naval assets.1(p257) (The 

carrier Yorktown and an escorting destroyer were sunk by a Japanese submarine on the 

way back to Pearl Harbor for repairs.1(p256)) 

 Guadalcanal is an island near Telavi in the Southern Solomon group. The Japanese 

established a seaplane base at Telavi and later started an airfield at Guadalcanal, from 

which the Japanese could threaten the sea lanes to Australia. On 7 August 1942 this 

initial Guadalcanal invasion began with 18,700 troops deploying to Guadalcanal. The US 

Marines were led by Marine Major General (MG) Alexander Vandergrift. The Marines 

made amphibious landings also on the neighboring islands of Telavi and Gavuth.1(p257)

Unfortunately, the American naval forces sustained a night attack, in what became known 

as the Battle of Savo Island, on 7 and 8 August,1(p258) while still unloading the Marines’ 

equipment and supplies. The escort withdrew, leaving the Marines to fend for themselves. 

In that Battle of Savo Island, three American cruisers and one Australian cruiser were 

sunk by the Japanese.1(p258) These events are well recounted in Newcomb’s 1961 book,

The Battle of Savo Island.14 The Japanese air assets from Rabaul (in New Britain, Papua 

New Guinea) had a fairly free hand to attack the Marines. The limited air power of the 

defending “Cactus Air Force” (the assembled Allied planes in the Guadalcanal area) was 

no match. On 13 October 1942, after 2 months of fighting, Army troops reinforced the 

Marines at Guadalcanal.1(p259),15(p717) The arrival of Major General Alexander Patch and 

Army Regular troops caused the Japanese to finally evacuate the island. Guadalcanal losses 

for the Japanese were approximately 25,000 dead, while for the Americans it was 1,490 

dead (mostly Marines) and 4,804 wounded.1(p259)

The Japanese had previously created problems in the American-owned Aleutian Island 

chain off the coast of Alaska. The Japanese had raided the Dutch Harbor Naval Base in the 

Aleutians with an air attack on 3 June and 4 June 1942. Losses at Dutch Harbor consisted 

of burning oil tanks and damage to the hospital and a barracks ship. The Japanese had 

taken the islands of Kiska (6 June 1942) and Attu (7 June 1942).16(p722) Almost a year later, 

on 11 May 1943, Army forces invaded the Aleutian Islands at Attu, off the coast of Alaska. 

Attu was briskly defended by the Japanese who were heavily dug in. The Americans 

sustained almost 3,929 casualties (580 killed), while the Japanese were exterminated except 

for 28 prisoners. The extent of Japanese involvement so close to the Alaskan mainland 

enhanced the importance of building the Alcan Highway as a military road to speed troops 

and supplies to the North.

16(pp722–723)
182 • FORWARD SURGERY

Elsewhere in the Pacific Theater of Operations, the Army would play varying roles in 

a largely Navy sphere of operation in the follow-up to Guadalcanal. Kwajalein, Saipan, 

Tarawa, Guam, Luzon, Iwo Jima, and Okinawa would be other famous battle islands in 

the drive toward the main Japanese islands. 

The China-Burma-India Theater of Operations

World War II involved many distant and diverse theaters of operation that required 

different types of engagement. For example, the Japanese saw India as a source of British 

manpower and resources and planned to take India with a view to connecting with the 

Germans in the Middle East.1(p188) The Japanese were moving toward India, the jewel of 

Britain’s Empire, until the May 1942 monsoon, which was so severe that it disrupted 

Japan’s plans. The Japanese took over Burma in May 1942. Burma and Thailand were 

to be part of the Japanese Greater East Asia Co-Prosperity Sphere. This Sphere was 

designed to tap the resources of these counties for the Japanese benefit.1(p188) Previously the 

Japanese had taken operational control of the Vichy French-held territory of Vietnam in 

an agreement with Vichy (in 1940). The Japanese invaded Thailand (8 December 1941). 

The Thai government then signed an alliance (21 December 1941) effectively giving the 

Japanese occupation of the country.1(p260)

Britain was unsuccessful in 1942 and 1943 in conventional warfare in its attempts 

to retake the Arakan, the coastal province of Burma, and Akyab Island, off the coast 

of Burma with an important airfield. Hence, the British adapted a unique version of 

irregular warfare (long penetration jungle fighting) that was the innovation of British 

Brigadier General (BG) (later MG) Orde Wingate.1(p260) An epic personality, Wingate was 

an unconventional officer employing irregular, but successful, techniques (such as hitand-run tactics and ambushes where the enemy least expected) against the Japanese in 

Burma. Wingate’s forces (3,000 men1(p262)) known as the “Chindits,” were composed of 

Indian, Gurkha, and British troops who engaged the Japanese far behind their lines.1(p260)

(The origin of the term “Chindit” is uncertain. Some feel that it may be Wingate’s version 

of the Burmese chinthe [lion] but only Wingate knew and he did not report it.1(p260)) The 

Chindit expeditions in 1943 and 1944 created much press publicity for their courageous 

raids. The reporters based in India (but not embedded with the units) popularized the tales 

of extraordinary human endurance. The public found encouragement in their dramatic 

episodes. 

As with the other theaters of operation, the China-Burma-India (CBI) theater had 

many casualties for the medical service to tend to. The forward surgical support for the 

wounded soldier had been well founded in World War I. The more refined forward surgery 

concept of World War II was exemplified in its most elemental form by the portable 

surgical hospital. The most “colorful” of the portable surgical hospitals was the Seagrave 

Unit headed by Lieutenant Colonel (LTC) Gordon S Seagrave.

GORDON S SEAGRAVE AND THE SEAGRAVE UNIT

Seagrave was born in Rangoon, Burma, to a family of Baptist missionaries. In fact, 

he was the fourth generation of missionaries, although he was the first to be a doctor. He 
CHAPTER SIX • 183

graduated from Johns Hopkins University School of Medicine in Baltimore, Maryland, 

in 1921. Seagrave then completed an internship at Baltimore’s Union Memorial Hospital 

before he and his wife came to Namkham (in the Shan States of the northeastern part of 

Burma) in 1922.17(p10)

Over the years, he developed a hospital, sponsored by the Baptist Mission, caring 

for native Karen, Kachin, and Shan people. (Seagrave enjoyed some fame after he was 

the subject of a Life magazine article, with photographs in 1943.18(p23)) As he noted in his 

books, Burma Surgeon (1943)19(p35) and his later Burma Surgeon Returns (1946),17(p10) he 

had provided dedicated care to these people in the local native tradition, honoring the 

family as the caretaker. Entire families would literally camp out with their family member 

patient and provide some of the simpler care.20(pp357–358) By 1942, his hospital had a 100-bed 

capacity. Interestingly, he had set up an in-house program to train native girls as nurses. It 

started with 11 students but he later expanded it to 19. Seagrave’s “Burmese nurses” were 

not Burmese at all, but instead represented the Shan, Karen, Kaelin, and a number of other 

ethnic groups.17(p10) His nurses called the chain-smoking surgeon “Doctor Cigarette.”17(p11)

The British hoped to reestablish control of Burma, while the Chinese were concerned 

with the loss of the Burma Road (which was a major supply route for China), and to that 

end the Chinese had positioned the 6th Army in the Eastern front.21(p33) The British under 

the command of Lieutenant General (LTG) Sir William Slim (14th Army Commander) 

requested that Seagrave provide medical care for the Chinese 6th Army, then operating 

in eastern Burma in the First Burma Campaign. The Chinese 6th Army was one of the 

Nationalist Chinese more elite units.22(p36) However, the Chinese had few medical supplies 

and their medical organization was almost nonexistent.22(p103) Seagrave organized his unit 

as a civilian mobile surgical hospital.23(p288) Seagrave and his staff of American and British 

ambulance drivers and British medical professionals took care of the Chinese. Seagrave 

found that the Chinese were in such poor condition that they required immediate medical 

attention.22(p104)

After Americans, in the form of LTG Joseph Stilwell and his military forces, arrived in 

Burma in February 1942,17(p32) Seagrave had a decision to make about joining the military 

effort. He could remain a civilian or he could become a military physician. Some in his 

Baptist missionary circle were critical of the decision that he reached. Seagrave said in his 

Burma Surgeon Returns, “I am a conscientious objector. I detest war . . . in the face of what 

Germany and Japan have done to the world, the pacifism that will choke over the idea of 

wearing a uniform in a reconstructing group is something the world can do without.”17(p120)

Seagrave also noted that, “All my life, I’ve been my own boss, often to the consternation 

of the American Baptist Burma Mission.”17(p110) He continued, “When you are actually 

fighting and hoping to wipe something bad out of the world, the Army is the only place 

to be.”17(p110)

Seagrave asked to be under American command after Stilwell arrived in Burma. 

Stilwell (called “Vinegar Joe” behind his back, reflecting his caustic personality24(p1)) had 

been appointed in 1942 by President Roosevelt and Chief of Staff General George Marshall 

as the Commander of American forces in the CBI and as the concurrent Chief of Staff for 

the Chinese leader Chiang Kai-shek.1(p265) Stilwell’s staff surgeon, Colonel (COL) Robert 
184 • FORWARD SURGERY

Williams, swore Seagrave in as a major in the US Army Medical Corps on 21 April 1942. 

Williams followed the now-Major (MAJ) Seagrave’s recommendation to split Seagrave’s 

repurposed missionary unit in order to care for both the 5th and 6th Chinese armies.23(p288)

Stilwell agreed to his request. Seagrave was joined by Captain (CPT) John Grindlay, who 

had graduated from Harvard Medical School in 1935. Subsequently, he completed a year 

at Dartmouth’s Mary Hitchcock Hospital as a pathology fellow and then another year 

at Hitchcock Hospital as a rotating intern. Grindlay then trained in surgery at the Mayo 

Clinic and earned an MS in surgery from the University of Minnesota. Grindlay became the 

head of surgical services for Seagrave’s unit.21(p28)

Seagraves’s medical supplies largely came from American Red Cross stocks at Lashio in 

Burma.22(p104) Grindlay had been sent from the American Military Mission, the military part 

of the American Embassy in China that provided assistance and distributed Lend-Lease 

shipments to China. CPT Donald H O’Hara, a dentist, also joined the unit. He had the 

misfortune to be allergic to rice, which due to shipping limitations necessarily formed part 

of the American rations available. O’Hara had come directly from the United States.23(p288)

General Joseph “Vinegar Joe” Stilwell

The war was not going well for the Allies in Burma during the period from March to 

May of 1942. The Japanese had defeated the British and Chinese armies and rolled the 

respective armies toward India (British) and back to China (Chinese). General Stilwell had 

sent part of his headquarters out of country by plane while he stayed with the rest. Stilwell 

actually did not have many American troops in his command. Most of his troops were 

Chinese units that he had been training. His headquarters unit was American (100 officers 

and enlisted soldiers), largely in an advisory, rather than command and control, sense. He 

famously declined to get on the evacuation plane, offering no reasons for his decision. Two 

Army Air Force colonels had been sent by General Hap Arnold who told them to “rescue” 

Stilwell.25(p292) It was because of this refusal that air advocates said that “Walking Joe” did 

not understand airpower.25(p293)

Because the Japanese were closing in on his forces, Stilwell had to leave quickly. 

He led a party, including Seagrave and his nurses, to Imphal, India, a journey of over 

600 miles. The group numbered approximately 100 people, which included 18 officers 

and six enlisted personnel. Seagraves’s unit, with 19 Burmese nurses and two civilian 

doctors, provided the medical support. An English Quaker ambulance unit of seven (the 

Friends Ambulance Unit) joined the group and helped with the provision of medical care, 

specifically the transport of patients. The remaining members of the ad hoc group consisted 

of some British officers, an American missionary, and some Malayan and Burmese porters 

and cooks.25(p293) COL Williams served as the headquarters detachment medical officer 

with the group.25(p290) Stilwell later added a group of 15 British commandos who were 

independently evacuating from Northern Burma. He also hired a Chinese pack train 

that his party came across. The mules were used to carry items that an additional hired 

contingent of 60 local people “carriers” could not transport.25(p295) Seagrave’s unit also 

created extensive good will by their treatment of Burmese villagers they encountered along 

the march. This good will was confirmed by the natives’ willingness to serve as porters 

and guides.24(p11)
CHAPTER SIX • 185

 Stilwell set the jungle march rate at the standard Army 105 steps a minute as infantry 

soldiers are taught. He kept the pace himself and was disgusted that many of the “soft” 

members of the group fell out from fatigue or heat exhaustion. Stilwell first had to grant a 

5-minute rest per hour.25(p296) Later Stilwell had to increase the rest period to 10 minutes per 

hour as malaria and dysentery took their toll on many of the marchers. Making matters 

worse, COL Williams’ supply of medicines was stolen at one point under suspicious 

circumstances (probably by a member of the party; the medications were not recovered). 

Williams called for more rest stops due to the sickness. Stilwell reportedly said to him, 

“Dammit, Williams, you and I can stand it. We’re both older than any of them. Why can’t 

they take it?”24(p6) Stilwell was in good physical shape despite his 59 years of age.26(p96)

Seagrave’s nurses, ages 17 to 22, kept the unit going with their good cheer and singing20(p60)

hymns, favoring “Onward Christian Soldiers.”23(p39) The personal diary of Grindlay16

details the arduous nature of the “walk out” as well as the courage of the participants. 

Grindlay kept up the 30 miles per day pace, which he credits to the efforts of Seagrave’s 

nurses.21(p29) Finally, largely due to Stilwell’s force of personality, the group made it to 

India without loss of life. The exodus took 3 weeks of moving through the jungles and 

mountains of north Burma.23(p298)

Stilwell described the earlier defeat that made necessary the trek to reporters as “a hell 

of a beating and it’s humiliating as hell.”23(p290) Stilwell’s frank comments were in contrast 

to those of the British Major General Sir William Slim, who had taken his troops on a 

roughly parallel 600-mile trek with two divisions with reduced strength of several thousand 

troops.26(p96) Slim tried to give the event a favorable spin by speaking in terms of “strategic 

withdrawal.” (In Burma, Slim was a corps commander in charge of the Burma Corps 

[consisting of the 1st Burma Division and the 17th Indian Infantry Division] under the 

command of General Sir Harold Alexander. Slim went on to command a joint English and 

Indian Army that eventually retook Burma in 1945.1(p567)) The Burma Corps of the British 

Army had sustained 13,000 casualties overall, of which 9,000 were missing in action. 

Stilwell reported in his Stilwell Papers that many of the missing were lost or Japanese 

prisoners of war.26(p97)

Stilwell’s plan, once he reached Imphal, India, was to train Chinese troops of the 6th

Army (an elite Chinese force) there to retake the northern part of Burma. Seagrave and his 

unit helped screen and treat the Chinese troops for various diseases and disabilities. Over 

the course of a few months, his unit vaccinated the thousands of Chinese troops against 

diseases such as smallpox, typhoid, and cholera with vaccines shipped from India.27(p326) At 

Ramgarh, India, Seagrave treated the damaged Chinese 22nd and 38th Divisions, which 

formed the main Stilwell forces there.27(p138)

CPT Grindlay became the head of surgical services under Seagrave at Ramgarh 

after the “walk out.”17,21(p36) The unit remained there until mid-1943, when it moved to 

northwest Burma. The unit provided medical care to Chinese and American construction 

units working on the Ledo Road, which was to be a replacement for the captured Burma 

Road to supply China. Seagrave later established a hospital at Tagap Ga to be followed by 

other units down the Ledo Road.21(p37) Grindlay told the Surgeon General that every jungle 

combat unit needed a mobile surgical unit. He felt there were enough restless surgeons to 

form teams if there were too few portables.24(p324)
186 • FORWARD SURGERY

By late 1942, Stilwell had some 32,000 Chinese troops in training. Stilwell was 

ultimately successful in his plan to train the Chinese to improve their combat readiness, 

despite opposition from the British, Claire Chennault, and Chiang Kai-shek. Chennault 

had resigned his Army commission to form a nascent air force for the Chinese to engage 

the Japanese. Chennault ultimately became a major general, in charge of the US Army Air 

Forces’ 14th Air Force in China. Chennault and Stilwell were in constant disagreement 

over the role of airpower in the CBI Theater.1(p268) Chiang Kai-shek resisted Stilwell’s more 

aggressive plans for utilization of the Chinese troops. Chiang and the Communists were 

more interested in keeping the other side from advancing its agenda. In the end, Chiang tied 

up Japanese troops, but was not able to take out the Communist Chinese.1(p268) The British 

were leery of armed Chinese troops in India because they might have some effect on the 

possibility of an Indian rebellion (which did not occur) to secure Indian independence.In 

some cases, the British detained fervent nationalists. Nonetheless, India supported Britain 

in World War II, adding many troops that served in all theaters. Furthermore, the Indians 

did not wish to use Chinese troops to retake Burma because it had been among British 

possessions. The British were concerned that Indian troops would support indigenous 

fervor for independence.10(pp314,315) Marshall’s support was critical to the success of using 

Chinese armies to defeat the Japanese in Northern Burma.28(p66)

Stilwell had been appointed by Chiang as his Chief of Staff (but he had no real control 

in this position)18(pp86–87) and by Marshall as the Commanding General of the US Army 

Forces in China. He was no stranger to controversy. His contentious relations with the 

Nationalist leader Chiang Kai-shek centered on Stilwell’s view that the leader was more 

interested in fighting the Chinese Communists than the Japanese. Stilwell’s vision of how 

things should go in the China-Burma-India theater didn’t correspond to those of General 

Chennault, Chiang, or the British. Stilwell has been accused of favoring Chiang merging his 

forces with the Communists to fight the Japanese. Stilwell did propose at one point that the 

Nationalists operate with the Communist 8th Route Army, to no success.23(pp388–389) Neither 

the Chinese Nationalists nor the Communists were as interested in fighting the Japanese 

as they were in keeping the other side down and jockeying for position once the war 

ended. The Nationalists and the Communists were more interested in fighting each other. 

(Because the Communists were ultimately the winners of the struggle in 1949, both Stilwell 

and General Marshall were subsequently incriminated in the 1949 loss of China by such 

notables as Herbert Hoover.29(pp352–353)) 

Stilwell had graduated from West Point in 1904. He stood 32nd in a class of 124 and 

ranked as a lieutenant of cadets.25(p15) In 1911, while stationed in the Philippines, Stilwell 

had his first contact with China, touring the country as a revolution took place installing 

Sun Yat-sen as president.25(pp37–41) Stilwell was a World War I veteran of some distinction. 

Over the following 20 years, he had assignments that alternated between the United States 

and China, becoming fluent in Chinese as a consequence. In World War II, Stilwell hoped 

for the command of troops in the invasion of North Africa, but deferred to Marshall’s 

selection.25(p86) Stilwell had diverse roles including the role as Commanding General of 

American forces in India, Burma, and China. He also had the job of controlling Lend-Lease 

material to be dispersed in theater. As General Albert Wedemeyer, Stilwell’s successor, later 
CHAPTER SIX • 187

learned, the position in China was an impossible one due to the ongoing NationalistCommunist struggle for power and the corruption of the Nationalist regime.30(pp109–130)

MERRILL’S MARAUDERS

On 6 January 1944, 3,000 men formed the group known as the 5307th Composite 

Unit (“Provisional”) (code named “Galahad”).27(p293) It was organized into three battalions 

with 700 pack animals total for the battalions. Each battalion had three combat teams. An 

air supply section was set up to provide the planned air supply for the troops, as well as 

for casualty evacuation.27(pp293–294) COL Charles N Hunter led the volunteer unit for several 

months before General Stilwell appointed a new commander, Brigadier General (BG) Frank 

D Merrill, in June 1944. Soon thereafter the unit was dubbed “Merrill’s Marauders.”27(p293)

The “Marauders,” an all-volunteer unit, were all physically fit and ready for a risky 

mission. They were expected to handle up to 3 months of jungle fighting. They were also 

expected to be in poor physical condition at the end of this period, and thus would require 

prolonged rest and healing. No replacements were anticipated.27(p294) They actually spent 

4 months in the jungle. They evacuated their sick and wounded to clearings in the jungle 

where light planes could evacuate a few men at a time for treatment.27(pp294–295)

The new unit marched 100 miles from Ledo to Shingbwiyang, where newsmen met 

them. This was the route through the mountains and jungles to deal with the Japanese as 

part of their first combat mission.27(p295) Merrill’s men stayed in the Burma jungles striking 

the Japanese for 4 months, suffering innumerable trials and privations. The diseases were 

numerous outside of battle injuries. The malaria rate was extremely high, despite Atabrine 

prophylaxis, to the extent that operations were impaired.27(p296) The Marauders also 

suffered from many diseases including dengue fever, dysentery, diarrhea of various diseases, 

neuropsychiatric conditions, and numerous skin conditions.27(p323) Amebic and bacillary 

dysentery were both common.27(p392) Scrub typhus was also a serious medical problem.27(p393)

The Marauder’s long trek of over 700 miles, including the 100-mile initial trek, compounded their exhaustion. Indeed, Merrill sustained a myocardial infarction during the 

strenuous march. Although Atabrine discipline was enforced, its use fell. The men’s morale 

was low because they were overcome by the pressures to continue the mission, as well as 

disheartened by the tough restrictions on evacuation and relief. As the morale fell, Atabrine 

discipline fell further.23(p395)

Air evacuation was critical to the Marauder mission. The Marauders were evacuated 

when possible from jungle clearings or even sand bars in rivers. Light planes (L-1 and 

L-5 planes) could get in and then out of such isolated areas. They would take the injured 

to landing strips where C-47s could land. The C-47s flew the casualties to the 73rd 

Evacuation Hospital or the 20th General Hospital, both located at Ledo.23(p307),27(pp325–326) 

A disadvantage of the longer land evacuation route to larger hospitals was that some 

patients could have been restored to duty more quickly if treated at a more forward facility. 

Combat Command directing the Marauder combat had no mobile evacuation hospitals 

but did improvise using the Seagrave unit and the 25th Field Hospital. The 400-bed 25th 

Field Hospital was able to function like three portable surgical hospitals by dividing itself 

into hospital sections. One such hospital section took over a Seagrave unit and treated 460 

cases in 8 days at Taipha Ga.27(p324)
188 • FORWARD SURGERY

The medical situation in the China-Burma-India theater was more complicated than in 

the Pacific. Troops in the Pacific did not have to endure the long periods of remote fighting 

behind enemy lines. They could be resupplied by sea while the troops in the China-BurmaIndia theater relied on air supply because the rough trails (and nonexistent roads) precluded 

other means. Supplies were obtained through British channels in Karachi, Pakistan, and 

other locations.23(pp507–508)

North Africa/Sicily/Italy Prelude to the European Continent

By 1943, the Americans had shifted their focus to the European area of operations as 

part of the “Europe First” decision. Britain, led by Prime Minister Churchill, was pushing 

for the defeat of Hitler as the priority before Japan. The Soviet Union put pressure on the 

Allies to relieve German pressure on Soviet troops by occupying the Germans elsewhere. 

President Roosevelt adopted this plan, although the US Chief of Naval Operations, 

Admiral Ernest King, felt the Pacific should be the priority. The emphasis on Europe had 

been decided at the highest levels. In part, this was driven by the fact that the Germans had 

quickly defeated the French forces and occupied the country. The British Expeditionary 

Force (BEF) withdrew from the Continent to the port area of Dunkirk, where their troops 

were evacuated. However, the British left most of their arms and equipment behind. The 

French surrendered on 22 June 1940. The Vichy French were allowed some autonomy until 

the Germans occupied the whole of France in November 1942.1(p77) The French colonies of 

North Africa remained loyal to the Vichy French regime. Hence, the initial Allied combined 

operations were directed to North Africa where “Operation Torch” was to take place. 

General Bernard Montgomery (later Field Marshal) had just won his victory at El Alamein 

in North Africa on 8 November 1942. The British needed a real land victory to restore the 

morale of the Commonwealth. The Germans’ Afrika Korps, depleted of resources, men, 

and munitions, was soundly defeated,1(p300) and provided this much needed morale boost.

MG Dwight D Eisenhower commanded the overall invasion force for Operation Torch 

on 8 November 1942. The operation consisted of an amphibious landing on Algerian 

and Moroccan beaches facing Vichy French forces.3(p645) Atkinson saw the North African 

operation as being very important. He pointed out that the North African invasion 

surpassed all other operations in World War II for its risk, complexity, and daring. It was 

also the first joint English and American operation.3(pp50–51)

Allied landings in Sicily on 7 August 1943 began the race to Messina between Patton’s 

and Montgomery’s forces. Once at Messina, Patton’s troops won the race, but the Allies 

found that the Germans had already evacuated to Italy proper.4(p651) The collapse of Sicily 

had the effect of hastening the end of Mussolini’s rule, despite the fact that a large German 

force was able to be evacuated to mainland Italy to fight again.1(p376) The 5th US Army, 

under the Command of LTG Mark C Clark, landed near Naples on 9 September 1943. The 

amphibious landings were planned for the Bay of Salerno (south of Naples), which was 

the most northern point that airpower could be concentrated at this point in the war.1(p378)

The Battle of Salerno, as the landing was called, ran from 9 to 16 September 1943, with a 

strong German defense of the beach.4(p652) The Germans had concentrated their resources 

in a bid to defeat Clark, which almost succeeded.1(p378) Indeed, LTG Clark came close to 
CHAPTER SIX • 189

ordering the withdrawal of the 6th Corps at Salerno.1(p380) The Allies had 15,000 casualties 

(out of 170,000 troops) at Salerno, as opposed to only 8,000 for the Germans.1(p381) Italy 

surrendered to the Allies on 18 September 1943. The Allies met difficult resistance going 

toward the North.3(p653) For example, the advance up the Apennine Mountains to reach the 

Po Valley was challenging, in part because of bad weather. However, the Germans used 

the 80-mile wide Apennine Mountains to help in their rearguard actions, while making 

great use of mines and booby-traps in villages.1(p382) The situation in Naples was poor with 

disease, starvation, and corruption rampant. With rain, snow, and temperatures at an 

all-time low, disease was an Allied problem (pneumonia, trench foot, fevers, jaundice, 

and dysentery).1(p382)

There were four battles of Monte Cassino involving a wide variety of Allied troops 

from many countries, holding up the Allied advance for 4 months.1(pp390,393) The great 

monastery hill of Monte Cassino was the strongest part of the heavily fortified German 

Gustav Line that bounded Mount Cairo. The town of Cassino surrounded the base of the 

1,700-foot high peak where the abbey was located.1(p386) The capture of Monte Cassino 

(although resulting in the destruction of the abbey) was necessary to break through the 

Gustav Line.1(pp388–389) 

The landing at Anzio (a small port used for holiday travels in peacetime that is located 

30 miles south of Rome1(p393)) and the resulting conflict were much criticized, especially 

by the British War Cabinet.1(p397) The Allied losses were high and the whole operation was 

stalled by the Germans. The German leadership of Field Marshal Albert Kesselring was 

hard to match. He was the German general with ultimate charge of the forces in Italy. 

Rommel reported to Kesselring in North Africa and in Italy. He was an infantryman who 

transferred to the Luftwaffe after its creation. Kesselring had a native genius for tactics.1(p378)

Not all of the action in Italy was on the ground. The Germans bombed the American 

ship John Harvey in the harbor at Bari, Italy, on 2 December 1943. Mustard gas had been 

introduced into the European Theater by the United States in case the Axis Powers used 

gas; the John Harvey was part of that plan, which was kept strictly classified for years. 

The mustard gas on board the ship mixed with oil on the surface of the water.3(pp653–654) The 

horrific burns that resulted were not acknowledged to medical providers to be gas-related 

for a number of weeks. During the interim period, medical personnel thought that they 

were dealing with exposure because the gas was diluted enough to escape detection. There 

were 800 casualties hospitalized, of which 628 were ultimately attributed to mustard gas 

exposure. Fifty-nine deaths were listed as a direct result of gas exposure. The majority 

of the casualties were American and many were merchant seamen. The injured were 

wrapped in blankets while still in contaminated clothing. The majority of the injured 

were hospitalized in British hospitals because the American hospital equipment had been 

destroyed in the bombing.11(pp350–351)

The Americans also considered using mustard gas and phosgene in the Pacific 

against the Japanese. Apparently Generals Marshall and MacArthur supported the 

recommendation of the Anglo-American Lethbridge Commission to use these materials. 

President Roosevelt, however, did not allow the measure to progress.1(p568) The Germans 

did not use gas because Hitler was opposed to its use in combat, based on his World War I 

experience in the trenches. 
190 • FORWARD SURGERY

The Americans were not involved in fighting on the Eastern Front, other than 

providing copious supplies and equipment under the Lend-Lease Program. The Germans 

had made remarkable progress in the early invasion of Russia in July and August 1941. 

The Germans would later be slowed into the spring of 1942 by the defense of Leningrad. 

The terrible Russian winter weather also slowed down any German advance. However, the 

German loss of Stalingrad on 2 February 1943,1(p343) and the tactical draw at Kursk1(p520) 5 

months later, turned the tide fully against Germany on the Eastern Front. The success of the 

Soviets did, consequently, affect the fighting in the West being waged by the Americans, the 

British, and the Free French. The Soviets were persistent in their demands for the Allies to 

mount a second front against the Germans to take pressure off the Soviets. The struggles on 

the Eastern Front had been epic in proportions. For example, the Stalingrad campaign ran 

from 17 July 1942 until the German surrender on 2 February 1943. Out of an estimated 

quarter million German troops in the city, only 90,000 remained to surrender at the end 

of that battle.1(p343) The Germans lost approximately 20 German divisions and several 

divisions of Allies at Stalingrad.1(p344) Kursk, which is situated 315 miles south of Moscow, 

was the site of the German Operation Zitadelle, an epic tank battle (only 5 months after 

the surrender at Stalingrad) between the Soviets and the Germans. Although losses were 

high for both sides, the Germans withdrew after 2 months of combat during July and 

August 1943.1(pp417,427–428)

The European Continent

The Allies moved on to Sicily after North Africa. As already noted, the Allied 

campaigns on the Italian mainland were to follow with the 1943 amphibious landings 

at Salerno (south of Naples). Italy capitulated and Mussolini was killed. Although the 

Germans in Italy were under the able generalship of Field Marshal Albert Kesselring, the 

Allies ultimately prevailed. 

Army operations in Europe were focused on the impending amphibious landings 

upon the well-defended coastline. Roberts, in his Storm of War, states that a significant 

defeat in the invasion of Normandy in 1944 “would almost certainly have had the effect 

of the United States abandoning the Germany First policy and turning to the Pacific War 

instead.”1(p461) In preparation for the invasion, the Allies mounted two Fortitude operations, 

which were elaborate deception operations started years prior to the planned date of the 

invasion.1(p463)

General Eisenhower had been chosen to be the Supreme Commander of the Allied 

Expeditionary Force in December 1943. His headquarters was located in London, which 

was the central planning site for the invasion. The original plan was to invade as early as 

May 1944, but the LST landing craft used at Anzio, Italy, had to be brought to England. 

Hence June 1944 was the new target with the actual date depending on the weather. The 

loss of an LST at Slapton Sands in a preinvasion exercise further strained the landing craft 

availability. 

After much planning and preparation, the invasion of the Continent began with 

Operation Overlord and D-Day on 6 June 1944. After the success of D-Day, the Allies 

began pushing forward, finally crossing the Rhine River into Germany in March 1945. 
CHAPTER SIX • 191

The Germans launched a nearly successful counteroffensive at the Ardennes in Belgium. 

However, the evitable momentum of Allied troops and the Soviets pushing in from the East 

sealed Germany’s fate.

STRUCTURE OF FORWARD SURGERY 

IN WORLD WAR II

Full-Sized Surgical Hospitals in Combat Environments

In actual practice, the 400-bed surgical hospital operated largely in the Mediterranean 

and Southwest Pacific area, in part to supplement the surgical capacity of field and 

evacuation hospitals. Organized under Table of Organization and Equipment (T/O&E) 

8-231, this unit consisted of two hospitalization units and one mobile surgical unit. The 

mobile surgical unit had integral transport. Interestingly, the two hospitalization units could 

each field 200 beds and could operate independently of one another.9(pp280–281)

The World War II evacuation hospital was usually about 400 beds (which was smaller 

than the World War I evacuation hospital, which could range above 1,000 beds, as needed). 

In Europe, the 1st Army prior to “Operation Overlord” (the Normandy Invasion) had 

organized 10 such 400-bed evacuation hospitals and a 750-bed evacuation hospital.31(p109)

The field hospital provided forward surgical support by sending a platoon with surgical 

teams closer to the actual combat. In Europe, the field hospital platoon provided most of 

the forward emergency surgery, drawing upon the experience of the World War I mobile 

surgical unit. 

The Pacific Theater of Operations and the China-Burma-India Theater of Operations 

were similar in that they both presented medical difficulties unlike that of the European 

Theater of Operations. Supply difficulties (especially in the CBI) were constant. The 

environmental conditions for the fighting were extraordinary. The mountains, jungles, and 

rain were found in the Pacific and the CBI, although many Pacific islands had relatively 

even terrain. The common thread in the Pacific and CBI theaters is that the conditions were 

hard to endure and conducive to disease. Tropical diseases such as malaria were rampant, 

which added to the burden presented by combat casualties. 

Portable Surgical Hospitals in Constrained Environments

Creation of the portable surgical hospital (PSH) was a direct response to the need for 

small mobile units to fit into the CBI and Pacific theaters. In New Guinea and Papua, the 

dense jungle and terrain made larger unit operations difficult. The standard evacuation 

hospitals of 400 to 750 beds were too large and cumbersome for the task at hand. The 

mobile surgical hospital described in Field Manual (FM) 8-5, Mobile Units of the Medical 

Department (1944),32 consisted of a headquarters and three subordinate units. The three 

units included one mobile surgical unit and two hospitalization units.32(p418a) The one mobile 

surgical unit was to hold “sufficient integral transport for its own movement, together with 

the necessary facilities for messing, supply and technical operations.”32(p423a) Evacuation, 

field, and surgical hospitals could not be where they were needed due to their inherent lack 
192 • FORWARD SURGERY

of mobility. Furthermore, division clearing stations were not intended to provide emergent 

surgery. 

The 12 January 1942 version of Military Field Manual 8-5, published by the War 

Department, made no mention of portable units, other than field hospitals.33 FM 8-5, as 

amended 20 April 1944, discussed the portable surgical hospital in detail.32 It was described 

as a mobile 25-bed unit that would “support the surgical service of a task force or division 

engaged in jungle or amphibious warfare.”32(p417) It would also provide “surgical care to 

the sick or critically wounded for whom transportation to the rear would be fatal.”32(p417)

Other functions outlined included provision of temporary hospitalization, pending arrival 

of larger units, and to support division clearing stations.32(p417)

FM 8-5 (per the 1944 amendment) also spelled out the deployment from land to 

amphibious operations. Of note, it pointed out that the portable surgical hospital (PSH) 

was to be “employed in areas where the terrain is such that . . . all equipment must be hand 

carried, and all patients must be evacuated by litter.”32(p418a) The PSH finds “its primary 

usefulness in jungle warfare.”32(p418a) In amphibious operations, the PSH are “moved 

on landing craft.”32(p418c) After landing, the portable surgical hospital would set up in a 

“sheltered area or near a route of evacuation.”32(p418c) The equipment would be “limited to 

bare essentials.”32(p418c)

The Military Medical Manual34 was published by the Military Service Publishing 

Company of Harrisburg, Pennsylvania, in a nonofficial format to introduce medical officers 

to medicine in the military, in preparation for their deployment to austere locations. It 

provided the young doctor with listings of Army tactics, organization, and procedures in a 

more readable format. The 1941 4th edition of the Military Medical Manual35 mentioned 

FIGURE 6-1. The interior of a portable surgical hospital showing the limited surgical 

equipment that had to be carried every 

step of the way. Improvised instrument and 

tray tables are shown. The portable surgical hospital had five operating room tables 

for the three surgeons, which allowed 

greater efficiency and the ability to handle 

more cases. The recovery period was 

geared to evacuate the patient by ground 

or air as soon as the tactical situation 

allowed. The wounded soldiers needing 

immediate surgery were taken to the portable surgical hospital. The less immediate 

surgery cases were taken to the clearing 

station located about 2 miles away from 

the portable surgical hospital. Photograph 

courtesy of the AMEDD Center of History 

and Heritage, Image #MU-WWII-LL-012.
CHAPTER SIX • 193

only the 400-bed surgical hospital in the Army’s inventory. The 1941 Mobile Units of the 

Medical Department, which was published by the Medical Field Service School, also listed 

only the 400-bed hospital.36 The 1944 edition of the Military Medical Manual presented 

more detail about the portable surgical hospital34 (Figure 6-1). (Of interest, Carlisle 

Barracks, the location of the Medical Field Service School [the training center for military 

medicine] had been the home of General Hospital No. 31 in World War I. The Medical 

Service School began classes there in June 1921. Carlisle Barracks is currently the home of 

the Army War College.)

Organization of the Portable Surgical Hospitals

COL Percy J Carroll (later brigadier general), the Chief Surgeon of the US Army Forces 

Far East and of the US Army Services of Supply, conceived of the need for the PSH. In a 

1944 article, COL Augustus Thorndike, Medical Corps, reported that Carroll discussed 

the PSH concept with his surgical service as early as June 1942. Carroll saw the PSH as a 

temporary solution to an operational necessity because evacuation in jungle warfare was 

problematic.37(p79) Carroll at first split the hospitals in Australia into smaller units that were 

mobile. He tried various configurations of personnel and equipment to reach the desired 

portable setup. These units were to be scattered around Australia in expectation of the 

Japanese invasion (which never came). The Japanese had landed on 8 March 1942 on the 

northeast coast of New Guinea.1(p210) The Japanese forces advancing toward Port Moresby, 

New Guinea, were repulsed at the otherwise indecisive Battle of the Coral Sea with the 

sinking of one Japanese light carrier and the damage of two additional carriers. The 

Japanese withdrew as their resources and supply lines were stretched too far. Hence, the 

threatened Japanese push toward Australia was halted permanently.1(p252)

Carroll noted that the difficult terrain, with mountains and jungle swamps in New 

Guinea and Papua, would call for smaller combat units and thus the need for small and 

mobile units to provide surgical/medical care. It is noteworthy that Carroll saw the PSH 

as a compromise method to offer emergency surgical care in the difficult jungle settings of 

the Pacific and the CBI theaters. Carroll envisioned that the portables would be replaced 

by larger hospitals as the war logically progressed. He felt that larger hospitals would be 

brought in as the combat situation stabilized, the areas were secured, and the need for 

evacuation lessened. However, Carroll felt the need for portables would remain in many 

diverse areas, including remote areas of Burma, the Philippines, and some Pacific islands 

with rugged terrain. These more remote locations would not be sites for larger hospitals. 

When combat commenced in these areas, the need for surgery close to the combat called 

for innovation because evacuations were hard in such conditions. 

The PSH was envisioned as a way to provide surgery on a smaller scale in jungle 

and amphibious operations. Carroll initially had an adequate supply of well-trained 

surgeons in Australia to assign to the new portables. (Unfortunately, the degree of surgical 

training for later assignees would not meet this standard. There was a tendency at higher 

command levels to assign the best trained surgical talent to the larger hospitals. The 

thinking was often that such talent would be wasted on small remote operations such as 

the portable surgical hospital.) Once stabilized, the wounded could be transported to larger 
194 • FORWARD SURGERY

FIGURE 6-2. Portable Surgical Hospital. Gloves are being sterilized in the portable sterilizer units. Gloves 

washed hanging out to dry. All parts of the portable surgical hospital had to be hand carried. Photograph 

courtesy of the AMEDD Center of History and Heritage, Image #MU-WWII-LL-015.

facilities.38(p541) Hence, the PSH was created to provide a truly mobile alternative to the 

400-bed evacuation hospital. Due to the European Theater of Operations priority of the 

Combined Chiefs of Staff, and the emphasis on the Southwest Pacific area (MacArthur) 

and the Central Pacific area (Nimitz) drives, the CBI theater was given a very low priority 

for much of the war for resources and manpower, thereby reducing the number of medical 

units to service combat operations there (Figures 6-1 through 6-3). 

In some locations, the Army Medical Department used existing structures for hospitals. 

For instance, the Lend-Lease Program allowed the United States to provide aid (food, oil, 

and various materiel) to its Allies, especially England and the Soviet Union. The British, 

in a “reverse Lend-Lease,” provided leases on facilities/bases, some of which were used 

by the Army Medical Department, in the Commonwealth and provided some equipment 

(such as Spitfire fighters) to the United States.1(pp87,130) Other facilities were created to meet 

the medical needs. In Europe and the Mediterranean, for example, the Corp of Engineers 

crafted hospitals using Nissan huts (a prefabricated corrugated steel building loosely based 

on a British building of the World War I era) or local materials. Existing buildings in 

Europe were often modified for hospital use once the invasion gained territory.38(p542)
CHAPTER SIX • 195

Portables’ Table of Organization and Equipment

As usual, the Army set up a T/O&E for the portable surgical hospitals (T/O&E No. 

8-572S) on 4 June 1943.39 The inevitable changes started with Change No. 1 to 8-572S on 

2 September 1943.40 Change No. 2 to the T/O&E came on 7 December 1943.41 The final 

T/O&E 8-572 for portable surgical hospitals came on 14 December 1944.42 T/O&E 8-572 

describes the concept of the portable surgical hospital as a mobile 25-bed unit “designed to 

furnish definitive surgical care in areas where it is impractical to use larger, more specialized 

medical units.”42(p418a) The document spoke to the necessity to hand carry all equipment, 

while the personnel would be on foot carrying patients on litters as needed.42(p418a) It is an 

“independent, self-contained unit”42(p415a) placed under the direction of “the division, task 

force or Army commander, depending upon the unit to which it is attached.”42(p415a)

The Medical Field Manual32(p419f2) stated that the hospital’s movement depended on the 

personnel carrying the organizational equipment, with loads not to exceed 40 pounds per 

man. It pointed out that the organic motor transport would not be sufficient to transport the 

portable surgical hospital. Native bearers were to be used if the unit required them.32(p419f2)

FIGURE 6-3. Portable surgical hospital tent. Note the covered dugout in front of the larger tent for shelter 

during raids. The staffing of the portable surgical hospital was to consist of four medical officers. Three 

were to be surgeons, of which one would be the commander. The fourth physician was to be an internist 

and anesthetist combination. In addition, there were to be 33 enlisted men, including 15 medical technicians and five surgical technicians. Photograph courtesy of the AMEDD Center of History and Heritage, 

Image #MU-WWII-LL08.
196 • FORWARD SURGERY

Staffing of the Portable Surgical Hospital

The staffing of the portable surgical hospital was to consist of four medical officers. 

Three were to be surgeons, of which one would be the commander. The fourth physician 

was to be an internist and anesthetist combination. In addition, there were to be 33 enlisted 

men, including 15 medical technicians and five surgical technicians. Exhibit 6-1 delineates 

the specific tasks of each individual.

The portable surgical hospital had five operating room tables for the three surgeons, 

which allowed greater efficiency and the ability to handle more cases. The recovery period 

was geared to evacuate the patient by ground or air as soon as the tactical situation 

allowed43(p61) and the patient was stable enough for the trip.

A smaller number of personnel helped in the mobility of the portable surgical hospital. 

Early on, the overall few numbers of personnel and medical units limited the support 

available. As an example, in 1943, 25 portable surgical hospitals were requested to 

support the Chinese Armies in northern Burma, but only five were received. These units 

were more likely to have obstetricians and pediatricians assigned than surgeons. The lack 

of experienced and trained surgical talent was a continuing problem in the Pacific and 

China-Burma-India theaters of operations.25(p298) The commentaries from the time show 

that the Army did not appreciate the difference between a medical officer designated to do 

surgery versus one trained to do surgery.44(p755) An Army Medical Bulletin article in 1943 

stressed that personnel for these Portable Surgical Army Hospital units must be young and 

vigorous. It recommended that officers be under 35 years of age while enlisted should be 

under 30 years of age.45(pp7–8)

An Example of the Use of the Portable Surgical Hospital: The Buna Campaign

Australian and American units in 1942 attacked the Japanese beachhead at Buna as 

part of the campaign to dislodge the Japanese from New Guinea and protect Australia 

from invasion by the Japanese. The Americans planned to set the stage for the Buna 

Campaign (Buna, New Guinea, November 1942–January 1943) by using three regimental 

task forces of the 32nd Division in the attack. The 126th Infantry Combat Team, the 127th 

Infantry Combat Team, and the 128th Infantry Combat Team were all deployed. The 

114th Engineer Battalion accompanied the 127th. Their engagement ran from November 

1942 until February 1943. The 107th Medical Battalion and the 19th Portable Surgical 

Hospital accompanied the 126th Infantry Combat Team. The 127th was serviced by the 

3rd Portable Surgical Hospital, the 4th Portable Surgical Hospital, and the 5th Portable 

Surgical Hospital.46(pp1–3) The 128th was accompanied by the 14th Portable Surgical 

Hospital and the 18th Portable Surgical Hospital. The choices for PSH placement were 

determined to be best near a trail close to the front. An area 1,500 yards (less than a mile) 

behind the front was safe enough to protect the hospital, its patients, and staff from the 

enemy, yet close enough to the front to be effective as a forward surgical element.46(p23)

The Owen Stanley Mountain Range in New Guinea was a natural obstacle and 

a hurdle for the Australian and the American forces there.47(p209) The 32nd Division, a 

unit composed largely of National Guard units, was under the command of MG Edwin 

Harding. The 32nd Division ultimately was composed of three infantry combat teams 

247-809_text_CX.indb 196 12/27/1
CHAPTER SIX • 197

(regimental task forces), each with a portable surgical hospital assigned. In the Buna 

Campaign, the 2nd and 9th Portable Surgical Hospitals were also attached, but remained 

in the rear near Dobadura to act as an evacuation hospital.46(p23) Unfortunately, the 32nd 

Division was felt to be undertrained; they were also lacking equipment such as artillery, 

grenade launchers, and flamethrowers.47(pp213–215) Because the division was not making 

progress addressing these shortcomings, MacArthur relieved Harding (a rare event for 

EXHIBIT 6-1. PERSONNEL AUTHORIZATION FOR A PORTABLE SURGICAL HOSPITAL

 NUMBER OF

RANK POSITIONS TITLE

COMMISSIONED OFFICERS: Total 4

Major/Captain 1 Hospital Commander/Surgeon

Captain/1st Lieutenant 2 Surgeon

1st Lieutenant 1 Internist/Anesthetist

ENLISTED: Total 33

Technical Sergeant 1 Chief Clerk

Staff Sergeant 1 Mess and Supply Sergeant

Sergeant 2 Medical Sergeant

Technician, Grade 4 1 Cook

Private First Class 1 Cook’s Helper

Medical Technicians

Technician, Grade 2 4 Medical Technician

Technician, Grade 5 3 Medical Technician 

Private First Class 3 Medical Technician 

Private 5 Medical Technician

Surgical Technicians

Technician, Grade 3 1 Surgical Technician 

Technician, Grade 4 1 Surgical Technician 

Technician, Grade 5 1 Surgical Technician 

Private First Class 1 Surgical Technician 1

Private 1 Surgical Technician 1 

Technician, Grade 5 1 Clerk/Typist

Technician, Grade 5 1 Carpenter, Construction

Technician, Grade 5 1 Driver, Light Truck

Private First Class 1 Driver, Light Truck

Private 1 Driver, Light Truck

Private First Class 1 General Clerk

Private 1 Basic Clerk

Note: The rank of Technician, Grade 3, was approximately equivalent to a staff sergeant; a Technician, Grade 4, was approximately equal to a sergeant; and the Technician, Grade 5, was roughly 

equal to a corporal. 
198 • FORWARD SURGERY

MacArthur) and replaced him with MG Robert Eichelberger. (MacArthur had come to 

recognize that the Australians were right that there was a lack of leadership.47(pp218–219)) 

Eichelberger brought effective leadership to the 32nd Division. For example, he made 

sure the troops had dry shoes and a hot meal before starting an offensive. He also had a 

medic check each man’s temperature in one company and found that all had a fever. The 

soldiers were all in poor condition with torn and rotted clothing, waterlogged and ruined 

boots, and little hot food to eat. Not surprisingly, the morale was low.47(p221)

The Buna Campaign was where the first portable surgical hospitals proved their worth. 

The combat was fought in jungle swamps. Malaria was rampant before Atabrine was 

valued and was available. There were between 900 and 1,400 “fever” casualties (most were 

known to be malaria) per 1,000 troops43(p9) in the Buna Campaign alone (out of a high 

mean strength of 10,650).43(Table3) Because the level of combat was low and the numbers 

of troops involved was limited, thus limiting wounded casualties, the malaria issue was 

paramount to the medical community. The medical cases were led by malaria, followed 

by “exhaustive states,” gastroenteritis, dengue fever, acute upper respiratory diseases, and 

typhus fever.43(p26)

The Buna portable surgical hospitals were close to the action. The portables were 

organized out of a station hospital and attached one to each combat team.43(p22) The 

medical setup for the 32nd Division’s three regimental task forces included three portable 

surgical hospitals, a clearing platoon, and a clearing company for each task force.9(pp22–23)

The Japanese frequently provided strafings and bombings, especially to the portables 

(the 14th and the 22nd), which were located on the coast. The 22nd Portable Hospital 

had previously been loaded into a boat with three other boats off Cape Sudest. When the 

Japanese attacked, they sank all the boats and thus all of the portable’s equipment.47(p9)

LTC Warmenhoven, the division surgeon for the 32nd Division, described conditions 

of these portable surgical hospitals. He said that “Portable hospitals were not portable 

after their first set up in practically all cases.”46(p24) Warmenhoven noted that a 40-pound 

load was all that could be carried by a man over a jungle trail. He recorded a “tendency 

to acquire tentage.”46(p24) LTC Warmenhoven stated that the pyramidal tent was the tent 

of choice for him. It could be easily moved and set up.46(p28) He mentioned that the heavy 

pyramidal tent and the small wall tent were difficult to carry while the tentage allowed 

by the Table of Basic Allowance (TBA) of the portable hospital was not heavy enough 

to work at night under blackout conditions. The ward tent required motor transport. 

Hence, the portable surgical hospital was not moveable with the required tentage, unless 

moved by motor transport.46(pp24–25) Warmenhoven placed emphasis on the importance 

of waterproofing supplies and equipment, while giving the Japanese credit in their 

waterproofing efforts. He spoke of using the Hydran Burners with thermos equipment, 

instead of field ranges (unless mounted on vehicles), in combat. The idea was to guarantee 

at least two hot meals a day for the hospital troops.46(p29)

The battalion aid station operated as close to the combat as possible, which varied 

between 200 to 1,000 yards (usually 300 yards distant).46(p23) The wounded were carried by 

the regimental detachment to the portable surgical hospital along jungle trails. In the Buna 

Campaign, the distance between the portable surgical hospital and the battalion aid station 
CHAPTER SIX • 199

was kept to a 20- to 30-minute on foot litter carrying time, depending on the terrain. The 

wounded soldiers needing immediate surgery were taken to the portable surgical hospital. 

The less immediate surgery cases were taken to the clearing station, located some 2 miles 

away from the portable surgical hospital.46(p23) The terrain was rough and the aid men 

acting as litter carriers periodically came under fire.46(p24)

In surgery, sodium pentothal anesthesia was used universally.46(p26) Blood plasma was 

used frequently; the plasma was started at the aid station. The surgery was done in tents set 

up in an as aseptic a situation as possible. The patients were kept in tents to be protected 

from the sun and rain. Work at night was carried out by flashlight to keep nearby Japanese 

soldiers from acquiring a target in the dark. The wounds were debrided, with sulfonamide 

powder spread topically (sulfa drugs were available then). Plaster of Paris immobilization 

for fractures was utilized. The postoperative patients remained at the portable surgical 

hospital for 24 to 48 hours before they were further evacuated by native carriers to a field 

hospital in the rear. This trip could last up to 8 hours. At the field hospital they were air 

evacuated through a gap in the Owen Stanley Mountains to Port Moresby, New Guinea. 

They were subsequently evacuated by hospital ship or air to a general hospital in Australia. 

The prompt and high-quality care at the portable surgical hospital allowed for good 

outcomes.44(pp34–54),47(p77)

In 19 days of the Buna Campaign, 560 patients were treated, with 389 of those being 

wounded, and the rest suffering from various diseases endemic to the combat area. Two 

hundred and two of the wounded were operated on. The operations frequency ranged from 

three to four per day to as many as 25 per day.46(p10,Table1)

Warmenhoven, following the Buna Campaign, opined that the “portable hospitals 

attached to the division during the Buna Campaign proved to be of tremendous value . . . 

it would be hard to give an exact estimate of the number of lives . . . saved by their 

emergency surgery and heroic work performed near the front lines.”46(p28)

To gain an appreciation of the scope of casualties that the medical department had 

to care for, it is important to note that in the Buna, Gona, and Sanananda battles, of the 

35,000 Australians and Americans involved, over one-third were killed, wounded, or sick. 

In Buna alone, the 32nd Division lost two-thirds of its strength (586 killed, 7,000 ill, and 

1,954 wounded).47(p225)

Portable Surgical Hospitals in Other Locations

The Buna Campaign discussion delineated in some detail the functioning of a portable 

surgical hospital in austere conditions. These same conditions were encountered elsewhere. 

For instance, in Burma, a number of American medical units arrived in portable surgical 

hospitals in late 1943 to support the Chinese armies. This included the 42nd, 43rd, and 

46th Portable Surgical Hospitals; the 25th Field Hospital; and the 803rd Medical Air 

Evacuation Transport Squadron.25(p307)

Unlike the CBI (especially Burma), the Pacific battles were varied as to duration, 

intensity, and casualties. Army medicine was significantly involved in the care of the 

wounded. The Navy and Navy medical personnel were obviously involved in this care 

as well, due to the insular nature of the theater. Naval resources were especially heavily 
200 • FORWARD SURGERY

involved in various phases of evacuation because the Army deferred to the Navy in 

that regard. 

The American troops were taken aback by jungle warfare in the beginning of the 

war. Marston, in his book The Pacific War Companion,48(p10) comments that by 1944, 

the Americans (and the Australians) had learned a great deal about jungle warfare. 

Bougainville, in the northern Solomon Pacific Island group, was the scene of American 

Marines landing on 1 November 1943.48(p11) It came to be characterized by epic diseases, 

with malaria and a wide assortment of tropical diseases, including scrub typhus, dengue 

fever, filariasis, influenza, and intestinal parasites.22(p194) In the Bougainville campaign, 

the Navy controlled all planning and actual evacuation from the beachhead.22(p193) The 

Australians took over control of Bougainville and New Guinea, which allowed MacArthur 

to focus on the coming Philippine invasion. 

Other areas also saw combat operations. In the Marshalls, Kwajalein was in reality an 

easy campaign, as was Eniwetok.23(p227) The Marshall Islands were invaded by American 

troops on 31 January 1944, to be followed by the Admiralty Islands on 29 February 

1945.48(p12) At Eniwetok, the Navy cleared an entire deck of the transport USS Wharton to 

be used as hospital space, which fortunately was not required. The Army set up a clearing 

company and a portable surgical hospital that worked with Navy personnel jointly.23(p232)

The Gilberts were dire in intensity and casualties, and Saipan in the Marianas (15 June 

1944) was heavily defended. The attack on the beaches was difficult. In the subsequent 

battles, the Japanese often held the jungle trail routes to collecting stations, which made 

evacuation difficult. Guam was invaded on 21 July 1944.48(p11)

In the invasion of the Philippines starting with the 9 January 1945 landings on Luzon, 

the 8th US Army conducted 51 amphibious landings on several dozen islands. In these 

battles, portable surgical hospitals reinforcing clearing companies performed most of the 

forward surgery. Later, in the Philippines, the role of the portables was diminished by the 

openness of the terrain. For example, in the 24th Division, two portables were combined 

by the division surgeon to form an extra clearing company. While in the Central Plains of 

Luzon, some portables functioned as surgical teams attached to medical battalion collecting 

companies.23(p347) Yet, in the more remote jungle areas of Luzon, the portables were of great 

value. For instance, in May 1945, a portable was doing surgery after a 5-day trek into the 

Luzon mountains.23(p348)

 The Battle of Leyte, Bataan, the recapture of Corregidor, and the Battle of Zig-Zag 

Pass on Luzon were featured 8th Army operations. COL Frank McGowan, the Consultant 

in Surgery, 8th US Army, reported that in the Battle of Leyte in the regions of Ormoc 

Corridor and the area of Cariaga, the entire surgical care of the wounded soldiers was done 

by two portable surgical hospitals and clearing companies. The two evacuation companies 

were 15 to 20 miles away, due to the mountainous terrain. In the follow up to the Subic 

Bay landings (the Battle of Zig-Zag Pass), two portable surgical hospitals did most of 

the forward surgery in their location 2 to 3 miles from the front.49(p565) In the invasion of 

Corregidor, the forward surgical care was provided by a regimental medical detachment, 

which jumped with the parachute troops, and one portable hospital, which was landed by 

water. The parachutists (503rd Parachute Regiment) had 182 injured from the jump itself 

(of 2,100 jumping), many with compound fractures.49(p571)
CHAPTER SIX • 201

McGowan also reported that the small units in the 8th Army handled the majority of 

the frontline surgery despite the fact that their surgeons were generally not well trained. He 

noted that the certified and more experienced surgeons were to be found at the general and 

evacuation hospitals. McGowan made a plea that in combat more experienced surgeons 

be assigned to the receiving areas for the casualties.49(p566) COL Robert Williams, General 

Stilwell’s staff surgeon,23(p287) when setting up the portable surgical hospitals in Burma, 

found that the staffing had many “pediatricians, general practitioners, and obstetricians but 

a minimum of trained surgeons.”23(p298) This was a problem that continued for all CBI and 

Pacific operations. Condon-Rall and Cowdrey noted the scarcity of competent surgeons 

and reported that in the South Pacific Area, 90% of the replacement medical officers had 

neither field training nor combat experience.23(p186) Besides the personnel training and 

experience issue, McGowan decried the lack of equipment for the portables, especially 

because they performed the majority of surgeries in theater. McGowan tried to attach 

them to separate clearing companies reinforced with surgeons. Being assigned to a portable 

surgical hospital was not without risk; McGowan reported that in the campaign for 

Mindanao in the southern Philippines, the Japanese ambushed a portable surgical hospital, 

destroying its equipment and bayoneting the commander.49(p567)

At Mindanao, in the Philippines, collecting companies served as hospitals, in contrast 

to the use of portable surgical hospitals in New Guinea as collecting companies, because 

they often had to hold patients for a period greater than 2 weeks.23(p350) The Chief of 

Surgery in the Philippines assigned one general surgeon and one orthopedic surgeon, along 

with six surgical technicians, to flexible surgical teams. In general, as the battles moved 

away from isolated islands and jungles, the portables were needed less.23(pp345–347) However, 

on Luzon, as late as 1945, portables were still in use.23(p322)

LEVELS OF CARE 

The levels (echelons) of care started at the unit level of care, with self-care and buddy 

care starting in the field. The scheme continued with the corpsman, then followed by 

treatment at the battalion or regimental aid station. The next level of care was at the 

division level, provided by the organic division medical battalion, including collecting 

and clearing companies. The next level fell to the field army with the field and evacuation 

hospital.

Field Hospitals

The field hospital was created in early 1942 to provide for a smaller and more 

mobile hospital in the Pacific Theater of Operations.50(p144) It had a headquarters and three 

hospitalization units that could function by themselves (as 100-bed units). The field hospital 

had organic tents to provide a mobile unit. The field hospital could function in isolated 

areas because it had its own transportation assets. When augmented by surgical personnel, 

it became a mobile hospital to support airborne or ground troops.23(pp144–145)

The field hospital was organized with 22 officers, 18 nurses, and 227 enlisted men. 

The headquarters of the field hospital had four commissioned officers, three nurses, and 19 
202 • FORWARD SURGERY

enlisted men. It was further divided into three identical hospital units with each having six 

commissioned officers, five nurses, and 67 enlisted men.23(p67) The nurses held “equivalent 

ranks” to officers until June 1944, when they were commissioned as regular officers.23(p67)

 Reflecting the versatility of the concept, the field hospital could function as one 400-

bed hospital or three 100-bed units.50(pp644–645) In reality, the field hospital’s units worked 

closely with the division clearing company to provide more definitive care for the division. 

(The lack of surgery teams in the field hospital [set up that way due to lack of surgical 

personnel] was one of the reasons for creation of the Mobile Army Surgical Hospital 

[MASH] later in the period. The Mobile Army Surgical Hospital had an expanded 

complement of 41 nurses and 16 medical officers to handle 60 beds, while the World War 

II field hospital had five Medical Corps officers and five nurses for the 100-bed hospital 

unit.51(p68))

Sometimes there were personnel problems in the field hospitals. For example, the ETO 

Anesthesia Consultant, COL Ralph M Tovell, described the situation in which the auxiliary 

surgery group had poor relations with the personnel of a field hospital in the Normandy 

area (1944). He attributed the problems to a lack of authority for the commander of the 

facility to ensure cooperation. He referred the matter up the chain for resolution. Guidance 

was issued that the commander had the authority to coordinate separate units under the 

same roof.52(p608)

In a 1945 interview with COL Paul Streit, who was a surgeon with the Central Pacific 

Base command, he observed that each division in Europe had an evacuation hospital and a 

field hospital. However, in the Pacific, one field hospital served a division. Streit commented 

that the field hospital had to function as an evacuation hospital as well as a field unit. 

Inasmuch as the field hospital had insufficient staff, surgeons and anesthetists had to be 

added to the field units before they were deployed.53(pp4–5)

COL Streit said that air transportation was key to holding down the mortality rate 

in the Pacific islands’ operations. At Iwo Jima, he notes that it was 6 days after landing 

before a field hospital was set up due to the level of combat. Casualties were taken to the 

LSTs, where surgery was performed before they were evacuated to the Marianna Islands 

for more definitive surgery. After the 7th day, C-54 transport aircraft were able to land and 

to evacuate the wounded.54(p5) COL Streit commented that the Japanese on Iwo Jima used 

less artillery than in other theaters of operations and hence there were fewer large shrapnel 

wounds.53(p7)

Portable Surgical Hospitals

LTC William J Shaw, who ultimately became the division surgeon for the 41st 

Division, 6th Army in New Guinea, gave an interview in September 1944, which well 

illustrates the lot of the surgeon in 1942 New Guinea. Such interview encounters provide 

a remarkable opportunity to see the 1942 experience from an individual’s vantage point.

Shaw was an early American arrival to Australia in March of 1942. After 9 months of 

training in Australia, Shaw was sent with the 41st Division to Biak Island (a coral reef) off 

the northwest coast of New Guinea. Assigned to the division were an evacuation hospital 

and three portable surgical hospitals, one designated for each regiment. In addition, there 
CHAPTER SIX • 203

was a clearing company along with two collecting companies. In the difficult terrain of 

New Guinea, he reported that it could take 20 native bearers taking turns to carry one 

patient over a 4-mile trail. A clearing hospital served as a base hospital. Shaw said patients 

presenting with multiple woundings were common. The portable surgical hospitals did 

the complex surgeries with a 2% death rate.55(pp1–2) Less serious cases were performed at 

the clearing hospital.55(pp1–2) Plasma was used at the portable surgical hospital but whole 

blood was available only at the clearing hospital. The hospitals there used nitrous oxide, 

thiopental sodium, and regional anesthetics. Disease became more of an overall issue for 

the medical staff because woundings were not that frequent.55(pp1–6)

While the Navy and Marines had been the predominant US forces in the Pacific, the 

Army was most extensively engaged in the Middle East, Africa, and Europe. The relatively 

more environmentally friendly theaters did not feature the rough jungle terrain with its 

disease threats. Hence, somewhat different medical assets were required. The evacuation 

hospital was the most common iteration.

Evacuation Hospitals 

The evacuation hospital was defined as a 400-bed or a 750-bed hospital. The 400-bed 

unit was semimobile with 25% of organic transport (trucks). The evacuation hospital was 

designed to be moved in 8 to 10 hours after the patients were first moved. It could then 

set up in a new locale in 4 to 6 hours. However, the 750-bed hospital was really immobile 

because in reality it had no organic transportation assets and the hospital personnel 

were not trained to break down and relocate for facility moves.50(pp632–633) The 750-bed 

evacuation hospital was designed to have a complement of 47 commissioned officers, 52 

nurses, a warrant officer, a dietitian, and 380 enlisted men. The evacuation hospital was 

intended to provide major definitive surgical and medical treatment as near to the front 

as possible. The evacuation hospital could then evacuate patients as needed to a general 

hospital in the rear echelon.51(p67)

The 750-bed evacuation hospital was seen by many as being too large and fixed to 

be of great value. The bed capacity could certainly be utilized, but the smaller 400-bed 

configuration was seen as more flexible and easier to provide command and control. COL 

William A Shambora, Commander of the 1st Medical Group and the 9th Army Surgeon 

(as of June 1944) was the officer-in-charge of medical operations for Europe in the 1st 

Medical Group area.56(p291) COL Shambora was known to have this opinion of the larger 

evacuation hospital. He went to some lengths to avoid attachment of such a hospital from 

the European Theater Services of Supply (where they were usually placed).51(p27)

In Europe prior to the Overlord Invasion, the 1st Army planned one convalescent 

hospital; five field hospitals (small, nonsurgical for resuscitation); 10 400-bed evacuation 

hospitals; one 750-bed evacuation hospital; various ambulance, collecting, and clearing 

companies; one medical gas treatment battalion; one medical laboratory; one medical 

depot; and one auxiliary surgical company.57(p61) As the invasion progressed, the 3rd Army 

had 11 evacuation hospitals and one field hospital to work with those of the 1st Army. 

Up to the end of July 1944, 1st Army had attached 22 evacuation hospitals and six field 

hospitals, which provided medical/surgical support for 16 divisions.57(p72)
204 • FORWARD SURGERY

FIGURE 6-4. Surgical tent of an evacuation hospital set on an abandoned concrete platform in the 

Palawan, Philippine Islands, 1943. Photograph courtesy of the AMEDD Center of History and Heritage, 

Image #MU-WWII-LL-016.

FIGURE 6-5. Operating room of an evacuation hospital in the Pacific. Note the autoclave, the surgical 

scrub table, the operating room table, and supplies with the concrete floor. Photograph courtesy of the 

AMEDD Center of History and Heritage, Image #MU-WWII-LL-017.
CHAPTER SIX • 205

On the beaches during the Overlord Invasion, surgery was done in the clearing stations 

of the amphibious battalions. However, as soon as field hospitals were established, surgery 

was transferred there. The field hospitals operated like evacuation hospitals. Auxiliary 

surgical teams were pressed into service to deal with the surgical load at the field hospitals. 

The field hospitals, operating close to the lines, saved many who could not have been 

transported. The field hospitals were too large to be considered mobile, but, due to their 

smaller size, could be located more forward than the evacuation hospital.50(p97) Evacuation 

hospitals were situated as close to the front as safety allowed. The evacuation hospitals had 

problems of surgical backlog also requiring auxiliary surgery unit help. Auxiliary surgery 

teams numbered from the usual three to four to the maximum of eight. The one 750-bed 

evacuation hospital generally operated without auxiliary teams except during overload 

situations that occurred during intense combat57(p99) (Figures 6-4 through 6-6).

Auxiliary Surgical Groups

A 1944 article, titled “Surgery at the Front,” discussed the formation of auxiliary 

surgical groups to complement portable surgical hospitals in providing emergent care. The 

analogy of these groups was to firemen who were always on call to put out fires.54(p2) Army 

FIGURE 6-6. Colonel Williams, Chief of Surgery of the 99th Evacuation Hospital (at the head of the OR 

table), Mindanao, Philippines, May 1945. Note that the operation was proceeding under tentage. The 

evacuation hospital was not mobile because it had no organic transportation for movement. Photograph 

courtesy of the AMEDD Center of History and Heritage, Image #MU-WWII-B1-001.
206 • FORWARD SURGERY

Surgeon General Norman Kirk hailed these innovations as reducing the mortality rate once 

soldiers were admitted for care.58(p3) 

The Army established auxiliary surgical groups under the War Department T/O&E 

8-571, titled Auxiliary Surgical Group, published 13 July 1942.59 Sixty-one surgical and 

shock teams of four to six personnel were established to expand the surgical capability 

of evacuation and field hospitals. The surgical teams were in the field army, designed 

partly to offset the lack of surgeons in the field hospitals. Because they couldn’t function 

independently, they could not be utilized in the field alone.57(pp78–92) These units were tried 

out initially in North Africa and later used in Europe.57(pp78–92) There were no auxiliary 

surgical groups in the Pacific and China-Burma-India theaters of operations to provide 

command and control of the placement of needed surgical teams, unlike their European 

counterparts. After recommendations from the surgical consultant, however, the Southwest 

Pacific Area organized surgical teams to facilitate the temporary meeting of those needs on 

the battlefield.

The auxiliary surgical groups had about one-half of their staff in general surgical 

teams, while the rest were in specialty teams doing neurosurgery, chest, nerve, and maxillofacial work.60(pp1–3) The teams were listed as Team EA General Surgery, EB Orthopedic 

Surgery, ED Maxillofacial Surgery, EE Neurosurgery, and EF Thoracic Surgery. These 

teams had one officer, one nurse, and three enlisted men in their group. Team EC was a 

shock treatment team with one officer, one nurse, and three enlisted men. Team EG was 

a gas treatment team with one officer and three enlisted. These teams were situated under 

a headquarters to form an auxiliary surgery group. Field Manual 8-5, dated 12 January 

1942, addressed the purposes of the mobile units of the Army Medical Department.60

Change No. 2, dated 20 April 1944, addressed changes to these units, including the surgical 

group and the portable surgical hospital.61 

As an example, mobile surgical units of the 3rd Auxiliary Surgical Group were set 

up with one surgical truck and three Proco Surgical Units (self-contained surgical units 

manufactured by the Proco Company). These units augmented field and evacuation 

hospitals. They had two operating tables and their own instruments and supplies. The 

mobile surgical units used in the ETO were of two types: (1) the “USA” type with a 21⁄2-

ton van with a 1-ton trailer attached and (2) the “ETO” type with three 11⁄2-ton trucks 

and a 250-gallon water trailer. The operating room tent (USA type) was double-walled 

and air-conditioned. These hospitals worked better with evacuation hospitals than field 

hospitals because the latter had heavier surgical capacity.62(pp22–25) The use of surgical teams 

from surgical auxiliary groups to augment the role of the field hospital was discussed in a 

military publication that showed abdominal injuries, chest wounds, and fractured femurs 

were the primary surgeries done.58(pp44–45) The 5th, 45th, and 91st Evacuation Hospitals 

did use the mobile units early in the war. These units fell into disuse as hospitals became 

more numerous and personnel shortages made filling the staffing needs of the mobiles 

difficult.58(p80)

In the 3rd Auxiliary Surgical Group, it was established that the team surgeon would 

handle all phases of surgical care in a field hospital, while in an evacuation hospital, 

the chief of surgery would have these responsibilities. Additional written instructions to 
CHAPTER SIX • 207

hospital commanders reminded them that the teams were meant to work as a team and not 

to be dispersed, as had happened in North Africa. The field hospitals depended entirely on 

auxiliary surgical teams for their surgical care so they had first call on these teams before 

an evacuation hospital could receive their services.58(p3) The 3rd Auxiliary Surgical Group 

fielded 25 general surgery teams, nine specialty teams, and 15 nurse teams.58(p58)

The 3rd was put to the test in the invasion of Europe in 1944. Its combat experience 

in the Mediterranean Theater was for 3 months in 1943, with only half of the group.63(p1)

The deployed group (North Africa) returned to England in November 1943, where the two 

separate groups were joined together. The procedure established was that only after the 

operating field hospitals had their surgical staffing filled would the evacuation hospitals be 

able to tap into surgeons.58(p3)

In the invasion planning, four surgical teams were to be with each of the three medical 

battalions and two each with each of the airborne medical companies.58(pp9–10) The purpose 

of the teams with the airborne units was to do forward major surgery from the start 

because evacuation of casualties wouldn’t be possible until the ground troops joined up 

with the airborne.

FORWARD SURGERY AS EXPERIENCED BY 

INDIVIDUAL PHYSICIANS

Major Albert Crandall, Medical Corps, Surgeon, 

3rd Auxiliary Group

Crandall wrote an account of his experiences as a surgeon in the 3rd Auxiliary Group 

and in the 1st Airborne Surgical Team. Crandall graduated in 1933 from the University of 

Vermont. He was inducted into the Army in 1942 and attended the Medical Field Service 

School at Carlisle Barracks, Pennsylvania. He volunteered for overseas duty and was 

assigned to the 3rd Auxiliary Surgical Group. Crandall crossed the Atlantic on the Queen 

Mary (converted to carry troops), arriving in Scotland in December 1942. He was then sent 

to various British facilities to observe and help as needed. Crandall described his surgical 

group as consisting of 30 teams. Twenty of the teams were general surgery. Four teams each 

comprised neurosurgery and thoracic surgery. He said at times there were also maxillofacial 

and orthopedic teams.64(pp1–2)

With his assignment to the 1st Airborne Surgical Team, Crandall described training 

in orientation to airborne techniques. The group worked to be able to field a working 

surgical team without resort to evacuation. Crandall’s group was the first to be assigned 

to an airborne unit. For the Normandy Invasion, Crandall’s unit equipment was loaded 

on a trailer, which was thereafter placed in a glider. The Americans used the Waco GG4A 

unit (made of wood, fabric, and a metal frame), which was smaller than the English Horsa 

glider. All gliders were towed by C-47 “tugs” (DC-3). The gliders were a load-capacity 

expander allowing the C-47 to carry more material and men, much like a truck pulling a 

trailer. A C-47 aircraft could tow and then release the glider closer to the landing area to 

allow a quieter approach and the ability to carry larger loads than could be accommodated 
208 • FORWARD SURGERY

in a transport aircraft alone.64 The gliders proceeded as a group and tried to land in the 

same general area. Crandall’s Waco glider landed near Hiesville in Normandy on 6 June 

1944. He received injuries in the landing, including to his neck and right eye. His auxiliary 

surgical group treated 125 casualties at the landing sites and 250 to 300 more at their 

station set up. More personnel arrived so that they were able to run five operating tables 

continuously. They were able to start evacuations 3 days later, on 9 June 1944.64(p5)

Crandall was west of Bastogne when his unit was captured by a German Panzer unit. 

At one point, they were loaded into railway cars, which were subsequently strafed by 

Allied fighters. The prisoners were marched into Germany proper, suffering from the cold; 

some even had frostbite. Crandall also described his experiences in various prisoner of war 

camps.64(pp9–14) He commented that the Russians who liberated them treated the Americans 

badly.64(p15)

1st Lieutenant Frank Davis, Medical Corps, 

Medical Officer LST 496 on D-Day, Normandy Invasion

An interview with Davis (dated 24 November 1944) is of interest because he was the 

officer-in-charge of medical service for LST 496 on D-Day. Davis had been classified as a 

general surgeon and an orthopedic surgeon in the Army way (he was a general surgeon 

who could do orthopedics). He had been a medical resident in Baltimore before his Army 

experience.65(p1) His LST, like the others, was to transport troops to the Continent and 

to return to England with casualties. Davis had two surgical technicians assigned to him 

on the LST. His LST landed troops at Omaha Beach. He soon had the DUKWs (not an 

acronym, but rather refers to a landing craft with wheels that could go onto the beach) 

returning with casualties. Davis had 20 Navy corpsmen to help with the litters. On the LST, 

Davis had two Navy surgeons and a Navy Chief Pharmacist Mate to help as a surgical 

assistant. Davis commented that the Army surgical technicians had never scrubbed on 

a major surgery case.65(p2) His LST could hold 250 litter cases. Upon the ship’s return to 

England, Davis had divided the cases into nontransportable, transportable, and ambulatory 

cases. The nonambulatory cases were transported only a mile for definitive treatment 

while the transportable were sent 30 miles inland. He described his Navy corpsman as his 

only death when an elevator fell on him.65(p4) Davis also described an episode in which his 

LST hit a mine left by a German E-boat (S-boot or Schnellboot). There were significant 

casualties. Davis sustained several fractured vertebrae, which required his ultimate 

evacuation back to the continental United States65(p4) (Figures 6-7 through 6-9).

Captain Willis P McKee, Medical Corps, 326th Airborne 

Medical Company, 101st Airborne Division–D-Day Invasion

Captain Willis McKee was assigned to the 101st Airborne Division, specifically the 

326th Airborne Medical Company, prior to D-Day in Europe. The airborne plan was for 

him to have 15 enlisted men and 85 containers filled with medical equipment. Captain 

McKee parachuted in and ended up near Hiesville, Normandy, with 10 men and only 

five containers full of supplies and equipment with which to perform major surgery. He 

(unlike many others) did land close to his deployed area. The later arriving gliders carrying 
CHAPTER SIX • 209

FIGURE 6-7. [Top] LST (Landing Ship, Tank) 

coming on to the beach, Italy, 1943. The LST 

was a key asset for the Anzio Invasion in 

Italy, and later in the Normandy Invasion. The 

invasion date for “Operation Overlord” (the 

cross-Channel invasion of Europe) had to 

be delayed due to a shortage of LSTs (two 

were lost in Operation Tiger near Slapton 

Sands, England, May 1944) while waiting 

for such landing craft to be redeployed to 

England from Italy. Photograph courtesy of 

the AMEDD Center of History and Heritage, 

Image #MU-WWII-LL-004.

FIGURE 6-8. [Middle] Patient being off-loaded from an LST (Landing Ship, Tank) on litter, 

14 April 1944, Pacific Theater of Operations. 

The LST was an essential feature of Operation Overlord (the cross-Channel invasion of 

Europe). An LST displaced more than 1,600 

tons when empty and was somewhat longer 

than a football field. The LSTs were constructed in the United States in inland points 

on the Ohio River. The LST could carry 20 

tanks, 30 large trucks, or 2,100 cargo tons, 

and sleep 350 soldiers. Due to the LST’s flat 

bottom, it could come right up to the beach 

to disembark its cargo. Photograph courtesy 

of the Office of Medical History, Uniformed 

Services University of the Health Sciences, 

Image #OMH-USUHS-0452.

FIGURE 6-9. [Bottom] LST (Landing Ship, 

Tank) carrying wounded on litters attached 

to the ship walls. The LSTs’ construction 

program was begun in 1942 for Operation 

Bolero, an early invasion of the Continent.

The North African invasion used existing LST 

numbers. The Pacific and Europe theaters 

of operations were in competition for these 

essential landing crafts. Photograph courtesy 

of the Office of Medical History, Uniformed 

Services University of the Health Sciences, 

Image #OMH-USUHS-0456.
210 • FORWARD SURGERY

additional medical people and supplies/vehicles landed safely and their personnel were also 

soon performing surgery. He described glider casualties consisting of limb fractures (legs, 

arms, and hips) and skull fractures. He also described small arms wounds and shrapnel 

wounds. Penicillin was not authorized for McKee’s unit due to its limited production and 

availability at this point in the war. The surgeons had to make do with traditional sulfa 

drugs, including the granulated powders sprinkled onto recent woundings.66

FORWARD SURGERY IN VARIOUS COMBAT THEATERS

Overlord + Invasion of Europe

Overlord was the code name given to the invasion of France, while Neptune was 

the code name for the naval aspect of Operation Overlord.1(p464) The invasion was finally 

launched on 6 June 1944 as the weather prevented going forward on the planned June 

5th date. The overall great size of the landing at Normandy was impressive in terms of 

the logistical planning, gathering of troops, landing craft, and supplies. On the first day, 

154,000 Allied troops landed, with 24,000 of them coming by parachute and glider.1(p465)

The LST was an essential feature of Operation Overlord (as well as the Anzio Invasion, 

Operation Torch with the invasion of North Africa, and later in the landing in the South 

of France after D-Day). An LST displaced 1,625 tons when empty and was 327 feet 

long.67(p18) The LSTs were constructed in the United States in inland points on the Ohio 

River. They were launched sideways into the Ohio River and sailed down the Mississippi 

into the Gulf of Mexico. The LST could carry 20 tanks, 30 large trucks, or 2,100 cargo 

tons. The LST had bunks for 350 soldiers. Due to the LST’s flat bottom (drawing only 

4’–7’ when loaded), it could come right up to the beach to disembark its cargo.67(p19) The 

LSTs’ construction program was begun in 1942 for Operation Bolero, or an early invasion 

of the Continent.67(p20) The North African invasion used existing LST numbers. The Pacific 

and European theaters of operation were in competition for the landing crafts. Further, LST 

production was halted and many yards were ordered to work on sections of destroyers and 

escort craft for convoys.67(p21)

No invasion on the scale of the Normandy operation had been planned or carried 

out up to 1944.68(p42) As Nigel Lewis, in his book Exercise Tiger,

68 observes, prior 

rehearsals such as Exercise Beaver (27–31 March 1944) were not successful. There was 

mass confusion and unit structure broke down. Hence, Operation Tiger was to be a most 

realistic dress rehearsal for the coming invasion. Slapton Sands (at Lyme Bay) not far along 

the coast from Plymouth, England, was picked because the beach conditions were most 

similar to the Normandy coastline.68(p43)

Exercise Tiger was to involve 25,000 men who would be on their LSTs for the time 

required to make the actual invasion run. Three hundred thirty-seven ships were to be 

involved and the plan would have two phases like the real one. The first phase would be 

the engineers clearing the beach obstacles, to be followed by the second wave, which would 

be the landing of the reinforcing troops.68(p43) The mixed American and British command 

had potential dangers not recognized before the exercise began, which included failure to 
CHAPTER SIX • 211

coordinate operations to deal with external threats. Even the simplest measure of common 

radio frequencies so that the commands could communicate was neglected.68(pp46–47)

The 261st Medical Battalion participated in “Exercise Tiger” from 22 April until 1 

May 1944 at Slapton Sands.68(pp11–13) Unfortunately, German E-boats (the English called 

these E-boats while the Germans termed them S-boot for Schnellboot—fast boat) of the 

German Schnellbootwaffe attacked the eight LSTs at 0200 on 27 April 1944. The 5th and 

9th Schnellboot flotillas were based at Cherbourg, France. These swift craft could run at 

37 to 40 knots per hour, in contrast to the 12 knots of the American LSTs. These S-boots 

carried two torpedoes and cannon/machine gun armament.68(p52) The German boats on 27 

April 1944 came upon the eight LSTs and a British frigate. The LSTs were carrying Jeeps, 

DUKWS (amphibious vehicles), weapons, and supplies. The German attack resulted in 

the loss of LST 507 (and damage to two other LSTs) and the loss of 197 sailors and 400 

soldiers.69(p145)

On one LST, Medical Teams 2 and 3 treated the casualties (18 casualties including 

an LST captain and his executive officer).68(p12) The loss of even LST 507 in this situation 

negatively impacted the coming invasion. The shortage of LST landing craft presumably 

delayed the invasion and postponed the invasion of the South of France, which at one point 

had been envisioned as a simultaneous invasion thrust with Normandy. The American 

admiral in charge of Operation Tiger subsequently killed himself.68(p145)

Over 100 bodies of officers privy to the Overlord Invasion plans (the so-called 

“bigoted”) were not initially recovered, increasing anxiety that the Germans had abducted 

survivors from the sea. It took a month to recover all the missing bodies. The bodies of the 

dead were secretly dealt with while the next of kin were not notified of their deaths until 

after the invasion, when they were designated casualties of the invasion (casualties were 

reported starting in mid-June 1944). The incident did not receive public awareness until 

1988.69(pp61–78)

The medical teams had different experiences in the Normandy Invasion on 6 June 

1944. Utah Beach was comparatively calm while Omaha Beach was chaotic. On Utah 

Beach, some 23,000 men landed with only 210 killed or wounded. On Omaha Beach, 

the 1st Division and the 29th Division sustained over ten times the casualties as on Utah 

Beach.1(pp473–474) On both beaches the teams were behind schedule in setting up operations, 

as could be anticipated. In particular, the cliffs at Omaha were more of an obstacle than 

had been considered.63(p30)

Despite a heavy naval bombardment (which turned out to be too brief to neutralize the 

German guns), the Germans still were able to focus heavy fire on Omaha Beach. After the 

first 2 hours, the landings at Omaha were halted due to the casualties and heavy fire. The 

Navy ordered the supporting American destroyers to get in close to the beach and provide 

bombardment. Twelve destroyers provided fire to support the Army Rangers who were 

assaulting the cliffs of the Pointe du Hoc.68(pp24–25)

The English and Canadian beaches, termed Gold, Juno, and Sword, had no cliffs and 

received more naval bombardment.1(p476) The loss of the majority (27 of 29) of the modified 

M4A3 Sherman DD (duplex drive) tanks, which were designed to float (with waterproofed 

canvas shells63(p31)), kept the Americans on the beaches longer than planned. The tanks sank 

when the waves came over their waterproof screens.1(p475) 
212 • FORWARD SURGERY

The casualty losses on D-Day were less than anticipated due to such interventions 

as early surgery. As an example, the early surgery on the beach at Omaha allowed the 

teams to operate on 900 wounded soldiers before the regular hospital units arrived.63(p3)

In the case of Omaha Beach, a recommendation after the fact was that the surgical teams 

at Omaha would have been more useful if they had been stationed on ships rather than 

being on the beach, concerned with their own safety due to the constant fire that made care 

difficult.63(p31) The 1st Engineer Special Brigade performed definitive surgery in its clearing 

hospital on Day 2 of D-Day. Two field hospitals arriving on the beaches from the 1st 

Brigade were used as evacuation hospitals. The first airstrip for evacuation was opened on 

D+4; 12 patients were air evacuated that day.68(p69)

The losses at D-Day included 9,000 Allied casualties. Of the number that were killed 

(4,572), 2,500 were Americans, 1,641 were British, and 359 were Canadian.1(p477) There 

were also 37 Norwegians, one Belgian, 13 Australians, and 19 Free French. The losses were 

considerably less than what had been anticipated (or feared).1(p477)

Combat/Medical Care Across France/Belgium

It was 11 months from D-Day to the German surrender.1(p491) The Allies carried out 

Operation Anvil in the South of France on 15 August 1944 as a diversionary tactic to tie 

up German troops that would otherwise be diverted to the north.

1(p491) (As noted earlier, 

Anvil had to be postponed due to a shortage of landing craft. It had been envisioned 

as a simultaneously landed diversionary tactic to keep German troops engaged in the 

south, while Operation Overlord was carried out in the north. Due to the delay until 15 

August, the Germans had largely withdrawn from the region to respond to the Normandy

invasion.

1(p469)) The 21st Army Group was to advance through Belgium. They would pass 

to the north of the Ardennes. Of Bradley’s 12th Army Group, Hodges was sent north of the 

Ardennes, while Patton moved to the Saar.1(p499)

The British-led Market-Garden Operation didn’t work out as envisioned, due to 

poor planning and strong German opposition in the area. Its implementation diverted 

manpower, petroleum, and supplies from Patton. The result was that Patton, closing on the 

Rhine, could not cross it for 6 months, which meant his forces remained static along the 

Rhine. The Germans used the period to reinforce the Siegfried Line.1(p502) On 16 December 

1944, the Germans launched their Ardennes offensive.1(p504) The surrounded forces at 

Bastogne were relieved by Patton’s 3rd Army, which had linked up with the 1st Army by 

8 January 1945.1(p507)

At Bastogne, the 101st Airborne Division and parts of the 9th and 10th Armored 

Division sustained significant casualties. The weather, with constant snow and fog, 

precluded air evacuation; furthermore, the perimeter was held by the Germans.60(pp415–426) 

On December 26th, two surgical teams were flown to Bastogne by glider. The 101st 

Airborne Medical Company had been captured by the Germans; thereafter care was 

delivered by echelon medical staff, which consisted of medical staff from the various 

divisions put together to function as a medical company.70(p10), 71 The most reliable figures 

for casualties at Bastogne are for the 101st Division for the period 15 December until 26 

December, which lists 704 battle casualties, as well as six other injuries and 573 “disease” 
CHAPTER SIX • 213

cases (including 84 neuropsychiatric cases).70(pp11–12) The 101st Airborne Division reported 

33 deaths in the period 19 December until 31 December.60(p424) In a 2-day period of 27th 

to the 29th of December, all Bastogne hospitalized patients, numbering 964 at the time, 

were evacuated by ambulance.60(p422) The military doctors had no instruments or supplies 

for major surgery. A medical hospital platoon with an attached surgical team was rushed 

into Bastogne when the siege was lifted60(pp416–426) by Patton’s 4th Armored Division on 

26 December 1944.1(p507)

A surgeon, Dr Henry M Hills, was flown in by glider to Bastogne with surgical 

instruments and supplies, and set up an operating room. Hills was a West Virginia 

orthopedic surgeon who had participated in the D-Day landings. He volunteered to go 

into Bastogne (for which he later received a Silver Star) to provide medical help. Originally 

he said the plan was to parachute, but as he had no experience with that, the plan 

was changed to a glider insertion.72 He supplemented the battalion aid surgeons, who 

were not really surgeons, per se, but had been trained as anything from a family doctor 

to a pediatrician. Additional medical supplies were dropped by air. The whole blood 

didn’t survive the air drop, but the supply of plasma was adequate.72(p4) Three days later 

additional surgical teams and supplies arrived. With the lifting of the siege,72(p23) ambulances 

of the 614th Medical Group arrived to evacuate some of the patients. Meanwhile, surgery 

continued with 50 major operations performed (and three deaths sustained).72(p2)

The field hospitals of the 1st Army had been operating in the 1st Division, acting to 

provide surgery for the nontransportable wounded. Other wounded or sick were sent 

to evacuation hospitals, which were kept mobile in the 1st Division area. They could be 

advanced when another unit was filled or the front moved.73(p132) After the breakthrough 

at St Lo, the 1st Army evacuation hospitals had a surplus of lightly wounded that had not 

received surgery. A decision was made to establish the 77th Evacuation Hospital in the rear 

of 1st Army to free up the hospitals.73(p132) The approach to the Siegfried Line (which was 

the German reinforced line with tank obstacles and mines to protect German territory) 

slowed the mobility needs for the hospitals.

The German lines were reached in September 1944. The contest for the Hurtgen Forest 

ran from September to December 1944. The combat in the Hurtgen Forest was part of the 

entire Siegfried Line campaign. In the campaign as a whole, the 1st and 9th Army together 

suffered 57,095 casualties. For the period 15 June to 31 December 1944, the 1st Army 

sustained 47,039 of the total, which included 7,024 killed, 35,155 wounded, and 4,860 

missing.74 The 9th accounted for the rest of the casualties, which included 1,133 killed, 

6,864 wounded, and 2,059 missing.74

In January 1945, the 1st US Army Medical Service was evacuating because of 

shortages of materials and adverse weather conditions, including snow and ice, that 

prevented vehicles from being able to turn around. Medical facilities could not be erected in 

fields because they quickly became impassable to vehicles.73(p144) In a push to gain sufficient 

medical bed space, the 45th Evacuation Hospital and the 5th Evacuation Hospital were 

set up together at Spa. The 4th Convalescent Hospital was subsequently moved to Spa. 

In February 1945, experiments were made using light planes in evacuation due to the icy 

roads, which were impassable for ambulances.73(p147) Some outfits, such as the 1st Medical 
214 • FORWARD SURGERY

FIGURE 6-10. [Top] Wounded being 

loaded into aircraft for evacuation. 

As the war progressed, the Army 

preferred to use air evacuation, 

rather than ships. The C-43 Commando (shown here) and the C-47 

(DC-3) workhorse were the primary 

planes. The C-54 (DC-4) was used 

late in the war for air evacuation. Air transportation was key in 

holding down the mortality in the 

operations in the Pacific islands and 

Europe. Photograph courtesy of the 

AMEDD Center of History and Heritage, Image #MU-WWII-LL-055.

FIGURE 6-11. [Bottom] Ambulatory 

evacuation patient being helped up 

plane’s ladder. Photograph courtesy 

of the AMEDD Center of History 

and Heritage, Image #MU-WWIILL-054.
CHAPTER SIX • 215

Group, in the short period between 27 February and 11 March 1945, moved five times 

(average of one move every two to five days), reflecting their flexibility.73(pp59–60) The 1st 

Medical Group received two auxiliary surgical teams and two shock teams from the 

5th Auxiliary Surgical Group to handle casualties from the Roer River crossing58(p47)

(Figures 6-10 and 6-11).

North African Campaign Surgery

Medicine and surgery in North Africa were less rushed because the casualties were 

fewer than anticipated. The plans for Operation Torch were developed by General Mark 

Clark and his staff. The Allies were to assault the Moroccan and Algerian coasts on 8 

November 1942.11(p108) Algiers surrendered first, due to previous contacts with the French 

and the presence of Admiral Jean-Francois Darlan, the Vichy naval military commander 

second to the authority of the Vichy President Marshal Henri Petain. In planning for 

Operation Torch, there were to be three commands in the form of eastern, western, and 

central task forces. The Eastern Task Force going into Tunisia had the most medical assets 

of the three task forces. The Eastern Task Force, commanded by MG George Patton, took 

Algiers, which surrendered with little resistance.11(pp108–109) There were few casualties on 

the actual day of invasion but later most casualties were from bombing raids and land 

mines.27(p111) The Central Task Force, commanded by MG Lloyd Fredendall, experienced 

more casualties than in the taking of Algiers, due to more determined French Vichy 

resistance. The Western Task Force, commanded by the British LTG KAN Anderson, made 

three separate landings on the Atlantic side. This force sustained the most casualties of any 

(694 casualties of which 603 were combat wounds and 91 were fatalities).11(p119)

The Western Task Force had provisional hospitals at Safi and Mehdia. The 750-bed 

8th and the 400-bed 11th Evacuation Hospitals came to Casablanca. The 400-bed 91st 

Evacuation Hospital came to the same region later. These evacuation hospitals were 

operated as fixed units.11(pp119–120) In the Oran region, the 48th Surgical, the 38th Evacuation 

Hospital, and the 77th Evacuation Hospital were joined by the 750-bed 9th Evacuation 

Hospital. The 1st Battalion 16th Medical Regiment lost all of its equipment with a ship 

sinking. The Eastern zone medical care was handled by the British forces in the Eastern 

Zone turned toward Tunisia.11(p120)

The Kasserine Withdrawal ended with the Germans defeating troops under the 

command of MG Fredendall (leading to his relief and replacement by MG Patton). 

The 200-bed 48th Surgical Hospital did demonstrate that it could evacuate its patients, 

dismantle, and move in less than 5 hours. In contrast, evacuation hospitals couldn’t move 

because they had no organic transport11(p127) (Figure 6-12).

Sicily and the Mediterranean

Sicily was the next selected target after North Africa.11(p147) In the invasion of Sicily, 

on 10 July 1943, the British and Canadians landed at the southern tip of the island. The 

Americans landed to the left of the British on a 70-mile strip of beach on the southern 

shore. There were no fixed hospital assets in Sicily and only one 400-bed evacuation 

hospital due to shipping limitations. A 750-bed evacuation hospital did make it to Sicily by 
216 • FORWARD SURGERY

FIGURE 6-12. Operating room in the 59th Evacuation Hospital, Casablanca, North Africa, February 1943. 

Photograph courtesy of the AMEDD Center of History and Heritage, Image #B2-02-014.

late August but with its equipment at sea, it worked out of an existing Italian facility.11(p164)

The wounded were therefore evacuated to Africa. The 15th Evacuation Hospital was able 

to expand to 950 beds by incorporating parts of a clearing hospital.11(p164) Evacuation of 

the wounded to Africa was evenly delegated to air and sea routes11(p167) (Figures 6-13 

through 6-18).

FORWARD SURGERY IN OTHER MILITARIES

The experiences of other countries’ armies’ medical care can be useful in planning and 

executing one’s country’s own care. In World War I, the United States’ close work with the 

British medical care system, including the rotation of a large number of American surgeons 

through their casualty clearing stations, clearly benefitted the implementation of the US 

military healthcare system. The French had much to teach in World War I in the design and 

use of mobile surgical facilities and in the use of the motorized ambulance, as discussed in 

the previous chapter.
CHAPTER SIX • 217

FIGURE 6-13. [Top] This is a postoperative ward of the 27th Evacuation Hospital in France, November 

1944. The ward is composed of three ward tents connected end-to-end with a 60-patient capacity in the 

ward. Photograph courtesy of the AMEDD Center of History and Heritage, Image #B1-11-38.

FIGURE 6-14. [Bottom] A patient is being helped out of an ambulance in North Africa, 1943, after having 

a shrapnel wound in his arm dressed at an aid station. He is being delivered to the receiving dispensary of 

an evacuation hospital for treatment. The World War II evacuation hospital was usually about 400 beds 

(which was smaller than the World War I evacuation hospital, which could range above 1,000 beds, as 

needed). Photograph courtesy of the AMEDD Center of History and Heritage, Image #B2-01-02.
218 • FORWARD SURGERY
CHAPTER SIX • 219

FIGURE 6-15. [Top Left] Army ambulance at the entrance to the 8th Evacuation Hospital, Teano area of 

Italy, March 1944. Note that the “red cross” symbols on the tents were visible from the air. Photograph 

courtesy of the AMEDD Center of History and Heritage, Image #MU-WWII-B1-002.

FIGURE 6-16. [Bottom Left] World War II, European Theater of Operations, France. 2nd Evacuation Hospital, with 750 beds. Note that the deployed tents are all marked with red crosses to be seen from the air. 

Later in the war, the Allies gained air superiority, making enemy bombing and strafing raids on hospitals 

like this one less likely. Photograph courtesy of the AMEDD Center of History and Heritage, Image #B1-11-31. 

FIGURE 6-17. [Top Right] World War II, European Theater of Operations, France. Note the medics and 

chaplain working with casualties. Chaplains offered spiritual comfort to the injured and sick, but also 

often pitched in doing active care. Photograph courtesy of the AMEDD Center of History and Heritage, 

Image #B1-11-29.
220 • FORWARD SURGERY

Spanish Civil War Forward Surgery

The Spanish Civil War, which lasted from 1936 until 1939, has been considered a 

testing time for the newer weapons and tactics of the supporters of each side. The Germans 

and the Italians supported the Nationalists, while the Soviet Union was the supporter of the 

Republican side. Britain, France, and the United States remained nominally neutral. The 

mobile surgical team concept was used in the war. Transfusions, the use of sulfa antibiotics, 

and the utilization of the tetanus vaccine were milestones in military medicine that were 

used extensively, depending on supplies. Many lessons in battlefield surgery were learned in 

this conflict.75(p252)

German Forward Surgery

The German Army has been always impressive in its ability to organize and plan; that 

admiration must be extended to the medical side. The German (Prussian) Army in the 

1870–1871 Franco-Prussian War had dedicated litter bearers and ambulances. It utilized 

the railroads for evacuation. World War I medical and surgical care was excellent until 

logistical problems reduced medical supplies and medicines.

In World War II, the German military surgeon received intensive training at the Army 

medical schools. After a few months of medical training, the trainee would be posted as a 

medical officer’s orderly. He would then receive basic infantry training for 8 months. The 

trainee would then attend the Berlin Military Medical Academy. Lectures at the Charité 

Hospital were next. The trainees took state examinations and then spent a year in the 

clinics. The trainee wrote a doctoral dissertation after which examinations followed. They 

FIGURE 6-18. Tents of the 11th Field Hospital (2nd Platoon), Italy, August 1943. Note the 2 1/2-ton trucks, 

one pulling a water tank. Tents were deployed over the hillside. Tents were very commonly used for 

hospital facilities in all theaters of operations. Photograph courtesy of the AMEDD Center of History and 

Heritage, Image #MU-WWII-B1-003.
CHAPTER SIX • 221

were only then sent to the line with a rank of Leutnant (lieutenant) (Assistenzarzt). In 

wartime, the training was necessarily shortened.76(p8)

All German battalions, regiments, and divisions had variable manning levels, 

depending on the circumstances. The basic battalion was made up of several companies of 

100 to 200 men. The battalion had a doctor with two corpsmen at the troop bandaging 

station. The division, which could vary from 10,000 to 20,000 men, had 16 doctors and 

500 medical corpsmen.76(p15) There were typically two medical companies, of which one 

was horse drawn and the other was motorized. In the companies, the main bandaging 

station was led by the surgeon.76(pp8–11)

German field hospitals were usually located some 20 kilometers (12 miles) behind 

the front. They were set up to handle 200 patients, but could be expanded to handle 

another 300 if needed. A surgery team with two to three surgeons could handle 30 severely 

wounded, or 60 to 120 less severely wounded, in a 24-hour period. The evacuation of the 

wounded would extend back to reserve hospitals in Germany.76(pp8–10)

The first-line medical attention was given by a medical officer and medics at the VD 

(Verwundetennest—equivalent to an aid station). The next step in the move was a litter 

transport to the TV (Truppenverbandplatz—a troop clinic), which was analogous to the 

American battalion aid station. After the wounded were stabilized, they were taken to the 

HV (Hauptverbandplatz—a higher level troop surgical and triage center), which performed 

clearing and hospitalization details. The HV was located to the rear. It was operated by the 

division Sanitaets Kompanie. Two surgeons could be augmented by six to eight more as 

casualty load developed. Major surgical operations were done at this level.76(pp8–11)

British Forward Surgery

The Army Surgeon General detailed consultants to Britain to learn of its experience 

with preparing for and caring for casualties. The British had been in combat since 1939 

and many of their innovations from World War I had been improved upon. The casualty 

clearing station of World War I fame was in operation but the new advanced surgical 

center (ASC) would supplement its function as an advanced surgical facility close to the 

front.75(p253)

The British had found that the great distance from a forward aid station to the casualty 

clearing station and then again to the general hospital mandated the creation of the ASC. 

The purpose of the ASC was to provide surgical care in the combat front lines. It was to 

be attached to a casualty clearing station or a field dressing station. The ASC was selfsufficient and could be moved to the area of greatest need. The ASC could deal with all 

areas of surgery and handled 15% of the overall surgery cases.75(p253)

SURGEONS GENERAL OF THE WORLD WAR II ERA

Charles Ranson Reynolds (1 June 1935–31 May 1939)

Reynolds graduated from the University of Michigan in 1895. He was a contract 

Army surgeon in 1900 and served in the Philippines. In World War I, he began his overseas 
222 • FORWARD SURGERY

service as a surgeon at Base Hospital No. 2. Later in the war, he was promoted to colonel 

and served in various staff positions. He directed his attention to frontline treatment issues 

and medical evacuation problems.77

Reynolds became the Surgeon General on 1 June 1935. As the threat of war increased, 

Reynolds was able to oversee some increase in medical officers and the reopening of 

medical internships in Army hospitals. He also oversaw the renewed emphasis on training 

at the Medical Field Service School. He was succeeded by James Magee on 1 June 1939.77

James C Magee (1 June 1939–31 May 1943)

Magee graduated from Jefferson Medical College (Philadelphia, Pennsylvania) in 1905. 

Interestingly, Magee worked as an Army contract surgeon from September 1907 until July 

1908, at which time he was selected as one of the first lieutenants in the newly created 

Medical Reserve Corps. Magee 

completed the Army medical 

school course in Washington, DC, 

after which he was appointed 

a first lieutenant in the Regular 

Army Medical Corps in 1909.78

His service prior to World 

War I involved time in the 

Philippines with campaigns 

against the Moros and with 

the Punitive Expedition with 

Brigadier General Pershing in 

search of Pancho Villa after the 

Mexican irregulars attacked a 

United States community. Magee 

went to France in 1917 with 

Base Hospital No. 12. He was 

moved to an administrative post 

in France with the Services of 

Supply.78

Magee was selected as the 

next Army Surgeon General in 

June 1939 to replace MG Charles 

Reynolds, who had completed 

his term of office. As previously 

noted, World War II began in 

September 1939 in Europe. 

Magee had to contend with 

changes in the reporting of his 

office. The Surgeon General and his office were moved from a direct War Department staff 

relationship to be subordinate to the Services of Supply. In addition, the personnel treating 

FIGURE 6-19. Surgeon General James Magee, US Army. 

Magee was selected as Army Surgeon General in June 1939 to 

replace Major General Charles Reynolds, who had completed 

his term of office; World War II started in September 1939 in 

Europe. Magee had to contend with changes in the reporting 

of his office. The Surgeon General and his office were moved 

from a direct War Department staff relationship to be subordinate to the Services of Supply. In addition, the personnel treating the Army Air Force were moved to a newly created Air 

Surgeon’s Office. Photograph courtesy of the National Library 

of Medicine, Image #SGV2.
CHAPTER SIX • 223

the Army Air Force were moved to a newly created Air Surgeon’s Office.79 Magee worked 

to have direct access to the Chief of Staff of the Army, rather than going through the Chief, 

Services of Supply (direct access was finally granted in 1944). Magee laid the foundation 

for worldwide medical supply, hospitalization, and evacuation to meet the expanding 

theaters of war80 (Figure 6-19). 

Norman T Kirk (1 June 1943–31 May 1947)

Kirk graduated from the University of Maryland in 1910. He served with Pershing’s 

Punitive Expedition into Mexico and also in the Panama Canal Zone. He spent World War 

I at the Medical Officer’s Training 

Camp at Fort Oglethorpe, 

Georgia. In 1919, Kirk switched 

his specialty from general surgery 

to orthopedics. He went on to 

serve at a number of hospitals, 

including Sternberg General 

Hospital in the Philippines. He 

was selected as the Surgeon 

General in 1943 because General 

Marshall did not want Magee 

appointed to another term. 

Marshall preferred Alfred Kenner, 

but he was not chosen; Kirk was 

the compromise candidate.81

Kirk is credited with taking 

surgery to the men at the front. 

The mobile hospitals and the use 

of trained medical aid men at the 

front were singled out for praise. 

Under his guidance, his office 

reported that 15 million patients 

during the period of World War 

II (1941–1945) were admitted to 

the 692 hospitals overseas and the 

65 general and 13 convalescent 

hospitals in the United States81

(Figure 6-20).

MEDICAL ADVANCES IN WORLD WAR II

Surgical recommendations were made by COL McGowan, the Surgical Consultant for 

the 8th Army, in his report to the Surgeon General. These recommendations were echoed 

FIGURE 6-20. Surgeon General Norman T Kirk. He was 

selected as the Surgeon General in 1943 because General 

Marshall did not want Magee appointed to another term. 

Kirk is credited with taking surgery to the men at the front. 

The mobile hospitals and the use of trained medical aid men 

at the front were especially singled out for praise. Under his 

guidance, his office treated 15 million patients during the 

actual period of World War II. Photograph courtesy of the 

National Library of Medicine, Image #B030267.
224 • FORWARD SURGERY

by other surgeons. He commented that in abdominal wounds gastric drainage was routine. 

He suggested liberal use of plasma and blood for support and the use of wire sutures. In 

chest injuries he suggested earlier diagnosis of hemothorax, as well as more liberal use of 

thoracotomy as needed.49(p577) The following discussion details other medical advances in 

World War II.

Anesthesia for the Wounded 

In the official history of World War I, George Crile, a surgeon, wrote the section 

on anesthesia because there was no anesthesia representative on the Surgeon General’s 

consultant list. In the “Great War,” a nitrous oxide and oxygen combination was used 

primarily.82(p53) Ether and chloroform gave better muscular relaxation; however, the ease of 

use and quick recovery without many side effects made both ether and chloroform valued. 

Abdominal surgery requiring greater muscular relaxation could be supplemented by 

regional anesthesia.82(p54)

A number of anesthetics were available to provide anesthesia, including thiopental 

(Pentothal Sodium), ethylene, and ethyl chloride. Beecher, the Surgeon General’s Anesthesia 

Consultant during World War II, noted that not all agents could be used in the interests of 

standardization. He also noted that the shortage of qualified personnel to deliver anesthesia 

called for agents that could be administered safely by nurses and physicians with limited 

anesthesia experience.82(p57) Hence, World War II anesthesia was limited to ether, thiopental 

sodium, and procaine hydrochloride (Figure 6-21).

To compensate for the shortage of trained personnel, a limited 6-month course was 

begun in 1939 at the Mayo Clinic to train one anesthesiologist at a time for 6 months, to 

be followed by another officer for another 6 months.82(p57) Army medical officers were to 

give anesthesia. Nurses gave inhalational anesthetics in Army hospitals mainly. Regional 

anesthetics were usually given by the surgeon. As the war progressed, the most able 

anesthetists were assigned to combat areas, at least in theory. Beecher observed that the 

evacuation hospital required the most personnel in the forward area. The field hospital 

was staffed by four auxiliary surgical teams with a physician anesthetist assigned to each 

team.82(p58)

The portable Heidbrink and McKesson equipment was used by the Army to 

deliver anesthesia. Henry Beecher designed a portable machine that was improved 

in configuration. It was small enough to be carried by hand and it had a feature that 

thoracic surgery could be done without using compressed oxygen, thereby conserving 

it.82(p63),83(pp602–608)

Because the Army combat focus had shifted to a “Europe first” plan, the increased 

number of troops to be stationed in England required that some English medical assets 

be utilized. The use of anesthesia in England for the United States Army Air Forces and 

Army units stationed there in the lead up to D-Day required the adaptation of American 

machines to use British gas cylinders (to save shipping). The plan was that the more serious 

cases would be evacuated to England for more definitive surgery until a strong foothold 

on the Continent could be achieved and more Allied medical assets could be based there. 

Training was set up to include lectures and practical work in British hospitals in 1943. 
CHAPTER SIX • 225

FIGURE 6-21. 11 August 1944, Major James H Spencer Jr, Chief Surgeon, operating on a patient in the 

280th Station Hospital, Audely, England. Note the nurse anesthetist administrating face-mask anesthesia. 

Photograph courtesy of the Army Nurse Corps Photograph Collection, Image #B2-02-07.

This instruction was later taken over by Americans proficient in anesthesia. Shortages of 

portable anesthesia machines were present in North Africa because the British could not 

supply enough machines.83(p601) Cyclopropane and ethylene were not used in North Africa 

due to flammability of the former and difficulty of supply for both. In the North African 

casualties, it was determined that seriously wounded soldiers needed little premedication, 

if at all. Morphine was used sparingly as a preanesthetic because the drug might still be 

around in the circulation from the dose given in the field. Endotracheal intubation was 
226 • FORWARD SURGERY

FIGURE 6-22. World War II, European Theater of Operations, 60th Field Hospital. Note the use of an 

existing building by the field hospital. The patients are awaiting surgery, which is being conducted on the 

stage at the rear. St. Max, France, 3 October 1944. Photograph courtesy of the AMEDD Center of History 

and Heritage, Image #B1-11-34.

used for all cases over an hour in length and in all cases of intracranial, abdominal, or facial 

wounds.82(pp77–78)

As Beecher pointed out, there were too few trained anesthetists even for the civilian 

world in peacetime America. The military supply of anesthesia personnel reflected that 

shortage at the start of the war. The Army anesthetist shortage appeared in the North 

African theater first because it was the site of the first prolonged fighting between the 

Americans and the Axis powers (Germany, Hungary, Bulgaria, Romania, Croatia, Italy, 

and Japan).82(p57) Hence, in an effort to improvise, anesthesia training was initiated in short 

schools and in on-the-job training. Regional anesthesia improvements included the addition 

of epinephrine hydrochloride in certain cases to reduce the amount of procaine used. 

Vasoconstrictors had to be avoided in surgery of tissues such as genitals, fingers, and noses 

to prevent tissue sloughing82(pp66–67) (Figure 6-22).
CHAPTER SIX • 227

Improvements in Vascular Surgery

World War II saw a large number of arterial wounds due to the larger number of shell 

wounds with shrapnel. These patients were sent to vascular centers in the United States 

(Zone of the Interior). The Mayo General Hospital (Vascular Center) in Minnesota and the 

DeWitt General Hospital in Virginia were the main centers in terms of activity. The centers 

concluded that extirpation of the lesion and the maintenance or restoration of the arterial 

continuity in the surgical repair of aneurysms and arteriovenous fistula were the preferred 

treatments. Previously arterial ligation was the usual treatment.84(pp267,300) Specialized 

vascular centers were established initially at Ashford General Hospital, White Sulphur 

Springs, West Virginia, and Letterman General Hospital, San Francisco, California. The 

vascular activities at Letterman were transferred in 1943 to Torney General Hospital, Palm 

Springs, California.84(p2)

During the conflict at the Siegfried Line in 1944, the 45th Evacuation Hospital set 

up a vascular clinic to improve the treatment of patients with main vascular injury to the 

extremities. One surgical team from the 3rd Auxiliary Surgical Group was attached to 

the 45th to facilitate this treatment.84(p160) Other facilities devoted special care to vascular 

injuries at this point.

Treatment of Shock and Advances in Transfusion Methods

The thoughts about shock that were accepted at the start of conflict in Europe included 

(1) the onset of traumatic shock came from a reduction of the circulating blood volume 

and (2) the main treatment was a replacement of blood volume by transfusion.79(p43) These 

improvements in the understanding of shock and the use of whole blood transfusions 

were an area of significant advance in World War II. (The Germans did not develop a 

blood bank system. Indeed, they had no method of storing blood. They did use only 

direct transfusions from the donor to the recipient. The Germans had an aversion to the 

transfusion of more than 1,000cc [1 liter], apparently on doctrinal grounds.79(p256))

Plasma was embraced at the start of the war because there was no effective overseas 

blood program and the value of whole blood in the treatment of the wounded was 

not appreciated. Plasma was much easier to maintain and to ship without special time 

constraints.79(pp48–49) Dried plasma was selected as a blood substitute. A package was 

designed that was 50cc in size to facilitate the use of plasma; it was soon seen that a 

larger size was needed.79(p133) Three million packages of plasma were produced in 250cc 

size and another three million were packaged in the 50cc size.79(p133) Liquid plasma was 

developed for use in hospitals in the Zone of the Interior (continental United States).79(p134)

Albumin, in the form of serum albumin transfusion, was useful in that it was immediately 

available for use, not requiring rehydration. Its storage required less space than the plasma 

supplies.79(p140)

In the Southwest Pacific Area Command, COL McGowan reported the use of whole 

blood increased with improvements in blood storage and packaging. For example, blood 

was supplied at Leyte in a package of 16 units with 17 pounds of cracked ice. McGowan 

had reaction-free tubing, which matched the ease of using plasma. The consultants for 

orthopedics and general surgery stressed the use of whole blood when possible.49(p573)
228 • FORWARD SURGERY

The need for whole blood readily became apparent in North Africa as casualties

mounted. The safe storage of whole blood was felt to be for only 5 days at the time.79(p50)

However, one surgeon reported use of blood over 30 days of age without problem.79(p50) In 

May 1943, the Subcommittee on Blood Substitutes of the War Department recommended 

the use of whole blood be adopted by the armed forces in a speedy manner.79(p54) The British 

found in North Africa that the use of plasma in severe wounds was not able to replace the 

use of whole blood.85(p55) The British at the Battle of El Alamein (May 1942) attempted 

large-scale combat casualty transfusion.79(p54) COL Edward D Churchill became the Surgery 

Consultant in North Africa in March 1943. He concluded after a review of the data that 

whole blood was the agent of choice. Four months later, a central blood bank was set up in 

the theater. LTC Candict W Carter, of the Surgeon General’s Surgical Consultant Division, 

stated that by July 1944, the value of whole blood was recognized for both the Zone of the 

Interior (the continental United States) and combat areas79(pp71–72) (Figures 6-23 and 6-24).

Improved Survivability in Thoracic Surgery

In World War II, 80% of chest wounds were caused by artillery shell fragments, and 

the remaining 20% from bullet wounds.86(p54) As the war progressed, more men recovered 

FIGURE 6-23. World War II clinical nursing. Operating room scene in a field hospital. Photograph courtesy 

of the AMEDD Center of History and Heritage, Image #B2-02-44.
CHAPTER SIX • 229

FIGURE 6-24. Jeep carrying patient receiving plasma. The 4-wheel-drive Jeeps were often used for 

evacuation of the wounded. Plasma was used at the start of World War II because there was no effective 

overseas blood program and the value of whole blood in the treatment of the wounded was not appreciated in the early part of the war. Plasma was much easier to store without any special time expiration 

dates. Dried plasma was selected as a blood substitute and featured even greater storage and transport 

capability over the liquid version. Photograph courtesy of the AMEDD Center of History and Heritage, 

Image #MU-WWII-LL-039.
230 • FORWARD SURGERY

uneventfully from chest wounds and had less surgery at fixed facilities. The surgery at 

forward surgery sites greatly improved. The indications for thoracotomy were established. 

Penicillin introduced to the postoperative scene helped recovery. Thoracotomy required 

more blood at different levels of complication. The improved availability of whole blood 

definitely helped recovery.87(p303)

A 1943 study of chest wound patients was initiated in the Mediterranean Theater 

of Operations. It showed that thoracotomies were performed unnecessarily in forward 

hospitals as a part of initial wound surgery. The study also showed that indications for 

thoracotomies in forward surgery facilities could be clearly defined. Procedures and practices 

were standardized with the net result that as part of this study, patients were followed until 

1961 with soldiers showing good long-term results following thoracotomy.88(pp441–443,525–527)

Wound Treatment as a Function of Ballistics

A review of the causative agents in wounding revealed interesting findings. Small arms 

fire accounted for 14% to 31% of casualties, depending on the theater of operations. The 

Pacific had 30.7% small arms woundings, compared to 23.4% in Europe. (Artillery and 

mortar fire accounted for 65% of casualties in Europe and the Mediterranean but only 

47% in the Pacific.89(p76))

A variety of weapons accounted for the small arms ballistic woundings. The Americans 

used the M1A1 Thompson submachine gun (.30 caliber). Many of the earlier M1928 A1s 

were also carried, especially by paratroops. The M1903 Springfield Rifle, of World War I 

fame, was still used by many troops, even on D-Day. The M1917 A1 heavy machine gun 

was used by the infantry. The M3 “grease gun” submachine gun could be made much 

more cheaply than the Thompson and was preferred in close quarters. The main infantry 

weapon was the M1 Garand. The carbine M1A1 had a folding stock and a 15-round 

magazine, which was popular. The British used the Lee-Enfield No. 4, Mk.I, and the Sten 

gun in .303 caliber. The Germans used the MP40 submachine gun and the MG42 machine 

guns. The Kar98k Mauser rifle with the 7.92 Mauser rifle cartridge was the standard 

German arm. Later in the war, the Germans developed and fielded the first assault rifle—

the FG-42 Type II Fallsschirm Jagerewehr. The main change from World War I was the 

availability of automatic weapons on an increased level for the troops, with a concurrent 

increase in lethality.90(pp43–47)

Development of Various Pharmaceuticals

One of the most important areas in forward surgery for World War II was the 

use of antibiotics. Prior to World War I, Germany was the world leader in developing 

pharmaceutical chemicals. The German firm Bayer had developed aspirin (acetylsalicylic 

acid) in 1899. The Germans developed Novocain and the synthetic antimalarial 

Atabrine in the period from 1900 to the 1920s. Tannic acid and gentian violet, which 

was sometimes mixed with sulfa powder, were used for burn treatment. Paul Ehrlich, a 

German and the winner of the 1908 Nobel Prize for his work, introduced Salvarsan and 

Neosalvarsan against syphilis in 1910. A treatment for venereal disease such as syphilis 

and later gonorrhea had obvious importance for the militaries of all nations.91(pp15–16) The 
CHAPTER SIX • 231

development of penicillin brought great effect against the ravages of syphilis.92(p6) Antibiotics 

in the form of the sulfonamides were used in the Spanish Civil War and their use was 

ensured for World War II.75(p254) The Spanish Civil War involved active participation by the 

Spanish, Germans, Italians, and the Russians. All of the participants from outside Spain 

used the war as a testing ground for new techniques, equipment, and medicines. Tetanus 

vaccine developed by the Pasteur Institute in 1931 was used in the Spanish Civil War for 

the first time.75(pp253–254)

Sulfa drugs were developed in the 1930s and marked a pivotal move of industrial 

pharmaceutical research and production from Germany to America, France, and 

England.91(pp8–9) Penicillin was produced by a critical English-American cooperative venture 

in 1942. Bayer Laboratories, of the firm IG Farben, introduced Prontosil, which was the 

first sulfonamide drug, in 1932.91(pp15–16) Sulfa medicines were available at Pearl Harbor. 

The military used sulfa for a wide range of diseases. Actually, penicillin was often used 

as an addition to sulfas rather than replacing them. Sir Alexander Fleming published his 

original British Journal of Experimental Pathology article reflecting his 1928 discovery of 

penicillin.93(p226) Sir Howard Florey placed penicillin in clinical use. He had significant help 

at the Rockefeller Foundation. Because the British had difficulty manufacturing penicillin in 

quantity at Oxford, the British then worked with the US Department of Agriculture at the 

Northern Regional Research Laboratory in Peoria, Illinois. In the quest for a better mold, 

a laboratory technician in Peoria brought in a cantaloupe from a market infected with an 

interesting fungus identified as Penicillium chrysogenum.

94(pp93,95–99) Production increased 

each year after 1943. The pilot use in troops was done at Bushnell General Hospital (Utah) 

and at Halloran General Hospital (New York).94(p106),95(pp64–67) In December 1945, 

Sir Alexander Fleming, Dr Ernst Chain, and Sir Howard Florey were awarded the Nobel 

Prize for their work on the discovery of penicillin.94(p119)

COL Cutler, the ETO Chief Consultant in Surgery, received a crate from the Merck 

and Company of New Jersey at a US Army Air Forces base containing the first penicillin 

in quantity. Cutler took the shipment to the 2nd General Hospital in England. He worked 

with Professor Florey in its use, storage, and recovery from the urine of patients due to 

its scarcity. The use of penicillin was restricted to gangrene, serious infections including 

osteomyelitis, eye infections (used in ointment), and “septic hands.”57(pp68–69)

Penicillin proved to be the most effective antibacterial agent used by military surgeons. 

The ability to mass produce penicillin saved many lives. For example, in 1943, there 

was just enough penicillin for 100 cases. In the next year, the penicillin production was 

increased to 3 billion units per year, which was enough to treat the Allied casualties. 

Although the Germans had been foremost earlier in the century in pharmaceutical research, 

they did not have access to penicillin.75(p254)

Treatment of Burns/Plastic Surgery

The Chief Surgeon in the European Theater of Operations made the plastic surgery 

service responsible for treating burns that might require skin grafting. The Army Surgical 

Research Unit was the first hospital set up as a burn center, which would become a model 

for burn centers in the future.57(pp539–540) Plastic surgery was considered a new specialty 
232 • FORWARD SURGERY

in World War II. A Consultant in Plastic Surgery was appointed. Cases that were to be 

considered in the realm of plastics were defined, including burns, maxillofacial injuries, 

and injuries requiring skin grafts or flaps.57(p521–522) There were 10 burn centers in different 

locations in England.57(p543),85(p176)

Mobile Surgery Units

In 1943, COL Elliott C Cutler requested that MG Paul R Hawley, the ETO Chief 

Surgeon, request that Washington assign auxiliary surgery teams to the ETO. Cutler 

believed that optimal care could be best given by bringing the surgeon to the wounded 

soldier. In February 1943, he attended a conference featuring MG David C Monro, Royal 

Army Medical Corps, and the consulting surgeon to the British Army. At this meeting, the 

experience of the British in Libya and their move away from casualty clearing stations and 

forward units in favor of mobile surgery teams were discussed. In North Africa, the British 

had field surgical units and later mobile surgical units. He stated that the surgeons used 

should be skilled and that fixed equipment in vehicles was not satisfactory because a single 

bullet to the radiator could stop the vehicle (the World War I Mobile Surgical Hospitals and 

the French auto-chir also illustrate this point).96(pp78–79)

Later, COL Cutler assigned MAJ Robert Zollinger, Medical Corps, of the 5th General 

Hospital (later colonel and Senior Consultant in General Surgery), to work up plans for 

a mobile surgical unit. Cutler stipulated that Zollinger should not have any vehicles with 

fixed installed equipment, that the tents and equipment were to be for a mobile surgical 

unit, and that the unit have enough materials and lighting to handle 100 major surgeries or 

200 minor cases.96(p80)

Significant advances in forward surgery were made in World War II. Although many 

lessons learned in World War I had to be relearned for this next war, the roles of the 

portable surgical hospital and the auxiliary surgery groups were important. The need for 

increased mobility and the need for talented surgeons brought about the Mobile Army 

Surgical Hospital (MASH) of the next conflict. Although this chapter did not cover the 

spectrum of World War II medicine and surgery, the increased importance of forward 

surgery was highlighted.

For forward surgery in its basic form, the 70 portable surgical hospitals received 

campaign credit during World War II. The Pacific theater counted 52 portable surgical 

hospitals, with 18 listed for the China-Burma-India theater. The six portable surgical 

hospitals utilized in the European theater were too late for combat, but received occupation 

service credit.97

The amphibious operations were carried out on varied terrain from coral atolls 

(Kwajalein) to large land masses (the Philippines). The evacuation hospital could not be 

employed in the small coral atolls and were used on larger targets. However, the portable 

surgical hospitals were perfect to support smaller landings and to provide support to 

division clearing companies in amphibious operations.98(p61)
CHAPTER SIX • 233

THE WAR ENDS

VE (Victory in Europe) Day was on 8 May 1945. Hitler had committed suicide on 30 

April 1945 in his bunker in a besieged Berlin along with his wife Eva Braun (married prior 

to their suicide). Joseph Goebbels, the Propaganda Minister, committed suicide with his 

wife after they had murdered their children.1(p560) Mussolini had met his end at the hands of 

Italian people on 28 April 1945.1(p405) Before his suicide, Hitler had removed Reichmarshal 

Herman Goering as his successor. Goering was captured shortly thereafter and stood 

trial after the war (but committed suicide from a secreted cyanide capsule1(p510)). Berlin 

surrendered on 2 May 1945; the remaining German forces capitulated on 8 May 1945. 

Hitler had designated Grandadmiral Karl Donitz as his successor.1(p559)

The Japanese surrendered on 14 August 1945.1(p577) The atomic bombing of 

Hiroshima, followed by the atomic bombing of Nagasaki, helped persuade the Japanese 

to capitulate. However, the entry of Russia into the Pacific War had had a more immediate 

effect. The surrender of the Japanese on the USS Missouri was presided over by General 

of the Army Douglas MacArthur. The ceremony was conducted on the ship in Tokyo 

Bay.1(p577)

Even with the end of the war, it was clear that the Soviet Union was following its own 

agenda. All of the countries taken over by the Soviets from the Germans were to remain 

in the Soviet sphere. The stage was being set for additional conflicts for which the Army 

Medical Department had to prepare.

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CHAPTER SIX • 237

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238 • FORWARD SURGERY

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US Army Med Dept. 1945;4(1):61–68.
INTRODUCTION

NAPOLEON’S SURGEON TO THE IMPERIAL GUARD, Dominique Jean Larrey, in 

Europe and the Army of the Potomac’s Medical Director, Jonathan Letterman, in the War 

Between the States were both faced with a similar dilemma—how to quickly render surgical aid to the wounded soldier in combat. 

Their struggle has continued to plague 

the surgeon in modern times. The critical 

challenge is balancing the close proximity 

of surgical care near the front lines where 

the wounded need it most, with the need to 

not become a casualty as well. The military 

surgeon must weigh his ability to protect 

himself and save others to fight another day.

Popular culture’s most highlighted 

medical story of the Korean War is 

the Mobile Army Surgical Hospital 

(MASH). Hollywood wove the tale of the MASH through the movie and television series, 

M*A*S*H. However, one actual MASH surgeon, Dr Otto F Apel Jr, cautioned that, “the 

interpretation [presented by the movie and television series] is several times removed from 

the reality it purports to depict. . . . The artistic presentation is always four or five times 

removed from reality.”2(p93) He did add, however, that the appearance of irreverent attitudes 

and lighter moments often depicted had basis in truth.2(ppxi–xiii,122–123) Intended originally to 

be close to the fighting front, the MASH was equipped to move on its own3–6 (Table 7-1). 

The light scale of medical services provided reflected this efficient mobility. As combat on 

the peninsula matured, becoming large and stalled, the MASH evolved into a stationary 

Chapter Seven

Forward Surgery in the 

Korean War: The Mobile Army 

Surgical Hospitals

SCOTT C. WOODARD

[I]N EVERY NEW WAR THE SAME STUPID MISTAKES ARE MADE AGAIN AND SOLDIERS LOSE 

THEIR LIVES AND LIMBS, BECAUSE THE DOCTOR 

WAS IGNORANT OF PAST EXPERIENCE. I CANNOT 

OVER EMPHASIZE THE NEED TO STUDY MILITARY 

MEDICINE AND SURGERY. 1(P716)

Colonel Edward D Churchill

US Army
240 • FORWARD SURGERY

TABLE 7-1. MASH MOVES BY YEAR

Unit 1950 1951 1952 1953

No. of moves No. of moves No. of moves No. of moves

8055th (9 Jul–31 Dec) (1 Jan–31 Dec) (1 Jan–31 Dec) (1 Jan–1 Feb)

14 9 0 0

8063rd (18 Jul–31 Dec) (1 Jan–31 Dec) (1 Jan–31 Dec) (1 Jan–1 Feb)

23 9 0 Unknown

8076th (2 Aug–31 Dec) (1 Jan–31 Dec) (1 Jan–31 Dec) (1 Jan–31 Dec)

7 9 0 1

1st (26 Sep–31 Dec) (1 Jan–31 Dec)

8209th 4 4

8209th (22 May–31 Dec) (1 Jan-31 Dec) (1 Jan-1 Feb)

 2 0 1

2nd (15 Apr–12 May)

8225th 1

 

8225th (13 May–31 Dec) (1 Jan-31 Dec) (1 Jan-1 Feb)

 2 2 0

8228th (15 Jun-31 Dec) (1 Jan-31 Dec) (1 Jan-1 Feb)

 0 2 0

Data sources: Annual reports of Medical Department activities for each MASH unit, National Archives 

II, Suitland, Maryland, boxes 144, 146, 239, 240, and 241.

facility with more capabilities. Initially, the unit was formed to provide surgical capabilities 

for one division. It transformed through the course of the war into a multidivision and 

multinational all-purpose hospital.7(pp88–89) For example, as early as November 1950, the 

1st MASH transformed from a 60-bed to a 200-bed capacity hospital. There was an 

expansion in workload (medical cases in addition to surgery) without a commensurate 

increase in personnel. Rapid patient evacuation was the only means of keeping up with 

the workload.8(pp115–116)

WORLD WAR II: PRELUDE TO MOBILE ARMY 

SURGICAL HOSPITALS

The MASH story began before the well-known fictional account of “Hawkeye” 

Pierce and the comedic 4077th in Korea. The idea was actually quite old. The experience 

of Americans in France during the “War to End All Wars” saw the emergence of this idea. 
CHAPTER SEVEN • 241

In World War I, hospital equipment and mobile surgical teams were transported, together 

with their equipment and tentage, in trucks across the front.7(p69)

In World War II, the European and North African theaters of operation generally 

employed linear battlefields where combat support and combat service support units 

provided services by doctrine along fairly defined battle lines in the mountains and fields 

of the European continent and the deserts of Africa. The intent was to bring definitive care 

to the seriously wounded in far forward areas through auxiliary surgical groups. Close 

attention was paid to the selection of individuals to compose surgical teams within the 

groups, balancing the need for varying specialties, as well as the requirement of healthy 

young men capable of performing major surgery of the abdomen, chest, and extremities. 

The theory of bringing well-trained surgeons to the critically wounded, rather than the 

older method of evacuating the seriously wounded far to the rear for definitive surgical 

care, was proven logical and sound. This helped reduce the mortality and morbidity among 

the troops wounded in the combat zone. Because chest and abdominal wounds formed 

the majority of wounded cases, it was emphasized that the specialist must also be a good 

general surgeon.9(pp385–386)

The other side of the conflict in Asia is contrasted in the surgical support provided in 

World War II to the Pacific and China-Burma-India theaters of operation where the jungle 

canopy and island combat made the fight nonlinear. Here portable surgical hospitals bore 

the brunt of front line definitive surgery. They lacked generators, electrical illumination, 

refrigerators, suction apparatuses, and resuscitation equipment. Because of this, the 

portable surgical hospital could not operate independent of clearing companies and 

reinforcement by surgical teams.9(p573)

INTERWAR YEARS (1948–1950)

After defeating the 

Axis powers, the United 

States Army Medical 

Department improved 

upon the knowledge gained 

in Africa, Europe, and Asia. 

Immediate far forward 

surgical care to front line 

troops was obtainable and 

proven in all theaters of 

operation.

Of the five MASH 

units between 1948 and 

early 1950 (Exhibit 7-1), 

none were in the Far East.10 Prior to the Korean conflict, the MASHs were organized under 

Tables of Organization and Equipment (T/O&E), but were not ready for deployment. The 

EXHIBIT 7-1. INTERWAR YEARS (1948-1950)

The five MASH units were as follows:

Unit Location Assignment

1st Fort Lewis, Washington VI Army

2d Fort Bragg, North Carolina III Army

3d Fort Meade, Maryland II Army

4th Munich, Germany EUCOM

5th Heidelberg, Germany EUCOM

Source: Station List, World Wide, US Army Medical Department 

Units, 31 January 1950, National Archives II, Suitland, Maryland, 

box 239.
242 • FORWARD SURGERY

1948 T/O&E called for a self-mobile, 60-bed holding capacity, tented surgical hospital. It 

contained the headquarters and headquarters detachment, preoperative and shock section, 

operating section, postoperative section, pharmacy, radiography section, and holding ward. 

Authorized personnel were 14 Medical Corps officers, 12 Army Nurse Corps officers, two 

Medical Service Corps officers, one warrant officer, and 97 enlisted soldiers. To meet the 

need of far forward surgical intervention, the physicians included a commander, radiologist, 

two anesthesiologists, an internist, four general medical officers, and five surgeons.7(pp69–70)

Typical of postwar drawdown, this organizational table was how the unit was supposed to 

be staffed, not how a unit might actually be staffed. For example, Fort Bragg’s 2nd MASH’s 

1949 Annual Report of Medical Activities detailed the inadequacies they faced as they 

“stood up” the new unit and implemented the T/O&E approved on 28 October 1948. 

With a skeletal crew of only 22 enlisted men, two administrative officers, and one warrant 

officer, the unit struggled to support a maneuver exercise and conduct its medical proficiency 

training. The unit equipment was fielded, but the personnel were slow in arriving. In the 

report’s closing remarks, the 2nd MASH commander requested that all incoming personnel 

not be raw recruits, that the aptitude test results for those to be assigned in the future be 

increased, and that medical noncommissioned officers be utilized when filling the authorized 

slots because this was such a “specially trained organization.”11(pp3–4)

MASH Table of Organization Review (1948)

During the MASH T/O&E review, at least one agency within the Medical Department 

reported on several mistakes and made recommendations to the Army Field Forces in Fort 

Monroe, Virginia. The observation of inadequate personnel and support equipment came 

from the Surgeon General’s Office and only addressed organizational and equipment issues 

pertaining to supply and field operations. No clinical review was documented.12

Mobile Striking Force (1948)

The Office of The Surgeon General, Deputy for Plans, focused on unit allocations to 

support divisional forces during the interwar years. As early as 1948, the intent for the 

newly created “Hosp, Surg” T/O&E 8-571 was to support a division-sized element. As 

the correspondence described, one surgical hospital would support one division in combat 

whether the total Army was 18, 20, 22, or 25 divisions strong. However, it noted the future 

requirement to identify whether the units would be procured from the Regular Army, 

National Guard, or the Organized Reserve Corps.13

As with all branches of the armed forces at the time, contingency plans to counter the 

perceived threat of Soviet aggression were instituted within the Medical Department through 

its support of the Mobile Striking Force of 1948. Initially, the minimum service support for 

this contingency operation was 60 days of overseas combat service. Each task force was 

configured to deploy as a divisional element. The medical portion supporting this Mobile 

Striking Force contained six “Med Hosp, Surg, Mbl” with a T/O&E 8-571 dated August 

1945. However, even though the “intended” MASH included specialty surgical teams for 

far forward care, the Mobile Striking Force, in addition to the six MASHs, had 18 medical 

detachments with labels such as neurosurgical, orthopedic, shock, surgical, and thoracic.14
CHAPTER SEVEN • 243

MEDICAL FIELD SERVICE SCHOOL (1950–1951)

The concept of far forward surgical care had been proven in war and staffed 

during peace. What were young officers attending the Medical Field Service School, the 

predecessor of the United States Army Medical Department Center and School, at Fort Sam 

Houston in San Antonio, 

Texas, learning about the 

newly formed MASH unit? 

A student “special text” 

reiterated the allocation 

of one MASH per division and emphasized 

there were currently 12 

in the inventory.15 This 

publication devoted one 

paragraph to one of the 

most critical medical units 

in an unexpected war 

merely months away:

Mobile army surgical 

hospitals are mobile 

units of the field 

army medical service 

[emphasis added] 

designed primarily 

to provide adequate 

facilities near the front 

for major operative 

procedures necessary to save life or limb, and which cannot be postponed until the 

casualty reaches an evacuation hospital; and to relieve clearing stations immediately of 

nontransportables in order to prevent the immobilization of such stations through the 

accumulation of casualties that cannot be immediately evacuated.15(p193)

During the 1951 Army Medical Service Organized Reserve Corps and National Guard 

Instructors’ Conference at the Medical Field Service School, Captain (CPT) RL Devine, 

Medical Corps, relayed his experience in treating frontline casualties. As if foreshadowing 

reports typical of conditions on the peninsula, he spoke of the extreme difficulties in traversing the harsh terrain, whether in attempting evacuation or resupply. Operations and 

support discussions concerning the MASH followed along doctrinal guidelines, just as the 

earlier referenced student special text had delineated.16(pp49–58) This would hold true in the 

early phases of the war, but as the mission changed and the front began to stabilize, so too 

the character of the MASH changed (Exhibit 7-2). 

EXHIBIT 7-2. MASH UNITS AND NOMENCLATURE

Throughout the war, the MASH changed numerical designations 

and nomenclature

Unit Numeric Change Numeric Change

8055th 43rd

8063d 44th

8076th 45th

1st 8209th 46th

2nd 8225th 47th

Prewar Mobile Army Surgical Hospital

1950 Mobile Army Surgical Hospital xxxx Army Unit

1953 Surgical Hospital (Mobile Army)

Sources: (1) Eighth United States Army Annual Report, Army 

Medical Service Activities, 1950, National Archives II, Suitland, 

Maryland, boxes 195–196; (2) Eighth United States Army Annual 

Report, Army Medical Service Activities, 1951, National Archives 

II, Suitland, Maryland, box 196; (3) Eighth United States Army 

Annual Report, Army Medical Service Activities, 1952, National 

Archives II, Suitland, Maryland, box 197; and (4) Eighth United 

States Army Annual Report, Army Medical Service Activities, 

1953, National Archives II, Suitland, Maryland, box 198.
244 • FORWARD SURGERY

KOREAN WAR

The joyous and peaceful years after the Allied victory in World War II soon transformed into the uneasy and fearful years of the Cold War. The Soviet Union, the United 

States’ former ally, was perceived as building Communist satellite-nations within Eastern 

Europe in preparation for a war against the forces of Western democracies. The perception 

gained momentum with the Soviet Union’s successful atomic bomb test in 1949. That same 

year, the Communist forces in the Chinese revolution established the People’s Republic of 

China. On 25 June 1950, Democratic People’s Republic of Korea (North Korea) forces, 

supported by fellow Communist China (in word) and the Soviet Union (in deed), invaded 

the Republic of Korea (South Korea). The United States immediately moved troops from 

Japanese occupation duty to block the Communist invasion. With this move, the United 

States spearheaded a United Nations (UN) force composed of 21 countries to combat the 

aggressive action of North Korea.17(pp445-446) Thus, the local conflict became an international 

effort.

Post-World War II had been 

marked by the rapid demobilization 

of the military as the United States 

had traditionally done in all previous 

wars. The United States Army Medical 

Department was no exception (Exhibit 

7-3). From June 1945 until June 1950, 

the Army lost 86% of its wartime 

officer strength and 91% of its enlisted 

strength.7(p8) This was difficult by itself. 

With the initiation of what President 

Harry S Truman agreed to describe as 

a “police action” (a quickly realized 

misnomer) in Korea, the results were 

disastrous. A dangerously small 

military poised against a large-scale 

enemy force was a recipe for failure. 

The nation, and subsequently the 

Army, had made no plan for partial 

mobilization or limited war.7(p3)

Unlike the Axis Powers in the 

European Theater of Operations 

in World War II, the North Korean 

People’s Army and Chinese Communist Forces were not signatories to 

the Geneva Convention. Indeed, the 

medical “red cross” now became 

the aiming point for enemy soldiers. 

EXHIBIT 7-3. RAYMOND W BLISS, SURGEON 

GENERAL (1 June 1947–31 May 1951) 

Raymond W Bliss replaced Norman T Kirk as 

Surgeon General of the Army in June 1947 during 

a time of transition for the recently victorious US 

Army. A former surgical student and subsequent 

instructor at Harvard College, Bliss eventually served 

as the Chief of Operations Service in the Surgeon 

General’s Office in World War II. It was here that he 

made a reputation for himself in the art of planning medical support that entailed patient evacuation and distribution, and the establishment of 

specialized hospitals. When the war ended, he was 

Assistant Surgeon General. During the interwar 

years, Bliss’ focus was on preparing for the next 

conflict and providing specialized training for new 

physicians. Army hospitals began offering residency 

training, emphasizing clinical and preventative 

medicine, research and pathological study. From this 

desire to enhance the professionalism of the Medical 

Service, Major General Bliss incorporated civilian 

consultants in the training hospitals. The early ability 

of the Army Medical Department to react strongly 

to the rapid chaos early on the Korean Peninsula 

exemplifies his judgment in equipping the surgeons 

in accomplishing low death and high recovery rates, 

and high morale.1

Source: (1) Heaton LD. Raymond W Bliss. Mil Med. 

1966;3(5):458–459. 
CHAPTER SEVEN • 245

Medical units were specifically attacked and, therefore, the red cross was covered and 

medics carried M-1 rifles, just like their infantry counterparts. In this environment, 

medical organizations now surrounded themselves with armed troops whenever 

possible.

Korean War (1950) 

Colonel (COL) Chauncey E Dovell, the Eighth Army Surgeon, reported that the 

activities of the Eighth Army in the last 6 months of 1950 were “highlighted by many 

events which have both cheered and tested the spirit of the entire army.”3(Preface) There was 

the UN breakthrough from the Naktong River in September, the pursuit of the Communist 

forces up the Korean peninsula, and finally the victorious entrance of UN troops in the 

North Korean capital of Pyongyang in October 1950. In opposite measure were the 

devastating reverses suffered in the very beginning of the conflict by the 24th Infantry 

Division and Task Force Smith, the Naktong Bulge penetration in August, the entry of 

Chinese Communist Forces in October, the 1st Marine and 7th Infantry Division’s bitter 

fighting in the Changjin Reservoir (“Frozen Chosin”) in November and December, and 

finally, the death of the Eighth Army commander, Lieutenant General (LTG) Walton H 

“Bulldog” Walker, at the end of December 1950.17(pp661–662)

Shortages of personnel, equipment, and supplies, and the lack of trained medical units 

characterized the medical problems present since June 1950, the beginning of the war. 

Therefore, centralized control was important in distributing the scarce resources across 

the combat zone. As doctrine had dictated, the MASH was utilized in direct support to 

the combat division. But the Army’s 400-bed evacuation hospital could not properly 

function on the peninsula because of the lack of transportation, an inadequate road and 

rail network, and the volatile tactical situation. Under COL Duvall’s direction, the MASH 

was “organized” to provide surgical care for all patients, not just nontransportables. The 

MASH now became a small 200-bed capacity (a 140-bed increase) evacuation hospital 

providing care to the division in addition to its intended surgical role. In some instances, the 

MASHs exceeded 400 patients a day.3(p5) There were three MASHs to support four United 

States infantry divisions and other United Nations forces until 26 December 1950. By the 

end of the year, when all medical assets from X Corps were transferred to the Eighth Army, 

there were four MASH units in support of seven divisions and attached United Nations 

troops. As a recommendation in his annual report, Dovell urged the US Army to develop 

an authorized unit, similar to the de facto MASH units struggling in Korea, to be planned 

and activated to cover the current needs in Korea.3(p5)

The MASHs organized for Korea were not intended for any extended service. They 

were actually filled utilizing a Table of Distribution (TD), today referred to as a Table of 

Distribution and Allowances (TDA).7(p69) The theory developed by the Surgeon General 

in the United States and the reality in the Far East Command were not one and the same. 

This rapid adjustment to the critical needs on the ground manifested itself within the field 

surgical ward. It was described by a real-life MASH surgeon, Dr Richard Hornberger, in his 

fictional account from the novel MASH.

18 His character explained, 
246 • FORWARD SURGERY

This is certainly meatball surgery we do around here, but I think you can see now 

that meatball surgery is a specialty in itself. We are not concerned with the ultimate 

reconstruction of the patient. We are only concerned with getting the kid out of here 

alive enough for someone else to reconstruct him. Up to a point we are concerned with 

fingers, hands, arms, and legs, but sometimes we deliberately sacrifice a leg in order to 

save a life, if the other wounds are more important. In fact, now and then we may lose 

a leg because, if we spent an extra hour trying to save it, another guy in the preop ward 

could die from being operated on too late.18(p195)

The 8055th MASH relayed critical elements to rapid field surgery in their 1950 

Annual Report of Medical Department Activities emphasizing triage techniques to quickly 

weed out nonsurgical cases coupled with the use of radiographs and lab work to quickly 

move patients into vital surgery. Most patients were evacuated in 2 to 3 days following 

recovery in the postoperative ward. Unfortunately for the 8055th, their medical technicians 

(corpsmen) and operating room technicians, enlisted strength, was only 65%.19(pp2–4,7–8) Onthe-job training was the only measure to fill the gap created by the lack of these qualified 

personnel. From this gap in specialty skills, it is logical to conclude the huge emphasis made 

in assigning and maintaining nurses in this type of unit.19(pp14–15) The report conveys that,

Corpsmen are not a suitable replacement for nurses, as demonstrated by the 

experience of this unit. At least this hospital has not found an adequate substitute 

for nurses during the short periods when operations were carried on without them. 

This is especially true in surgery where they are considered the most essential.19(p13) 

According to its annual report, the 8063rd MASH began to feel the strain of not 

having enough enlisted soldiers on hand. Cold weather affected the radiographic developer, 

but was mitigated once better heaters were used. During the 23 moves in 1950, women 

were transported by helicopter because of the security issues en route to each destination. In 

reviewing the types of surgical cases, the commander recommended additional orthopedic 

surgeons because 60% of all surgical cases required orthopedic interventions.20 More 

generator power was requested. This continued to be a common theme throughout all the 

MASHs in theater for the entire conflict. Tent heaters had to be used in the operating room 

to manage the extreme cold of the winter; insect screens had to be requested to combat the 

vermin that came from open windows in the summer. This time of the war was particularly 

difficult. The annual report noted that the local civilian population was starving and 

resorted to taking the hospital’s food waste for any kind of nourishment. Air evacuation 

was cited as excellent. By continuously locating near airfields, patients could be evacuated 

to the rear when defenses were overrun in order to prevent capture. In closing, the 8063rd 

commander commented that the medical troops needed overall “tightening” up in military 

discipline and training.20

During the first move of the 8076th MASH in combat that August 1950, the unit 

worked through the night while fighting off “guerilla” attacks. They were operational 

and ready to receive casualties the very next day. Their own mess sergeant was their 
CHAPTER SEVEN • 247

first patient. In November, American forces were surprised by the intervention of the 

Communist Chinese Forces, and had no cold weather gear for fighting. Over the course of 

6 days the 8076th admitted 1,836 patients, 661 in one day.21(pp1–2)

The casualty flow matched the intensity of the cold where temperatures ranged from 

20 to 30 degrees below zero Fahrenheit. Some of these patients froze to death while waiting 

transport into the hospital after the ambulances dropped them off. Shelter within the 

canvas was not always sufficient. Patients froze inside the hospital confines, too. The chaos 

of battle, and its subsequent injuries, was always exasperated by the elements.21(pp2–3)

It was during this particular time in November 1950 that the tactical situation 

necessitated the order to “bug out” in advance of the Communist Chinese Forces. 

The roads were clogged with retreating UN vehicles and personnel. After all means of 

evacuation had been exhausted, 40 patients remained that required transport. Unable 

to move, one doctor and several corpsmen stayed with the remaining patients while the 

MASH rapidly escaped under orders to move. Fortunately, 4 hours later the entire group 

was rescued before capture by enemy forces.21(p3)

In that same move from Kunuri to Pyong-yang along a designated route, Lieutenant 

Colonel (LTC) Kryder Van Buskirk, just promoted earlier that month, decided that the 

prescribed left turn at a fork was unsafe and chose to continue along the right. This 

decision saved the 8076th MASH and its patients from disaster. Every unit that took the 

FIGURE 7-1. Captain Joseph W Hely of St Louis, Missouri, 2nd Helicopter Detachment, 2nd Logistical 

Command, lands a Bell H-13 at his detachment headquarters following an evacuation from the front (31 

December 1950). Note the litters covering patients like a “casket,” and skids replacing the wheeled landing gear. Photograph courtesy of the AMEDD Center of History and Heritage, Army Nurse Corps Photo 

Collection, Korean War, Box 25, Item #B4-04-02(1).
248 • FORWARD SURGERY

left turn encountered a Communist Chinese roadblock and the soldiers were killed or taken 

prisoner. Van Buskirk’s unit continued to experience enemy attacks.21(p3) In response, he 

fashioned a 10-man guard section that he felt did not disrupt the medical shifts.22(p2)

Several recommendations were made to improve orthopedic sets for this particular 

type of field environment. Additionally, there were several recommendations made to 

improve the surgical procedures included in Technical Bulletin Medical 147 (TB Med 

147), Notes on the Care of Battle Casualties.

23 Those included specific procedures for 

intraabdominal wounds, chest wounds, and wounds of the genitourinary tract.22(pp2,6–7) In 

the area of environmental controls, much dissatisfaction was heaped upon the assigned gaspowered space heaters, which were referred to as “gadgets rather than as functional pieces 

of equipment.”22(p3) In fact, one had been converted to run using an electric motor. Litter 

and blanket exchanges worked well with the train system, but not within the air evacuation 

platform. Because of the extreme cold, each patient had six blankets during evacuation 

to the rear, but the helicopters could not exchange the patient blankets with six more 

blankets from their supply stock upon their delivery. It was commented that “too much 

cannot be said in praise of the helicopters”22(p3) (Figure 7-1) in getting patients in remote 

and inaccessible locations on the front lines quickly transported to the MASH, therefore, 

minimizing shock and delay in surgical intervention. The standard method of evacuation 

from the regimental area was by ground evacuation in wheeled ambulances accompanied 

FIGURE 7-2. The Korean civilian hospital in Inchon, Korea, was operated by the 1st MASH and had little 

or no supplies initially (3 October 1950). Fixed facilities were much better than canvas tents and were 

utilized whenever possible. Photograph courtesy of the AMEDD Center of History and Heritage, Army 

Nurse Corps Photo Collection, Korean War, Box 25, Item #B4-03-02(1).
CHAPTER SEVEN • 249

by medics, unless distance or medical condition dictated a quicker response with rotarywinged aircraft. Hospital trains were used to move patients throughout Korea. Fixedwinged aircraft were used to move patients out of the combat zone to Japan. However, 

these airplanes were utilized to transport within the peninsula at times as well.

The 1st MASH (later designated the 8209th in 1951) arrived late in September 1950. 

The hospital began caring for enemy prisoners of war while awaiting the arrival of its 

equipment. Because of this, this treatment became pure “clinical medicine” inasmuch as 

there were no supplies. The hospital at one time set up in an old school (Figure 7-2). One 

can only imagine the frustration of the early days in Korea as described in the annual report,

The abysmally insanitary conditions and revolting nature of the gangrenous and 

maggoty wounds and accompanying complications were of such nature as to stir 

all concerned to their utmost endeavor to relieve the suffering. It was an experience 

which impressed each and every member of the unit with the value of the supplies and 

equipment which are ordinarily taken for granted in our modern medicines.24(p8)

They finally became fully operational as a MASH late in the year, 27 December 1950. 

Compared to the textbook and academic training they had undergone in the United States, 

in combat they became fully functional on patient movement, unloading, and set-up.24(p9)

Korean War (1951) 

The following year, 1951, the new Eighth Army Surgeon’s report from COL Thomas 

N Page (Figure 7-3) to the Surgeon General (Exhibit 7-4) was much more upbeat. The 

Army Medical Service had suffered and succeeded along with their fellow soldiers in the 

Eighth Army under General (GEN) Matthew Ridgway. As COL Page reported, many of 

the problems faced in the early days of the war no longer existed. The UN regained the 

FIGURE 7-3. Colonel 

Thomas N Page, Eighth 

Army Surgeon, in Joju, 

Korea (March 1951). In a 

note to his mother, he 

remarked how much 

weight he had lost. Photograph courtesy of the 

AMEDD Center of History 

and Heritage, Thomas N 

Page Collection, Box 1, 

Image #2010.11.5. 
250 • FORWARD SURGERY

offensive in late January, including 

the great counterblow to Communist 

Chinese Forces at Chipyong-ni in 

February, the UN stood its ground at 

the 38th parallel in June that began 

the truce talks, and battles such as 

Heartbreak Ridge beginning in August 

ensured the lines were held through 

the year. The Chinese had taken Seoul 

in January, but the aforementioned 

UN offensive directly reclaimed Seoul 

in March. Fierce fighting and testing 

of the lines characterized the combat, 

but UN forces under the direction of 

GEN Ridgway (after GEN Douglas 

MacArthur’s recall in April), held 

fast the new cease-fire line. From this 

movement in leadership, LTG James 

A Van Fleet assumed command of the 

Eighth Army.4(Preface),17(pp662–663)

The previous staff policy of 

centralized administration began to 

change as Page better utilized the 

abilities of various staff members 

upon his appointment in July. 

Surgical consultants, as well as 

those in medicine and neuropsychiatry, were assigned. This further raised the standard of 

medical professionalism of the Eighth Army and began the remarkable record of surgical 

intervention, primarily in neurosurgery, displayed in the MASH on the battlefields of 

Korea. Research teams in surgery and cold injury arrived to work with the MASHs to fully 

capitalize on newly developing techniques in modern medicine. Through the latter part 

of the year a concerted effort was made to move the MASHs closer to the front lines of 

the fighting, usually 10 to 20 miles away. This balanced easy access for the wounded and 

still allowed surgeons to operate with a “fair margin of safety.”4(p24) Because the MASH 

received the greatest casualty load, relatively inactive hospital staffs in the rear were moved 

to augment the heavily burdened MASHs. As a matter of concern for Page in his annual 

report, certain individuals, presumably from higher headquarters in the continental United 

States, visited “supposedly to check”4(Preface) on conditions in the field. Inasmuch as these 

individuals were inexperienced in field service, he stated that the “desirability of continuing 

this somewhat extravagant policy becomes questionable.”4(Preface)

The pace and movement of the MASH in 1951 was a replication of the experience 

from 1950. The introduction to the MASH operations in the 1951 annual report is 

exactly the same as the earlier annual report of 1950. But now there were five US MASHs 

EXHIBIT 7-4. GEORGE E ARMSTRONG, SURGEON 

GENERAL (1 June 1951–31 May 1955) 

Unique to most physicians, George E Armstrong 

began his career as an enlisted member of the 

National Guard. Upon commissioning, he rose 

through the ranks obtaining vast experience in the 

Philippines and China during the interwar period 

and World War II where he eventually served as 

the Theater Surgeon, China Theater. Before his 

appointment as Major General and The Surgeon 

General, he was the Deputy Surgeon General for 4 

years under Major General Raymond Bliss.1

 Some 

of the highlights of his tenure were the remarkable 

decrease of the death rate from World War II’s 4.5% 

to Korea’s 2.3%. Helicopters and their use in medical 

evacuation became an integral part of the medical 

field organization. Surgical Research Team investigations and progress in vascular surgery marked the 

increased knowledge gained from focused research 

as witnessed to an 80% arterial repair success rate 

compared to the previous 50% in World War II.2

Sources: (1) Biographical Files (Armstrong GE), 

2010.7.1, AMEDD Center of History and Heritage, 

Archival Repository, Joint Base San Antonio-Fort 

Sam Houston, Texas; and (2) Armstrong GE. Military 

medicine in Korea. US Armed Forces Med J [USGPO, 

Washington, DC]. 1954:1–7.
CHAPTER SEVEN • 251

and a Norwegian Mobile Surgical Hospital (60-bed capacity) in support of US and UN 

troops. One MASH, with the exception of the higher medical professional personnel, was 

held in reserve. Standards were established as these MASHs developed through the year. 

They disassembled, loaded on vehicles, and were ready to depart with a 6-hour notice. 

After arrival at their new destination, they were operational within 4 hours. Each MASH 

operated five surgical tables in a shift with a highly organized system of managing shock 

patients. A ground ambulance platoon was attached to each MASH to facilitate the rapid 

evacuation when postoperative recovery was complete. Additionally, four helicopters were 

attached to each MASH. They, in turn, were utilized for resupply, rapid patient delivery 

to the MASH, and comfortable (compared to a bumpy ground) evacuation from the 

MASH.4(p5)

Through Page’s direction, auxiliary surgical and neurosurgical teams were assigned 

to augment and aid the “extremely busy and somewhat overworked”4(p24) mobile surgical 

hospitals. The surgical cases followed the flow of battle. The hospitals were crowded with 

Allied and enemy wounded personnel during the winter and early spring. The situation 

FIGURE 7-4. Aerial view of the 8076th MASH in Chounchon, Korea (29 July 1951). Note the Basic “U” used 

to build the tented hospital. It was here that the core functions were established—preoperative, postoperative, and surgical wards. Photograph courtesy of the AMEDD Center of History and Heritage, Thomas 

N Page Collection, Box 4, Image #8A/854-9/FEC-51.
252 • FORWARD SURGERY

changed in late spring and summer following the slackened intensity of fighting and, 

therefore, the flow of wounded was sporadic. However, after the ceasefire negotiations 

seemed to be failing in September and October, the flow of wounded mirrored the pace of 

fighting on the front.4(pp23–24)

CPT Samuel L Crook, detachment commander of the 8076th MASH, described in an 

after-action interview the utilization of the basic “U” and split operations of his MASH 

developed by the previous hospital commander, LTC Kryder Van Buskirk, and the current 

hospital commander, LTC John L Mothershead (Figure 7-4). 

The hospital is moved in two phases. In Phase I, the tents housing Registrar, Receiving, 

and Holding are taken down. The laboratory, the pharmacy, and the admitting 

functions of Receiving are moved into the Pre-operative ward. The tentage which has 

been struck is then moved to the new location with half the personnel of Pre-operative, 

Post-operative, Surgical, Central Supply, and one receiving clerk. This tentage is erected 

at the new location to form the Basic “U,” consisting of Pre-operative, Post-operative, 

and Surgical. Central Supply functions, which consist of sterilizing instruments and 

dressings, are carried out in the surgical tent. 

At one point, therefore, there are two completely functioning hospitals. The 

hospital in the rear continues to admit patients until the forward installation is ready 

to operate. When the advance unit opens to patients, the rear installation ceases to 

receive. When all its patients have been evacuated, the rear unit moves up and joins the 

advance hospital as Phase II of the move. Tentage brought up is added externally to the 

Basic “U” in the new location.25(pp4–5)

Dr Otto F Apel Jr, chief surgeon at the 8076th MASH, wrote of his experience as a 

medical eyewitness from 1951 to 1952. As relayed earlier, the MASH was still in its infancy. 

Unlike the end of the war, the MASH was still truly mobile during the second year of 

fighting. Within Apel’s first year with the 8076th, the unit moved about every 3 weeks, just 

as described by CPT Crook.2(pp49,57) In addition to constant movement, continuous sustained 

operations characterized the busy MASH. Upon his arrival, Apel operated for 72 hours 

on combat casualties and had to cut off his boots due to the swelling in his feet.2(pp36–37,39)

The 8055th Table of Distribution increased their manpower strength and equipment. 

Patients flowed from the front lines 20 to 50 miles away into the MASH within an hour to 

an hour and a half from the time of injury. Plasma and whole blood were the agents used 

to fight shock, using intraarterial transfusion and positive pressure oxygen inhalation. It 

should be noted that there was discussion within the surgical community as to whether 

intraarterial transfusion was more beneficial than the traditional intravenous method in 

the resuscitation of the wounded. Studies conducted by the Surgical Research Team later in 

1952 to 1953 at the 46th Surgical Hospital (formerly the 8209th MASH) determined “no 

definite conclusions”26(p64) could be drawn. Sometimes surgical staff had to conduct surgery 

before the shock was controlled, but a large percentage of patients improved quickly 

from the surgeons finding the source of bleeding and stopping it. The radiograph was a 

critical tool in identifying foreign objects and became the policy of the unit for all battle 
CHAPTER SEVEN • 253

casualties to have radiography performed to simplify the work of the surgeons. The old 

authorization tables were created in 1948, but now the 8055th was transforming to new 

authorizations and steadily increased their size. In the first part of 1951, the hospital was 

all in canvas tents. But by December, the preoperative, operative, and postoperative wards 

were in prefabricated buildings. Across the board Japanese products were cited as inferior 

in quality and this caused major problems in the upkeep of the hospital and, in medical 

products specifically, hurt patient care. Patients also were referenced as reasons to adopt 

electric heaters because of the noise and maintenance required from the poorly performing 

gas heaters then on hand. One could minimize the importance of heat for the staff because 

winter clothing was on hand; however, it was often the wrong size.27(pp2–5,11–13,18–20) This 

would continue to plague the MASH staffs throughout the theater and the war.

In an endorsement for the 8063rd’s annual report for 1951, COL Page acknowledged 

the poor quality of Japanese procured equipment and supplies and mentioned that 

they were being replaced. While acknowledged throughout the theater for its benefits, 

the radiography equipment had problems from the heat of the summer. The 8063rd 

commander insisted that visits from the radiological consultant be longer and more 

often because they did not have their own radiologist assigned to the MASH.28(End4)

Ironically, the leadership of the 8055th argued the radiologist should be deleted from 

the authorization the following year because there were no problems in interpretations 

among the technicians.29(p10) With the increased equipment, a pattern emerged where 

units remarked that the current level of equipment and supplies on hand was beyond the 

capability of relocating the hospital in one move (Figures 7-5 and 7-6). With the addition 

of a neurological team, the lack of enough generator power was troublesome for the daily 

operations of the MASH because it could not carry the full load of the hospital when it was 

operating at its maximum capacity. The first part of the year, strangely enough, saw the 

preponderance of all the illness (sick; noncombat wounded) cases within the unit for the 

entire year. By the command’s own admission, there was no explanation for this. By late 

FIGURE 7-5. A litter 

patient is presented for triage at the entrance to the 

8063rd MASH (1951). Note 

the results of fewer moves 

reflected in the “garden.” 

Photograph courtesy of 

the AMEDD Center of History and Heritage, Joseph 

Hely Collection, Box 2, 

Image #2010.11.13.
254 • FORWARD SURGERY

FIGURE 7-6. Operating room of the 8063rd MASH (1951). Note the wooden floors improved the environment, but limited directional lights and single bulbs still provide lighting. The procedure in the foreground 

appears to be on a surgical table and the background shows several instrument set boxes holding up 

a litter replicating a surgical table. Photograph courtesy of the AMEDD Center of History and Heritage, 

Thomas N Page Collection, Box 2, Image #2010.11.5.

June 1951, however, the first cases of hemorrhagic fever discovered and properly diagnosed 

in the war were seen at Kachae-Ri. For epidemic hemorrhagic fever, this was the beginning 

of a long battle for UN forces with this disease, first identified in 1939 by the Japanese in 

Manchuria. The unit praised and benefitted from the clinical consultant program instituted 

by the Far East Command and Eighth US Army Korea Surgeon. The 8063rd commander 

specifically lauded the benefits to general surgery, ear-nose-throat surgery, and oral surgery. 

He did, however, request that the visits should last at least 2 to 3 days.28(pp5,8–9,11–13)

Throughout the year, the 8076th was 5 to 10 miles from the front. The weather was a 

constant aggravation where the rain and mud oftentimes would not allow the tent stakes 

to stay in the ground, and thus the tents collapsed under the deluge (Figure 7-7). The 

hospital had to resort to placing its vehicles under the tents to keep the tentage up.21(pp4–5)

In the opinion of the 8076th’s command in 1951, the guard section was inept in its duties, 
CHAPTER SEVEN • 255

with average or below average intelligence. In LTC Maurice R Connolly’s opinion, they 

were of poor quality, possessed low morale, and had a slovenly appearance while on guard 

duty. In his assessment they were not fulfilling their mission based upon the numerous 

thefts and penetration of the perimeter and he, therefore, disbanded the group. Instead of 

a permanent group, most enlisted soldiers rotated through the duty, but this soon affected 

MASH operations. A newly formed guard section was created under better selection 

criteria and supervision and proved to be worthwhile.30(pp5–6) The 8076th’s interaction with 

the Communist Chinese Forces was not at an end. There was an enemy clearing company 

overrun by UN forces and 200 wounded Chinese were admitted to the hospital within an 

hour. One Chinese nurse stayed with the patients for 1 month, taking care of them.21(p6)

Within the clinical realm, the preoperative and shock treatment sections were 

combined with great results and remained so, even though the new Table of Authorization 

separated them. More gas heaters were converted to electric-motor-operated heaters. The 

hospital had to improvise in making operating room and orthopedic tables, surgical lights, 

and scrub sinks. Several feats of improvisation and ingenuity were detailed in drawings of 

these recommendations that included a portable version of an operating room table, an 

operating lamp that moved (original one did not bend), a surgical scrub sink with a heater, 

and a transtracheal anesthesia apparatus.30(pp6,8,12,77–80)

FIGURE 7-7. Ground view of the 8076th MASH in Chounchon, Korea (29 July 1951). Note the condition of 

the road network approaching this section of the hospital. Rain and mud proved to be constant environmental challenges. Photograph courtesy of the AMEDD Center of History and Heritage, Thomas N Page 

Collection, Box 4, Image #8A/854-8/FEC-51.
256 • FORWARD SURGERY

By late December 1951, the preoperative and postoperative wards, as well as the 

operating room, were in prefabricated buildings. Much improvement to temperature 

control was evidenced through the use of 250,000 BTU (British thermal units) blowers used 

in the hospital (when the motors worked). Cases of suspected epidemic hemorrhagic fever 

were immediately evacuated to the rear. Because of the high suspicion of disease, not all of 

those evacuated were shown to have this illness. 

The unit focused on efforts to improve the clinical practice of the MASH and again 

made recommendations to the newly revised Technical Bulletin Medical 147, now titled 

Management of Battle Casualties.

31 Specifically, the report addressed treatment and intervention in intraabdominal, intrathoracic, and neck wounds, as well as vascular injuries 

and anesthesia. Supplies requisition continued to be problematic with several needed 

articles marked “not in stock.” With the construction of five prefabricated hutments to 

house the hospital, the basic-U plan for the 8076th MASH, in practical terms, became 

immobile.30(pp8,16,18–19,21–24,28,33)

It is interesting to note that the 1951 annual report recommended a “mobile surgical 

platoon” that could keep up with division clearing stations. Initially the mobile surgical 

platoon would stay with the main hospital. Evacuation flights would come directly from 

regimental clearing stations. Because of inadequate road networks between the MASH and 

division clearing stations, the idea of this mobile surgical platoon was born. In concept and 

design, it foreshadowed the current forward surgical team concept. According to the plan, 

the surgical platoon would 

leave the main hospital and attach itself to the Division Clearing Station. The platoon 

would use the facilities of the clearing station for shock, pre-op, and x-ray. (For many 

years the need of a portable x-ray for the Division Clearing Station has been evident, 

and would be necessary for our concept). It would set up a two table operating room, 

work-room and a small anesthesia recovery ward. The two surgical teams would 

select only those cases who obviously would not live to reach the main hospital, and 

would not stock-pile a group of cases. Most of their work would probably be during 

the hours of darkness when the helicopters can not (sic) evacuate direct to the main 

hospital.30(p42)

It was in 1951 that the 1st MASH was redesignated to be the 8209th MASH.32(p1)

Evacuation was primarily through fixed-wing aircraft and train, while helicopters were 

used in emergencies, simultaneously solving the problem of prompt refill of a depleted 

blood supply. Most reports of the MASH described the challenges of balancing security and 

the mission. The 1st actually had a Raider platoon—elite volunteers who fought irregular 

warfare—assigned to the hospital to provide security. Like the year previously, abandoned 

buildings were used when available. At one time the surgical suite occupied a former 

bank building. Blankets became a problem during exchanges with aircraft. During one 

operation, the MASH went through about 1,000 blankets per week and had to begin using 

staff blankets to keep patients warm.33(pp1–2,4–5) The 8209th staff served as consultants to 

the Korean Army and civilian hospitals. Interestingly, the 8209th never used their holding 
CHAPTER SEVEN • 257

section during this time because patients did not stay long. At each location, patients were 

rapidly evacuated, enabling the hospital to “leap frog” to the next position. The forward 

hospital received the more severely injured patients, while the rear hospital took the overflow of the lightly wounded. Before each move, patients were evacuated from the two 

functioning sections of the MASH conducting split operations. Extra duty details were 

performed by the staff.32(pp4–5)

Field expediency dictated replacing the issued light sets with improvised lights in the 

operating room (Figure 7-8). Like the other MASHs, the equipment authorized exceeded 

FIGURE 7-8. A team from the 1st MASH performs surgery on a wounded soldier in Inchon, Korea (14 February 1951). Left to right are: Corporal Bob Crain of Los Angeles, California, surgical technician; Lieutenant 

Junior Grade Bruce Meiers of Berlinger, California, Navy surgeon; Captain John J Wilsey, Newark, New 

York, surgeon; and First Lieutenant Marie Smarz of Shelton, Connecticut, Army Nurse Corps. Note what 

appears to be a vehicle light serving as an improvised surgical lamp. Photograph courtesy of the AMEDD 

Center of History and Heritage, Army Nurse Corps Photo Collection, Box 25, Image #B4-03-02(1).
258 • FORWARD SURGERY

the power generation system that was available. Furthermore, gasoline engine heaters were 

notoriously inoperative (nine of 12 were out at one time) and were replaced with electric 

motors. This, of course, only strained the already overburdened generators.32(pp6–7)

As the year progressed, morale was enhanced through numerous outdoor recreational 

activities that included baseball, softball, volleyball, horseshoes, and swimming parties. 

Nightly movies were shown in the tent theater that held 400 people, which also made for 

the perfect venue for a United Service Organizations tour stop. It was no wonder the 1951 

annual report cited these amenities as a reason for a significant reduction in depression 

among the staff.32(p8)

The 8209th 1951 annual report noted that the incoming enlisted personnel were so 

poorly trained that only a small percentage could be used immediately upon their arrival. 

For example, out of the 70 new soldiers who arrived in 1951, 43 had to be given other 

temporary jobs before being allowed to practice their “trained” skill set. A medical society, 

which included medical personnel from a supported division, met weekly. Here they 

followed up cases, reviewed patient care summaries from patients transferred to Japan, 

and produced medical papers. By year’s end all sections were still in tents with frames and 

floors except for the prefabricated buildings containing the preoperative ward, operating 

room, postoperative ward, and the combined admissions, dental, optical, refraction, and 

pharmacy sections.32(pp11–12) 

After its arrival to the peninsula from Japan, the 2nd MASH became operational 

in April 1951 with about 95% of the authorized 10 days of supplies. However, they 

had to request additional material to transform from a 60-bed to a 200-bed hospital. 

With only a little over a month in combat, the hospital was redesignated as the 8225th 

MASH. While most of the unit was under tentage with dirt and tarp floors, winterization 

brought wooden and concrete floors, walls, wooden frames and doors, tent liners, and, 

most importantly, Herman Nelson heaters. The Admission and Disposition Sections 

morphed into an Outpatient Clinic. Like other MASH units, they had to evacuate any 

head, neck, and eye injuries for a lack of the specialty to treat those injuries. With the 

exception of small burns, no plasma was administered, but rather whole blood was given 

to treat shock. During the summer months (when the war raged in the heat), there was a 

great demand for intravenous fluids and blood. Until July, there were actually four Navy 

doctors on the surgical staff.34(pp2–7,9) The presence of Navy doctors in Army units was 

indicative of the severe shortage of medical personnel in the Far East Command. Army 

interns and residents from hospitals in Japan, and Navy residents, had filled the gaps 

in field units facing the North Koreans and eventual Communist Chinese early in the 

war.7(p140) A cold-injury ward was created and physicians collaborated with the Army’s 

Cold Injury Research Team in the care and in research of these patients. It was policy to 

radiograph every combat wound, which assisted the surgeon in debridement, and the 

film was then transported with the patient during evacuation. But this created a scenario 

where two of the six radiography technicians’ blood count displayed evidence of excessive 

radiation exposure.34(pp12–13)

The triage effort between the preoperative section and the operating section was 

critical and several recommendations were made based on the unit’s experience: (a) there 
CHAPTER SEVEN • 259

was a great need for more anesthetists; (b) there should be at least two orthopedists; (c) 

acute head injuries should be dealt with in the MASH; and (d) the MASH should have 

well-trained surgical teams where the commander was a surgeon and provided policy and 

consultative advice. During heavy patient flow, the dentist was used as a surgical assistant. 

Defective Japanese equipment was lamented, with examples describing syringes breaking, 

intravenous bags leaking, and plaster of Paris falling apart. The problem of not having 

enough generator power was evident once again. Blood was good only because of the 

transport by helicopter and fixed wing aircraft. Clothing for hospital staff was abysmal. 

When patients no longer needed items, staff used their boots and clothing. There was also a 

period of clothing issuance where sizes were just too small. For the lack of proper uniforms, 

women were issued male clothing.34(pp10,16–17)

The year 1951 was the first year for the 8228th MASH. COL Page described it as the 

only replacement MASH in the Eighth Army. Initially the unit was composed of a small 

cadre: two medical service corps officers and four to six carefully selected enlisted soldiers. 

Toward the end of the year they were busy unloading equipment from the train and using 

replacement personnel as guards, some of whom had transferred from other MASHs. 

Within the barbed wire containing the newly arrived hospital equipment, two-man patrols 

were required to keep vigilance against theft. Making good use of their time and consulting 

with the other MASHs, the unit began realistic training and had 95% of their medical 

equipment along with 85% of the technical services equipment by year’s end.35(pp1–4)

Korean War (1952) 

The fighting stalemated and resembled the entrenched defenses of World War I as 

peace talks slowly drug on through April 1952. Enemy prisoners of war held in UN 

hands began rioting in April, with the rioting lasting through June. This even included 

an enemy prisoner of war patient riot in two field hospitals. General Mark Clark became 

the third Korean War commander of the Far East Command when he replaced Ridgway 

in the summer. The casualty flow, in turn, mimicked the steady waiting in which the two 

forces engaged in bearing down upon one another. When battle cries and horn blasts 

erupted from the Chinese Communist Forces on hilltops, the wounded flowed once again 

through the MASH.5(pp1,3–4) As the war pressed on and the battle lines became fixed, so did 

the MASH. Concrete and wooden buildings replaced the canvas tents of earlier months. 

Specialized surgical consultants and research teams began to develop and improve the 

status of care and surgery on the front lines.

The Eighth Army Surgeon, Brigadier General (BG) L Holmes Ginn Jr (Figure 7-9), in 

his annual report for 1952 again lamented the shortages of personnel. Of the 139 fieldgrade Medical Corps officers authorized by T/O&E in country, only 36 were present. 

Fortuitously, the battle lines remained relatively static. Only two of the six US Army 

MASHs moved the entire year. MASHs began to establish permanent residence and 

construct temporary buildings or were issued prefabricated buildings (tropical shells with 

insulating kits) to provide better care and comfort to patients. Few individuals on duty 

in a 1952 MASH in Korea had ever seen their unit move. In contrast to the first 2 years 

of combat in Korea, the MASHs functioned within their authorized 60-bed capacity for 
260 • FORWARD SURGERY

priority surgical patients. The 8055th was the only exception.5(pp1,4–5;AnnexIV,pp7,26) Because 

battle injuries remained constant, disease and nonbattle injuries “accounted for the 

preponderance of our hospitalization,”5(p1) according to Ginn. The 8228th MASH became 

host to the onslaught of teams researching Eighth Army hemorrhagic fever cases. Moving 

from field conditions to a fixed facility in Seoul with 62 concrete-floor Quonset huts,36(p6)

the 8228th became the logistical and support center for hemorrhagic fever in Korea. As 

cases of hemorrhagic fever decreased in the winter and cold weather injuries increased, the 

8228th emerged as the consolidated center for the treatment of cold injuries5(pp4–5;AnnexIV,pp7,13)

(Figure 7-10).

A stabilized combat situation, coupled with a lack of resources, resulted in each 

MASH beginning to develop its own specialization, similar to the 8228th. Neurosurgical 

detachments were stationed with both the 8209th MASH, in the east, and 8063rd MASH, 

in the west. It is interesting to note Ginn’s knowledge of the auxiliary surgical groups in 

World War II in his annual report. He stated the past concept was sound and could also 

work in Korea, if only the staff were available. In his opinion, the use of “professional 

FIGURE 7-9. Major General George E Armstrong, US Army Surgeon General, visits the X Corps Headquarters in Chounchon, Korea (22 January 1952). Standing left to right are: Colonel Thomas N Page, 

Eighth Army Surgeon; Brigadier General Lawerence E Dewey, IX Corps Chief of Staff; Major General Armstrong; Lieutenant Colonel Francis L Carroll, IX Corps Surgeon; Brigadier General Earl E Standlee, Army 

Field Forces Surgeon; Brigadier General William E Shambora, Far East Command Surgeon; and Colonel 

Holmes Ginn, incoming Eighth Army Surgeon. Photograph courtesy of the AMEDD Museum Photo Collection, Korean War, Volume 2, Image #KW-0309.
CHAPTER SEVEN • 261

service detachments,” as he called them, however, were much diminished because the 

MASH was organized as a fully staffed surgical hospital superseding the field hospital 

platoons that performed the priority surgery at forward locations in the past. Significant 

reductions in infections were seen because minor surgical cases and debridement were 

properly handled at the division clearing stations. Now priority surgery could be done more 

quickly at the 60-bed MASH instead of waiting along with all other surgery patients in the 

200-bed MASH.5(p5;AnnexIV,p26,Section2;AnnexVI,pp1–2)

From 1952 to 1953, Dr Mel Horwitz served in the 8055th MASH and 8225th 

MASH (later designated 8225th Army Surgical Hospital, Mobile).37(p212) As discussed 

earlier, the lack of hospital movement reflected the stationary warfare of the third year 

of fighting.7(pp88–89,167) Dr Horwitz worked in a more mature MASH with prefabricated 

buildings and new equipment, in correlation to the stagnated front lines.37(p99) Just as the 

experiences of Drs Apel and Horwitz differ, so does the MASH differ according to the time 

and place. 

The biggest “medical lesson to remember” that unfolded in 1951 and came to resolution by 1952 was the debate on medical specialization versus field medical education. 

FIGURE 7-10. Doctors’ tents serve as the background for a reunion of University of Pennsylvania Nursing 

School colleagues now with a Surgical Research Team (February 1952). From left to right are: Captain 

Howard, Medical Corps; 1st Lieutenant RE DeLaney, Army Nurse Corps; and 1st Lieutenant Scott, Medical 

Corps. Photograph courtesy of the AMEDD Center of History and Heritage, Army Nurse Corps Photo Collection, Box B24, Image #B4-02-03.
262 • FORWARD SURGERY

FIGURE 7-12. Medics from Company A, 32nd Infantry Regiment, 7th Infantry Division, climb Hill 902 carrying litters in preparation to evacuate the wounded from Companies A and B to the division clearing 

station for further treatment (23 April 1951). Note that the “red cross” is not displayed on the uniforms to 

identify medical personnel. Photograph courtesy of the AMEDD Center of History and Heritage, Thomas 

N Page Collection, Box 3, Image #X/FEC-51-13264.

FIGURE 7-11. Medics from the 23rd 

Infantry Regimental Collecting Station, 2nd Infantry 

Division, load a 

casualty onto a 

Bell H-13 litter for 

air evacuation 

near Sangchon, 

Korea (14 April 

1951). Photograph 

courtesy of the 

AMEDD Center 

of History and 

Heritage, Thomas 

N Page Collection, 

Box 4, Image #X/

FEC-51-12427.
CHAPTER SEVEN • 263

In competition with the civilian medical community during the interwar years, US Army 

Medical Department officials had emphasized the opportunities to specialize in a particular 

field of medicine in order to attract more physicians. The result was that there was no interest in field medicine, but only specialties. Doctors were supplemented with Medical Service 

Corps (healthcare administrative) officers who were versed in procedural paperwork and 

field/combat operations. This concerted effort, in effect, halted the training of young medical officers in combat medicine after World War II. Clinical expertise and military medicine/

field expertise were not the same. The lack of combat acumen for physicians proved to be 

disastrous, resulting in preventable soldier and doctor deaths.7(pp34–35,189,191) The leader in 

condemnation for the condition of Army field medicine was BG Crawford F Sams, former 

Chief of Public Health and Welfare in Korea. Sams had extensive experience as a “field 

soldier” and physician. (In March 1951, for instance, he led a three-man special operations 

“commando-type” infiltration mission into Wonson, North Korea, to determine whether 

intelligence reports of bubonic plague were true, but determined they were not.7(pp175–176,188)) 

BG Sams blamed the current program of placing recently graduated medical residents 

fresh from the halls of a hospital directly into a battalion aid station for the amateurish 

state of military field medicine (Figures 7-11 and 7-12). There was no field or tactics 

training. His son-in-law, a battalion surgeon, was killed defending his patients in November 

1950. He painfully recalled how his son-in-law was not prepared for his assignment, had 

fired a weapon for the first time just months before, and was “largely ignorant of field 

procedures, organizations, and weapons.”7(p188) Sams rightly argued in June 1951:

Our younger men were thrown into combat without a day’s training—similar to 

taking a boy out of a drugstore and saying “I’ll give you a gun—go fight the Koreans.” 

We did this to our young doctors. They were pulled out of the specialty programs, 

arrived in Japan, because we had nothing else; given field equipment which they had 

never seen before, told they were going to be assigned to field units the names of which 

meant nothing to them. Those young men, within five days after their arrival, were 

being shot at by the enemy. . . . That, I think, was one of the most disgraceful things in 

the military service. And still, a year later, we are almost in the same fix insofar as the 

men who are physically in the forward echelons are concerned at this time.7(p189)

Professional medical experience was common, but unfortunately, command rank and 

military experience were not.7(p234) Dr Apel received no military field medicine training prior 

to reporting to Korea and pointed out that there was no remedy for lack of experience. 

He painfully remarked how he and his fellow physicians did not know how to establish a 

defensive perimeter, had no field manuals, and did not know tactics. Everything they did 

to survive in combat was from figuring it out by themselves.2(pp15,35) Improvements and 

recommendations were implemented to correct the obvious problems within the training of 

the Army Medical Department at the Medical Field Service School under Sam’s direction 

as the Assistant Commandant.7(pp195–196) By the end of the first year of fighting, better 

field training was initiated for officers and enlisted personnel.7(pp192–195) A clear example 

of this change is evidenced by Dr Horwitz’s 8 weeks of field medical training at Fort Sam 
264 • FORWARD SURGERY

Houston, Texas, in 1952 prior to reporting to Korea,37(p7) compared to Dr Apel’s complete 

lack of field training in 1951.2(p35)

Paralleling the changes taking place at the Medical Field Service School under Sams’ 

leadership, Ginn instituted a tough in-country training program for officers and enlisted 

medical personnel in Korea in 1952 (Figure 7-13). He stated, 

Field training with a division, is an indispensable ingredient of [the medical officer’s] 

education, especially if he is in the regular service, no matter how rarified and sacrosanct his MOS [military occupational specialty]; . . . along with knowledge and skill, 

a young medical officer must be taught a sense of mature responsibility toward his 

patients which comes from experience and from living with his mistakes.7(pp196–197)

The 8055th treated shock as it had previously and also emphasized that in surgery the 

type of agent or technique in anesthesia was not as important as the manner used.29(pp2–4,7–9)

Looking with modern lenses, the 1952 annual report’s discussion of surgical preparation 

seems strange, but the message is delivered with all seriousness: “We feel that the wounded 

man is entitled, if feasible, to undergo surgery while asleep.”29(p7) Some of the problems 

FIGURE 7-13. Students from the first class of the Seoul Branch Medical Field Service School listen as the 

commander of the 44th MASH, Colonel WS Cornell, explains the function of the Neuro Surgical Ward 

(22 February 1953). Note the improved facilities—hardened structure, bug screens, built up tables, and 

three surgical lights configured together. Photograph courtesy of the AMEDD Museum Photo Collection, 

Korean War, Volume 2, Image #KW-0450.
CHAPTER SEVEN • 265

affecting the radiograph’s ability to assist the surgeon were the great fluctuations in 

temperature, which affected the quality of the film development. It was noted, however, 

that the films were good enough for a general surgeon to interpret and the command 

recommended replacing the authorized radiologist with another general surgeon.29(pp9–10)

This was the opposite opinion held by the 8063rd commander just the year before28(p4)

(Figure 7-14).

By December, the headquarters detachment and mess facility were in prefabricated 

buildings, following the earlier preoperative, operative, and postoperative wards transitions. Japanese products, again, accounted for complaints of inferior quality. And again, 

winter clothing was on hand, but not the right size. The unit was challenged with getting 

FIGURE 7-14. Chaplain (Captain) Thomas L Doyle (left) from Lowell, Michigan, and Airman First Class 

Peter J Farpell (right) from Albany, New York, tend to a casualty just arrived from the front lines in an 

Sikorsky H-5 rescue helicopter at the 8055th MASH (20 November 1952). Note the litter cover lying on 

the ground has a transparent viewing area, removing the “casket” experience of early Korean War evacuations. Photograph courtesy of the AMEDD Museum Photo Collection, Korean War, Volume 2, Image 

#KW-0400.
266 • FORWARD SURGERY

replacements into the hospital. Enlisted soldiers with medical specialties were diverted to 

fill administrative jobs to keep the unit functioning. The quality of the soldiers also affected 

the performance. Of the 132 enlisted personnel, only 53 were high school graduates. Low 

morale concerning promotion and rotations was countered with interventions such as 

building a club tent, Red Cross reading and game room, hosting unit parties, and showing 

movies every night.29(pp11,14–20)

The Far East Command’s endorsement of the 8063rd annual report supported the 

units’ request for improved radiographic capabilities and facilities to continue the essential 

task of identifying foreign bodies. This ability, combined with the presence of a neurological 

team, would greatly increase favorable outcomes for the battle casualties arriving at 

the MASH.38(End,pp1–2) Ground and air ambulance evacuation means were “heartily 

recommended”38(p2) to continue in providing care to and from the hospital. Interestingly, the 

commander was severely critical of his medical counterparts because of their insistence in 

transferring ambulatory patients for radiography, labs, and general medical illnesses. LTC 

WS Cornell’s comments echoed BG Sams’ concerns from 1951 when he lamented, 

A misunderstanding seems to exist on the parts of the medical officers in forward 

echelon stations as to the capacity of the MASH. The function of this unit as stated in 

the Service Regulations is to treat emergency surgical conditions and the unit is not in 

a position to administer any more or better treatment of non-surgical conditions than 

is available in the division clearing stations. This fact should be made apparent to the 

medical officers of these installations.38(p4)

Additionally, the report warned it would be stressed under sustained action because of 

its current minimum staffing. The command had to train its nurses in anesthesia because 

of want of an anesthesiologist and had to train its surgical technicians with on-the-job 

training because they were unprepared out of the schoolhouse. Because the laboratory 

was still in tentage, reagents froze and the blood box overheated. This was corrected 

once the lab moved into a prefabricated building. The pharmacy also found it hard to 

keep medicines and liquids from freezing, but this also was remedied after moving into 

a tropical shell. Two and a half years of wear and tear were taking its toll on the vehicles 

of the unit. There was a considerable record of waiting for vehicle parts and the return of 

unserviceable vehicles. Recreational outlets such as swimming, softball, and ice skating, 

and entertainment through movies and United Service Organizations shows helped to 

improve morale.38(pp5,7,10–11) The radiograph was emerging as a critical piece to the ability of 

surgeons to properly identify and remove the elements of battle that damaged their young 

patients, but the machines in the MASH were not adequate. This knowledge and plea was 

supported by the report’s citing Dr Eldridge Campbell in the March 1952 Symposium on 

Treatment of Trauma in the Armed Forces, 

Prior to debridement of a wound of the brain or spinal cord, it is essential to ascertain 

the location of in-driven bone, skull and rock fragments. Plain films, even of good 

quality, are inadequate. Good stereoscopic views are necessary, since not only the 
CHAPTER SEVEN • 267

depth and exact location but even the identification of many small shadows can be 

determined only in this manner. This technique was not available in World War II, and 

thus far not in the Korean conflict. This can and should be adopted without delay.38(p12)

Not surprisingly, the 8063rd commander states that most personnel in the unit were 

“not used to the rigors of Army life and life in the field.”38(p15) Within the realm of clinical 

experience, the hospital made improvements in vascular repair by using clamps fashioned 

after Potts arterial anastomosis clamps. These clamps and subsequent training program 

came about directly from the general surgery consultant from the Far East Command. 

The treatment of severe burns and traumatic shock were improved through the use of 

polyethylene tubing for continuous intraarterial and intravenous fluid administration. 

Because the forward aid stations were using less morphine, patients were now able to 

go into surgery much sooner than they had in the past because the complications with 

anesthesia were far less. The unit now had eight tropical shells, concrete floors, and framed 

tents38(pp18–19,22–23) (Figure 7-15). 

FIGURE 7-15. US doctors and medics of the 8063rd MASH treat a Republic of Korea battle casualty from 

the Battle of White Horse Mountain (8 October 1952). Note the standard surgical lights are now configured to hang from a movable structure above. Photograph courtesy of the AMEDD Museum Photo Collection, Korean War, Volume 2, Image #KW-0361.
268 • FORWARD SURGERY

The 8076th began the transition from a surgical hospital mission to a de facto area 

medical support-type hospital. The care they began to provide was equal to the evacuation 

and station hospitals in other locations throughout the peninsula. Because of the lack of 

increased authorizations of enlisted personnel, the command utilized indigenous labor in 

support of the Post Exchange, sanitation requirements, and utilities details. The security 

requirements of the enlisted personnel affected the surgical, preoperative, and postoperative 

sections’ efficiency. There was obviously an institutional memory within the organization, 

enough to gain notice in the annual report and admit their current situation was not as bad 

as it had been in 1950 and 1951. It was acknowledged that the current fleet of vehicles, 24 

in all, was not enough to move the hospital personnel and equipment. The winterizing and 

improvements of the MASH had created a larger and more spread out unit. Tents were 

replaced with wooden frames and new tentage, liners, and wooden and cement floors. The 

postoperative, preoperative, and surgical wards were all in prefabricated buildings. The 

prefabricated structures also bought comfort to a new chapel/theater, enlisted day room, 

garage for the motor pool, and an officer’s mess. (Half-way through the year these separate 

dining facilities were established for the enlisted and officers. This was considered “more 

desirable” according to the annual report.39(Encls1–2,10)) In fact, the summer brought about a 

change of attitude, if not mission.

Prior to this everyone was too occupied in work, keeping warm and moving to be very 

much concerned about the adequacy of latrines and quarters, the suitability of the 

Enlisted Men and Officers Clubs, etc. Now a concerted effort was put forth to improve 

the living conditions and the recreational activities in order that personnel could 

derive some comfort from their fairly comfortable surrounds. In conjunction with the 

improvement program, a training program was also put into effect for the first time 

in the history of the unit. Paper work, reports and red tape in general commenced to 

increase to an extent that times the expression “police action” seemed a vague term as 

applied to the general situation as far as the 8076th was concerned.21(p7)

Along the lines of health of the command, three cases of hemorrhagic fever were 

diagnosed after some staff members were walking and hunting in a surrounding brushy 

area, which was soon put off-limits. Those three and the other 13 cases were evacuated 

to the 8228th MASH. The unit received only 67 cold injuries compared to 400 from the 

previous year. This decrease was attributed to the improved tactical situation, better cold 

weather protection, and education of the troops. The first half of the year US soldiers 

made up the surgical cases, but the second half were mostly Republic of Korea soldiers. 

Unfortunately, the higher morbidity rate for the South Koreans was directly attributed 

to the slower Republic of Korea Army evacuation system because it delayed arrival to 

definitive surgical intervention. Noteworthy surgeries included abdominal cases with 

thoracotomies, fractures, vascular injuries, and amputations.39(Encls3,5–6)

A team from Walter Reed Army Medical Center trained staff on vascular surgery, 

focusing on the repair of peripheral arteries. Verbal approval was given for the Potts-type 

arterial clamps, but the unit was presently still awaiting their receipt.39(Encl6) It appears the 
CHAPTER SEVEN • 269

clinical practice of fashioning on-hand clamps to replicate the clinically preferred Potts 

clamps was making the rounds as also documented earlier in the 8063rd.39(p19) Dr Apel told 

of paying a silversmith to make a clamp based upon his own hand drawing while he was 

on rest and relaxation leave in Japan.2(p162)

These surgeons all knew they were in a unique time and opportunity. Across the 

command, the doctors agreed that, “the experience gained as a result of being assigned to a 

MASH has no counterpart in the Army or civilian life.”39(Encl7) There was an added note for 

nursing. The command supported 6-month rotations back to Japan citing “at best the field 

conditions under which they are required to live in is considerably harder on females than 

males.”39(Encl7) Thus, nurses were authorized to request a rotation back to Japan after being in 

Korea for 6 months. On the enlisted side, an influx of less intellectual and technically trained 

personnel toward the latter part of the year was troublesome. This, combined with their 

concerns for points and promotions, produced low morale. The MASH replicated the usual 

on-the-job training for the enlisted, but the doctors and nurses started a formal professional 

training program. Of interest to note, it was recommended that the dental technician 

be taught operating room techniques in order to assist the maxillofacial surgeon. The 

technician’s skills in the dental chair were good, but lacking in the operating room.39(Encls7,12)

 The 8209th served as a 200-bed surgical hospital in the beginning, but transformed 

into the 60-bed MASH variety by October. The hospital provided neurosurgical support and 

had the Surgical Research Team of the Army Medical Service and Graduate School assigned 

the entire year. Much medical literature and research was produced during this time. In fact, 

the annual report, consisting of only three pages, seems to suggest that the Surgical Research 

Team was the de facto reservoir of any official record of unit history and clinical research. 

On-the-job training occurred, but the unit lacked an anesthetist, a recurring theme in the 

anesthesia story of the war. Interestingly, it was noted that one-third of the intravenous fluids 

were lost due to the glass bottles breaking in shipment. The commander ended his terse 

report suggesting the MASH may finally move because it was “somewhat far behind [the] 

Division which it supports”40(pp1–3) some 8 miles forward.

The 8225th functioned in its prescribed manner until 18 May. Then it was closed for 

training until 24 September. During this training phase, the unit practiced individual military 

and branch training, field training, and use of medical equipment. Technicians were also sent 

on temporary duty to other medical units to receive required training. During this time there 

was terrible flooding, so there was plenty of opportunity to exercise the evacuation plan of 

the hospital. Once the training cycle was complete, the MASH temporarily occupied an old 

rice paddy that required draining while waiting for improvements on the final destination 

just 700 yards away. Once the site was properly prepared, the entire hospital moved 

piecemeal into the new location. For several hours there were patients in the operating 

room at both locations simultaneously. The division clearing station was now 7 miles away 

and ground ambulances traversed the evacuation route. Oftentimes, however, helicopters 

travelled straight from front line battalion aid stations. The airstrip was 1 mile away. 

Priorities were set for determining further evacuation requirements. It was deemed that 

wounds of the spinal cord, brain, and eye requiring specialized care warranted evacuation 

to a higher-level care, while those presenting with only minor wounds could be further 
270 • FORWARD SURGERY

transported to evacuation hospitals for care. In November, the Eighth US Army in Korea 

Surgeon directed that all minor battle casualties be given surgery in the clearing stations. 

This filtered out many patients normally bound for the MASH.41(pp1–3,Encls2–3)

The 8225th’s annual report described the advantages of collocating the administration 

and disposition, preoperative, and radiography sections in the same building. This collocation eliminated crossing over other sections and improved the electrical distributions and 

prevented “bottlenecks.” This proximity also enabled the radiograph’s use in finding all 

debris in battle wounds early in the process.41(pp3–5)

Problems with supplies and personnel still existed, however. The pharmacy reported 

the arrival of smallpox vaccine after its expiration date. The laboratory technicians’ skills 

were found lacking and on-the-job training ensued. This situation may have contributed 

to the US Armed Forces–Far East Command arguing against the use of fresh whole blood 

within the MASH in its endorsement memo for the report. The higher command insisted 

that a mistake would be fatal and the dangers outweighed the advantages.41(End,p6)

There was gradual improvement in some areas. In reviewing the layout, the two 

hospital sites described in the 8225th’s annual report provide examples of this improvement 

to MASH facilities in the theater, compared to the crude canvas of earlier years. The first 

operating room was a prefabricated building with wooden floors containing two standard 

field-operating tables, two litter frames, and one cast table for the five operating room 

tables. The lights were a three-cluster arrangement of 100-watt bulbs that moved on a cable 

and slide. These were augmented with truck lights running off the truck’s batteries. Once 

the hospital occupied the well-prepared site, an additional field-operating table replaced a 

litter frame. Now the operating room was in a prefabricated building, but with concrete 

floors. Two portable lamps replaced the old truck lights. Curtains were even arranged on 

cables between patients, which enabled surgery on an unconscious patient to be private, 

and not intimidate the adjacent patient only receiving local anesthetic administration.41(p7)

However, the lack of nurses caused operating room technicians to function as nurses if one 

nurse supervised. But sometimes there were no nurses at all. 

Efficiencies were incorporated that saved numerous staff hours and are interesting to 

read in light of today’s advancements, which have incorporated some of them or used the 

method to alter modern practices. These included: 

• a glove powdering box limiting the dust in central supply;

• suspended drapes and intravenous bottle holders allowing draping and decreasing

the number of poles on the floor; 

• cast cart at surgical table saving time in walking;

• leg traction holder within the ceiling allowing surgical preparation at table;

• prep stands at surgical table allowing for consolidation of all items for surgical

preparation; 

• lighting that allowed movement of the lights over a cable system;

• portable intravenous stands allowing blood to be given in transit while attached to

the litter; 
CHAPTER SEVEN • 271

• sterile mimeographed supply check list allowing for item listings with levels for

rapid reference; 

• card index of unsterile supplies allowing for a quick reference and standardization;

• procedure book providing more MASH-centric surgical procedures readily

available; and 

• prepacked lockers and cases allowing for rapid mobility.

41(pp8–9)

Beginning in September, the 8225th started to train all enlisted technicians in nursing because the 60-bed MASH had only two nurses. The eventual intent was to train 

and increase the enlisted medical proficiency in order for them to operate without 

nurse supervision at all.41(pp11–12) The Eighth Army Surgeon reported it as “entirely 

successful.”5(AnnexIV,p7) This is interesting in light of the 1950 annual report from the 8055th 

arguing the opposite, that “corpsmen are not a suitable replacement for nurses,”19(p13) and 

emphasizing the incredible reliance and importance of nurses in the MASH.19(p13)

The 8228th MASH was unlike any of the other MASHs on the peninsula. The first 4 

months of 1952 were dedicated solely to training. On 7 April, the 8228th was designated 

as the primary hemorrhagic fever center and on 27 November, it was also designated as 

FIGURE 7-16. Visitors like Maurine Clark, wife of the Far East/United Nations Commander, General Mark 

Clark, were able to visit because the MASHs began to remain in place as the battlefields became stagnant 

(12 August 1952). Here Mrs Clark is visiting the hospital staff of the 8228th MASH. Photograph courtesy of 

the AMEDD Museum Photo Collection, Korean War, Volume 2, Image #KW-0335.
272 • FORWARD SURGERY

the primary facility for cold weather injuries. Their first move entailed 33 trucks and 25 

trailer loads over 3 days in March. As the hemorrhagic fever center, surgical supplies were 

not needed, but more laboratory and ward spaces were needed. The second move, in 

November 1952, took 7 days with 132 patients distributed among 17 ground ambulances 

and five helicopters. The MASH occupied 60 new prefabricated buildings with sidewalks, 

enough space for 500 beds and a detachment of 200 (Figure 7-16). There was no canvas 

tentage for the entire hospital. Because of the mission, treatment was medical rather 

than surgical. The medical officers were internists. Most were experienced with extensive 

residency training. Surgical technicians became medical technicians. On-the-job training 

related to hemorrhagic fever was conducted. 

The mission change affected the ability to get the right types of supplies, which 

required letters of justification because the MASH was only authorized those items integral 

to surgical care. Some drugs had to be pulled from other installations in Korea by the 

medical depot trying to fulfill the new requirements. The commonly recurring saga of 

inferior Japanese products still emerged, even within this pristine MASH, but it was limited 

to light bulbs. Clothing in the wrong sizes continued to be a prevalent problem. One 

interesting note on equipment sustainability is seen where Japanese stapling machines were 

issued to the hospital, but only American staples were available through the supply system. 

In the spirit of redistributing desperately needed equipment, the unit received authorization 

to turn in unnecessary equipment needed elsewhere. 

Along the lines of the clinical investigations, the clinicians knew the vector for 

hemorrhagic fever was an arthropod. Soon the center was conducting studies on rodent 

ectoparasites such as ticks, fleas, and mites (chiggers). As of the 1952 annual report, 

studies were looking into the theory that chiggers were the vector for hemorrhagic 

fever.36(pp1–6;AppC,pp1–3)

Korean War (1953) 

The closing events of the Korean War only covered the first 7 months of 1953. The 

earlier stalemate following the deadlocked truce talks continued on through the beginning 

of the year. General (GEN) Maxwell Taylor replaced GEN Van Fleet as the Commander, 

Eighth Army, in February. Not all the battle lines were quiet, however. Veterans from Pork 

Chop Hill that April, and the subsequent savage fighting through May, would testify to an 

eventful “stalemate” while peace talks were negotiated. On 27 July 1953, a little over 3 

years from the North Korean invasion of South Korea, a ceasefire agreement was finally 

signed that ended the fighting.17(p664)

In June, the 30th Medical group assumed medical service support to the Eighth 

Army. The medical units that had previously provided third-echelon medical care to the 

Eighth Army were organized under this new structure and commanded by BG Paul I 

Robinson. There were six MASHs in country, with one listed as inoperative. Following 

the armistice, additional equipment was assigned to the MASH to meet the increased 

demands of providing support to newly repatriated prisoners and maintaining the health 

of the populace in the devastated countryside. With this new command structure came a 

new name for the MASH—the “Surgical Hospital, Mobile Army.” However, everyone still 
CHAPTER SEVEN • 273

called it the MASH.6(pp1–2,4–5) As discussed earlier, the MASH moved into fixed facilities, in 

the words of Robinson, “so that hospitals could render more effective Medical and Surgical 

type care.”6(p4) And he added, “With the construction of semi-permanent buildings the fire 

hazard in the Surgical Hospitals has been decreased.”6(pp4–5)

A shortage of personnel plagued the 8076th as it sought the ability to handle 

additional duties and, again, local nationals were used to fill these positions. The “mobile” 

hospital now had 19 vehicles on hand, even less than the previous year’s warning that there 

were too few to adequately carry out their mission, and again declared they would not be 

adequate to perform their mission when they transferred their excess and reached their 

authorized 14 vehicles.42(Encls2,9) A good news story clinically, the final report of the 8076th 

MASH noted that,

[t]here has been a change in the form of new incoming men in our surgical service from 

a professional viewpoint and also enlisted men for our operating room. Both of these 

changes have brought well trained men to our service and should be adequate for the 

performance of good work, carried out in a logical and well supervised manner.42(Encl6)

It appears that the ebb and flow of training had come back to producing better-trained 

medical personnel after the strained effort to get many medical men into the battle very 

quickly. Medical services were in abundance over surgeries due to the stagnant front. 

FIGURE 7-17. Members of the 45th MASH conduct a mission rehearsal for the exchange of sick and 

wounded prisoners on a Sikorsky H-19 helicopter in support of Operation Little Switch to begin the next 

day (19 April 1953). Photograph courtesy of the AMEDD Museum Photo Collection, Korean War, Volume 1, 

Image #KW-0173.
274 • FORWARD SURGERY

Because of this move to general medicine, the command actually requested two more 

general duty medical officers to supplement their authorizations.42(Encls6–7)

The MASH continued to train 4 hours every week on required subjects such as guard 

duty, security of the unit, physical training, close order drill, firefighting and prevention, 

military courtesy, and air-raid precaution, augmented with subjects related to management 

of battle casualties for the doctors and nursing staff (Figure 7-17). With the transfer of 

excess equipment, the 200-bed 8076th MASH was transforming into the 60-bed 45th 

MASH.42(Encls8–9) The 45th practiced tearing down and then resetting the new unit for 

patients within 5 hours.21(p9)

During “Operation Little Switch” in April, the first prisoner exchanges occurred 

and 213 UN patients were seen at the MASH. It was a relatively short visit; each patient 

averaged about 40 minutes in the hospital. In August, a section of the hospital was 

sent forward to provide direct surgical support to the 40th Infantry Division, while the 

remaining portion supported “Operation Big Switch,” treating five UN patients and 15 

Korean People’s Army and Communist Chinese Forces soldiers. Most injuries to the enemy, 

however, were from stone-throwing civilians. The unit conducted split operations, once 

again, during September through October, in order to move forward. The heavy winds 

whipping through rugged mountainous terrain pounding the tents tethered to soft ground 

helped to ensure a rapid transition to Quonset huts to replace the old canvas21(pp9–10) 

(Figure 7-18).

The 8209th made the move alluded to in the previous year’s report and conducted a 

two-phased move closer to its supported divisional elements in January (Figures 7-19 and 

7-20). The new location was much better because it was off from the main supply route, 

avoiding the usual dust, and was more dispersed. However, any plans to dig drainage 

and latrines were postponed until the ground thawed later in the summer. The Surgical 

Research Team of the Medical Service and Graduate School was still assigned there.43(p1)

The 8225th MASH continued on with its normal surgical care of nonevacuated battle 

casualties, but now had the mission of training enlisted technicians to replace nurses. The 

FIGURE 7-18. On the back of this photograph (circa late 1952/early 1953) anesthesiologist Captain Louis Eisenberg, 

Medical Corps, handwrote the following 

personal message, “46th A. S. H. [Army 

Surgical Hospital] My BOQ [Bachelor 

Officers’ Quarter] is in rear—Nurses 

Janeway type of hut [Quonset Hut] in 

foreground. Notice Diesel oil drums on 

stand with rubber hose into tent. Oil 

brought up every day by KSC’s [Korean 

Service Corps].” Photograph courtesy of 

the AMEDD Center of History and Heritage, Louis Eisenberg Collection, Box 1, 

Image page #2010.11.30.
CHAPTER SEVEN • 275

FIGURE 7-19. Members of the 46th MASH pack up the hospital to move forward on the battlefield (April 

1953). It was at the 46th MASH, converted from the 8209th MASH in February 1953, where the Surgical Research Teams conducted studies 8 to 10 miles from the front. Photograph courtesy of the AMEDD 

Center of History and Heritage, Louis Eisenberg Collection, Box 1, Image page #2010.11.30.

FIGURE 7-20. Jumping forward, the Central Supply section is shown conducting a typical split operations 

move on the battlefield (April 1953). Note the rice stalks along the ground to mitigate mud and dust. 

Photograph courtesy of the AMEDD Center of History and Heritage, Louis Eisenberg Collection, Box 1, 

Image page #2010.11.30.
276 • FORWARD SURGERY

60-bed configuration only had two nurses authorized and this was obviously a strain 

within the operating room and elsewhere. Medical officers often had to serve and nurse 

in the postoperative sections. The commander emphasized the importance of incoming 

enlisted personnel possessing high intellect and scores to fulfill the task of replacing nurses 

in the MASH.44(pp3–7)

The 8228th MASH continued to serve as the hemorrhagic fever and cold weather 

injury centers. All suspected cases of hemorrhagic fever were evacuated there for 

confirmation and treatment. A medical clearing company was assigned and became the 

convalescent and rehabilitation section of the hospital. Five more prefabricated buildings 

were added, bringing the total hospital building count to 65, which included eight 20’ 

x 108’ wards. All surgical cases were transferred to the 121st Evacuation Hospital 

and only minor procedures were performed at the 8228th. In the first part of the year 

the Army Surgeon General MG George Armstrong, Far East Command Surgeon MG 

William Shambora, and BG Ginn were presented with the preliminary results of the 

hemorrhagic fever research. Outdoor sports and military formations were conducted for 

the convalescents and this therapy was found to be productive. Universal praise was given 

to the educational teaching within the hemorrhagic fever center and the quality of training 

coming out of the Medical Field Services Staff School.45

The Surgical Research Teams

The Surgical Research and Renal Insufficiency Teams were lauded with praise. 

Through their efforts every department of the hospitals improved as they encountered 

various combat medicine problems.6(pp3–4) The major research unit was established at the 

46th Surgical Hospital (formerly the 8209th MASH) where most of the studies took place, 

about 8 to 10 miles from the front lines. Monthly statistics of patients were compiled by 

the surgeons and reviewed, allowing for on-the-spot improvement to patient care. This, 

along with data in annual reports, shows the evolving patient statistics through the war 

(Table 7-2). Results were pulled from the operating room records and statistical data sheets 

that were part of the patient’s charts upon admission. The more active Western Front 

hosted the vascular surgical unit located at the 43rd Surgical Hospital (formerly the 8055th 

MASH).46(pp5–6),47(p4) Surgeons from the Surgical Research Team instructed at each hospital. 

Immediate results of the work done through primary arterial repairs and vein grafts 

resulted in amputation rates falling sharply after arterial injuries. For example, following 

popliteal anastomosis, the amputation rate fell from World War II’s 72% to approximately 

20% in the Korean War.46(pp9,17) The research work was primarily performed from the 

summer of 1952 through the winter of 1952 to 1953. The liver function study was one 

part of the entire effort and took place simultaneously with all the other research. It documented this ideal clinical setting, a relatively immobile front line, providing a picture of 

conditions in the mature MASH: 

The casualties usually arrived at the hospital between 3 and 5 hours after wounding 

with range of 1 to 9 hours. The soldiers were all young and previously healthy. As a 

generalization, the more severely injured men were selected for study. Shortly after 
CHAPTER SEVEN • 277

injury, the casualty was treated at the battalion aid station. When needed, plasma, 

albumin or dextran was administered along with tetanus toxoid and penicillin. The 

casualty was then evacuated to the forward Surgical Hospital for definitive therapy 

where this study was begun. . . . Detailed clinical records were maintained throughout 

the period of study. Blood, 10 to 20 days of age, was used almost exclusively after the 

casualty reached the hospital. Operations were performed under pentothal, nitrous 

oxide, oxygen and ether anesthesia.48(pp149–150)

Another study conducted from May to August 1953 provides an additional snapshot 

of events at the mature MASH (Figures 7-21 and 7-22). Even though the survey was a 

short one, it appeared to replicate the previous 15 months of experience at the MASH. Of 

250 battle casualties, except for open fractures where ground ambulance was the mode 

of transportation, approximately half of all casualties were evacuated by helicopter. From 

the data collected, it is apparent that the length of time in surgery for abdominal and 

thoraco-abdominal wounds was greater than all other types of wounds. For patients with 

abdominal wounds and those requiring amputations, an average of 3.5 liters of blood was 

given in the first 24 hours following their battle injury. And finally, the feared “gut wound” 

of so many wars before had an 82% survival rate.49(pp9–12)

Each war presents different circumstances that affect the casualty rate, and therefore, 

mortality rate. In relation to casualty care at the MASH, the last year of the Korean conflict 

was almost ideal. The battle line was stable, the UN forces had air dominance, and the 

hospital was close to the front. Because of shorter evacuation times and the availability of 

helicopters for evacuation, more patients were evacuated than would have survived in the 

past. This created a situation where more seriously wounded casualties were present at 

forward surgical hospitals. Survivability was improved because of the shorter evacuation 

times, large administration of resuscitative fluids before and after surgery, and the routine 

use of antibiotics.49(p20)

It was the opinion of the lead author, then-Major Curtis P Artz, who had been a 

member of the Surgical Research Team assigned to the 46th Surgical Hospital (formerly 

the 8209th MASH),49(p1) that the “greatest single difference in the management of casualties 

in Korea appears to be the large quantities of blood administered throughout resuscitative 

periods.”49(p20) In the 46th Surgical Hospital from January 1952 to August 1953, the overall 

fatality rate for the 4,671 casualties admitted was 2.4%. Of the 402 abdominal wounds, 

the casualty rate was 12.6%.49(p1) These results also coincide with the statistics bearing out 

the cumulative results of the Korean War showing the fatality rate was a “new low of 2.5 

percent compared to the 4.5 percent experienced in all of World War II.”50(p83)

In laying out the ideal surgical team during the Course on Recent Advances in 

Medicine and Surgery at the Army Medical Service Graduate School in April 1954, Artz 

argued there should be two groups, each able to perform 12-hour shifts.51(pp237–239) Each 

group should have a team captain, a deputy supervised by the chief surgeon, and both 

should possess the most experience in battle casualty management among the other 

surgeons. He believed they should both visit the evacuation hospital to monitor followup care. The relationship between the chief surgeon and his deputies would mimic that 
278 

• FORWARD SURGERY

TABLE 7-2. PATIENT STATISTICS BY UNIT AND YEAR

Patient Statistics 1950 1951 1952 1953

8055th (9 Jul 1950-31 Dec 1950) (1 Jan 1951–31 Dec 1951) (1 Jan 1952–31 Dec 1952) (1 Jan 1953–1 Feb 1953)

Admission 8,577 29,579 15,012 510

Surgical Patients 1,516 5,751 5,689 292

Surgical Procedures 2,280 8,245 12,421 610

8063rd (18 Jul 1950–31 Dec 1950) (1 Jan 1951–31 Dec 1951) (1 Jan 1952–31 Dec 1952)

Admission 5,173 20,359 10,125Surgical Patients 1,008 Not reported Not reported

Surgical Procedures 1,048 5,416 4,7878076th (2 Aug 1950-31 Dec 1950) (1 Jan 1951–31 Dec 1951) (1 Jan 1952–31 Dec 1952) (1 Jan 1953–1 Feb 1953)

Admission 9,008 21,408 8,253 155

Surgical Patients Not reported Not reported Not reported Not reported

Surgical Procedures Not reported 5,176 2,917 741st8209th (26 Sep 1950-31 Dec 1950) (1 Jan 1951–20 May 1951)Admission 95 6,642Surgical Patients Not reported Not reportedSurgical Procedures 282 Not reported

8209th (1 Jan 1951–31 Dec 1951) (1 Jan 1952–31 Dec 1952) (1 Jan 1953–1 Feb 1953)

Admission 8,806 9,360 416Surgical Patients 2,128 Not reported 273Surgical Procedures 2,400 9,485 350
CHAPTER SEVEN 

• 279

TABLE 7-2 CONTINUED. PATIENT STATISTICS BY UNIT AND YEAR

Patient Statistics 1950 1951 1952 1953

2nd

8225th (15 Apr 1951–12 May 1951)Admission 1,409Surgical Patients Not reportedSurgical Procedures Not reported8225th (13 May 1951–31 Dec 1951) (1 Jan 1952–31 Dec 1952) (1 Jan 1953–1 Feb 1953)Admission 8,108 3,155 328Surgical Patients Not reported Not reported 318

Surgical Procedures 2,312 1,541 Not reported8228th (15 Jun 1951–31 Dec 1951) (1 Jan 1952–31 Dec 1952) (1 Jan 1953–1 Feb 1953)

Admission for Hemorraghic Fever 0 1,936 21

Confirmed Hemorraghic Fever 0 885 3

Admission for Cold Injury 0 193 105

Evidence of Cold Injury 0 170 85

Data sources: Annual reports of Medical Department activities of each MASH unit, National Archives II, Suitland, Maryland, boxes 146, 239, 240, and 241.
280 • FORWARD SURGERY

FIGURE 7-21. Captain Louis Eisenberg, Medical Corps, commented that these vehicles were the “new 

ambulances” for the new 46th MASH (February 1953). They appear to be Dodge M43 ambulances. Photograph courtesy of the AMEDD Center of History and Heritage, Louis Eisenberg Collection, Box 1, Image 

page #2010.11.30.

of the teaching professor conducting training with two assistants. With adequate rest, 

many operative procedures without an assisting surgeon could be performed with the aid 

of one or two capable operating room technicians. In cases with multiple wounds, two 

surgical teams could operate on the same patient—one team on the upper body while the 

other team performed on the lower body. This decreased the time required for surgery and 

anesthesia, thus benefitting the patient. 

The chief surgeon should be a more experienced Regular Army officer trained in 

the principles of resuscitation and combat surgery. Oftentimes the most junior were sent 

forward and the more senior surgeons remained in the rear, but this was not the most 

ideal situation for the patient. In fact, Artz believed all Regular Army surgeons should be 

thoroughly trained in trauma with a subspecialty in forward surgery. His insistence that 

“Young career surgeons in the Regular Army should always be given an opportunity to 

gain experience in forward surgical hospitals”51(p239) seems to advocate the flip side and 

positive reason for pushing surgeons to the front versus the policy of reluctantly sending 

surgeons into combat for 90-day rotations to limit the effect on patient care back at the 

home station. Finally, as COL Page had implied in 1951, MAJ Artz emphasized that a 

surgical consultant visiting the MASH was better used for 2 weeks instead of 1 to 2 days 

so that his “knowledge could be better utilized if he actually performed some surgery and, 

by first-hand experience, became extremely familiar with the problems of the particular 

institution he visited.”51(p239) 
CHAPTER SEVEN • 281

Ironically, the Eighth United States Army Surgeon’s Annual Report for 1953 notes less 

time for research was available as the war ended. Staff members found themselves occupied 

with promotion, courts-martial boards, and so forth. Now the fixed/garrison MASH had 

to train for combat and began to participate in field exercises to train the surgeons in the 

practice of military surgery.6(pp3–4) The MASH had come about full circle.

CONCLUSION

The innovations seen in the Korean War MASH were not effectively matched in the 

civilian world for another 15 to 20 years. The combined effort in trauma management 

through rapid helicopter evacuation, enlisted medics (paramedics), and advanced methods 

in the treatment of shock would be the model for future modern metropolitan trauma 

FIGURE 7-22. While routine/nonurgent patients were evacuated by ground, the Sikorsky H-19 helicopter was one of the workhorses for rapid evacuation of urgent wounded (March 1953). Note this is the 

same helicopter pictured before in the Operation Little Switch rehearsal at the 45th MASH. Photograph 

courtesy of the AMEDD Center of History and Heritage, Louis Eisenberg Collection, Box 1, Image page 

#2010.11.30.
282 • FORWARD SURGERY

centers.7(p209) LTC Kryder Van Buskirk, previous commander of the 8076th MASH, 

looked back upon his experience and stated, “Those of us who were fortunate enough to 

command this new unit in the recent Korean conflict are well satisfied with its performance, 

flexibility and versatility.”52(p31) Dr Otto F Apel Jr, a MASH surgeon from the same unit, 

emphasized that the personnel of the MASH were particularly different from their medical 

compatriots in rear-echelon hospitals. MASH members saw, smelled, and heard the 

battle.2(ppxii–xiii) COL Charles L Leedham, Medical Consultant in the Far East Command, 

aptly closes this chapter in forward surgery, 

These hospitals were, to me, the most remarkable field installations of the Army. The 

number of lives and limbs saved because of the MASH’s special location and function 

cannot be comprehended unless one could see such a unit during a military operation 

when the flow of wounded was heavy. Many a veteran now living owes his life or one 

or more of his limbs to these units. Really emergency life-saving surgery was done here. 

The job they did was a truly outstanding one, while their accomplishments were rarely 

paralleled.53(p23) 

REFERENCES

1. DeBakey MJ. History, the torch that illuminates: lessons from military medicine. Mil Med. 

1996;161:711–716. 

2. Apel OF Jr, Apel P. MASH: An Army Surgeon in Korea. Lexington, Ky: University Press of Kentucky, 1998.

3. Eighth United States Army Annual Report, Army Medical Service Activities, 1950, National

Archives II, Suitland, Maryland, boxes 195–196. 

4. Eighth United States Army Annual Report, Army Medical Service Activities, 1951, National

Archives II, Suitland, Maryland, box 196.

5. Eighth United States Army Annual Report, Army Medical Service Activities, 1952, National

Archives II, Suitland, Maryland, box 197.

6. Eighth United States Army Annual Report, Army Medical Service Activities, 1953, National

Archives II, Suitland, Maryland, box 198.

7. Cowdrey AE. The Medics’ War. Washington, DC: US Army Center of Military History; 1987.

8. Westover JG, ed. Combat Support in Korea. Washington, DC: US Army Center of Military History; 1987.

9. Coates JB, ed. Activities of Surgical Consultants. Vol 1. Washington, DC: Office of The Surgeon 

General, Department of the Army; 1962.

10. Station List, World Wide, US Army Medical Department Units, 31 January 1950, National 

Archives II, Suitland, Maryland, box 239.

11. Annual Report of Medical Activities (1949), 2nd Mobile Army Surgical Hospital, 3 March

1950, National Archives II, Suitland, Maryland, box, 144.

12. Memorandum: T/O&E 8-57 IN (sic), Mobile Army Surgical Hospital Review, 11 August 1948, 

National Archives II, Suitland, Maryland, box 40.

13. Memorandum: Tentative Troop Bases of the 18, 20, 22, and 25 Division Forces, 18 July 1948, 

National Archives II, Suitland, Maryland, box 40.

14. Memorandum: Mobile Striking Force Troop Basis (Tentative), 29 April 1948, National Archives 

II, Suitland, Maryland, box 40.

15. Special Text 8-10-1, Medical Service in the Theater of Operations, National Archives II, Suitland, Maryland, box 157.
CHAPTER SEVEN • 283

16. Transcript of Proceedings: 1951 Instructors’ Conference, National Archives II, Suitland, Maryland, box 157.

17. Fehrenbach TR. This Kind of War. New York, NY: The MacMillan Company; 1963.

18. Hooker (Hornberger) R. MASH. London, England: Cassel Wellington House; 2004.

19. 1950 Annual Report of Medical Department Activities, 8055th, National Archives II, Suitland,

Maryland, box 146.

20. 1950 Annual Report of Medical Department Activities, 8063rd, National Archives II, Suitland,

Maryland, box 240.

21. Unit History, 45th Surgical Hospital (8076th AU): 19 July 1950–19 July 1954, National Archives II, Suitland, Maryland, box 144.

22. 1950 Annual Report of Medical Department Activities, 8076th, National Archives II, Suitland,

Maryland, box 240.

23. War Department. Notes on the Care of Battle Casualties. Washington, DC: War Department, 

Technical Medical Bulletin 147; March 1945.

24. 1950 Annual Report of Medical Department Activities, 1st, National Archives II, Suitland,

Maryland, box 239.

25. 8076th MASH, After Action Interviews, 3rd Historical Detachment (EUSAK), National Archives II, Suitland, Maryland, box 347.

26. Sako Y, Artz CP, Howard JM, Bronwell AW, Inui FK. Experiences with intra-arterial and rapid 

intravenous transfusions in a forward surgical hospital. In: Howard JM, ed. Battle Casualties in 

Korea: Studies of the Surgical Research Team. Vol 3. The Battle Wound: Clinical Experiences. 

Washington, DC: Army Medical Service Graduate School, Walter Reed Army Medical Center; 

1956.

27. 1951 Annual Report of Medical Department Activities, 8055th, National Archives II, Suitland,

Maryland, box 239.

28. 1951 Annual Report of Medical Department Activities, 8063rd, National Archives II, Suitland,

Maryland, box 240.

29. 1952 Annual Report of Medical Department Activities, 8055th, National Archives II, Suitland,

Maryland, box 240.

30. 1951 Annual Report of Medical Department Activities, 8076th, National Archives II, Suitland,

Maryland, box 240.

31. War Department. Management of Battle Casualties. Washington, DC: War Department; Technical Medical Bulletin 147 (rev); 1951.

32. 1951 Annual Report of Medical Department Activities, 8209th, National Archives II, Suitland,

Maryland, box 240.

33. 1951 Annual Report of Medical Department Activities, 1st, National Archives II, Suitland,

Maryland, box 239.

34. 1951 Annual Report of Medical Department Activities, 8225th, National Archives II, Suitland,

Maryland, box 240.

35. 1951 Annual Report of Medical Department Activities, 8228th, Endorsement, National Archives II, Suitland, Maryland, box 241.

36. 1952 Annual Report of Medical Department Activities, 8228th, p. 6, National Archives II, Suitland, Maryland, box 241. 

37. Horwitz, DG, ed. We Will Not Be Strangers: Korean War Letters Between a MASH Surgeon 

and His Wife. Urbana, Ill: University of Illinois Press; 1997.

38. 1952 Annual Report of Medical Department Activities, 8063rd, National Archives II, Suitland,

Maryland, box 240.

39. 1952 Annual Report of Medical Department Activities, 8076th, National Archives II, Suitland,

Maryland, box 240.

40. 1952 Annual Report of Medical Department Activities, 8209th, National Archives II, Suitland,

Maryland, box 240.
284 • FORWARD SURGERY

41. 1952 Annual Report of Medical Department Activities, 8225th, National Archives II, Suitland,

Maryland, box 240.

42. 1953 Annual Report of Medical Department Activities, 8076th, National Archives II, Suitland,

Maryland, box 239.

43. 1953 Annual Report of Medical Department Activities, 8209th, National Archives II, Suitland,

Maryland, box 240.

44. 1953 Annual Report of Medical Department Activities, 8225th, National Archives II, Suitland,

Maryland, box 240.

45. 1953 Annual Report of Medical Department Activities, 8228th, National Archives II, Suitland,

Maryland, box 241.

46. Howard JM. Introduction: historical background and development. In: Howard JM, ed. Battle 

Casualties in Korea: Studies of the Surgical Research Team. Vol 1. The Systemic Response to 

Injury. Washington, DC: Army Medical Service Graduate School, Walter Reed Army Medical 

Center; 1955.

47. Artz CP. Preface. In: Howard JM, ed. Battle Casualties in Korea: Studies of the Surgical Research 

Team. Vol 3. The Battle Wound: Clinical Experiences. Washington, DC: Army Medical Service 

Graduate School, Walter Reed Army Medical Center; 1956.

48. Scott R Jr, Olney JM, Howard JM. Hepatic function of the battle casualty. In: Howard JM, ed. 

Battle Casualties in Korea: Studies of the Surgical Research Team. Vol 1. The Systemic Response 

to Injury. Washington, DC: Army Medical Service Graduate School, Walter Reed Army Medical 

Center; 1955.

49. Sako Y, Artz CP, Howard JM, Bronwell AW, Inui FK. A survey of evacuation, resuscitation, and 

mortality in a forward surgical hospital. In: Howard JM, ed. Battle Casualties in Korea: Studies 

of the Surgical Research Team. Vol 3. The Battle Wound: Clinical Experiences. Washington, DC: 

Army Medical Service Graduate School, Walter Reed Army Medical Center; 1956.

50. Reister FA. Battle Casualties and Medical Statistics: US Army Experience in the Korean War.

Washington DC: The Surgeon General, Department of the Army; 1973.

51. Artz CP. Discussion on consultants and organization of surgical service. In: Recent Advances 

in Medicine and Surgery: Based on Professional Medical Experiences in Japan and Korea 

1950–1953. Vol 1. Washington, DC: Army Medical Service Graduate School, Medical Science 

Publication No. 4, Walter Reed Army Medical Center; 1954.

52. Van Buskirk KE. The Mobile Army Surgical Hospital. Mil Surg. 1953(July–December);113:27–31. National Archives II, Suitland, Maryland, box 342.

53. Leedham CL. Use of medical consultants in the Far East Command. In: Recent Advances in 

Medicine and Surgery: Based on Professional Medical Experiences in Japan and Korea 1950–

1953. Vol 2. Washington, DC: Army Medical Service Graduate School, Medical Science 

Publication No. 4, Walter Reed Army Medical Center; 1954.
INTRODUCTION

THE VIETNAM WAR PRESENTED CHALLENGES to the Army Medical Department 

(AMEDD) that were unique to the conflict and terrain. The signal change in forward surgery was the widespread use of the helicopter in medical evacuation. In a sense, the soldier 

was brought to the surgical treatment facility rather than having forward surgery come to 

the soldier. These facilities were located within accessible distances by air. Hence, rapid and 

more definitive surgery could be rendered in reduced time compared to previous conflicts. 

AN OVERVIEW OF VIETNAM 

It is necessary to understand the geography and people of Vietnam to follow the 

Vietnam conflict’s often confusing and shifting battlefronts. Only 20% or so of Vietnam 

is truly level land. Vietnam has three distinct areas: (1) the Mekong Delta, (2) the Chaine 

Annamitique (Annamite Mountains) (including the Central Highlands plateau area/

mountains), and (3) the Central Lowlands.1(pp4–5) The Mekong Delta is well known from 

wartime press coverage and is the largest area, occupying the southern 40% of the country. 

The Delta was created by the five branches of the Mekong River. The heavy rainfall during 

the flood periods made combat there a challenge.1(p4) The Central Highlands consists of 

bamboo/broadleaf forests with rubber plantations and farms. The Highlands feature 

mountains ranging from 5,000 to 8,000 feet in elevation. The Central Lowlands features 

a narrow coastal strip of land. The coastal plain varies in width from 15 to 40 kilometers 

(km) but runs for most of the 1,400 km of the Vietnamese coast. Rice, sugar cane, and 

Chapter Eight

Vietnam: The Rise of 

Helicopter Medical Evacuation

in a War Against a New 

Kind of Enemy

LANCE P. STEAHLY, MD
286 • FORWARD SURGERY

fishing villages are typically found here. Some of the larger Vietnamese cities such as Da 

Nang, Hue, and Cam Ranh are located along the coast in this region.1(pp4–5)

These geographic areas formed boundaries for the South Vietnamese military zones. 

The I Corps zone (northern) largely had mountains and jungles in it. The II Corps 

area incorporated much of the coastal plain. The III Corps zone was a mixed type of 

geographical constituents centered in Saigon but extending from the North Mekong Delta 

to the Southern Central Highlands. The IV Corps zone consisted largely of the Mekong 

Delta area. The climate varied with the location. The north of the country is a humid 

subtropical area, while the Mekong Delta is a tropical climate with distinct wet and dry 

seasons. In the north and in the Central Highlands, fog and low clouds were common. 

Vietnam generally was well described as a land of oppressive heat with temperatures in the 

90s moving into the 100s. The dry season in the winter would mean heat that could range 

from 100 to 110 degrees Fahrenheit. In the winter, the south is dry while copious rains 

are abundant for the rest of the year. In the summer, the monsoon rains are epic in degree. 

Snakes, leeches, mosquitoes, ants, and rodents were in abundance all the time.2(p101)

The Vietnamese people proper mostly lived in small urban centers or in rural areas. 

Only 10% of the Vietnamese lived in major city centers. In the mid-1960s, ethnic Chinese 

made up over 85% of the population in the Mekong Delta, the river valleys, and the 

coastal regions. The Montagnards (mountain people) were a minority group living in the 

highlands, consisting of some 30 diverse tribes that played an increased role as irregular 

anti-Viet Cong fighting forces.3(pp21–22) The Montagnards were among the groups that were 

not trusted by the Communists.

BACKGROUND OF THE VIETNAM CONFLICT

After the French took control of Vietnam as a colony in the mid-19th century, Saigon 

became known as the “Paris of the Orient.” In the past, most Vietnamese people lived in 

the delta area around Saigon. Later, the majority of the population actually lived in rural 

or small urban centers. The French had created rail and roads, rubber plantations, and 

irrigation systems that increased cultivation in the Mekong Delta. The French also had 

established universities at the Pasteur Institute in Saigon as a medical research institution, 

hospitals, and schools. The French reduced the incidence of malaria and also reduced the 

incidence of other tropical diseases.1(pp1–8)

American involvement in the Vietnam conflict followed a complicated regional history. 

The treaty of Hue, in 1883, effectively established Vietnam as a French colony. The French 

had bombarded Da Nang in 1857 and captured Saigon in 1861.4(pp4–5) However, despite the 

French military, social, and environmental successes, the nationalist spirit was raised early 

in the 20th century. Not surprisingly, the Vietnamese aspired to return to an independent 

state. Ho Chi Minh made an appearance at the Paris Peace Conference in 1919, following 

World War I, pushing for an independent Vietnam. The French continued their role in 

Vietnam after World War I until World War II and the fall of France. In World War II, the 

Vichy French capitulation allowed the Japanese to take over Vietnam.5(p8)
CHAPTER EIGHT • 287

The Communist Ho Chi Minh formed the Viet Minh, which began military operations 

when Japan lost the war. Following the end of World War II, the French reasserted their 

colonial status in Vietnam. Starting in November 1946, the Viet Minh, under General Vo 

Nguyen Giap, started a war of attrition against the French and Vietnamese government. 

The Franco-Viet Minh War (March through May 1954) ended following the French defeat 

(despite American logistical and financial support) at Dien Bien Phu. The French became 

encircled there by the Viet Minh and could only be resupplied by air. The Americans 

declined to help relieve the beleaguered French. After the French defeat, the war ended 

and an armistice was signed in Geneva between the French and the Viet Minh in July 

1954. Another agreement was also signed in July 1954, titled the “Final Declaration of the 

Geneva Conference,” which separated North and South Vietnam at the 17th parallel. The 

demarcation was supposed to be temporary but it was envisioned as a compromise that 

would satisfy all.4(p19) The country north of the 17th parallel was to be controlled by the 

Viet Minh. Ho Chi Minh was to lead the Democratic Republic of Vietnam. The country 

south of the parallel (the Republic of Vietnam) was led by President Ngo Dinh Diem (until 

he was assassinated in 1963). The Americans effectively took over from the French starting 

in 1954 in an attempt to avoid more losses to the Communists in Southeast Asia.6(p30) In 

January1955, the US Military Assistance Advisory Group–Indochina was established.4(p21)

The first casualties among the American advisor group occurred in 1961. US involvement increased with the Kennedy and later the Johnson administrations. General William 

Westmoreland assumed command of the US Military Assistance Command, Vietnam 

(MACV) and US Army, Republic of Vietnam (USARV) in late 1964, preceding a major 

troop buildup starting in 1965. In 1965, the landing of the 9th Marine Expeditionary 

Force at Da Nang signaled the expansion of the American involvement in Vietnam. Troop 

strength continued to increase through 1965, with 184,300 reported by 31 December 

1965. The troop numbers peaked in 1969, with 543,300 reported as of 20 April 1969. The 

numbers fell to 24,200 by 31 December 1972. Only 240 were left on 30 March 1973. On 

30 April 1975, “Operation Frequent Wind,” the evacuation of the American Embassy in 

Saigon, was completed with a helicopter lifting off from the Embassy rooftop with the last 

11 US Marine guards.4(p449)

Soldiers in Vietnam were younger than those in either Korea or World War II due to 

the draft excluding those who were in college or divinity school, or were fathers.1(p111) In 

World War II and the Korean War, the soldier was older because there were no college 

deferments, although there were occupational (war essential) deferments. Because there 

were so few years between the end of World War II and the beginning of the Korean War, 

the Selective Service System worked much the same for both mobilizations. In Vietnam, 

however, the Reserves (and National Guard) were never mobilized as in the other conflicts. 

(The Reserve component has traditionally held older members.)

Whatever their age, as Marine MAJ Curt Munson said, “the real learning took 

place”2(p113) in combat with an operational unit. Much of the flavor of combat and 

especially helicopter airmobile operations can be gleaned from the book We Were Soldiers 

Once . . . and Young, written by Lieutenant Colonel (LTC) (later Lieutenant General) 

Harold G Moore and Joseph L Galloway. The intensity of the battle and the role of the 
288 • FORWARD SURGERY

medical personnel are also characterized in We Were Soldiers. The demands on personnel 

and material could be enormous.7(p313)

The Tet Offensive in 1968, actually won by the Allies (which included the Republic 

of Vietnam and the Republic of Korea [South Korea]), was lost in the rancor of antiwar 

protest in the United States. In January 1968, the Viet Cong and elements of the North 

Vietnamese Army (NVA) initiated extensive attacks on Saigon, Da Nang, Pleiku, Nha 

Trang, and other cities. The Tet Offensive involved some of the most extreme fighting of 

the war and phases continued into September 1968 and later. Combined Allied forces 

successfully repulsed the enemy forces. However, the media and antiwar activists were 

successful in obscuring any victory aspects, while concentrating on the futility of the war. 

President Nixon, elected in November 1968 on an end-the-war promise, initiated peace 

talks while continuing operations, especially by air.8(p307)

The experience of the troops helped define the complexity of the political and military 

equation. As one example, an American soldier said in Voices From the Vietnam War,2 the 

soldiers “were unprepared for what they would experience in combat against Communist 

forces in an unfamiliar land”2(p101) and “did not fully understand what was going on in 

Vietnam.”2(p101) Or as Philip Caputo wrote in A Rumor of War9 about the Vietnam War, 

“What had begun as an adventurous expedition had turned into an exhausting, indecisive 

war of attrition in which we fought for no cause other than our own survival.”9(pxiv) Caputo 

had entered the Marines by joining the Platoon Officer Candidate Program, much as the 

fictional Mellas in Marlantes’ Vietnam novel Matterhorn.10 The real and the fictional 

Marines both experienced the Vietnam War on a most complex and personal note. 

In the early years of the Vietnam War, the Army dealt largely with insurgent forces. 

Later, the commitment of large concentrations of regular NVA forces made the war more 

like a conventional one.4(p309) Yet, the Vietnam conflict illustrates the adage that there are no 

winners in a war. North Vietnam did enjoy victory in terms of eventually occupying all of 

Vietnam and control of the government, but they also lost many people. As recorded in the 

Embers of War,5 the Vietnamese conflict “killed in excess of three million Vietnamese and 

wreaked destruction on huge portions of Vietnam, Laos, and Cambodia.”5(pxv)

CASUALTY STATISTICS OF THE VIETNAM WAR

To get some idea of the nature of the Vietnam War, a look at casualty statistics is 

instructive. In that regard, the Vietnam Conflict Extract Data File of the Defense Casualty 

Analysis System is the official reference for casualties. For the Vietnam War, it lists “Killed 

in Action” (KIA) as totaling 40,934, with later additional deaths of 17,286 for a total 

of 58,220. (Each year the number of additional deaths is adjusted to reflect those who 

have subsequently died of their original wounds.) The statistics it notes for “Non-Fatal 

Woundings” are a total of 153,303 for the 1960 to 1974 period.11 The Vietnam War 

Almanac4 lists a total KIA from 1960 to 1974 for the United States of 46,370, with a US 

total of 153,735 wounded in action (WIA). These figures from the Almanac represent a 

pooling from several diverse sources.4(p529)
CHAPTER EIGHT • 289

DEPLOYMENT OF MEDICAL UNITS AND EVOLUTION OF 

MOBILE ARMY SURGICAL HOSPITALS AND MEDICAL UNIT, 

SELF-CONTAINED, TRANSPORTABLE SETS 

As discussed, in 1961 President John F Kennedy started measures that over the 

next 4 years resulted in the United States being committed to Vietnam. In 1961, the 8th 

Transportation Company (Fort Bragg, North Carolina) and the 57th Transportation 

Company (Fort Lewis, Washington), both light helicopter units, arrived in Vietnam with 

H-21 helicopters. Two more helicopter companies arrived in 1962.3(pp23–24)

In 1962, the 8th Field Hospital and the 57th Medical Detachment (Helicopter 

Ambulance) were the first medical units in Vietnam. The 57th Medical Detachment’s UH-1 

(Hueys) began to evacuate Army of the Republic of Vietnam (ARVN) troop casualties by 

May 1962. By November 1962, the Army had 199 aircraft of various types in support of 

ARVN operations.3(p26) In 1963, the call sign “Dust Off” was adopted by the 57th.3(p30) By 

1964, the “dust off” helicopters, commanded by Major (MAJ) Charles Kelly, did not have 

the resources to answer the call for all medical evacuation missions (Figures 8-1 and 8-2). 

(MAJ Kelly was lost to hostile action that year.3(pp37–38)) The Army perfected techniques of 

helicopter evacuation in the period 1965 to 1970. The two original “dust off” units, were 

augmented by others with the start of the 1965 buildup.3(p32)

The flavor of Army medicine in the early years can be gained by reading a book 

such as the one written by Jerry Martin, MD, titled Soldiers Saving Soldiers. Vietnam 

Remembered: A History of the 18th Surgical Hospital.

12 In it he describes his experiences 

as a physician at the 18th Surgical Hospital during the period June 1966 to June 1967 

while deployed to the Pleiku Province area. There are other books of this nature but this 

is especially informative because it contains a copious number of color photographs.12

In 1965, the 1st Air Cavalry (Airmobile), and the attached 15th Medical Battalion 

(Airmobile), participated in its first combat operation in the Battle of the Ia Drang Valley 

in western Pleiku Province. This involved regular NVA troops and insurgent Viet Cong. 

Ia Drang Valley is located in a remote region of the Central Highlands of Vietnam. Regular 

NVA soldiers were engaged in the first major fighting with American troops. Martin 

recalled that the 1st Air Cavalry moved a large group of helicopters to a field across the 

highway from his 18th Surgical Hospital (MA [Mobile Army]). Soon thereafter, this 

hospital began receiving wounded from the fight in the Ia Drang River Valley.12(p62) In the 

4 days of fighting, the NVA suffered 1,800 killed and an equal number wounded, 

contrasted with 240 killed and 300 wounded for US forces.13(p2)

The importance of the airmobile medical support battalion with its air ambulance 

platoon (12 helicopters) was established in this 4-day battle.14(p87) These “dust off” 

helicopters evacuated casualties to the clearing stations, although they could bypass if 

needed and go directly to the hospitals.14(p88) The 23rd (Americal) Infantry Division used 

helicopters to evacuate wounded in their area of operation; it used ground ambulances 

for other activities. The 25th Infantry Division deployed to the northwest sector of 

South Vietnam and air evacuated to the 45th Surgical Hospital in Tay Ninh, a city in 

southwestern Vietnam about 90 km to the northwest of Saigon. The 45th Surgical Hospital 

was one of the notable forward-located hospitals and a Medical Unit, Self-Contained, 
290 • FORWARD SURGERY

FIGURE 8-1. [Top] Male and female nurse 

cut the bandages from a newly admitted 

patient at the 2nd Surgical Hospital, 

Lai Khe, Vietnam, September 1969. 

Photograph courtesy of the Army 

Medical Department Center of History 

and Heritage, Fort Sam Houston, Texas, 

Image #MU-VN-B1-001.

FIGURE 8-2. [Bottom] 45th Surgical 

Hospital Admission/Disposition Section—

a five-section inflatable shelter. Photograph courtesy of the Army Medical 

Department Center of History and 

Heritage, Fort Sam Houston, Texas, 

Image #MU-VN-B1-002.
CHAPTER EIGHT • 291

Transportable (MUST) unit. This hospital was a mobile shelter with expandable patient 

care wards, radiology, laboratory, pharmacy, dental, and kitchen areas. The 326th Medical 

Battalion, with an air ambulance company added, was known as an “Eagle Dust Off” unit 

with the 101st Airborne. The air ambulance company provided air evacuation in areas 

where the 101st operated, which included some of the more notorious “hot spots.”14(p89)

A New Approach to Forward Surgery

Brigadier General (BG) Elliott C Cutler had served as the Chief Surgical Consultant 

for the European Theater of Operations in World War II. His war diary provides a unique 

view of his thoughts during that conflict.15(pp353–356) In World War II, while speaking of 

the future, Cutler wrote, “I heartily approve the system for care of the heavily damaged 

non-transportable in Field Hospital platoons. I would even urge an extension of this 

forward surgery, believing ‘surgery should be brought to the soldier,’ not the soldier to the 

surgeons.”15(p122) However, the direction of the medical support in the Vietnam War didn’t 

proceed exactly as Cutler envisioned. The wide use of helicopter air evacuation did, in fact, 

quickly bring the patient to the surgeon.

As the war progressed, military medical care in Vietnam was generally excellent. Ben 

Eiseman, MD, Emeritus Professor of Surgery, University of Colorado, was quoted in 1967 

in his role as a naval surgical consultant as saying that if “wounded in the remote jungle or 

rice paddy of Vietnam, an American citizen has a better chance for quick definitive surgical 

care by a board-certified specialist than if he were hit on a highway near his hometown 

in the continental United States.”16(p237) The Neurosurgery Consultant for USARV, LTC 

Robert C Leaver, Medical Corps, said that the best equipment found in United States 

civilian hospitals could also be found in Vietnam.17(pp4,45,308)

As Neel points out, the hospital mortality rate was only 2.6% for the period from 

January 1965 to December 1970. The rates for World War II and Korea were 4.5% for 

the former, while the latter was 2.5%.18(pp50–51) The slightly lower rate for Korea reflects 

the rapid evacuation characteristic also seen in Vietnam. Most of those wounded would 

have died before reaching treatment in the earlier conflicts. Further, the ratio of KIA to 

WIA in Vietnam was 1.5:6. Korea was a ratio of 1.4:1 while World War II was a ratio 

of 1.3:1.18(pp50–51)

Hospitals

MOBILE ARMY SURGICAL HOSPITAL

A development in the war was the replacement of the tents and equipment of the 

Mobile Army Surgical Hospital (MASH) from the Korean War with the aforementioned 

Medical Unit, Self-Contained, Transportable (MUST) set (1965), which was viewed 

as a significant improvement. The MASH was usually a 60-bed setup, which could be 

augmented with several MUST units. Hence, some MASH operations were converted to 

200-bed combat support hospitals by such means.10(p65) In the Korean War, MASH units 

could be 60 to 100 beds and still be expanded to 200 beds.18(p503),19(pp423–424) MASH units 

were also used by US allies, such as the 9th Mobile Army Surgical Hospital of the 9th 

Infantry Division, Army of the Republic of Korea.2(p178)
292 • FORWARD SURGERY

THE MEDICAL UNIT, SELF-CONTAINED, TRANSPORTABLE SET

The MUST sets were conceptualized as early as 1961, but they were not demonstrated 

until 1965 at Fort Sam Houston, Texas, for Surgeon General Leonard D Heaton and 

Senator Richard Russell, Chair of the Senate Armed Services Committee. Surgeon General 

Heaton, writing in 1968, stated that “demand from the field for MUST equipment far 

exceeds availability.”20(p371) Heaton announced plans to reequip Army units with MUST 

equipment within 5 years.20(pp371–372) 

MUST units were utilized in Vietnam with differing levels of success, if one considers 

the limitations to a concept that seemed forward thinking at the time. The MUST unit 

was transportable, which was an asset not used to advantage as the facilities moved to 

permanent or semi-permanent locations. Still, the logistics of transportation and setting up 

the MUST were cumbersome. The three basic elements of a MUST could be moved by air 

or flatbed truck. The three components consisted of (1) the expandable surgical element, 

(2) the air-inflatable ward, and (3) the utility element or power package. The power element 

consisted of a turbine that could use a variety of fuels. The turbine’s engine power packages 

were termed utility packs. The packs required constant maintenance, adding to the 

logistical worries. The gas turbine powered a generation unit that supplied electricity for 

the air-conditioning, heating, lighting, refrigeration, hot water, and air to keep the inflatable 

elements up (Figure 8-3). The surgical element was rigid walled and self-contained. The 

sides were expanded out in an accordion-like fashion. The air-inflatable ward was a unit 

with double walls to house the casualties. Extra expandable units were used to house 

radiography, laboratory, dental, and pharmacy facilities.18(p65)

The MUST unit’s particular advantage was to provide controlled temperature and 

humidity, unlike the tents of the MASH hospital sets. However, MUST units used up to 

2,400 gallons of JP4 aviation fuel each day.8(p313) More fuel could be needed depending on 

the requirements. For instance, the 2nd Surgical Hospital reported using more than 3,800 

gallons of JP4 fuel per day.4(p332) Some units had to refuel every day to avoid running out. 

The requirements for fuel of all types were staggering, despite the usual ready availability 

of jet fuel.8(p313) Mortar attacks were fairly common, with the resulting shrapnel easily 

deflating the wards and bringing them down on their patients. Also, the wards needed 

concrete pads to prevent their floating after heavy rains. Especially in the monsoon season, 

the rains could be heavy and continuous.8(p313)

The mechanics of setting up the MUST units were complicated by the need for good 

alignment, although the MUST hospital had no organic forklifts or other lifting equipment 

to move the pieces. The equipment had to be borrowed from neighboring engineer or 

supply units that did have the requisite equipment. Large equipment wrecker trucks could 

be used to set up the units. Because the MUST hospital was planned to be moved in 72 

hours and to be set up in less time, such infrastructure problems were significant. A more 

realistic timetable would be to allow many more days.8(p313)

The 45th Surgical Hospital is an example of a successful MUST-equipped unit. It 

arrived in Vietnam October 1966; on 4 and 11 November 1966, the 45th came under 

mortar attack and its commander was a casualty. The hospital came under several more 

attacks until it received its first surgical patients on 13 November. It operated as a true 

forward surgical hospital in 1967.18(pp65–68)
CHAPTER EIGHT • 293

Three additional MUST-equipped hospitals were set up in 1967: the 3rd, 18th, and 

22nd Surgical Hospitals. The 95th Evacuation Hospital was given some MUST equipment, 

pending completion of its fixed facilities. Previous attempts to move the 18th and 22nd 

Surgical Hospitals were difficult. Neal noted that the MUST units were not used as mobile 

units until mid-1968, when the USARV Surgeon ruled that two MUST units were to 

keep their equipment and train to be mobile. The 18th and 22nd Surgical Hospitals were 

therefore deemed mobile MUST units. In a 1968 attack, the 3rd Surgical Hospital sustained 

hits in the bachelor officers’ quarters, a MUST main tent, and shrapnel deflated part of the 

MUST. Later the 3rd Surgical Hospital sustained three separate mortar attacks in that same 

year, causing damage to physical structures, but only minor wounds to staff.18(p67)

Byerly and Pendse described their experience at the 22nd Surgical Hospital, a MUSTequipped unit in the area of an old French rubber plantation at Lai Khe, northwest of 

Saigon.21 Their description spanned the period of 9 January to 30 November 1969. There 

were 1,963 admissions during this period, of which 92% required surgery. Of these, 73% 

were battle injuries, with the majority being small arms bullet injuries. More than one 

anatomical area was involved for 75% of these admissions. Their average of 65 minutes 

between wounding and admission spoke to the efficient evacuation system.21(pp221–226)

Kelly, writing in the journal Neurosurgery, described the development of a “refined 

system for the triage, management, and evacuation of wounded military personnel that 

evolved in Vietnam.”22(p939) In Fisher’s oral history project interview of Dr Steven Phillips, 

some of the limited experience that he had assigned to a MASH hospital toward the end 

of his tour in Vietnam (1968–1969) is detailed for the reader.23 Dr Jerry Martin perhaps 

best summed up his experience the year he spent with the 18th Surgical Hospital. He 

commented that “[i]nnumerable anecdotes of narrow escapes and harrowing experiences 

could be described. There are multitudinous, unreported memories that could be recalled 

FIGURE 8-3. 45th Surgical Hospital. Inflation 

of the units using an air 

supply from the utility 

pack with connected 

valve manifold system. 

Note the UH-1 “Huey” 

helicopter in the background. Photograph 

courtesy of the Army 

Medical Department 

Center of History and 

Heritage, Fort Sam 

Houston, Texas, Image 

#MU-VN-B1-003.
294 • FORWARD SURGERY

and recorded, although among them are those unpleasant and unwanted memories which 

are intentionally left untold.”12(p143) He is speaking to the loss of life and suffering that are 

so difficult to talk about and perhaps best forgotten.

Demands on personnel and equipment could be enormous. During the 1967 Battle 

of Dak To, for example, the 71st Evacuation Hospital at Pleiku had to run six overloaded 

operating rooms while expending large amounts of medical supplies.8(p313) From September 

1968 through August 1969, the 250- to 300-bed 67th Evacuation Hospital at Quinhon 

received, on average, 50 surgical admissions each day, and during large-scale combat 

operations, like the Tet Offensive, the surgical workload rose to as many as 200 cases per 

day.24(p227)

Adapting to Meet Changing Needs

The policy in Vietnam had called for minimal movement of hospitals (although 

modified somewhat in 1968 and 1969 in support of increased combat activity in certain 

locales). Hospitals were not moved in the support of tactical operations, as had been the 

case in World War II and Korea. In this conflict, the move was toward more permanent 

structures for hospitals.21(pp61–63) MAJ Allgood reviewed the use of his unit, the 24th 

Evacuation Hospital, as an experimental unit to try different configurations. The World 

War II cantonments that were parallel and unconnected could not be used in Vietnam for 

a number of reasons. Instead, the 24th adopted a series of interconnecting corridors. The 

corridor concept allowed a way to deal with the heat, humidity, rains, and dust that were 

everywhere. The operating room, the preoperative area, and the intensive care unit were 

surrounded by a 6-foot high security reinforced wall to protect against explosions. Three 

other permanent hospitals were built like the 24th.25(pp12,14)

The nature of the war and the ready availability of rotary air evacuation contributed 

to limited hospital movement before 1968. The movement policy was changed somewhat 

in 1968 and 1969. However, these moves were made in support of increased combat in 

certain areas. In Korea and World War II, more mobile hospitals contributed to combat 

units logistical and tactical military support. Aside from the brief use of MUST units, the 

moves were to semipermanent facilities. The fact that forward hospitals in Vietnam were, 

in the main, stable allowed the utilization of more advanced equipment.18(p50)

The number of hospitals and air ambulance units was reduced in the period between 

1969 and 1970, corresponding to reduced combat operations. In 1969, a number of 

hospitals were deactivated (the 7th and 22nd Surgical Hospitals and the 29th and 36th 

Evacuation Hospitals) and three US Army Reserve units were returned to the continental 

United States. By 1970, more hospitals were deactivated or redeployed (8th Field, 2nd 

Surgical, 45th Surgical, and 12th Evacuation Hospitals).18(p78)

In retrospect, the MUST units were generally used as stationary structures (Figures 

8-4 through 8-6). The transportability factor was a serious shortcoming of the concept. 

However, they could be raised more quickly than fixed structures. Hence, the MUST units 

could have been used as the resource for immediate treatment in a new operation area, to 

be later replaced as needed by more permanent structures. The lack of transportability is 

being addressed in current iterations of this concept.26(p174)
CHAPTER EIGHT • 295

FIGURE 8-4. 45th Surgical Hospital. Patient being moved by litter toward surgery. Photograph 

courtesy of the Army Medical Department Center of History and Heritage, Fort Sam Houston, Texas, 

Image #MU-VN-B1-004.

Evacuation

Helicopter medical evacuation, employing Sikorsky helicopters, was used in a few cases 

by the Army in World War II (on a limited basis in India and in the Philippines19(p9)). This 

set the stage for a more aggressive use in Korea, although helicopter medical evacuations 

in Korea were small (17,700) compared to the much larger number in Vietnam.19(p4) Air 

ambulance evacuations by helicopters in Vietnam moved between 850,000 and 900,000 

Allied military personnel and Vietnamese civilians who were sick, injured, or wounded 

between May 1962 and March 1973.3(pp115–116) In addition, the Korean air evacuation 

situation had enemy aircraft as a factor, which was not the case in Vietnam.27(p18) (By 

comparison, the French had 18 medical evacuation helicopters in use at the end of 1953. 

The French, in the period of 1950 until 1954, evacuated 5,000 casualties by helicopter.27(p4)) 

The Sikorsky H-5 was first delivered to the military in February 1945. The H-5 

gained fame in medical evacuation in Korea as well as in pilot rescue.28 The original H-5 

(designated the R-5 by the military) helicopters were replaced by the more powerful H-13.29

The Bell H-13 Sioux was the helicopter featured in the famous M*A*S*H television 

series. It carried two stretchers attached externally. Originally, no litter attachments were 
296 • FORWARD SURGERY

available, so attachments were made for the skid rails. No medics were on board. Most of 

the helicopter aeromedical evacuations were done by the H-13.3(p15) These craft, however, 

were not designed for air-evacuation roles due to inadequate power and no designed litter 

attachments.

The original Hueys (UH-1 models A and B) lacked enough power to operate in the 

heat and humidity of Vietnam. The UH-1D was introduced in the early 1960s and could 

handle six litter cases due to its longer body. The improved gas turbine engine gave it 

more lifting power for that model, but it was still not enough for mountainous regions. In 

1967, the newly arrived 45th Medical Company (Air Ambulance) brought the new UH1H model, which finally solved the engine power issue. The UH-1H and the later UH-1G 

models were fully instrumented for night and poor weather flying and had sufficient lift to 

effectively use a hoist.3(pp67–69)

“Hueys,” the UH-1 (models A to the late war H, and the H to G series with litters), 

were the aircraft used, with a crew of four including a pilot, copilot, medic, and crew 

FIGURE 8-5. Improvements include sidewalks, landscaping, and painting of buildings at the 45th Surgical 

Hospital, as seen from the air, January 1967. Note the inflation system behind the units. Photograph 

courtesy of the Army Medical Department Center of History and Heritage, Fort Sam Houston, Texas, 

Image #MU-VN-B1-005.
CHAPTER EIGHT • 297

FIGURE 8-6A. [Top] MUST (Medical Unit, Self-Contained, Transportable) surgical complex. Three 

complete surgeries and a sterile preparation area constitute the four expandable units. Photograph 

courtesy of the Army Medical Department Center of History and Heritage, Fort Sam Houston, Texas, 

Image #MU-VN-B1-007. 

FIGURE 8-6B. [Bottom] Preoperative Ward of the 45th Surgical Hospital. Beds are left undressed and 

are used as litter stands. Photograph courtesy of the Army Medical Department Center of History and 

Heritage, Fort Sam Houston, Texas, Image #MU-VN-B1-008.
298 • FORWARD SURGERY

chief.4(p321),11(p66) The UH-1 could carry six litter patients if the crew chief was left behind. 

In contested areas (ie, “hot zones”) an armed soldier was added. He typically carried some 

type of automatic weapon. If the areas were “quiet,” the soldier would be left in favor of 

carrying one more patient. He would be picked up later.18(p75)

There was often conflict over the control of aviation assets for medical evacuation. 

When the first dedicated air evacuation helicopters were introduced, the command wanted 

to use them for troop/supply transport activities, when available. While these differences of 

opinion on use continued, dedicated air evacuation assets were defined. The UH-1D was 

then turned over to troop transport duties when the “H” model became the standard for 

medical evacuation.3(p67)

The thick jungle made helicopter evacuation difficult. The Army used a variation of 

the “Jungle Canopy Platform System” as a means of extracting the wounded from the 

jungle below while the helicopter hovered above. The “Personal Rescue Hoist” advanced 

the state of performing jungle extraction.3(pp70–71) The hoist device was created to more 

effectively lift the wounded while the helicopter hovered. The hoist system was introduced 

in 1966, but required constant modification to the design until the end of the war.3(p71) The 

more powerful “H” model of the UH-1 made hoist operation less risky. Prior to the “H” 

model, the crew would be reduced to the pilot, co-pilot, and a hoist boom operator. The 

helicopter also carried a reduced amount of fuel to lessen weight and thus allow more lift. 

The hoist consisted of a winch with a cable on a boom. The cable could hold a hook and 

ring to which a jungle penetrator, a Stokes litter, or a rigid litter was attached. Another 

extractor device, the “Air Jungle Penetrator,” provided seats to which casualties could be 

strapped—a preferred method by the crew as the device was less likely to become snared in 

the foliage.18(p75) 

The evacuation helicopter was most exposed while extracting a patient in a high 

hover mode. Ground fire of any type was a definite risk. The extra weight of the hoist/litter 

mechanism added to the tension of the maneuver. When the enemy got new weapons such 

as the AK-47, RPD light machine gun, and the SKS carbine in 1964, these weapons and 

the exposed hover time caused an increase in hits on medical evacuation helicopters. The 

introduction of the SA-7 heat-seeking missile in 1972 could have greatly increased the loss 

of aeromedical evacuation assets had the war continued.3(pp85–86)

Patient Experience

The typical casualty could arrive at the helipad of a medical facility sometimes less 

than 30 minutes after helicopter pickup. The casualty was usually received within the 

“golden” 6-hour period after injury, often within 30 minutes.29(pp1–2) He would have been 

splinted and bandaged and the nature of the casualty’s wounds would have been relayed by 

radio. The patient was then moved directly to the preoperative and resuscitative area to be 

evaluated, treated for shock, and moved to the operating room as needed.18(p66) The hospital 

receiving areas had intravenous hangers and litter racks, and adequate radiography areas. 

Most operating rooms and recovery areas were in air-conditioned spaces.29(pp1–2) This rapid 

evacuation changed the nature of forward surgery perhaps more than any other factor. 

There were, however, some cases where evacuation was delayed due to weather or heavy 
CHAPTER EIGHT • 299

fighting.30(p34) The rapid helicopter evacuations increased the survival rate; it also brought in 

more seriously wounded than in past conflicts, many of whom survived. 

Most surgery in military hospitals in Vietnam was performed under a general 

anesthetic. The usual method involved thiopental induction followed by halothane, nitrous 

oxide, and oxygen maintenance. Halothane was the preferred inhalational anesthetic over 

the explosive and flammable ether and cyclopropane.19(p55) The use of local anesthetics was 

only for minor wounds or in some rare cases where there was primary delayed closure. 

Spinal anesthetics were rarely used. 

The experience of the 12th Evacuation Hospital is illustrative of the many different 

types of surgeries done. Their unit history for the period 1 January 1970 to 15 November 

1970 recorded 5,418 operative procedures, of which 4,004 were classified as major 

procedures. The operations consisted of 753 delayed closures, 3,576 debridement 

procedures, 425 thoracotomies, 951 laparotomies, 379 major amputations, 189 minor 

amputations, 147 vascular injuries, 10 craniotomies, and 201 ocular procedures.31

The importance of the clearing station in the evacuation chain was well recognized. In 

the 1965 Ia Drang Valley campaign, the value of an airmobile medical support battalion in 

transporting wounded to the 1st Cavalry Division’s four clearing stations was established. 

The personnel at the clearing station became well skilled in triage, treating shock, and 

administering blood.32(pp87–88) Yet, as pointed out by Neel, by 1967 with the reliance on 

helicopter evacuation, the battalion and divisional clearing stations were excluded from the 

evacuation chain. A surgical, field, or evacuation facility was often within the same flying 

distance.18(p92)

In a 1968 report, “Operations Report–Lessons Learned 2-68: Medical Lessons 

Learned,” emphasis was placed on the role of the clearing station, which had a medical 

officer with approximately 3 years of surgical specialty training. The report pointed out 

that the heavy fighting in the Dak To area showed that relatively immediate professional 

care at the clearing station for casualties brought there by helicopter saved many who 

might have been lost in the evacuation over extended distances to a hospital. None of 

the 929 wounded in action admitted to the clearing station at Dak To died there or in 

subsequent evacuation. In this situation, the availability of the air evacuation helicopter 

made the clearing company relevant.33(pp22–23) In Captain (CPT) Goodrich’s description of 

his 9 months as a battalion surgeon in 1965 to 1966, he spoke to the role of the clearing 

station in evacuation. Specifically, he addressed the life-saving role of immediate treatment 

of casualties in his facility.34(p796)

American forces in the Central Highlands in the period of 1968 to 1969 featured 

widely dispersed combat troops who were supported by “light” clearing stations. A 

physician and nine to 10 medics went with the units they supported. The main medical 

company was located at the semipermanent base camp in protected bunkers. The “light” 

clearing company triaged the wounded, gave care, and prepared the wounded for 

evacuation to the base camp. The clearing station possessed basic equipment for emergency 

treatment and resuscitation. This innovative use of clearing company assets fit the 

particular situation of that combat.18(p92)

The effective use of the clearing station can be seen in 1970 when the 4th Medical 

Battalion was in support of the 4th Infantry Division in the Cambodian incursion in May 
300 • FORWARD SURGERY

and June. Six “dust off” helicopters were available to support the clearing station. The 

majority of the casualties received at least initial treatment at the clearing station at the 

Cambodian border.18(p92) Because combat units were often dispersed, the “light” clearing 

station evolved to subdivide the assets of the unit. A doctor and seven to 10 enlisted would 

form the complement of the “light” clearing station. They were deployed to landing 

zones or fire support bases for a week to 10 days. The clearing station was to prepare the 

wounded for helicopter evacuation to the base camp. The base camp field operation would 

further triage and stabilize the wounded to be passed on to the next level of care.18(p92)

Helicopter Air-Evacuation System

A radio medical network aided the helicopter evacuation. An in-flight assessment 

was made of the casualties and then they could be directed to an appropriate facility by 

radio.18(p70) Field regulators (noncommissioned officers) at troop concentrations or at the 

combat point could call in the flights. Combat medics on site could also call in flights via 

the “dust off” network.18(p76) Hence, the helicopter evacuation was guided by the medical 

radio system and formed the nucleus of the medical regulator system to direct patients to 

the correct facility. Time was the critical factor more so than the distance.18(p74) The 44th 

Medical Brigade assumed management of the regulator system for all of the airspace in 

South Vietnam. As a rule, the telephones were unreliable, so single sideband radios were 

acquired.18(p73)

Pilots and their crews braved enormous odds. Air ambulances and crews sustained 

casualties equal to one-third their number. Indeed, air ambulance helicopters received more 

damage than even combat helicopters or gunships.2(pp117,198) In that regard, the exploits 

of Patrick Brady, a helicopter pilot, are worthy of recognition. Brady had been sent to 

evacuate soldiers, including wounded, surrounded by the enemy in the vicinity of Chu Lai, 

which he did successfully despite enemy fire. He returned to rescue more soldiers trapped in 

a mine-field, landing in the middle of that field to extract the wounded.2(p65) (In recognition 

of his bravery and daring, President Nixon awarded the Medal of Honor in 1969 to thenMAJ Patrick Brady, Medical Service Corps [MSC] becoming the first MSC officer to receive 

that award. Brady later became a major general in the Transportation Corps.8(pp326–327))

The Vietnam-era helicopter medical evacuation system helped to improve the civilian 

care system later. A civilian version of the air evacuation radio/control system, the MAST 

(Military Assistance to Safety in Traffic) Program, has a direct link to the experience gained 

in the Vietnam War.8(p180)

Air Evacuation to Japan/Philippines/Continental United States

At the start of the major American involvement in Vietnam, the US Air Force 

would evacuate patients from the Republic of Vietnam to Clark Air Force Base (AFB) 

in the Philippines. The evacuation could continue to Hawaii, Ryukyu Islands, or Japan 

proper, depending on the condition of the patient and the nature of the wounds. In 

1966, air-evacuation was extended directly to the continental United States (CONUS). 

It could involve a direct flight to Travis AFB in California or a flight to Andrews AFB 

in Washington, DC, after refueling in Alaska. Soldiers could be sent to military general 

hospitals nearest their homes or to selected Class I hospitals (larger military facilities such 
CHAPTER EIGHT • 301

as Walter Reed) within more immediate proximity to their homes, if beds were available. 

In Japan, the Army set up the equivalent of three general hospitals to handle the evacuation 

load.18(p70)

In the early years of the conflict, all of Vietnam was designated as a combat zone 

so that the usual long-term treatment facilities were not in-country. The three general 

hospitals that were set up in Japan were to treat patients who could be returned to duty 

in Vietnam in 60 days, or those who were not stable enough for immediate transport to 

the United States. While in Japan, they would be held in a treatment facility or its medical 

holding company while undergoing treatment that would allow their return to Vietnam. 

In Vietnam, the treatment plan was to retain soldiers in a medical facility in-country if they 

would be able to be returned to duty in 15 to 30 days.18(p71) 

Combat Medicine

Following Korea, the Army added a medical brigade (to command and control corpslevel medical assets) headed by a brigadier general,35(pp125–128) while the medical command 

(to command and control medical assets in the larger theater such as Vietnam) was 

commanded by a major general.8(p308) In Vietnam, the 44th Medical Brigade was created 

to handle nondivisional medical units. An example of this asset type would be the surgical 

and evacuation hospitals at the field Army level.8(p313) The 44th was assigned to the 1st 

Logistical Command, rather than having it serve as a major subordinate command.36(p39)

The position of the Surgeon, USARV and the 44th Brigade commander were made one 

in 1967. The US Army Medical Command, Vietnam, was established in 1970, with four 

surgical hospitals, three field hospitals, eight evacuation hospitals, and one convalescent 

FIGURE 8-7. Emergency room before patients arrive. Photograph courtesy of the Army Medical Department Center of History and Heritage, Fort Sam Houston, Texas, Image #MU-VN-B1-009.
302 • FORWARD SURGERY

FIGURE 8-8A. UH-1 “Huey” helicopter—the workhorse of aeromedical evacuation in Vietnam. Photograph 

courtesy of the Army Medical Department Center of History and Heritage, Fort Sam Houston, Texas, 

Image #MU-VN-B1-010.

FIGURE 8-8B. Note the rotor on the helicopter is still turning while the patient is off-loaded. Photograph 

courtesy of the Army Medical Department Center of History and Heritage, Fort Sam Houston, Texas, 

Image #MU-VN-B1-011.
CHAPTER EIGHT • 303

FIGURE 8-9A. Operating room scene. New surgeons acquired new skills in trauma. Debridement was a 

skill difficult to learn at first for the new surgeon. Photograph courtesy of the Army Medical Department 

Center of History and Heritage, Fort Sam Houston, Texas, Image #MU-VN-B1-013.

FIGURE 8-9B. Surgeons at work. Surgeons maintained a high level of care despite the turnover in staff. 

Photograph courtesy of the Army Medical Department Center of History and Heritage, Fort Sam Houston, Texas, Image #MU-VN-B1-014.11.
304 • FORWARD SURGERY

FIGURE 8-9C. Another operating room scene. The typical operating room was functional but simplistic in 

setup. Prompt triage brought the injured to the operating room. Photograph courtesy of the Army Medical Department Center of History and Heritage, Fort Sam Houston, Texas, Image #MU-VN-B1-015.
CHAPTER EIGHT • 305

FIGURE 8-10. Helicopter 

landing at the 3rd Surgical 

Hospital at Bau Cat, Vietnam, to pick up casualties 

secondary to engagement 

with the Viet Cong, 10 

miles away. The casualties 

were to be flown to the 1st 

Division Headquarters near 

Bien Hoa, November 1965. 

Photograph courtesy of 

the Army Medical Department Center of History and 

Heritage, Fort Sam Houston, 

Texas, Image #MU-VN-B3-

CC-32318.

FIGURE 8-11. Loading wounded officer on UH-1 helicopter. Photograph courtesy of the Army Medical 

Department Center of History and Heritage, Fort Sam Houston, Texas, Image #MU-VN-B3-CC-33940.
306 • FORWARD SURGERY

center. The 44th Medical Brigade was released from the 1st Logistical Command. At that 

time the 44th Medical Brigade assumed a number of functions previously delegated to the 

1st Logistical Command. It was to ensure central control that the 44th Medical Brigade 

was to report directly to USARV headquarters. BG (later Major General [MG]) Glenn J

Collins was the first to command; MG Spurgeon Neel followed.37(p25)

Prior to 1965, the only Army facility in Vietnam was the 8th Field Hospital (100 beds) 

at Nha Trang.36(p59) There was a Navy medical operation in Saigon of 100 beds.18(pp60–61)

The 3rd Field Hospital arrived in April 1965. Later that year, two evacuation and two field 

hospitals, along with field units, arrived. They were located near the 8th Field Hospital in 

Nha Trang and the 3rd Field Hospital in Saigon.1(pp60–61) In 1965, evacuations from Vietnam 

happened within 15 days of wounding. In mid-1966, patients were evacuated after 30 

days due to more in-country facilities. If they could be returned to duty within that period, 

the soldiers were retained in Vietnam.36(p50) By 1967, there were six evacuation and four 

surgical hospitals, along with the 6th Convalescent Center36(p61) (at Cam Ranh Bay). More 

hospitals arrived in 1968, including the 312th Evacuation Hospital, the largest US Army 

Reserve unit in Vietnam. As of December 1968, there were 5,283 beds in country. The 

medical build-up was basically completed by December 1968 (Figures 8-7 through 8-11). 

After the Army strength fell from 331,000 in January 1970 to 119,700 at the end of 1971, 

there was a proportional fall in AMEDD beds, with only 1,000 beds then. US medical 

operations in Vietnam ended by the end of 1972.36(p50) 

OTHER PROGRAMS SUPPORTED BY MEDICAL ASSETS

Civilian medical aid programs started in the early years of US involvement. Programs 

were initiated to help the people of Vietnam. Such programs included MILPHAP (Military 

Provincial Health Assistance Program), MEDCAP (Medical Civic Action Program), and 

CWCP (Civilian War Casualty Program). These programs had mixed success due to 

problems of civil strife, geographic isolation, and warfare.18(pp162–163)

The medical needs of special groups were additional duties. The Special Forces 

operated small hospitals to provide medical care for the Montagnards, the hill people who 

supported US troops.18(p314) They were trained by Special Forces troops in the methods of 

irregular warfare. The largest detractor in using these irregular troops was that due to their 

help, these peoples were at risk for serious retribution by the NVA and the allied Viet Cong 

irregulars. However, they were motivated fighters and more familiar with their terrain than 

the Viet Cong or NVA regulars.18(p332) 

Initially, the enemy (NVA and Viet Cong) prisoners of war (POWs) were medically and 

surgically treated by both the ARVN and US Army units. The POW treatment program 

was turned over to the ARVN by 1969. US units continued to treat POWs in their regions 

until they could be transported to ARVN facilities.18(pp69–70)

Internists and Pediatricians

Originally, fully trained internists were assigned to surgical hospitals (and MUST 

units). These hospitals did not have beds for prolonged holding of the sick or wounded; 
CHAPTER EIGHT • 307

however, attached laboratory facilities were able to complete the usual surgical tests. The 

internists functioned as triage doctors and surgical assistants. The internists were reassigned 

to larger hospitals starting in 1968 so that they could function more as internal medicine 

physicians.36(p41) In 1969, 52 internists were assigned to hospitals in teams of three or four. 

Medical illnesses in such a tropical climate were varied and included amebiasis and other 

parasitic diseases, malaria, bacterial diseases, and arboviruses and other viral diseases.36(p52)

Internists added to the improved “team” care of the wounded after surgery.36(p50)

The ability of internists to deal with the ever-present malaria was greatly valued 

because many of the wounded had malaria as an additional medical problem that had 

to be addressed. Plasmodium falciparum was the major prevalent strain. An increase 

in the chloroquine-resistant malaria cases presented a crisis because these new malarial 

cases were not prevented by the usual prophylaxis regimes. In 1965, these cases were 

typically found in combat troops in contact with the Viet Cong because the troops were 

in areas where mosquitoes were common and combat units tended to not always observe 

chemoprophylaxis regulations. In 1966, a major breakthrough came in the control of 

malaria with the introduction of a new drug. DDS (4-4-diaminodiphenylsulfone), initially 

recognized as an important agent in the treatment of leprosy, was also shown to be an 

effective agent to treat resistant strains of malaria. Internists also had to deal with infectious 

hepatitis and used immunoglobulin in that regard.26(pp170–171)

Interestingly, pediatricians were assigned to Vietnam as part of the Civilian War 

Casualty Program. All USARV hospitals accepted civilians on a space available basis 

under this program. The use of pediatricians in hospitals and the field was limited. These 

physicians augmented adult caregivers as needed, including duty as surgical triage doctors 

and surgical assistants.36(pp43,44) US Province Senior Advisors (civilian advisors) tried to 

implement programs to help the local people and to neutralize the influence of the Viet 

Cong. Medical care for civilians, including children, went along with programs such 

as Village Self-Development and Public Works.38(pp244–245) The Agency for International 

Development (AID) had sent civilian teams of physicians, nurses, and technicians to 

Vietnam as early as 1962.26(p162) Indeed, the MILPHAP was a joint venture of AID and 

MACV, which provided civilian physicians and nurses with a mission to improve the 

health of Vietnamese civilians.26(pp162–163)

Convalescent Facilities

The 6th Convalescent Center, located near Cam Ranh Bay, was the major convalescent 

center in country. It opened in 1965 upon the recommendation of Surgeon General Heaton. 

In its first year of operation alone, 7,500 medical and surgical patients were admitted. 

Later, the average admission rate was about 1,000 per month.18(pp67–68) Internists provided 

much of the staff for this center.

SURGICAL/MEDICAL CARE ADVANCES OF THE VIETNAM WAR 

The hallmark of surgical care in Vietnam centered on wound debridement, wound 

exploration, and delayed closure. The wounds resulted in a low infection rate and no gas 
308 • FORWARD SURGERY

gangrene. Burkhalter pointed out that assignment of Regular Army (RA) medical officers 

(in the case of more senior surgeons from Korea and more junior surgeons from work 

in emergency rooms and operating rooms of Army facilities) with experience in wound 

management avoided having to relearn the lessons of past conflicts.39(pp210–211) 

The level of surgical skill was high and was maintained despite surgeon rotation 

turnover. However, due to assignment variables, surgical specialists were often used 

as general surgeons. A case in point, Colonel (COL) Harold Griffiths, US Air Force 

Reserve, Medical Corps, was a general surgeon in Vietnam. He spoke of the situation 

where subspecialists were assigned to a hospital and were expected to function as general 

surgeons. He described the importance of trauma skills and triage in treating those injured 

in combat, as well as the transfer of these skills to those meeting trauma in the civilian 

world, especially in mass casualty situations.40(pp228–229) 

The trauma surgery skills were increased for the surgeons involved. Because the new 

surgeons arriving in country had little in civilian trauma experience to prepare them, they 

were attached to experienced teams that could get them trained. In the larger facilities, the 

team approach, involving multiple disciplines operating even simultaneously, added to the 

overall success. Debridement (particularly fasciotomy for orthopedic surgeons) was difficult 

to learn, especially making wide incisions and aggressive removal of devitalized tissue.39(p211)

Delayed closure was an emphasis in World War II and Korea.41,42 However, a feature of the 

high-velocity Vietnam wound was that delayed closure could cause problems, primarily of 

infection and delayed healing.39(p212) Surgeons concluded that closure could be an elective 

procedure to be done when appropriate. 

Every war has its own unique advances that benefit the military and civilians as 

well. Vietnam was no exception. Areas of advancement and interest in the war included: 

the military blood program, treatment of shock, treatment of metabolic and respiratory 

problems, body enzyme changes resulting from wounding and shock, advances in antibiotic 

therapy, treatment of posttraumatic renal insufficiency, burn treatment, advances in 

vascular surgery, and innovative advances in the use of tissue adhesives and aerosolized 

antibiotics. 

The Vietnam Military Blood Program

In the conflict, frequent transfusion of whole blood was done with type O low-titer 

blood well before the injured reached a facility with cross-match capability. From 1965 

forward, the push for blood was expedited because liquid (unlike frozen) whole blood had 

an expected life of only 21 days from donor to recipient. A source of whole blood from 

outside the country was an early priority. In 1965, the 8th Field Hospital did the only 

transfusions and they received 10 units each week from Japan. Early surges in need were 

met with local donor sources. As Neel points out, the whole blood program in Vietnam 

was supported by donors from the military, their dependents, and civilians employed at 

military facilities throughout the world.32(p126)

The arrival of the 3rd Field Hospital in 1965 allowed it to become the central blood 

depot for Vietnam. The 406th Mobile Medical Laboratory was given the distribution task in 

country.33(pp114–115) The continued expansion of the blood program required the establishment 
CHAPTER EIGHT • 309

of the USARV Central Blood Bank in 1967. The first shipment of whole blood from the 

United States arrived in Japan in 1966. After that date, blood shipments came from the 

United States weekly to Japan and from there to the Central Blood Bank in Vietnam.32(p122)

In 1965, it was decided to ship only universal donor low-titer group O blood to 

Vietnam. More specific blood types were reserved for the Philippines and off-shore 

facilities. After 1965, while clearing and field hospitals were still unable to cross-match 

and continued to use universal O blood, the evacuation hospitals switched to more specific 

transfusion programs. As the Vietnam in-country facilities became more advanced, specific 

blood types were made available.32(p122) 

Blood was generally to be used within 21 days. Because the blood received from outof-country sources was 4 to 7 days old already, the effective life of the supplies was only 

about 2 weeks. Blood that was 21 days to 31 days old was given to the ARVN units and 

the civilian facilities. Originally, blood over 31 days old was destroyed, but later in the 

conflict, the blood was converted to plasma. It was found that the addition of the amino 

acid adenine could extend the useful blood life to 40 days.32(p124)

In 1968, fresh frozen plasma was sent to Vietnam to deal with coagulopathies 

following surgery and massive transfusions. Because the freezer compartments in 

the standard cooling units were inadequate, a freezer was adapted from one used in 

construction to cool steel rivets. By 1969, freezers specifically designed for fresh frozen 

plasma had been introduced.32(p123)

The Styrofoam blood box was introduced in 1965. Many authorities called Vietnam 

the “war of the white Styrofoam blood box.” The Collins box replaced the earlier 

Hollinger box because it could hold 18 units of blood, was smaller in size, and retained its 

coolant twice as long.32(p125)

Extensive transfusions could also have their problems. Neel describes one case 

requiring 92 units of blood.19(p56) There could be bleeding posttransfusion, which could be 

controlled by fresh whole blood or fresh frozen plasma. A drop in the patient’s temperature 

posttransfusion was a problem; blood warming technologies helped overcome this issue. 

Metabolic/Respiratory Issues

The soldier became acclimated for Vietnam duty soon after arrival, but chronic 

dehydration was a continuing problem.30p(3) Research continued into the soldier’s health 

in Vietnam from a number of approaches. The Walter Reed Army Institute of Research 

(WRAIR) pointed out in their studies the importance of the metabolic state of the 

soldier. The WRAIR Surgical Research Team also worked to investigate the care of the 

wounded.29(p4) BG Robert Hardaway described the state of surgical research in Vietnam 

while he was the Chief, Division of Surgery, at the WRAIR.43(pp873–877)

One prong of the studies of the WRAIR team (Heisterkamp et al) looked at 

respiratory insufficiency as a factor leading to casualty hypoxemia, shifts in serum 

sodium concentrations with anesthesia, and serum enzyme changes noted with 

wounds.44(pp36–59) Other facets of the Heisterkamp studies included study of serum enzymes 

in wounding,44(pp1-8) study of oxygen tensions postsurgery,44(pp49–96) and the effects of massive 

transfusions.44(pp111–118) Shock is an issue when the arterial blood flow is not adequate to 
310 • FORWARD SURGERY

deal with metabolic needs of tissues. Regional hypoxia results from subsequent lactic 

acidosis (due to anaerobic metabolism in peripheral tissues) as well as eventual endorgan failure. Shock and acidosis complicated hypoxemia (defined as a p02 less than 

80%). There are many causes of shock recorded. Hypovolemic shock is due to loss of 

blood, plasma, and loss of fluid and electrolytes. Obstructive shock can be due to tension 

pneumothorax.45(pp422–423)

Shock

Hardaway wrote an excellent review of the history of shock and its treatment by 

military surgeons through the wars. He had a unique background that included handling 

casualties from the Japanese attack on Pearl Harbor. He pointed out that the Vietnam War 

was characterized by “the beginnings of serious shock research in the Army.”46(pp267–268)

Hardaway published an article describing shock lung47(pp311–315) (now called acute 

respiratory distress syndrome [ARDS]). Surgeons attributed the condition to a postulated 

intravascular coagulation. 

Hardaway described the establishment of the first shock trauma unit at Walter Reed 

Army Medical Center in 1963 followed by a duplicate unit in Vietnam in 1965.47(p268)

Hardaway’s 2009 article details the Army’s extensive experience in the study of shock and 

his own experience from Pearl Harbor to the present.48(pp944–947)

Prolonged shock was found to lead to DIC—disseminated intravascular coagulopathy. 

The WRAIR team noted sporadic DIC occurred in severe trauma, as indicated by an 

abnormal prothrombin time and partial thromboplastin time tests. Platelets and fibrinogen 

are reduced. Episodic nonlethal DIC probably occurred in the recovery from shock and 

trauma as postulated by Heisterkamp et al.44(pp111–148)

Serum Enzyme Changes in Wounds/Shock

Studies of serum enzyme changes with wounds noted that changes came about in 

specific enzymes such as SGOT (serum glutamic-oxaloacetic transaminase, now known 

as AST or aspartate aminotransferase); LDH (lactate dehydrogenase); and SGPT (serum 

glutamic-pyruvic transaminase, now known as ALT or alanine aminotransferase). All 

of these enzymes can be elevated in liver, heart, or muscle disease. Of these enzymes, the 

SGOT test was felt at the time to be the most accurate and sensitive test for soft tissue 

trauma.44(pp49–96),49(pp272–274)

Antibiotic Use

Antibiotic use prior to 1944 mainly featured sulfanilamide drugs. Penicillin became 

available in mid-1944 in significant quantities. The clinical approach in World War II for 

antibiotic use included having soldiers start oral sulfanilamide antibiotics when wounded; 

sulfa granules were sprinkled into the wound by the corpsman when first seen. As noted by 

Cleveland, the low rate of infection in World War II was attributed to good debridement 

and whole blood use, rather than the use of penicillin or sulfa.50(p169) 

Arts et al stated in the WRAIR Research Team Report that 13 different species of 

bacteria were found in Korean War wound cultures.43(p606) Lindberg, writing in the Annals 
CHAPTER EIGHT • 311

of Surgery, described the finding of a large proportion of cases showing both anaerobic 

and aerobic pathogens. Those studies found Staphylococcus aureus, Aerobacter aerogenes, 

Pseudomonas, and Proteus present; penicillin was not the drug of choice for these 

pathogens.51(pp369–374)

Antibiotics used in Vietnam after injury included penicillin or penicillin in combination 

with chloramphenicol or streptomycin.40(p211) The most commonly used were penicillin and 

streptomycin. However, it was noted that this combination was ineffective in over half of 

the patients evacuated in Vietnam. Mandelamine was found to be useful. Matsumoto, of 

the WRAIR Surgical Team, reported in 1968 that the effectiveness of penicillin was doserelated, requiring larger doses to be administered intravenously. Starting with the work of 

the WRAIR Surgical Research Team, surgeons learned the value of microbiological cultures 

to guide them in which antibiotic agents to use later. The WRAIR team also commented 

on the fact that wound infection was to be considered not as a response to soft tissue/bone 

destruction but rather to the environment and the level of foreign material in the wound. 

Surgeons also learned that prolonged treatment, which was often unnecessary, could lead 

to problems of hospital-acquired infections of another organism or further complications 

such as a pulmonary embolus.40(p212) Broad spectrum antibiotics were available only late in 

Vietnam.29(p12)

In Vietnam, the WRAIR Surgical Research Team found organisms causing morbidity 

and mortality included Staphylococcus aureus, Pseudomonas aeruginosa, and Klebsiella 

pneumonia. The most common organism in Vietnam wounds causing problems was 

Staphylococcus aureus (in 30% of wounds), followed by Pseudomonas (18%) and E. coli

(17%).29(p13) The bacterial flora found in orthopedic wounds as reported by Heggers et 

al were quite instructive.52(pp602–603) Serratia marcescens had increased in wound cultures. 

Aggressive blood culture techniques and an attempt to provide good respiratory care to 

patients on ventilators were both done in an attempt to prevent Serratia sepsis.29(p13)

Despite widespread antibiotic use, the old standard of widespread debridement and 

delayed closure significantly helped to reduce infection.29(p13) The principles of debridement 

and delayed closure had not undergone much evolution since World War II. The 1958 

NATO Emergency War Handbook and its 1975 revision discuss antibiotic use as a support 

therapy, not to replace good surgical debridement.53 In debridement, an adequate and 

aggressive incision is necessary to reach the devitalized tissue. Inadequate exposure may 

mean missing the damaged tissue. Debridement of muscle tissue is difficult in that the 

surgeon may have trouble judging the soundness of muscle. Fascia should be incised to 

allow decompression of underlying injured tissue. The Korean War taught that muscle tissue 

viability can be evaluated by its consistency, ability to bleed, and contractility.53(pp266–273)

The incidence of gas gangrene and tetanus was almost nonexistent in Vietnam 

casualties. Tetanus toxoid was given as a routine to each wounded soldier. The rapid 

debridement of wounds and antibiotic use was in part responsible. However, it was 

reported that gas gangrene and tetanus were seen in Viet Cong casualties.54(pp1445–1451)

WRAIR had worked with the Pasteur Institute in 1964 to set up a plague research 

laboratory in Vietnam.8(p315) The plague laboratory did work to help combat an expanding 

problem at the start of the war. In another research area—the management of shock—the 
312 • FORWARD SURGERY

onset of shock lung/wet lung after a wound to the chest was noted. The use of diuretics was 

helpful in dealing with this manifestation.29(p5)

Posttraumatic Renal Insufficiency—Advances in Treatment

The advances in treatment of acute renal insufficiency (ARI) following trauma were 

significant in the Vietnam experience. The 629th Medical Detachment (Renal) was organized to deal with ARI. Of note, the 629th was a specialized intensive care operation that 

used hemodialysis and peritoneal dialysis to combat renal failure. It served as a referral 

center for renal patients of the US military and US civilians. It also treated Vietnamese 

civilians and military, as well as other foreign nationals in Vietnam. Once the patients were 

stabilized after a round of dialysis, they could be then evacuated to CONUS. Facilities in 

the Philippines, Japan, or Hawaii could be used en route if more immediate dialysis was 

needed.37(pp465–466)

The largest group of patients with ARI treated there were those resulting from trauma 

following wounding in battle. This entity was known in World War II and treated in Korea 

with hemodialysis. In World War II (prior to the development of the artificial kidney), 

the fatality rate was 90% among the wounded with ARI.37(p466) With early hemodialysis 

treatment in Korea, the fatality rate was lowered to 68% in the wounded.37(p466) The 

mortality rate in the first year of operation in Vietnam was 87% (for the posttraumatic 

renal failure) versus 6% for those with only medical causes. The posttraumatic cases were 

more complicated, demonstrating multiple organ failure and extremity wounds with 

attendant oligemic shock and hemorrhage.37(pp471–473) The rapid evacuation of the wounded 

by helicopter, rapid treatment, and resuscitation reduced the incidence of ARI from one in 

200 woundings in Korea to one in 600 in Vietnam. Despite improvements in treatment, 

still two out of three soldiers died once ARI had occurred. (Of interest is that the 629th 

became the first Army unit to perform a successful renal transplantation in June 1969. The 

patient was a Vietnamese civilian. Military transplantation centers in CONUS followed this 

success.37(pp475–476))

Other Advances

Rehabilitation was quite important to the wounded soldier, especially in orthopedic 

injuries and amputations. The Army introduced a physical therapist to Vietnam in 

1967.30(p6) The use of an expanded physical and occupational program in the Convalescent 

Center and the larger facilities added greatly to recovery of the wounded.

The use of “flak jackets” body armor greatly reduced the number of chest wounds. 

Hence, the proportional number of wounds of other areas was increased.19(p55) When worn, 

the flak jackets were said to be effective against three-fourths of the fragments striking 

the thorax. Exact figures on the wear of the jacket are not known. The primary issue was 

the extra heat generated and the extra weight. As in any military situation, the level of 

command oversight had an obvious bearing.19(p55)

The Vietnam War ushered in improvements in anesthesia, burn care, and the employment of plasma expanders. The usual general anesthesia was a thiopental induction 

followed by a mix of halothane, nitrous oxide, and oxygen. Halothane proved to be a great 

anesthetic in Vietnam offering safe inductions and uncomplicated recoveries.19(p56)
CHAPTER EIGHT • 313

BURN TREATMENT

In the Korean War, the experience of the 46th Surgical Hospital and the experience of 

other facilities were coordinated with the Burn Study Ward at Brooke Army Hospital in 

San Antonio, Texas. The so-called “Universal Protective Dressing” was found to be helpful. 

A report was sent to the Surgeon for the 8th Army in Korea in July 1953, discussing the 

“Universal Protective Dressing,” which was very effective and more comfortable for the 

patient. The dressing continued to be used throughout the Vietnam era.55(p189) Suggestions 

for the management of burns in the field were evolved. Suggestions for the level of response 

in critical care at each level of evacuation were formulated. Attention to fluid replacement 

in the first 24-hour period and continuing fluid replacement in the next 24 hours were 

outlined. The patient was to be transported on the third day to an evacuation hospital, 

provided fluid replacement therapy had been done. The importance of designating centers 

specializing in burns had been noted during the Korean War years.55(pp189–190)

In Vietnam, burns were often fatal if associated with enemy action (as opposed to the 

half that were accidental). The 70% of the deaths due to burns were associated with enemy 

action because of their severity and the fact that other wounds were often sustained at the 

same time.19(p56) The percentage of combat burn injuries was 5% of the total casualties 

in Vietnam. It is surprising that over half of the burns in Vietnam were accidental and 

therefore presumably preventable. Burn patients were only stabilized before evacuation 

to Japan. Later, over 66% of these were sent to the Burn Center at Brooke Army Medical 

Center in San Antonio, Texas.19(pp56–57) Sulfamylon ointment was started to reduce the 

infection rate.19(p56) In the specialized centers, teams of physicians and nurses were joined 

by occupational therapists, physical therapists, and respiratory therapists. Burn casualty 

management included timely triage, resuscitation, initial treatment, and air evacuation to 

a tertiary burn center. In the years since World War II and the Korean War, the treatment 

of burns greatly improved with the onset of specialized centers and the use of ancillary 

personnel. In the Korean War, phosphorus burns were treated with a copper sulfate 

solution. The solution was no longer used as it was found to be toxic in itself. Hence early 

debridement was deemed even more important for those burns.19(p57)

TISSUE ADHESIVES AND AEROSOL ANTIBIOTICS

In 1968, the WRAIR Surgical Research Team devised tissue adhesives and an aerosol 

antibiotic to be given by medics at the combat site. The WRAIR Team also tested a number 

of experimental products in Vietnam designed to aid wound healing. The aerosol antibiotic 

was given out to a number of tactical units and it was found to retard bacterial growth 

when given early on an open wound. Morbidity could be thereby reduced. Plastic polymers 

were used as tissue adhesives. Such adhesives could help with controlling bleeding and 

in facilitating tissue repair.19(p57) The tissue adhesives had low toxicity with fairly rapid 

degradation. The WRAIR Surgical Research Team found tissue adhesives valuable in 

surgery of the liver, lung, and kidneys, which were difficult to suture.19(p57) The treatment 

of severe liver injuries was a challenge because it involved significant transfusions and 

removal of large amounts of tissue. In addition, control of bleeding was a problem because 

it involved gaining access to relatively inaccessible spaces. As discussed, tissue adhesive use 

proved helpful in liver cases.
314 • FORWARD SURGERY

VASCULAR SURGERY

Vascular surgery started irregularly in the Korean War but it became common in 

Vietnam. Vascular injuries were common in both conflicts but the experience and resolve 

to deal with these injuries in Korea was not common. Vascular surgery techniques, 

operation tools, and experience rose precipitously in Vietnam. The surgery was performed 

by the general surgeon, the orthopedic surgeon, or the vascular surgeon, depending on 

personnel availability. These surgeons became quite proficient in the now commonplace 

vascular procedure without regard to their subspecialty. Of the wounded, 2% to 3% 

had arterial/venous vascular injuries. The amputation rate of limbs with vascular injury 

was 13%, which was the same as Korea; compared to the 49% rate of World War II, the 

improvement is impressive.19(pp52–53) In a few interesting cases, limbs were salvaged by the 

construction of an extra anatomic bypass, with tunneling the graft through a new route 

around the area. When the wound healed, a permanent graft could be done.19(p57) COL 

Norman Rich pointed out that the documentation and repair of both arteries and veins 

became more common in Korea and especially in Vietnam. In his article recalling the 

historical heritage of vascular trauma, Rich points out the value of mentorship and the 

legacy to be passed on of the management of arterial and venous injuries.56

“SIGNATURE” WOUND OF THE VIETNAM WAR

In each conflict, the nature of the combat yields a characteristic “signature wound.” 

In the Vietnam conflict, severe wounds caused by high-velocity projectiles were common. 

These wounds were more severe than low-velocity projectiles from prior conflicts. As Rich 

discusses, the high-velocity projectile (such as the AK-47/M-16 round) produced greater 

tissue destruction than any other weapon used in Vietnam or other wars.57(pp157–158) The 

high-velocity projectiles caused much tissue damage, but the jungle foliage could also 

cause the rounds to tumble, thus increasing the wound damage, with increased cavitation 

effect and secondary fragments (such as pieces of fragmented bone).19(p53),30(pp7–8) Additional 

tissue damage was invariably caused by rounds that yawed or disintegrated into pieces. 

The high-velocity projectile wounds show characteristics of explosive nature due to 

the high kinetic energy of the missile. The energy exceeds the elastic limit of the injured 

tissue.57(pp157–158)

Statistical data on Army troop wounds from January 1965 to June 1970 showed more 

small arms deaths and injuries in Vietnam than in Korea or World War II. The numbers 

of “booby trap” and mine injuries were also greater in Vietnam than the other conflicts. 

However, there were fewer artillery, mortar, and other projective device wounds in Vietnam 

than in Korea or World War II.9(p53)

Of those injured by the various means above, 31% were returned to duty immediately.19(pp51–52) Of the wounded actually admitted to the hospital, approximately 42% 

returned to duty in Vietnam.19(p52),29(p8) This impressive return-to-duty rate reflected 

the dedication and hard work of the doctors, nurses, administrative officers, medical 

evacuation pilots, and medics. 
CHAPTER EIGHT • 315

Neel, in his 1973 Medical Support of the US Army in Vietnam 1965–70,

19 reported 

that multiple wounds were more commonly seen than in prior conflicts.19(p53) The multiple 

wounds in Vietnam were due to the lightweight high-velocity round, the rapid fire of 

automatic weapons, and the use of mines/booby traps.30(p7) This finding was, again, due to 

the extremely high velocity and kinetic energy of the wounding agent. Automatic weapons 

accounted for high rates of fire that was often at close range. Further, these projectiles could 

cause cavitation, which also resulted in external contamination and secondary fragments 

(such as bone) entering the wound. In the extremities there could also be nerve damage and 

fractures.19(pp53–55)

 Claymore mines could cause serious wounds with the multiple steel ball projectiles. 

The Claymore was fielded by both sides in Vietnam (the ARVN and Viet Cong used 

captured mines of this type). The Claymore mine resulted in peppering with multiple 

fragments that often penetrated deeply. The mines could be specifically directed by positioning for a certain trajectory field. The enemy often used booby traps with significant 

contamination.19(pp53–54) In the Republic of Vietnam, mine and booby trap wounds were 

three times the rate of those of the Korean War or World War II.26(p173) The booby traps 

and mines caused increased injury due to the close nature of the wounding. In addition, 

multiple fragments with contaminants (such as dirt, fragments, and micro-organisms) made 

the surgery complicated. The alternatives often involved a choice of more radical surgical 

debridement and excision versus a more conservative approach attempting to salvage more 

tissue, which could result in more infection.19(p53)

The Vietnam conflict also saw the Viet Cong use Punji stakes. These stakes were 

bamboo spikes sharpened to a point at the end and smeared with animal or human fecal 

material, and generally placed in groups. Dr Jerry Martin, the author of Soldiers Saving 

Soldiers. Vietnam Remembered: A History of the 18th Surgical Hospital and an Army 

surgeon in the RVN, didn’t see many of these wounds, but he did note that they required 

wide debridement and thorough irrigation to prevent life-threatening infections.12(p121)

SURGEONS GENERAL OF THE VIETNAM WAR PERIOD

Silas B Hays (1 June 1955–31 May 1959)

Hays received his medical degree from the State University of Iowa in 1928. He was 

commissioned in 1928 when he started his internship at Letterman General Hospital, 

San Francisco, California. He completed the Army Medical School and the Medical Field 

Service School in 1930 to 1931. Hays received 20 months of training in general surgery 

and urology at Walter Reed General Hospital in the period 1934 to 1937. Hays graduated 

from the Army Industrial College in 1940 before being assigned to the Surgeon General’s 

Office Finance and Supply Division. In 1944, Hays was assigned to the European Theater 

of Operations as Chief of Supply in the Theater’s Surgeon Office. In 1950, Hays was 

appointed as the USARMY Pacific Surgeon. In 1951, Hays became the Deputy Surgeon 

General. In March 1955, Hays became the Army Surgeon General.58 Hays pursued 

significant construction to replace aging medical care facilities. He began a medical care 
316 • FORWARD SURGERY

program for military dependents, which greatly helped troop morale. Hays encouraged 

research projects and was particularly interested in the study of radioactivity effects on 

health.58

Leonard D Heaton (1 June 1959–30 September 1969)

Heaton graduated in medicine from the University of Louisville in 1922. He entered 

active duty in 1926. He was an intern at Letterman General Hospital. Heaton served in 

a variety of assignments leading up to Hawaii in 1940. At that time, Heaton became the 

Chief of Surgery for the hospital at Schofield Barracks. On 7 December 1941, Heaton 

and a colleague were strafed by Japanese planes in their car. He immediately headed to his 

hospital where he treated casualties. Heaton was assigned to England in 1944 where he 

commanded two hospitals. In 1948, Heaton was promoted to brigadier general. In 1950, 

he became a major general and Commander of Letterman General Hospital. In 1953, 

Heaton became the Commander of the Walter Reed Army Medical Center. In 1959, he 

became the Army Surgeon General and the first Medical Corps officer to be appointed in 

the rank of lieutenant general. Heaton retired in 1969 and subsequently died in 1983 at 

Walter Reed.59 Heaton had many famous patients including President Eisenhower. Heaton 

encouraged the use of helicopters for medical evacuation and led the rapid expansion of 

medical services for the Vietnam War.59

Hal B Jennings (1 October 1969–30 September 1973)

Jennings graduated from the University of Michigan in 1941. He interned at the 

University of Michigan and entered active duty in 1942. Jennings served in the South 

Pacific until the end of the war. Jennings completed a general surgery residency at 

Letterman and a 2-year plastic surgery training period at Washington University. He 

gained certification as a plastic surgeon in 1953, and subsequently became the Chief of 

Plastic Surgery at Walter Reed in 1959. After assignments in Europe, Jennings deployed 

to Vietnam with the 1st Cavalry Division (Air Mobile). In May 1968, he became the 

command surgeon to the US Military Assistance Command, Vietnam. In September, he was 

promoted to brigadier general. In July 1969, Jennings became the Deputy Surgeon General. 

On 1 October 1969, he became a lieutenant general and the new Surgeon General.60

Richard R Taylor (1 October 1973–30 September 1977)

Taylor graduated from the University of Chicago in 1946. He completed an internal 

medicine residency at Letterman General Hospital, 1951 to 1953. He served in Korea 

from September 1953 to December 1954. In 1955, he completed a 1-year residency in 

pulmonary disease at Fitzsimons Army Medical Center, Aurora, Colorado. Taylor spent the 

years from 1956 through 1964 in a number of research and development units. In 1969, 

he became the Command Surgeon, US Military Assistance Command, and RVN. From 

1970 to 1973, Taylor was the Commanding General, US Army Medical Research and 

Development Command, Washington, DC. From March to September 1973, Taylor served 

as the Deputy Surgeon General, and then he became the Surgeon General on 1 October 

1973.61 Taylor guided the drawdown of assets in the closing years of the Vietnam War. True 
CHAPTER EIGHT • 317

to his background, he fostered research and development projects providing the template 

for programs in the coming decades.61

THE WAY FORWARD 

The Army Medical Department acquitted itself well in the Vietnam War. In an 

excellent review of this showing from his unique perspective, COL Kenneth Swan gave the 

Heaton Lecture at the 7th Medical Command Medical-Surgical Conference in Germany 

in 1990. His talk, “Combat Casualty Care,” was later published in 1992. Swan had the 

particular perspective of being a trauma surgeon in Vietnam (as well as Operation Desert 

Storm in 1991). He had the added perspective of being a professor of surgery in a major 

school of medicine. He attributed the success of the AMEDD in combat casualty care to six 

factors. Swan listed air superiority as the first point because the threat was removed of air 

attacks. Ground security followed. He spoke to the high density of “semimobile hospitals” 

that were in truth fixed. This concentration of hospitals, including evacuation hospitals, 

resulted in the success of the evacuation system. In allowing facilities to be less mobile, 

the evacuation hospital rose to the level of a university or level-1 trauma center. Fourth, 

he noted that a large number of trauma-trained surgeons were available and that the 

whole period of the Vietnam War provided an unparalleled experience to a generation of 

surgeons. Fifth, Swan spoke to the importance of the ready availability of whole blood, and 

finally, he quite correctly gave a great deal of credit to the effective use of the air evacuation 

ambulance.62(pp4–10)

BG Hardaway’s 1982 Sir Henry Wellcome Prize Essay spoke to the achievements 

in medicine on the battlefield. He had calculated the increased losses that would have 

occurred in Vietnam had the medical care been the same standard of care employed in 

World War II or Korea.63(pp1011–1017) Still to be considered in the assessment of the success of 

medical care in Vietnam is a thought-provoking 1984 editorial by Bzik and Bellamy.64(p230)

They speculated that Hardaway’s picture of the Vietnam era care was too favorable. They 

noted the relative lethality of the Vietnam battlefield, while acknowledging the rapid 

evacuation from the battle to surgical treatment facilities. They discussed that in Vietnam 

the Marines had an emphasis upon forward/field resuscitation of casualties while awaiting 

air evacuation, which they felt had a favorable outcome. Bzik and Bellamy surmised that a 

more balanced approach calling for forward resuscitation and rapid evacuation might be 

the way to go in doctrine.64 Clearly therein lays a challenge to incorporate such thinking for 

the future.
318 • FORWARD SURGERY

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320 • FORWARD SURGERY

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229–230.
INTRODUCTION

THE CURRENT MANIFESTATION OF FORWARD surgical elements in the US Army 

evolved over several iterations of combat experience, shifting more capable surgical assets 

farther forward as the operating environment became less linear. Between World War I and 

Vietnam, the percentage of troops killed in action (KIA), defined as those who died before 

reaching a military hospital, hovered between 18% and 24%.1(pp1–8) However, the percentage of casualties who eventually died of their wounds (DOW) after reaching a military hospital improved as healthcare evolved (9% in World War I, 5% in World War II, less than 

3% in Korea, and just over 3% in Vietnam).1(pp1–8) Advances in technology altered military 

tactics and equipment, while also improving medical care to the combat wounded. In Vietnam, air evacuation brought patients to military treatment facilities earlier than in the past, 

so that many who previously would have died on the battlefield reached a hospital. If the 

Vietnam DOW is statistically corrected to exclude casualties who died within 24 hours of 

admission to the military treatment facility, it becomes 1%.1(pp1–8) 

As medical and military capabilities progressed, so too did the implementation of 

medicine on the battlefield. The meandering, linear battlefields of the two world wars and 

Korea gave way to the low-intensity conflicts of Vietnam and the fast-paced maneuvers of 

Operation Desert Storm. Tactical medicine transitioned, at first through ad hoc means, to 

forward surgical elements that moved closer to the battlefield. These efforts, supported by 

Army Medical Department studies demonstrating that 67% of all casualties listed as KIAs 

actually died within 10 minutes of wounding—a period in which little can be done to save 

the casualty—were aimed at saving the 33% of KIAs who survived the 10-minute mark.1(p9)

It was not until the late 1990s that forward surgical teams (FSTs), seen as an innovation to 

Chapter Nine

From the Falklands to the 

Balkans: Toward 

Formal Designation of the

 Forward Surgical Team

CHRISTOPHER A. VANFOSSON
322 • FORWARD SURGERY

the modern mechanisms of war, became formal, permanent parts of Army medical doctrine 

and structure.2,3 The presence of such highly skilled and mobile teams on the battlefield today, coupled with a focus on implementing combat lifesaver training, the development and 

use of “blood expanders,” and the advent of improved evacuation platforms reduced the 

DOW rate to 0.5% by the end of Desert Storm.1(p8) Formal inclusion of the FST into Army 

tactical doctrine made permanent the changes necessary to support the Army in today’s 

nonlinear operating environment. 

DEPLOYMENT OF FORWARD SURGICAL ASSETS 

IN THE 1980S AND 1990S

This chapter will explore four deployments of forward surgical assets in the period 

since the Vietnam War —the Falklands War, Operation Urgent Fury, Operation Just Cause, 

and Operations Desert Shield and Desert Storm—to demonstrate the evolution of the FST 

in the 1980s and 1990s. These deployments set the stage for the transition to the FST’s 

formal designation as a permanent unit.

Falklands War: The 1982 British Invasion of the Falklands Islands

Although the United States was not directly involved in the Falklands War, the lessons 

learned from the British experience during the invasion of the Falklands Islands provided 

the US Army a recent reference operation for the rapid deployment of troops to island 

protectorates. As an indicator of possible future American military operations, the British 

experience demonstrated the need for medical planning prior to rapid deployments to far 

off lands. The sudden Argentinian invasion of the Falklands Islands, a United Kingdomowned chain of islands 450 miles off the coast of Argentina, on 2 April 1982 triggered an 

unexpected deployment for the Royal Navy and its medical department. Three days later, 

the United Kingdom deployed its first naval units to expel Argentinian troops from the 

Falklands.3,4 

The British possessed no contingency plan for combat service support for the defense 

of the island territory nearly 8,000 miles away. The lone staging base for the Royal Navy, 

at an American airfield (Wideawake Airfield) on the Ascension Islands,3 was only halfway 

to the Falklands, lending little comfort to the logistics planners that rapid replenishment 

of combat service needs would be possible.4(p50),5 During the Falklands campaign, air 

operations at Wideawake expanded from 40 flights per day to 400 flights per day and 

solidified Ascension Island’s place in British military plans for contingent operations south 

of the equator in the decades to come.3

Although the Royal Navy was responsible for the overall operation in the Falklands, 

the Royal Navy Medical Department split from tradition to liaise with its counterparts in 

the British Army and Royal Air Force to develop a rough medical plan before the first units 

departed for the Falklands.6 The SS Uganda, a cruise ship transporting a group of students 

to Gibraltar just off the southern coast of Spain, was called to military service on 2 April. 

Within 3 days, the Uganda was refitted as a hospital ship. The students were flown home 
CHAPTER NINE • 323

to Britain while the hospital staff flew to Gibraltar to populate the new floating infirmary. 

Within 4 days of its call-up, the fully outfitted SS Uganda set forth toward the Falklands in 

preparation for war.3

By 5 April, medical planners had identified and activated the 16th Field Ambulance 

of the Royal Army Medical Corps, surgical teams drawn from the 16th Field Ambulance 

(Parachute Clearing Team) and the 2nd Field Hospital of the Royal Army Medical Corps, 

and the regimental medical officers already assigned as organic personnel to each of the 

major combat units.6 The field surgical teams, potentially the most important asset of the 

group, consisted of a surgeon, an anesthetist, a resuscitation officer, four operating room 

technicians, a blood transfusion technician, and a clerk.4(p57) Their employment would place 

these teams as far forward as possible on the battlefield, aiming to provide surgery and 

resuscitation to the combat wounded within 6 hours of injury.7

Medical evacuation was anticipated to be difficult. Ground evacuation, the first line 

of evacuation from the point of injury to the regimental aid post, would be limited by the 

“rocky, craggy terrain.”4(p61) It was planned that the small forward surgical elements would 

move forward on foot with the regimental aid posts, resuscitating patients and stabilizing 

them for evacuation to the next level of care. Rotary wing aircraft were the planned 

primary means of evacuation from the battlefield. Their use would be limited, however, by 

the weather and the medical commander’s lack of command and control over the medical 

evacuation assets.4(p57) In anticipation of fierce fighting, and reflecting his concern over the 

limited evacuation capabilities once the invasion began, the British medical commander 

ordered the landing of the 2nd Field Hospital at Ajax Bay in the Falkland city of San 

Carlos.4(pp60–62) The 2nd Field Hospital would then serve as a staging facility for those 

patients who required surgery after injury. According to the plan, these patients would 

eventually be evacuated to the Uganda for stabilization before being transferred to one of 

three ambulance ships (the Hecia, the Herald, or the Hydra) for transport to Montevideo, 

Uruguay. From Uruguay, the Royal Air Force would fly the casualties back to Britain for 

convalescence.3,4(p68)

To compensate for the short mobilization timeline, British military leaders used the 

3-week movement to the Falklands to more completely plan the operation and gather 

intelligence. Much of this intelligence came from Britons fleeing the Falklands after the 

Argentinian invasion, who provided important insight into the topography of the obscure 

island chain and the weaponry used by the Argentinian forces.3 Additionally, the Royal 

Navy used the voyage to the Falkland battlefield to more specifically plan the medical 

support for the operation and to train the infantry on the essentials of combat first aid. 

British soldiers were trained on immediate resuscitation, treatments for shock, hemorrhage 

control, the use of first-aid dressings, and the proper administration of morphine as an 

analgesic.3,8 In the end, this training compensated for long ground evacuation times. The 

patients arrived at the aid station more stable, requiring less resuscitation, and thereby 

allowing for an earlier evacuation to the Uganda.

3

 In anticipation of the ensuing battle, and 

recognizing the possible length of the evacuation trains, soldiers on the ships also donated 

units of blood to the medical teams, augmenting the supply already shipped by the Royal 

Army Blood Supply Depot in Britain.4(p58)
324 • FORWARD SURGERY

The British invasion of the Falkland Islands, aimed at ejecting the occupying 

Argentinian troops, began on a wintery 8 May 1982, with troops setting forth from the 

inhospitable South Georgia Island east of the Falklands.3,4(pp46–49) Almost immediately, 

limitations in the medical support plan became apparent. The British troops struggled to 

get many of their casualties to surgery within the aimed-for 6-hour window, often because 

the rotary wing aircraft used for evacuation were diverted for transportation of supplies 

and other needs.4(pp62–63),9 Also, at least one helicopter was shot down while extracting 

patients, possibly as a result of its dual use as a transport for ammunition into the fight.4(p63)

Regimental aid posts and field surgical teams were essential to the medical success 

of the mission, moving forward on foot as maneuver elements surged across the islands 

toward Port Stanley. Much of the ground evacuation to the regimental aid posts took an 

average of 2.5 hours, with patients often carried by stretcher rather than transported by 

ambulance. Though weather, terrain, and aircraft availability limited medical evacuations 

to the 2nd Field Hospital, the regimental aid posts and forward surgical units filled the gap 

in patient care. These patients eventually ended up at the Fitzroy and Teal Inlet.3,4(p66) Once 

it became operational on 21 May 1982, the 2nd Field Hospital, set up in a refrigerator 

plant at Ajax Bay near Port San Carlos, became the primary destination for evacuations.3,10

At one point, the 2nd Field Hospital’s staff performed 100 surgeries in a single 48-hour 

period.10 By 9 June, when the 2nd Field Hospital ceased operations, the staff had treated 

450 out of the 783 casualties treated during the Falklands War and conducted almost all of 

the initial surgeries needed during the campaign.3,11 Despite the prolonged evacuation times, 

only three British casualties died after reaching a hospital, indicating the importance of 

forward surgical asset availability when medical evacuation capabilities are limited.9

The British medical experience in the Falklands solidified British medical doctrine and 

demonstrated that the medical support system could support tactical operations.4(p68) Only 

once in the deployment did the medical support system nearly crack, when the HMS Sir 

Galahad was bombed, producing 179 casualties.7 After-action reports identified numerous 

shortages in planning and logistics support, such as insufficient heating, communication, 

paper, and potable water.4(pp62–65),11 Some reports indicated that many casualties who died 

likely exsanguinated due to underuse of tourniquets.12 Yet, with the cooperation of the three 

British services and the medical commander’s ability and willingness to maneuver personnel 

on the battlefield, the adaptability and professionalism of British medical support personnel 

ensured that the medical needs of the Falkland Islands Campaign were met.4(p68)

Operation Urgent Fury: The 1983 US Invasion of Grenada

At first glance, Cold War-era national security strategies might seem focused wholly on 

the linear conflict that might have erupted between the United States and the Soviet Union. 

The battlefields of the 1980s and 1990s, however, were less linear and on a much smaller 

scale than military planners anticipated. The geopolitical environment was changing, and 

therefore, so were the potential military missions. These changes also affected the medical 

support structures in the US Army. The conflict in the small island country of Grenada 

served as a successful example of rapidly deployable American land forces in this new 

geopolitical environment and highlighted the need for American medical planners to 

develop small, rapidly deployable elements to support these missions.
CHAPTER NINE • 325

Maurice Bishop, a communist-leaning political player in the nation of Grenada, 

assumed power of the small island country in 1979. Amid Cold War concerns for the 

growth of communism in the Americas, Bishop’s ascension to power concerned the US 

Department of State, which feared Bishop might move the island nation politically closer 

to America’s Cold War nemesis, the Soviet Union.13 These concerns appeared justified 

as Bishop, while claiming to be neutral, garnered Cuban support and embarked on the 

construction of a 10,000-foot reinforced runway. Such an airstrip concerned US officials 

due to the strategic location of the island nation and the potential for the Cubans or Soviets 

to use the strip for military purposes. The island location and the airstrip length could allow 

for aircraft capable of interdicting US air and sea routes, as well as serving as a collection 

point for Soviet arms bound for Central American communist sympathizers.4(pp81–84),13–16 By 

late 1983, the airstrip was complete and Bishop had been overthrown by a more hardline 

Marxist regime, led by Bernard Coard and backed by the Grenadian army.4(pp81–84),13,17 With 

the new airstrip complete and Coard in charge, the nation of Grenada could assume the 

role of a “Soviet aircraft carrier” within striking distance of the United States.14

Concerned that the sudden change in Grenadian leadership posed a significant 

threat to the 600 American students in Grenada, and with the Iranian hostage crisis in 

recent memory, US President Ronald Reagan ordered the Joint Chiefs of Staff on 17 

October 1983 to begin planning to evacuate the students from Grenada (Figure 9-1).18

The execution of Bishop on 19 October increased tensions even more. By 21 October, the 

FIGURE 9-1. A map of 

the island of Grenada, 

October–November 

1983. Note the location 

of Point Salines and 

Saint Georges in the 

southwestern portion of 

the nation. The medical clearing station and 

surgical team were 

established at the airstrip near Point Salines. 

Photograph courtesy of 

Colonel (Ret) Joseph P. 

Jackson, Jr, MD (private 

collection).
326 • FORWARD SURGERY

Organization of Eastern Caribbean States requested American assistance to ensure the 

stability of the government of Grenada and the safety of the students from the United States 

and those from other regional countries.19(p2) With little time for preparation, Combined 

Joint Task Force 120 (led by Vice Admiral Joseph Metcalf III of the US Navy’s Second 

Fleet) commenced Operation Urgent Fury on 25 October 1983.20 Land forces made up of 

“two Army Ranger battalions, some Special Forces, two 82nd Airborne Division brigades 

and a Marine Amphibious Unit secured all significant military objectives and successfully 

rescued all US citizens” within 4 days of commencement of the operation.4(pp83–84) While 

successful in accomplishing its objectives, the Task Force mission resulted in 18 service 

members KIA, 116 wounded in action (one of whom died of wounds later), and 28 

nonbattle injuries.21

Planning for such a rapidly developing operation was challenging for military leaders, 

especially those charged with sustaining the maneuvering forces. In contrast to the British 

challenges in the Falklands (where distance served as the greatest challenge), American 

military planners struggled with the compressed timeline of the situation.4(p84) Most 

elements, such as the 82nd Airborne Division assets, operated on preexisting contingency 

plans.22 Unfortunately, due to operational security considerations, many of the planning 

elements within the 82nd Airborne Division and the XVIII Airborne Corps were bypassed, 

eliminating planning elements that were well versed in rapid deployment planning 

scenarios.4(pp91–92),20 The two 82nd Airborne Division brigades, who made up the bulk of 

the American land forces bound for Grenada, relied heavily on their preexisting rapid 

deployment packages to provide the appropriate amount of sustainment (including medical 

sustainment) for the entire operation.4(pp93–94)

Once mobilized for deployment, medical planners within the 82nd Airborne Division 

brigades began to unofficially alter their task organization to better support the mission. 

This was difficult, however, because some leaders within the organization were unaware of 

the mission destination until combat operations began.4(p90) The 307th Medical Battalion, 

82nd Airborne Division, led by Lieutenant Colonel (LTC) Edward B Wilson, would serve 

as the division-level medical support for all land forces during the operation. Medical 

platoons organic to the Ranger elements, Special Forces teams, and the Airborne battalions 

would provide all medical support doctrinally organic to the unit.4(p91),13 Fortunately, due 

to the division’s normal tactical mission capability, 82nd Airborne Division medical assets 

were well suited for “maneuvering on the fly.”

Based on its forced-entry mission, the airborne division is potentially separated from 

the larger medical support capabilities in the combat zone. The larger hospitals of the 

day, such as the MASH (mobile Army surgical hospital), were too large to “jump in” 

with the airborne medical assets during insertion operations.20,23 The airborne medical 

companies were therefore augmented with small surgical teams of personnel and materiel, 

which would perform urgent surgeries normally provided only in a MASH or CSH 

(combat support hospital). Alerted on 24 October 1983, the 307th Medical Battalion 

sent an orthopedic surgeon (Colonel [COL] Joseph Jackson) and five medics with the 2nd 

Battalion, 2nd Brigade of the 82nd Airborne, which departed from Pope Air Force Base 

in North Carolina.14,18,24 The team’s mission was to augment the 2nd Battalion’s battalion 

aid station and, if the battalion aid station moved off the airfield, remain at the airfield to 
CHAPTER NINE • 327

establish a casualty collection point (CCP).14,20 This CCP on the airfield would become the 

hub of patient evacuation throughout the operation.

As the invasion of Grenada commenced on 25 October, the first medical assets on 

the ground were the medics assigned to the Rangers, who parachuted from an altitude of 

500 feet onto the airfield at 0500 hours, 12 hours before the advance elements of Charlie 

Company, 307th Medical Battalion (with 2nd Battalion, 2nd Brigade), arrived at Point 

Salines.4(p83-84),14,20 COL Jackson and his team, however, did not jump into Grenada. Instead, 

they remained in the aircraft until it landed on the airfield,25,26 reaching Point Salines at 

2200 hours on 25 October. Jackson’s team had no surgical capacity, bringing with them 

only a few items to conduct Advanced Trauma Life Support operations.14 Furthermore, 

the only blood products and narcotic pain medications arrived in the Styrofoam container 

Jackson hand-carried onto the airfield in Point Salines.25,26 Until the 307th could become 

more established, the medical support plan called for the Rangers and the other land 

forces to rely on Navy medical assets floating off shore. Ground commanders in the 82nd 

Airborne Division believed that these assets, the USS Guam and the USS Saipan, had a 

medical support capability equal to a 100-bed CSH or MASH.4(p91)

Early elements of the Rangers and the 82nd Airborne were expected to face stiff 

resistance upon landing in Grenada. Early intelligence indicated that Cuban workers and 

the Grenadian forces were organizing against the invasion.13 Based on his understanding 

that the Navy could provide the medical support needed by his troops, the 82nd Airborne 

Division commander, Major General (MG) Edward L Trobaugh, delayed the arrival of 

critical combat support assets, including medical personnel, in exchange for more combat 

troops.4(pp93–96) By the morning of 26 October, MG Trobaugh and his staff learned that the 

Navy ships were not as capable as first thought.4(pp97–98) The USS Guam had one general 

surgeon and an orthopedic surgeon, as well as one operating room and eight patient 

beds.14,25 The USS Saigon was not a fully staffed medical asset either. This misunderstanding 

of the capabilities available delayed the arrival of the rest of the 307th Medical Battalion 

(which included three physicians, a nurse anesthetist, and 14 others) until the afternoon of 

26 October and the evening of 27 October.4(pp97–98),25 Fortunately the Rangers experienced 

only light casualties initially, which allowed the few Army medical personnel on the ground 

to determine which assets were actually required in the forward areas and coordinate for 

shifts in deployment priority to get the needed medical assets on the ground—all while 

providing care to the few injured Rangers in Point Salines.4(p99) 

Originally setting up operations in a construction shack just off of the runway at Point 

Salines (Figures 9-2 and 9-3), COL Jackson and his team received their first casualty at 0600 

hours on 26 October (Figure 9-4). The soldier, who arrived on the hood of a dump truck, 

sustained gunshot wounds to bilateral sides of his chest, requiring chest tubes. Unfortunately, 

the medical aide bags airdropped for COL Jackson and his team contained no chest tubes. 

Jackson inserted a 14-gauge needle into both sides of the patient’s chest before sending 

him off to the USS Guam by helicopter. Because there was no established coordination for 

medical evacuation, COL Jackson’s team had to flag down a helicopter flying overhead. 

Unqualified to land on vessels at sea, the aircraft carrying this patient moved to three 

different naval vessels before finally locating and landing aboard the Guam. Fortunately, the 

prolonged evacuation did not negatively impact this patient’s outcome.14,24,25 
328 • FORWARD SURGERY

FIGURE 9-2. [Top] A view of 

the 307th Medical Battalion 

clearing station located just off 

of the airstrip at Point Salines, 

October–November 1983. 

Photograph courtesy of Colonel 

(Ret) Joseph P. Jackson, Jr, MD 

(private collection). 

FIGURE 9-3. [Bottom] This tent, 

made out of a parachute, poles, 

and tree branches, served as 

the living quarters for a member of the surgical team located 

just off of the airstrip at Point 

Salines. October–November 

1983. Photograph courtesy of 

Colonel (Ret) Joseph P. Jackson, Jr, MD (private collection).
CHAPTER NINE • 329

Later that day, COL Jackson’s team moved the CCP from the shack to an area near 

the “jungle trees and out of mortar range.” Continually working to improve their patient 

caring capacity, the team coordinated with the Rangers and Special Operations soldiers 

headquartered in the area to obtain much needed intravenous fluids and other medical 

supplies. Meanwhile, the young medic who escorted the patient to the Guam took time 

while aboard the ship to gather many badly needed medical supplies before returning to the 

Point Salines airfield. The throughput of medical supplies, equipment, and personnel was 

an apparent afterthought to the military planners, and personnel involved struggled to keep 

pace with operations on the ground.24,25

With the medical students secured by the morning of 26 October (Figure 9-5), the 

arrival of three medical evacuation helicopters from the 57th Medical Detachment on the 

morning of 27 October almost appeared unnecessary.4(p100) However, the arrival of the 

helicopters and the rest of Charlie Company, 307th Medical Battalion, on 27 October 

turned out to be fortunate, because the Rangers and paratroopers were poised at the time 

to assault the Cuban headquarters at Calivigny Barracks.24,26 Though this objective was 

secured by 2100 hours,26 two helicopters collided during the operation, and an attack 

helicopter inadvertently fired upon the 2nd Brigade tactical operations center, sending 45 

casualties to Charlie Company, 307th Medical Battalion, in a 30-minute period.4(p101),14,24,25

These patients, who arrived amid a violent rainstorm, were evaluated by flashlight while 

lying in the mud. Army chaplains, there to minister to the wounded, were asked to hold 

bags of intravenous fluids and assist with bandaging.25 Nearly overwhelmed, the 307th 

evacuated four patients (and an accompanying physician and nurse anesthetist) by a US 

Air Force C-130 aircraft to the hospital at Roosevelt Roads Naval Air Station, Puerto 

Rico. The USS Guam was reserved for those casualties needing more urgent surgical care 

beyond the capabilities of the 307th Medical Battalion assets on the ground.4(p101),14,24,25

The remainder of the 307th Medical Battalion would not arrive until the 6th day of the 

operation.27

FIGURE 9-4. An 

“ambulance,” acquired 

from the Grenada 

locals, sits outside the 

307th Medical Battalion 

clearing station, October–November 1983. A 

makeshift hand washing 

station is also visible. 

Photograph courtesy of 

Colonel (Ret) Joseph P. 

Jackson, Jr, MD (private 

collection).
330 • FORWARD SURGERY

FIGURE 9-5. [Top] Rangers near the airstrip at Point Salines preparing for an air assault, October–November 1983. The Ranger in the foreground took time to show the medical team his assault camouflage. 

Photograph courtesy of Colonel (Rer) Joseph P. Jackson, Jr, MD (private collection).

FIGURE 9-6. [Bottom] Members of the surgical team at Point Salines clean a wound to the right arm 

of a soldier after he was injured by a 50-caliber round that ricocheted off of the front of a nearby 

weapon, October–November 1983. Photograph courtesy of Colonel (Ret) Joseph P. Jackson, Jr, MD 

(private collection).
CHAPTER NINE • 331

By the end of combat in Grenada (Figures 9-6 through 9-8), it became apparent to 

medical planners that many lessons would be learned from their experiences on the small 

island nation. While the medical mission was hindered significantly by the omission of 

medical planners from the planning stages of Urgent Fury and the absence of a senior 

medical commander in the Joint Task Force, the ingenuity of the medical leaders overcame 

most planning failures.4(pp101–102),14,20 Perhaps the most glaring lesson was that the ground 

forces needed a “small, easy-to-insert surgical capability” to maneuver on the battlefield 

with the combat forces.28 The experiences of COL Jackson and his team24,25 reinforced 

the recommendations of medical leaders of the early 1980s, which advocated for the 

integration of small surgical assets into the medical plan of numerous tactical operations 

(real and training).3–11 Based on British experiences in the Falklands, medical planners 

advocated for field surgical teams that are rapidly deployable and operational within 15 

minutes.14 Adding credence to this position, in 1984 COL Ron Bellamy published an article 

in Military Medicine that described the real concern for medical planners.29

Mid-1980s Evolution of Medical Planning

In his article, Bellamy identified the statistical reasons for combat deaths on the modern 

battlefield and found that many were preventable. The statistical significance of preventable 

FIGURE 9-7. The interior of the surgical team’s treatment tent, October–November 1983. Note the anesthesia apparatus in the foreground. Photograph courtesy of Colonel (Ret) Joseph P. Jackson, Jr, MD 

(private collection).
332 • FORWARD SURGERY

deaths from extremity hemorrhage, tension pneumothorax, and airway obstruction caused 

a revolution in medical training in the Army.29 Combat medic training was realigned, and 

combat lifesaver training developed, to focus on identifying and treating these conditions.30

Medical leaders began to consider the development of small, agile surgical assets to fill the 

geographic void between the fast-maneuvering combat units and the large, cumbersome 

surgical hospitals. Also in 1984, after the Army’s Medical System Program Review at the 

Academy of Health Sciences, 82nd Airborne Division medical planners began looking 

at developing such a surgical capability, modeling it after the French parachutist surgical 

unit or the British parachute clearing troop.20 In efforts that were replicated by the 326th 

Medical Battalion, 101st Airborne Division,27 this “surgical squad field light,” a portion 

of the treatment platoon assigned to the headquarters and Alpha Company of the 307th 

Medical Battalion, was a precursor to the eventual 782nd FST.31

Surgical squads, such as the one assigned to the 307th Medical Battalion, became 

one of six modular support systems for division-level and corps-level units. The 10-person 

FIGURE 9-8. Surgeons cleansing a hand wound of a soldier in the makeshift operating room just off of 

the airstrip at Point Salines, October–November 1983. Photograph courtesy of Colonel (Ret) Joseph P. 

Jackson, Jr, MD (private collection).
CHAPTER NINE • 333

squad consisted of one general surgeon, one orthopedic surgeon, two medical-surgical 

nurses, two certified registered nurse anesthetists, two operating room technicians, and two 

licensed practical nurses. Although surgical squads were normally a corps-level asset, the 

Army allocated two organic surgical squads to each airborne and air assault division. The 

squads were meant to save lives, provide resuscitative surgery for seriously wounded or 

injured casualties, and preserve physical function. To accomplish their mission, the squads 

had to co-locate with some sort of holding capability (such as a division clearing station), 

usually in the brigade or division support area, for postoperative support. These assets were 

placed in the divisions in the mid to late 1980s, and in 1991 they were included in Army 

doctrine.32

The 44th Medical Brigade, a subordinate command of the XVIII Airborne Corps 

at Fort Bragg, North Carolina, also participated in the early development of a forward 

surgical capability. The brigade first established the 274th Medical Detachment as a test 

organization in 1987. COL Bruce T Miketinac, commander of the 44th Medical Brigade, 

carved the 274th Medical Detachment (General Surgical) from the airborne positions 

allocated to the 36th Clearing Company, which held the majority of the brigade’s airborne 

positions. The 274th was given provisional status.27,33 Colloquially referred to as the 1st 

FAST (Forward Airborne Surgical Team), the 274th was activated after Vietnam as a 

general surgery detachment. 

An Army Nurse Corps officer, Captain Steve Janney, recommended that the surgical 

detachment add a postoperative capability and equip the team so that it could participate 

in airborne operations. Janney teamed with Major David Rivera, a surgeon assigned 

to Fort Bragg’s Womack Army Community Hospital, to identify the needed changes to 

the 274th Medical Detachment table of organization and equipment (TO&E) to meet 

this new airborne, surgical, and postoperative capability.27 From 1987 to 1989, leaders 

within the brigade tested personnel and equipment schemes during field training exercises. 

Some equipment posed a challenge for the brigade, which worked around normal Army 

acquisition processes to purchase and redistribute supplies to stand up the team. The drawover anesthesia device, for example, was used by the British during the Falklands campaign 

but was not approved for use in the United States amid concerns about inconsistent 

delivery of the volatile gases used for anesthesia. The sturdy construction and size of 

the draw-over device, however, made it the optimal choice for use by the new surgical 

capability, and the unapproved piece of equipment was added to the 274th Medical 

Detachment TO&E. The draw-over, however, would be limited to combat use only.27

As designed, the team of 17 personnel was capable of loading a two-bed operating 

room and four-bed intensive care capability onto two Air Force pallets and into a C-130 

aircraft for movement to an area of operation. The team and equipment could parachute 

from the same aircraft and were capable of becoming fully operational within 2 hours 

of exiting the aircraft.33 LTC Alan Muench, assigned to Eisenhower Army Medical 

Center at Fort Gordon, Georgia, soon joined the team as a Professional Filler System 

(PROFIS) officer. A former Special Forces Group surgeon familiar with operating in 

austere environments, Muench recommended adding a communications specialist, an 

administrative officer, and an additional noncommissioned officer to the team.27
334 • FORWARD SURGERY

On 8 March 1989, as a demonstration of the team’s capabilities, the 274th Medical 

Detachment parachuted into Honduras as a part of the annual Ahuas Tara 89 exercise. 

After securing their equipment on the drop zone near La Paz and preparing it for sling load, 

the surgical team moved by helicopter to Soto Cano Air Base The team was accompanied 

by MG James Rumbaugh, then commanding general at Walter Reed Army Medical 

Center, who provided instrumental support for the development of the 274th Medical 

Detachment while serving as the commander of Womack Army Community Hospital 

at Fort Bragg.27,33,34 Tragically, Rumbaugh suffered a hard landing on the drop zone and 

died while being transported to Brooke Army Medical Center in San Antonio, Texas, for 

treatment.33,34 

The 5th MASH, another subordinate unit of the 44th Medical Brigade, also began 

developing a forward surgical capability in the mid-1980s. Called the 5th FST, this team 

would be heavier than the 274th Medical Detachment and would not be air-droppable. 

Instead, it was “designed to enhance the medical capability organic to the Joint Special 

Operations Command.” Both the 274th Medical Detachment and the 5th FST were 

allocated canvas tents, a small generator for operating room lights, and supplies needed 

for life-saving resuscitative surgery.27 Though small surgical elements such as these were 

the beginning of the development of forward surgical capabilities,27,28 it would be another 

decade and two significant conflicts before the American FST became a doctrinal reality.

Operation Just Cause: The 1989 US Invasion of Panama

The US invasion of Panama in 1989 did not suffer from the planning shortages that 

befell Operation Urgent Fury. The situation in Panama developed slowly over the course 

of the 1980s, leading American leaders to believe that military action in the isthmus nation 

might become necessary.35 Expecting a short-notice need for agile assets on the ground, 

Operation Just Cause was the first time in US Army history that a forward surgical asset, 

though only considered provisional, was formally deployed to a theater of operations. 

Developed after the American experience in Grenada, and with strong consideration of 

Bellamy’s information about preventable combat deaths, the Army’s new surgical squads 

were in the works by 1986. By the time of the invasion of Panama, the surgical teams were 

trained parachutists and were important members of the invasion plan.28

Operation Just Cause stemmed from a long, complicated relationship between the 

United States, Panama, and Manuel Noriega. The United States had been involved in the 

security of Panama since the beginning of construction on the Panama Canal in 1904, 

deeming the operability of the canal to be a matter of national security.36(p5) In 1983, after 

the death of his dictator mentor, Brigadier General Omar Torrijos, Noriega took command 

of the Panama Defense Force and began to wield absolute power in the small nation. By 

1987, the United States had become concerned about Noriega’s abuse of power in Panama 

and his known involvement in the drug trade. On 5 February 1988, the Panamanian 

dictator was indicted in US federal courts on drug trafficking charges, irritating an 

increasingly aggressive Noriega. Concerned that his increasing hostility toward the United 

States, and his growing relationships with Cuba and Nicaragua, might threaten the 

Panama Canal (which accounted for $35 billion in cargo traffic annually) and the 35,000 
CHAPTER NINE • 335

Americans (including 9,500 service members) living in Panama or stationed near the Canal 

Zone, the Department of Defense began in 1988 to develop plans for the possible invasion 

of Panama.35,36(p6),37

Dubbed “Blue Spoon,” the contingency plan called for the gradual build-up of troops 

in the Canal Zone (to a maximum of 13,000 troops just prior to the commencement 

of operations), with increasing economic and diplomatic pressure being placed on the 

Panamanian government in an attempt to “minimize the adverse effects of economic 

sanctions on the Panamanian people, while demonstrating the US resolve to secure the 

Canal Zone and force Noriega from power.”36(pp7–8) As American forces moved into the 

Canal Zone, relations with Panama deteriorated rapidly. On 15 December 1989, the 

Panamanian legislative body declared war on the United States and named Noriega the 

“maximum leader.” By 17 December 1989, violence towards Americans in Panama 

reached new heights, climaxing with the death of a Marine at the hands of a Panamanian 

soldier. President George HW Bush grew frustrated with the situation in Panama 

and ordered the commencement of Operation Just Cause, an escalation from “Blue 

Spoon.”35,36(pp27–28)

A well-planned operation, Just Cause was led by Joint Task Force South (under the 

XVIII Airborne Corps) and consisted of the 193rd Separate Infantry Brigade, elements 

from the 82nd Airborne Division, the 7th Infantry Division (Light), the 5th Infantry 

Division (Mechanized), a Marine expeditionary battalion, a military police brigade, Special 

Forces elements, and a contingent of combat support elements.38 Joint Task Force South 

was tasked to protect American lives, secure key sites and facilities, and neutralize the 

Panamanian Defense Force. American troops would also be expected to restore law and 

order while supporting the installation of a US-recognized government in Panama.37

Operational security remained a concern, but combat leaders had learned from the 

lessons of the recent past and integrated medical personnel into the operational planning, 

beginning in March 1989. COL Jerome Foust, commander of the 44th Medical Brigade, 

and four other medical planners (two of whom were Special Operators) took part in the 

medical planning.27,37 Medical support was aligned under the Joint Task Force South 

Surgeon39 (COL Foust) and included the organic medical assets of each maneuver unit, the 

5th MASH FST, the 274th Medical Detachment, the Air Force’s 24th Medical Group and 

1st Aeromedical Evacuation Squadron, a portion of the 7th Medical Battalion, a portion 

of the 307th Medical Battalion, the 142nd Medical Battalion, and the 214th Medical 

Detachment.37,38,40 The mission of the 44th Medical Brigade and its subordinates included: 

the provision of resuscitative surgical and postoperative care and patient holding capacity 

for all Joint Task Force South elements; the provision of ground and air evacuation; the 

provision of medical supply and resupply to all forces; the assumption of command and 

control for all Army and Air Force nondivisional and installation medical assets in theater 

(Gorgas Army Hospital and the clinics at Howard Air Force Base); and the provision of 

medical regulating for all patients leaving the joint operating area. Unfortunately, due to 

operational security, most of the leadership subordinate to COL Foust was unaware of 

these requirements until the units were already moving towards Panama.37
336 • FORWARD SURGERY

 The initial medical support plan (Figure 9-9) anticipated a very short operation 

and called for establishing a joint casualty collection point (JCCP) at Howard Air Force 

Base in Panama, where casualties would be triaged, treated, and evacuated as necessary. 

Evacuated casualties would be medically regulated to either Wilford Hall Medical Center 

at Lackland Air Force Base or Brooke Army Medical Center at Fort Sam Houston, both in 

San Antonio, soon after being surgically stabilized. Initially, Air Force leadership expressed 

concern that patients evacuated so soon after surgery might not fare well during transport. 

LTC Robert Brannon, commander of the 1st Aeromedical Evacuation Squadron (AES), 

intervened, however, and equipped the evacuation aircraft with the supplies and equipment 

necessary to care for critically ill patients, assuring Air Force leaders that his team was 

ready for the mission. Gorgas Army Hospital, in Panama, was not included in the plans to 

cover the medical needs of the operation, largely because much of the staff was made up 

of Panamanian local nationals.27,38 The facility’s proximity to Panamanian Defense Forces 

strongholds also made its use in the initial invasion a high-risk proposition.39 The medical 

assets at Howard Air Force Base were the focus of the medical support for the majority of 

the mission (Figures 9-10 through 9-13).

FIGURE 9-9. A diagram of the Joint Casualty Collection Point at Howard Air Force Base, Panama, early in 

Operation Just Cause, December 1989. Diagram courtesy of the Army Medical Department Television and 

Multimedia, Fort Sam Houston, TX, Video #A1701-90-0087.

Drainage Ditch

Special Cat

FST-5 MASH

Bde HQ

MIN

HOLD

MASF

EVAC

Triage MASF

FLIGHT LINE

N
CHAPTER NINE • 337

FIGURE 9-10. [Top Left] An aerial view of Howard Air Force Base, Panama. Photograph courtesy of the 

Army Medical Department Television and Multimedia, Fort Sam Houston, TX, Video #A1701-90-0087, 

1990.

FIGURE 9-11. [Bottom Left] Airmen off-loading supplies at Howard Air Force Base, Panama. Army Medical 

Department Television and Multimedia, Fort Sam Houston, TX, Video #A1701-90-0087, 1990.

FIGURE 9-12. [Top Right] One of the tents used as the Joint Casualty Collection Point just off of the flight 

line at Howard Air Force Base, Panama. Army Medical Department Television and Multimedia, Fort Sam 

Houston, TX, Video #A1701-90-0087, 1990.

FIGURE 9-13. [Bottom Right] A soldier recovering from abdominal surgery at the Joint Casualty Collection Point just off of the flight line at Howard Air Force Base, Panama. Army Medical Department Television and Multimedia, Fort Sam Houston, Texas, Video #A1701-90-0087, 1990.
338 • FORWARD SURGERY

Expecting to be in Panama until 5 January 1990, the 1st AES mobilized almost 

immediately after the National Command Authority ordered the invasion.39 The first of 

thousands of additional troops bound for Panama,35 the initial echelon of the 1st AES and 

the provisional FST from the 5th MASH flew from Pope Air Force Base, North Carolina, 

at approximately 2045 hours on 17 December 1989, 3 hours after being notified for 

mobilization. This early element of medical professionals arrived at Howard Air Force 

Base, Panama, and became operational at approximately 0200 on 19 December, nearly 

24 hours before the invasion was scheduled to begin.39 By 0100 hours on 20 December, 

Special Operations forces began attacking key Panamanian targets. Forty-five minutes 

later, conventional forces began movement to seize the land approaches to Panama 

City.36(pp38–40),37 By 0115, the first casualties arrived at Howard Air Force Base. The first 

C-141, carrying approximately 40 patients and two medical attendants, lifted off for Kelly 

Air Force Base in San Antonio at approximately 0715 on 20 December 1989.39

The JCCP, located just off of the runway at Howard Air Force Base, was home 

to the 44th Medical Brigade tactical operations center, the 5th MASH FST, and the 

1st AES. The Air Force’s 24th Medical Group, normally assigned to staff the medical 

facilities at Howard, also provided personnel and coordinated for some power, billeting, 

communication, and supply requirements for the JCCP. Initially, 14 physicians (including 

10 surgeons) triaged patients as they arrived at the JCCP. While the primary means of 

evacuation was air (Figure 9-14), the JCCP received patients from a variety of sources, 

including UH-1, UH-60, OH-6, HH-53, CH-47, and C-130 aircraft, as well as bus, van, 

pick-up truck, high-mobility multipurpose wheeled vehicle (HMMWV), and motorcycle. 

Some patients also walked in.27,37

Those patients requiring surgical intervention were taken to the tent for the 5th MASH 

FST for care. The patients remained at the FST for up to 4 hours before being transferred 

FIGURE 9-14. An Army medical evacuation helicopter sits in a field in Panama, awaiting an evacuation 

mission. Undated. Photograph courtesy of the Army Medical Department Center of History and Heritage, 

Fort Sam Houston, TX, Image #19851176-5-large.jpg. 
CHAPTER NINE • 339

FIGURE 9-15. A diagram of the Joint Casualty Collection Point at Howard Air Force Base, Panama, late in 

Operation Just Cause, December 1989–January 1990. Diagram courtesy of the Army Medical Department 

Television and Multimedia, Fort Sam Houston, TXs, Video #A1701-90-0087.

to the nearby mobile aeromedical staging facility (MASF), manned by the 1st AES, in 

preparation for evacuation to Kelly Air Force Base. In the first 48 hours of the operation, 

the JCCP had no holding capacity, and all patients were evacuated out of theater if they 

could not be immediately returned to duty. Eventually, the JCCP was augmented with 

the 274th Medical Detachment and a clearing platoon that, combined with the MASF, 

provided an 80-bed holding capacity.27,37 The 307th Medical Battalion deployed a small 

surgical team with the 82nd Airborne Division as well. However, while the 307th Medical 

Battalion treated 474 Americans and 288 Panamanians in a 23-day period, the seriously 

injured patients were taken to the JCCP (Figure 9-15) for treatment and evacuation rather 

than being treated surgically by 307th Medical Battalion personnel.27

By Christmas 1989, most of the Panamanian Defense Forces were neutralized, 

the Panama Canal remained open, and American forces secured the release of thirteen 

hostages held by remnant Panamanian Defense Forces.36(pp49–53) With Noriega’s capture 

still outstanding, the American military focus in Panama turned to securing the new 

Panamanian government and providing humanitarian assistance to local nationals in need. 

Dubbed Operation Promote Liberty, the civil affairs mission took ownership of most Joint 

Drainage Ditch

Special Cat

FST-5 MASH

SLEEP

MIN

HOLD

MASF

EVAC

SLEEP

Triage MASF

FLIGHT LINE

N Sleep Sleep

FST-274th

MASF

SLEEP

SUPPLY

WARD

CL VIII

ANTENNA

FARM

MORGUE

Bde HQ

SLEEP

SLEEP
340 • FORWARD SURGERY

Task Force South assets.36(p65) From 26 December to 3 January, American forces distributed 

1,660 tons of food and 218 tons of medical supplies (worth $3 million) to the Panamanians 

while organizing a camp for nearly 5,000 local nationals displaced during combat 

operations. Eight days after the invasion began, the 44th Medical Brigade transitioned 

all surgical needs for the joint operations area to a team of professionals at Gorgas Army 

Hospital, whose staff was augmented by staff from a medical mission in Honduras as well 

as Fitzsimmons Army Community Hospital in the United States. On 3 January 1990, just 

after the capture of Noriega, many of the 17,000 American troops (who entered Panama 

just a few days prior) began to return to the United States.36(pp63–69),37

According to COL Foust, the JCCP medical staff treated a total of 365 patients, 

over half of which were Panamanian civilians or Panamanian Defense Force troops. 

Of these, 261 patients came in the first 2 days of the operation.27,37 The majority of the 

patients (233) arrived by ground. In the 8 days they supported Just Cause, the 5th MASH 

FST and the 274th FST conducted 73 surgical procedures. Only 22 were categorized as 

“major surgeries,” most of which involved abdominal or chest procedures. Specifically, the 

cases were categorized as: head (5, or 7%), chest (10, or 14%), abdomen (11, or 15%), 

extremity (35, or 48%), and multiple wounds (12, or 16%).37

All told, of the 26,369 American troops deployed to Panama for Operation Just 

Cause, 322 suffered injuries and an additional 23 were fatalities.31,36(p65),37 Only two of these 

service members reached an FST prior to death,38 one dying while in surgery at Howard 

Air Force Base and the other dying after arriving at Kelly Air Force Base.39 Of the 322 

American casualties, 258 were evacuated to Kelly Air Force Base and regulated to one of 

the two military hospitals in San Antonio. Of these casualties, 149 suffered only one injury, 

while approximately 90 had two or more injuries. The vast majority of all injuries (86%) 

were the result of penetrating injuries, and 71 casualties were injured during the nighttime 

airborne operation into Panama.39,41

As a low-intensity conflict, Operation Just Cause provided valuable insight into the 

future doctrine of American FSTs. The mission marked the first time an American FST 

parachuted into a combat zone. Unfortunately, the team’s effectiveness as a medical asset 

on the drop zone was hindered by the need to wait for the aircraft to land before the team 

could access and set up its equipment.28 Future iterations of the airborne FST would see 

the equipment (hardened for the airborne mission) parachuted onto the drop zone minutes 

prior to members of the team exiting their own aircraft. 

Establishing a medical logistics train and an evacuation pathway soon after combat 

operations began were also important factors. The early hours of the operation resulted in 

the greatest workload for the medical teams. Of the 257 patients treated at the JCCP, 192 

casualties were treated, stabilized, and evacuated in the first 27 hours. Furthermore, the 

surgical team at Howard conducted 20 major surgeries in the first 36 hours of operation.39

Additionally, and unexpectedly, one battalion aid station reported caring for more than 

140 casualties in the first 12 hours of the operation, 100 of whom were Panamanian local 

nationals. This early transition to humanitarian care forced upon the American medical 

logistics system a sudden need for obstetrics and gynecological, field sanitation, and 

pediatric supplies and equipment.38,42 Such factors may not have been anticipated prior to 
CHAPTER NINE • 341

FIGURE 9-16. Medics of the 4th Battalion, 6th Infantry Regiment, 5th Infantry Division (Mechanized) 

crossing the Panama Canal in an M113 ambulance days after the invasion into Panama, December 1989–

January 1990. Photograph courtesy of the Army Medical Department Center of History and Heritage, 

Fort Sam Houston, TX, Image #19851176-22-large.jpg.

Operation Just Cause, but this American experience would serve as a prelude to important 

considerations prior to the employment of FSTs in future operations (Figure 9-16).

Operation Just Cause served as an important step towards the formal establishment 

of FSTs in the US Army, validating their usefulness in a combat zone.27,37 Vetted in the 

experiences of Urgent Fury and Just Cause, agility and adaptability would soon become a 

benchmark of forward surgical doctrine. Various Army units began to create ad hoc, locally 

funded and equipped surgical squads similar to the 274th Medical Detachment or the 

5th MASH FST. The 25th Infantry Division developed a “light surgical unit deployable,” 

while the 6th Infantry Division deployed an airborne-capable team to Australia in 1991 to 

conduct exercises with the Royal Australian Surgical Team.27 In rapid deployment scenarios, 

health service support operations face numerous challenges, including operating in urban, 

mountainous, and jungle environments. Additionally, in operations during this period 

medical planners found that supply, communication, evacuation, patient accountability, 

and task force composition considerations were hindered by operational security 

considerations.37,38 The ability of the FST to adapt to the operating environment, and to 
342 • FORWARD SURGERY

function as independently as necessary, might have reduced the effect these limitations had 

on mission execution in Panama, and proved prescient in the following years.

Operations Desert Shield and Desert Storm: 

The 1990–1991 Persian Gulf War

As the operational environment has evolved, rapid deployment of American military 

assets in response to a sudden tasking from the National Command Authority has become 

an increasingly likely occurrence. These small, low-intensity conflicts, while more frequent, 

have not completely replaced the large-scale wars of decades past. For the US military, 

the consecutive operations Desert Shield and Desert Storm served as the first large-scale 

conflict since the Vietnam era, resulting in more than 500,000 personnel deployed to the 

Middle East by the end of hostilities in March 1991.43,44 As the conflict began, there was no 

immediate need for small-scale surgical assets in the deserts of the Middle East. American 

forces moved into the region over several months prior to the start of combat operations, 

allowing for the gradual buildup of medical assets in Saudi Arabia and other Arab nations 

in the region, which eventually peaked at 44 Army hospitals (more than 13,000 hospital 

beds).43,45 The US Air Force also provided 15 hospitals (more than 1,000 beds), while the 

US Navy provided three fleet hospitals (approximately 1,500 beds) and two hospital ships 

(approximately 2,000 beds).45 Once combat operations began, however, the need for a 

highly mobile surgical capability became apparent.

 In the months after the fall of the Berlin Wall, the strategic equation throughout the 

world changed significantly. The Soviet Union fell, and with its collapse, the alliances 

between the Kremlin and Eastern Block nations, Cuba, and many countries of the Middle 

East disintegrated. The United States became the lone “super power” and began to 

renegotiate alliances with some former members of the Soviet Union and Warsaw Pact 

nations. Free of the diplomatic reins laid upon him through Iraq’s patron-client relationship 

with the Soviet Union, Saddam Hussein grew emboldened to lay claim to the oil-based 

wealth of the kingdom of Kuwait in order to pay off the debt his nation accrued during 

the Iran-Iraq War of the 1980s.46(pp1–2) Hussein invaded Kuwait in the first days of August 

1990. The United States, at the behest of the Saudi king, acted quickly to position troops 

between Iraq and Saudi Arabia, signaling America’s intent to protect the oil-rich nation. 

The first American troops began arriving in Riyadh, Saudi Arabia, on 9 August 1990.46(pp5–6)

Within a few short months, as tensions rose and Saddam Hussein became more resistant 

to international pressures to withdrawal from Kuwait, the American-led coalition grew to 

more than 500,000 soldiers.43

Months of political wrangling between the United States, the United Nations (UN), 

the Arab community, and Iraq proved fruitless. Hussein refused to withdraw his forces 

from Kuwait. The prelude to a lightning quick defeat of the Iraqi forces began on 17 

January 1991.46(p29) Massive air strikes and missile bombardments nearly eliminated the 

Iraqi military command and control capabilities. The coalition achieved air supremacy and 

began targeting the Iraqi Scud missile architecture in an attempt to limit the missile’s impact 

on the coalition ground forces staging in the region.46(pp29–30) Thirty-eight days into the air 

campaign, the ground assault into Kuwait and Iraq began.46(p35) Starting on 24 February 

1991, General Norman Schwarzkopf’s now infamous “left hook” sealed the Iraqi forces 
CHAPTER NINE • 343

in Kuwait and cut off the Iraqi logistics trains coming from Baghdad, eliminating any 

opportunity for the Hussein regime to mount a significant resistance, while the bulk of 

the coalition pushed the Iraqi forces from Kuwait.46(pp34–63) Coalition forces achieved their 

objective, the liberation of Kuwait, in a little more than 4 days.

The health service support plan for operations Desert Shield and Desert Storm 

required the “fastest military buildup the AMEDD [Army Medical Department] had ever 

undertaken.”47 Concerned over the potential use of chemical weapons (Hussein was known 

to have used chemical weapons against Iranian soldiers during the previous decade), the 

Army ordered 23,493 healthcare personnel to Southwest Asia. In addition to executing 

other medical missions, these healthcare providers equated to 13,580 patient beds in 

44 hospital units throughout the theater of operations.48,49(pp12–13) By the time combat 

operations began, 198 medical units littered the deserts of Southwest Asia.48(p12)

Because the Army was in the midst of a medical support reorganization, which 

saw many Army Forces Command medical units fielding deployable medical systems 

(DEPMEDS) and doctrine moving to the Medical Force 2000 concept, many of these 

hospital units were ill-equipped for maneuvering on the battlefield with the high-speed 

flow of operations.43,47,48(pp4–5),49,50 Of the 44 Army hospitals in theater, 35 completed the 

transition to DEPMEDs before the operation began. The other nine hospitals (from the 

Reserve component) staffed host-nation facilities in Saudi Arabia and did not need to 

transition at that time.51 However, hospital units lacked the equipment necessary to move 

the supplies and equipment needed to function. Moving a MASH, with its personnel and 

1,450 tons (or 42,000 cubic feet) of supplies and equipment, required enough trucks to 

move 21 M1A1 Abrams main battle tanks.48(p40) Similarly, moving a CSH, with all of its 

personnel and equipment, would take approximately 7 calendar days.48(p42) In development 

since the early 1980s, the Medical Force 2000 concept did not recognize the need of FSTs 

beyond an augmentation capability. The goal of this concept was to move state-of-theart surgical capabilities forward, but it did not formally call for movement of forward 

resuscitative capabilities outside of the hospital setting.27 Instead, to meet the health service 

support challenges brought on by General Schwarzkopf’s fast-paced maneuvers on the 

battlefield, commanders developed adjustments in the operability of these medical units.

To meet the need for speed and mobility, the two Army component command elements 

took varying approaches to adjusting how they employed the CSHs and MASHs, assigned 

as corps-level assets. Deployed in a ratio of roughly one per division, the MASH became 

the locus of healthcare for the maneuver units.52 The XVIII Airborne Corps attempted 

to make its hospital units completely mobile. In doing so, the Corps actually reduced 

the surgical and bed capacity of its hospitals by half, including one MASH that had 12 

beds and four operating room tables.48(p43),52 Rather than reducing capacity, the VII Corps 

decided to keep its hospital units intact, moving them as complete sets when necessary. 

They were unable to keep up with the combat operations, however, and were forced to 

accept increasingly long evacuation routes as a consequence.43,46(p43–44) In the end, only the 

159th MASH became fully operational for the VII Corps.52

Although it was unplanned, employment of the 5th MASH and the 274th FST 

(Airborne), formerly the 274th Medical Detachment, both assigned to elements of the 

XVIII Airborne Corps, served as the “proof of concept” for the FST of future Army 
344 • FORWARD SURGERY

medical doctrine. The 5th MASH FST, a subcomponent of the MASH (as it was designed 

and employed during this war), was meant to break off from the MASH and push forward 

in an area with the advancing maneuver units.43,44,48,53 Once in place, the FST would 

function independently while the rest of the MASH moved forward (over 24–36 hours). 

The FST’s 20 personnel and two operating room tables were designed to be operational 

within 2 hours.43,44,53

During the ground portion of Operations Desert Shield and Desert Storm, the 5th 

MASH was tasked with moving into Iraq as a part of the “left hook.” The 5th MASH 

forward surgical element (FSE), a 110-person element with four operating room tables, 

pushed into Iraq and operated fully for 48 hours before being joined by the 5th MASH 

(-). The 5th MASH (-), a slightly larger portion of the MASH (but not the main body of 

the hospital), provided a 36-bed hospital capacity and four operating room tables. Once 

joined up, the 5th MASH FSE and 5th MASH (-) combined to care for injured patients for 

7 days inside of Iraq. The 5th MASH FST, a subcomponent of the 5th MASH FSE, pushed 

even farther into Iraqi territory and operated for a week while American combat elements 

retrograded into Saudi Arabia, receiving much of its logistical support from other medical 

elements (battalion aid stations and forward support companies) in the area.27,43,44,54

The 274th FST (Airborne), commanded by LTC Al Muench, became the lead element 

of Task Force 6, a medical task force created by COL Eldon Ideus, commander of the 1st 

Medical Group. Supported by a platoon from the 595th Clearing Company, a platoon 

from the 547th Clearing Company, and the 565th Ground Ambulance Company, Task 

Force 6 was attached to the 24th Infantry Division (Mechanized) and provided care to 

elements of the lead brigade as they entered Iraq. Although 100% mobile, proximity and 

poor weather forced the task force to work closely with the division medical company, 

using the company’s expandable container trucks to perform surgery after the division’s 

first engagement. Once weather improved, Task Force 6 moved with the assaulting 

elements of the 24th Infantry Division, using its canvas shelters to provide cover during 

surgery on three separate occasions. By the time the cease-fire was announced, Task Force 

6 had moved past Objective Orange near the Euphrates River and began movement east 

along Highway 8. Unexpectedly, the medical element’s largest onslaught of casualties came 

after the cease-fire, when an Iraqi element unaware of the cessation of hostilities attacked 

the 24th Infantry Division, producing a large number of Iraqi casualties.27

While not the only FSTs operational during Operations Desert Shield and Desert Storm, 

the XVIII Airborne Corps employment of the 5th MASH FST and the 274th Medical 

Detachment demonstrated how the operational limitations of MASH and CSH units 

could be overcome. In the years following Operations Desert Shield and Desert Storm, 

medical planners began to evaluate future developments in combat operations, operating 

environments, and strategic threats.48 For example, during a September 1991 forward 

surgery conference sponsored by the Army Medical Department Center and School, medical 

leaders from the 5th MASH, 101st Airborne Division, Special Operations Command, 44th 

Medical Brigade, and XVIII Airborne Corps used their combat experiences to shape forward 

surgical doctrine, establishing that an FST would have enough supplies to be capable of 

treating 10 seriously injured patients in 24 hours. Further, conference attendees agreed that 

after 48 hours of continuous operations, the assigned FST personnel would need to be 
CHAPTER NINE • 345

rotated out in order to maintain the surgical capability at that location.27 Non-Department 

of Defense entities, such as the General Accounting Office, made recommendations on the 

future of war as well.48 Medical units needed to be lighter, more rapidly deployable, and 

fully mobile, many reports argued.48,50,55 Foreseeing an operational environment that did 

not include air superiority, but required fast-moving or distant combat operations, medical 

planners recognized that “[p]roviding good medical care to wounded soldiers where they 

really need it may require [the Army] to sacrifice equipment and supplies as a cost of 

doing business.”55 In time, many MASH units were deactivated as a part of the Medical 

Reengineering Initiative, the successor concept to Medical Force 2000,27 making room on 

the Army rolls for the rise of individually designated FSTs. 

TRANSITION TO FORMAL FORWARD SURGICAL 

TEAM DESIGNATION

It would be more than a decade before the Army faced another major conflict that 

required the linear battlefield and fast-moving pace of combat seen in Operation Desert 

Storm. The downward trend of DOW rates for American forces (from 9.0% in World 

War I to 0.5% in Operation Desert Storm), and the ease of victory in Operation Desert 

Storm, gave the American military a newfound sense of strength.1(p8) As the 20th century 

came to a close with the United States as the lone “super power,” the National Command 

Authority increasingly tasked American military personnel to enforce peace in situations 

throughout the world. These relatively small, low-intensity conflicts (sometimes referred to 

as asymmetric warfare) appeared to be the future of American military missions. Yet major 

combat operations, and the desire to reduce the DOW rates even further, remained at the 

forefront of medical operational planning. Medical planners recognized the usefulness of 

the FST in a variety of operational settings and knew that such environments would require 

“increasingly mobile and flexible trauma surgical support.”43

Operations Restore Hope and Continue Hope: Somalia 1993

Though interested in demonstrating the capabilities of the FST, military medical 

planners could not justify the use of FSTs in every military operation in the 1990s. 

Popularized by the storied events of October 1993, commonly referred to as the “Black 

Hawk Down” incident, Operations Restore Hope and Continue Hope (8 December 1992–

25 March 1994) were generally inconsequential to the development of FSTs in the US 

Army.56,57(pp483–485) Aimed at providing armed delivery of relief supplies to the impoverished 

and famine-stricken citizens of Somalia, the UN-sanctioned operations developed in 

phases, allowing for deliberate medical planning and positioning, rather than the urgent 

deployment of an agile FST. Additionally, with the involvement of some 38,000 soldiers 

from 23 different nations, the operations were on a larger scale than could be adequately 

supported by FSTs.56

Instead, operations Restore Hope and Continue Hope were supported by the 

86th Evacuation Hospital out of Fort Campbell, Kentucky, followed by the 42nd Field 

Hospital (Fort Knox, Kentucky) and the 46th CSH (Fort Devens, Massachusetts) in 
346 • FORWARD SURGERY

rotation.57(pp484–485) The facility, which at one point reached a capacity of 104 beds, 

consistently cared for 40 to 50 patients in the emergency room and approximately 50 

inpatients per day, well beyond the capabilities of a FST.57(p491) It was the 46th CSH that 

absorbed the brunt of the casualties when Task Force Ranger attempted to capture Somali 

warlord Mohamed Farrah Aidid on 3 October 1993. The 46th CSH had only 52 beds, half 

of the previous iterations of the hospital, and was only staffed for 32 beds. In 2 days, the 

46th CSH received 60 casualties from the operation, conducted 56 operative procedures, 

and evacuated 55 patients to Landstuhl Army Medical Center in Germany.57(p495) Across 

the span of the operations, the 11 contingency hospitals in Somalia saw a total of 5,938 

admissions and 198 strategic evacuations.56 Certainly, the scope and length of medical 

coverage required in Somalia could not have been better provided by a FST.

United Nations Intervention in the Former 

Republic of Yugoslavia: 1992–2004

Almost simultaneously, along the Mediterranean Sea, unrest in the formerly Sovietbacked Republic of Yugoslavia splintered the nation into eight geopolitical entities. 

By December 1991, nearly 10,000 Balkan citizens died at the hands of their fellow 

countrymen and another 600,000 became refugees57(p503) as the various political entities 

jockeyed for power and the republics maneuvered for independence. By April 1992, as civil 

war erupted, the UN (under Security Council Resolution 749) authorized the movement 

of a peacekeeping contingent to the region, scattering personnel throughout the Bosnia 

and Croatia republics.57(p503),58 UN Protection Forces, led by a US contingent, swelled to 

more than 40,000 personnel from 38 different countries by 1995.59 Throughout this civil 

war, even with the UN troop presence, between 140,000 and 250,000 people were killed 

and 1.3 million sought refuge throughout the Balkan region by the time the Dayton Peace 

Accords were signed in 1995.58

Health service support for the initial peacekeeping contingent in Bosnia and Croatia 

came from Europe-based MASHs, which were charged with providing Role 3 coverage 

to the UN Protection Force. The 212th MASH was ordered to deploy in October 

1992, landing in Zagreb, Croatia, the following month. The 60-bed hospital located at 

Camp Pleso, just outside of Zagreb, was ordered to provide care and a 30-day patient 

hold capability for the over 20,000 strong UN forces, including UN civilians in the 

area.57(p505),60(pp18–20) A joint, unified effort, the Role 3 responsibility at Zagreb rotated from 

the 212th MASH to the 502nd MASH (April 1993–October 1993), then to the Air Force’s 

48th Air Transportable Hospital (October 1993–March 1994), and finally to the Navy’s 

Fleet Hospital 6 (March 1994–August 1994).60(p16) Role 2 care in theater was assigned to 

the European partners in the UN Protection Force.60(pp19–23)

FSTs were used in the early operations in Bosnia and Croatia, specifically in locations 

such as Kinin in the Republic of Serbian Krajina and Visoko in Bosnia and Herzegovina.59

They were not, however, employed by American units. During the initial rotations of 

American medical units, the 212th and 502nd MASHs (surrounded by a large population 

of refugees) clung to the initial guidance for the medical rules of engagement and avoided 

sending medical personnel out into the various sectors of the theater.60(p20) It was not until 

the 48th Air Transportable Hospital took charge of Role 3 care that Americans began 
CHAPTER NINE • 347

supplying medical personnel at the Role 2 locations, providing liaisons to various regions 

of the theater, and expanding the mission to include refugee care. During its rotation, Fleet 

Hospital 6 expanded the healthcare mission in theater even further, taking on the Role 4 

mission (in conjunction with local hospitals) as well as much of the Role 2 mission.60(pp20–23)

It was not until American forces returned to Bosnia and Herzegovina in 1995, as a 

part of Operation Joint Endeavor, that an American FST-type unit was deployed to the 

Balkans. After the North Atlantic Treaty Organization (NATO) launched air strikes into 

the region in August 1995, representatives from the warring Serbians, Croatians, and 

Bosnian Muslim factions gathered at Wright Patterson Air Force Base near Dayton, Ohio. 

An agreement, eventually referred to as the General Framework Agreement for Peace, was 

signed in Paris on 14 December 1995.58 However, medical assets would still be needed, and 

the 67th CSH was notified of its impending mobilization in support of Operation Joint 

Endeavor (20 December 1995–20 December 1996) on 11 December 1995.57(p513) By the 

time the contingent of 67th CSH personnel arrived in the Balkans in January 1996, the 

212th MASH FSE was already in place near the Sava River.57(p514) Once the 67th CSH was 

in place, the 212th MASH surgical element redeployed to Germany. As stability began to 

spread in the region, numerous MASH and CSH units rotated to theater in support of the 

NATO peacekeeping mission in Bosnia and Herzegovina.57(pp520–524),58

As Bosnia and Herzegovina stabilized, however, ethnic Albanians in the Serbian 

region of Kosovo began an aggressive pursuit of independence. In 1996, the Kosovo 

Liberation Army began launching attacks on Serbian police forces. In response, the Serbian 

government began a practice of expulsion of ethnic Albanians, resulting in 1,500 dead 

and 400,000 Albanian refugees.61(pp9–10) In early April 1999, in preparation for execution 

of Operation Allied Force, the 67th FST deployed to Camp Able Sentry, Macedonia, 

in support of Task Force Falcon. At approximately the same time, a sliced portion of 

the 212th MASH (roughly equivalent to 1.5 FSTs) deployed to Tirana-Rinas Airport in 

Albania, with lead elements of NATO forces, in support of Task Force Hawk.57(pp524–525),61

The two FSEs provided forward resuscitative surgery in their respective regions for several 

months. On 16 June 1999, just after Operation Joint Guardian began, the 67th FST moved 

to Camp Bondsteel, near Urosevac, Kosovo, where it provided resuscitative surgery until 

14 July 1999, when the larger 67th Contingency Medical Force took over responsibility 

for the region.57(p524) By 2 August 1999, the 212th MASH and all Task Force Hawk units 

departed Albania, and Operation Allied Force had ended.61 As Task Force Falcon settled 

into the 6-month rotations of personnel in and out of Kosovo in support of Operation Joint 

Guardian, two new medical elements entered the rotation as augmentations to the medical 

task forces slated for service in the theater. 

Formal Establishment of the Forward Surgical Team: 1994 

In January 1994, based on the rapid deployment and high mobility needs of the Army 

in Panama and Iraq, the Army chief of staff approved the formal establishment of the FST 

on the Army manning documents.57(p526) In March, proponents of the FST began circulating 

for comment draft TO&E documents for the “medical team, forward surgical” and 

“medical team, forward surgical (airborne).”27 With the goal of reducing the overall DOW 

rate by providing early intervention and rapid evacuation, the formal fielding of the new 
348 • FORWARD SURGERY

units began in fiscal year 1997.1 In September 1997, the first version of Field Manual 8-10-

25, Employment of the Forward Surgical Team, was published.27 The deployment of the 

67th FST into Kenya in 1998 and the 160th FST and 250th FST into the Kosovo theater 

of operations in 1999 and 2000 marked the first formal deployments for the newly minted 

Army FST.25,57(p526)

A little closer to home, in mid-September 1994, elements of the XVIII Airborne 

Corps, the 82nd Airborne Division, and the 10th Mountain Division deployed in support 

of Operation Uphold Democracy.57(p541) Bent on protecting Americans in the small island 

nation and returning to power the democratically elected president, Jean Bertrand Aristide, 

American forces gained control of Haiti on 19 September 1994 without shots being 

fired.62(pp69–79) Members of the 274th FST were among the first medical assets to arrive on 

the island, establishing a surgical capability by the end of the day on 20 September 1994. 

Within days, portions of the 28th CSH and the 47th Field Hospital followed.57(p543) The 

relatively uneventful operation gave the military medical teams opportunity to provide 

humanitarian assistance to the Haitian locals and identify health requirements that could be 

addressed by nongovernment organizations already operating in Haiti.62(pp130–132) 

On 31 March 1995, the American mission in Haiti was formally turned over to the 

UN as a nation-building mission. The 25th Infantry Division replaced the 10th Mountain 

Division as the senior command element on the ground and began working to establish 

some semblance of normality within the small island country.62(pp136–137) In the years that 

followed, the UN Mission in Haiti continued to provide humanitarian assistance to Haitian 

locals, and American military elements continued to be a part of that mission. Until 2000, 

medical personnel from all three branches of the US military rotated through Haiti on 

scheduled organizational rotations. FSTs, including the 555th FST out of Fort Hood, Texas, 

were a part of that medical rotation.57(p548)

On the recommendation of many government agencies, including the Government 

Accounting Office, FSTs were increasingly included in military and medical training 

scenarios, including the establishment of an FST-specific training program at Ben Taub 

Medical Center in Houston, Texas, in September 1998. Transformation of the Army 

medical force structure continued as personnel and equipment were regularly reallocated 

to field the 44 FSTs across the Army (active and Reserve components). In October 2001, 

just weeks after the terrorist attacks on the World Trade Center, the Army opened the doors 

to the Army Trauma Training Center at the Ryder Trauma Training Center in Miami, 

Florida.27 Coupled with the realistic, combat-oriented training at their home stations, FSTs 

that rotated through the Army Trauma Training Center soon became hardened teams 

ready for the eventuality of war. 

SURGEONS GENERAL DURING THE POST-VIETNAM ERA

LTG Bernhard T Mittemeyer (Falklands War and Grenada)

Lieutenant General (LTG) Bernhard Theodore Mittemeyer served as the surgeon 

general of the Army from 1 October 1981 to 31 January 1985.63 Mittemeyer immigrated 
CHAPTER NINE • 349

to the United States from Holland in 1944, when he was 14 years old. At the outset of 

the Korean War, the young college student was deferred from the draft so that he could 

attend medical school. When he eventually came on active duty, Mittemeyer volunteered 

for the 101st Airborne Division, in appreciation of the American unit that previously 

liberated his native country.64 A urologist by training, Mittemeyer served primarily in 

clinical roles throughout his early career. He was then assigned as commander of the 326th 

Medical Battalion and division surgeon of the 101st Airborne Division in Vietnam. Later, 

Mittemeyer was multi-hatted as the commander, US Army Medical Command-Korea; 

command surgeon, UN Command/US Forces Korea/Eighth US Army; and commander, 

121st Evacuation Hospital, before moving to the Office of The Surgeon General, where 

he served as the director of Professional Services and chief of Medical Corps Affairs. 

Mittemeyer served as the commanding general of Walter Reed Army Medical Center just 

prior to his appointment as the surgeon general.65 During his tenure as surgeon general, the 

Army instituted the three-event Army Physical Fitness Test for soldiers of all ages. Prior to 

1982, only soldiers under the age of 40 participated in the Army Physical Fitness Test due 

to concerns that rates of sudden cardiac death may rise for soldiers over 40.57

LTG Quinn H Becker (Mid-1980s Evolution)

LTG Quinn H. Becker served as the surgeon general of the Army from 1 February 

1985 to 31 May 1988.1 An orthopedic surgeon by training, Becker served primarily in 

clinical roles until he was assigned as commander of the 5th Surgical Hospital (Mobile 

Army) at Heidelberg, Germany. He later served as the division surgeon and commander 

of the 15th Medical Battalion, 1st Calvary Division (Airmobile), in Vietnam as well as 

surgeon of the XVIII Airborne Corps and commander of the US Army Medical Activity at 

Fort Bragg, North Carolina. Becker served as the surgeon, US European Command; chief 

surgeon, US Army Europe; and commander, 7th Medical Command, Heidelberg, Germany, 

just prior to his appointment as the surgeon general.66 During LTG Becker’s tenure as 

surgeon general, he oversaw the implementation of major quality assurance reforms in 

the Army Medical Department amid reports of serious problems with the medical care 

provided in the Army healthcare system.67,68

LTG Frank F Ledford, Jr (Mid-1980s Evolution)

LTG Frank Finley Ledford, Jr, served as the surgeon general of the Army from 1 June 

1988 to 30 June 1992.1 Also an orthopedic surgeon, Ledford served primarily in clinical 

roles until he was assigned as the surgical consultant at the Office of The Surgeon General. 

He later served as commander of the US Army Medical Activity, Fort Riley, Kansas, and 

then commander of the US Army Medical Activity, Fort Benning, Georgia. Ledford also 

served as the commanding general of Letterman Army Medical Center at the Presidio of 

San Francisco, California. Just prior to being appointed surgeon general, Ledford served 

as commanding general of the 7th Medical Command and surgeon of US Army Europe/

Seventh Army, Heidelberg, Germany.69 Operations Desert Shield and Desert Storm occurred 

during Ledford’s tenure as surgeon general. Due to concerns about Saddam Hussein’s 

propensity to use chemical weapons in combat, Army medical leaders, under Ledford’s 
350 • FORWARD SURGERY

direction, undertook unprecedented training and preparation for these Operations.70

Operations Desert Shield and Desert Storm required the first large-scale call-up of Army 

Reserve medical personnel since Vietnam.4 Many of the reservists bore a significant 

personal cost as they sacrificed their personal medical practices, often risking bankruptcy, 

to serve overseas.9 LTG Ledford also oversaw the medical operations for Operation Just 

Cause in 1989 and the initial operations into Yugoslavia in 1992.

LTG Alcide M LaNoue (Restore/Continue Hope, Formal 

Forward Surgical Team Establishment)

LTG Alcide Moodie LaNoue served as surgeon general of the Army from 8 

September 1992 to 30 September 1996. The third consecutive orthopedic surgeon to be 

named surgeon general, LaNoue served primarily in clinical roles until his assignment as 

commander of the 209th General Dispensary, 97th General Hospital, US Army Europe, 

the first of four consecutive command positions. LaNoue next served as commander 

of the US Army Medical Activity, Fort Stewart, Georgia, then at the US Army Medical 

Activity, Fort Benning, Georgia. LaNoue then served at Eisenhower Army Medical Center, 

Fort Gordon, Georgia, as the commanding general. He also served as commandant of 

the US Army Academy of Health Sciences, deputy surgeon general at the Office of The 

Surgeon General, and commanding general of the US Army Health Services Command 

prior to his appointment as surgeon general.71 During his tenure as surgeon general, LTG 

LaNoue oversaw the medical operations for operations Restore Hope and Continue Hope 

in Somalia. Additionally, LaNoue directed the development and maintenance of a new 

readiness posture in the Army Medical Department while significant downsizing occurred 

throughout the Army.72

LTG Ronald R Blanck (Yugoslavia Operations)

LTG Ronald Ray Blanck served as surgeon general of the Army from 1 October 

1996 to 30 June 2000. An internist by training, LTG Blanck initially served as a battalion 

surgeon in Vietnam before taking on roles primarily in clinical arena until his assignment as 

commander of the US Army Hospital, Berlin. Subsequent positions included commander, 

Frankfurt Army Regional Medical Center, Frankfurt, Germany, and director of professional 

services and chief of Medical Corps affairs in the Office of The Surgeon General. Just prior 

to his appointment as surgeon general, Blanck was assigned as commander of Walter Reed 

Army Medical Center and Northern Regional Medical Command.73 During his tenure as 

surgeon general, LTG Blanck also led the Army Medical Department through significant 

downsizing while balancing the need for medical personnel to support peacekeeping 

operations in Yugoslavia, a humanitarian mission in Haiti, and chemical/biological terrorist 

concerns in Japan.74

CONCLUSION

The evolution of forward surgery in the US military has followed an arduous path 

toward the reality of today’s battlefield. The medical lessons learned on the battlefields 
CHAPTER NINE • 351

of yesterday helped shape the care provided to the combat casualties today and in future 

conflicts. Adding FSTs to the medical formations on the battlefield provided the operational 

commander an element of agility and adaptability not previously known in American 

military history. Military operations since Vietnam provided a thorough testing ground for 

forward surgical doctrine. Through the continued evolution of that doctrine, the battlefield 

of the future may become more survivable.

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1 June 2015.
INTRODUCTION

THE SURPRISE ATTACKS ON THE WORLD TRADE CENTER and the Pentagon, 

and a third failed attack on an unknown target, by hijacked airliners on 11 September 2001 

marked the beginning of a new era in the United States that will be felt around the world for 

decades to come. Not since the surprise attack on Pearl Harbor had there been such support 

by US citizens, the government, and the military for a common cause. With the onset of 

the Global War on Terrorism (GWOT), the 

capabilities of US Army surgical personnel 

and forward surgical teams (FSTs) would be 

put to the test.

In 2001, Army forward surgery entered into an accelerated period of development, 

innovation, and overall significance. Members of US Army FSTs, their sister component 

surgical team equivalents from the Air Force, Navy, and the North Atlantic Treaty Organization (NATO), and the various supporting medical units, including logistical and evacuation assets, enabled the provision of life-, limb-, and eye-saving resuscitation for tens of 

thousands of military, civilian, and enemy patients.2 The FSTs’ ability to improve patient 

outcomes grew significantly over this period due to theater maturity, innovative concepts, 

and innovative technology. These capabilities were made possible by dedicated and passionate surgical leaders from the Medical Corps, Nurse Corps, Specialty Corps, Medical Service 

Corps, and Medical Enlisted Corps who chose to go beyond what was required of them. 

These leaders documented events, passed on lessons learned, and pushed for improvements. 

Chapter Ten

Put to the Test: 

Forward Surgical Teams 

Challenged During the 

Global War on Terrorism

JASON M. SEERY, MD, and DAVID W. CANNON, SR

IN THE MIDST OF CHAOS, THERE IS ALSO 

OPPORTUNITY. 

Sun Tzu1(p41)

247-809_text_CX.indb 355 12/27/
356 • FORWARD SURGERY

They followed their hearts rather than the expected path. This chapter will tell their story, 

describing how, in the chaos of war, they found opportunities to improve survival chances 

for the soldiers who took the greatest risk. Following in the footsteps of Napoleon’s famous 

chief surgeon and the father of modern military surgery, Baron Dominique Jean Larrey,3

these FST leaders and team members put the desire to save the combat wounded above 

their own fears of injury, made great sacrifices, and devoted themselves entirely to their 

patients. Their service in this period is the latest example of a time-honored tradition 

among combat surgeons and combat surgical support staff dating from the first wars of 

this country.

Over the course of the GWOT, the terminology for some key elements changed. One 

example was the evolution of the term “echelons” of care to “levels” of care, and then to 

the currently used “roles” of care. The term “levels,” which replaced “echelons” in 2001,4 

aligned joint assets into the level of care they were capable of providing when tactically employed. As the battlefield changed from linear to nonlinear, the term “roles” came into use 

about 2006 to better describe the medical unit’s capabilities, rather than the level or quality 

of care provided.5 This change also aligned with NATO medical terminology to ensure that 

all allied countries involved in the GWOT were following similar standards and “speaking 

the same language.”6 For the purpose of this chapter, the word “role,” when used to discuss the location and capacity of a unit, will refer to “echelon,” “level,” and “role,” unless 

otherwise specified, to lessen confusion.7–9

Another key definition that changed over the GWOT was what made up the Role 2 

surgical element or team for each of the services. During this period the US Department of 

Defense (DoD) conventional forces Role 2 surgical team varied significantly among the services. The Army Role 2 surgical unit, the FST, is a 20-person team made up of three general 

surgeons, an orthopedist, two anesthetists, an emergency care registered nurse, an operating 

room registered nurse, a critical care registered nurse, three licensed practical nurses, three 

operating room technicians, four medics, and one medical administration officer. Over 

the past 15 years, the FST has commonly been employed in a split 10-person configuration. The FST is assigned to augment a Role 3 Army combat support hospital (CSH), but 

is usually forward employed attached to a Role 2 medical company. Although the FST 

was specifically designed to not stand alone, it can conduct limited stand-alone operations 

(usually while supporting Special Operations forces). While working with a Role 2 medical 

company, the FST has access to additional physicians and registered nurses, dental support, 

combat and operational stress control staff, preventive medicine staff, and limited laboratory and X-ray capabilities.8,9 At times other nondoctrinal units have been established to 

fill the Role 2 surgical team position within the Army. This was usually done by forwardly 

deploying a section of a CSH. Known as a forward surgical element (FSE), its size ranged 

from 6 to over 30 staff members, based on unique mission needs. 

The Air Force Role 2 surgical unit comes in three basic platforms. First is the mobile 

field surgical team (MFST), a five-person team made up of a surgeon, orthopedist, anesthetist, emergency medicine physician, and an operating room registered nurse or operating 

room technician. The MFST is the basic surgical component of the two other Air Force 

Role 2 surgical assets. The second is the small portable expeditionary aeromedical rapid 
CHAPTER TEN • 357

response (SPEARR) team. This is a 10-person team made up of the MFST with the addition 

of a three-person critical care air transportation team (CCATT) and a two-person preventive medicine team. The CCATT consists of an intensivist physician, a critical care registered 

nurse, and a cardiopulmonary technician, while the preventive medicine team has a flight 

surgeon and public health officer. The third platform is the expeditionary medical support 

(EMEDS) basic, a 25-person team that includes the 10-person SPEARR team and an additional 15 staff members who provide medical or ancillary capabilities including sick-call 

capability, dental care, and limited laboratory and X-ray capability. The Role 2 EMEDS can 

be expanded with 10 extra staff and additional equipment (known as the EMEDS +10) that 

provide added holding capability, but no additional surgical capabilities.8,9

The Marine Corps Role 2 surgical unit comes in two basic platforms. First is the 

forward resuscitative surgical system (FRSS), an eight-person team with two surgeons, an 

anesthesiologist, a critical care registered nurse, two operating room technicians, and two 

corpsmen. Four FRSSs, along with four Role 1 shock trauma platoons and four en-route 

care teams, make up the larger surgical element known as the Marine surgical company. 

Of note, the surgeons, nurses, and enlisted corpsmen in the Marine Role 2 surgical units 

are Navy personnel, since the Marine Corps has no organic medical personnel.8,9 Similar 

to the US Army and Air Force, the Marines created nondoctrinal appropriately sized teams 

to perform the Role 2 surgical team mission. One example was the surgical shock trauma 

platoon (SSTP), which consisted of two FRSSs and one shock trauma platoon.10 

The Navy Role 2 surgical units also consist of two platforms, the casualty receiving 

and treatment ship (CRTS) and the fleet surgical team.8,9 These teams are ship-based, as opposed to the above-mentioned land-based platforms for the Army, Air Force, and Marines. 

Also of interest is how the NATO definition of the Role 2 is different than that used 

by the DoD. US forces use a more basic definition of Role 2 for a medical treatment facility 

providing greater resuscitative capability than that available from a Role 1 individual or 

facility. Surgical capability is not mandatory at Role 2 per US military doctrine, as opposed 

to the NATO definition, which states that a Role 2 facility will have the ability to provide 

damage control surgery. Therefore, in addition to the term “role” covering all prior definitions for the continuum of care, the term Role 2 surgical team, and at times FST, will describe the generic DoD or NATO Role 2 surgical unit, unless otherwise specifically stated.6

THE TWO MAJOR OPERATIONS OF THE 

GLOBAL WAR ON TERRORISM

Operation Enduring Freedom 

Intelligence agencies identified al-Qaida, a terrorist network led by Osama bin Laden, 

as the group that designed and executed the 11 September 2001 attacks. Al-Qaida was 

a global terrorist organization, but at the time of the attacks its leader and main facilities 

were based in Afghanistan. Afghanistan’s ruling government party at the time, the Taliban, 

was supportive of al-Qaida, protecting them from the United States and allied governments. After diplomatic efforts with the Taliban government leadership failed to resolve the 
358 • FORWARD SURGERY

capture of the al-Qaida attackers, military actions were implemented. Operation Enduring 

Freedom (OEF) commenced on 7 October 2001 in Afghanistan, marking the beginning of 

the GWOT. OEF’s initial primary mission was to locate and capture or destroy al-Qaida 

equipment, members, and leadership. Intense bombing of known training and command 

and control areas was done by the US Navy, with Tomahawk cruise missiles, and the US 

Air Force, with a variety of air-delivered bombs and missiles. Various Special Operations 

forces were simultaneously inserted to capture or kill remaining al-Qaida members and to 

coordinate an anti-Taliban movement.11,12

Healthcare for US and coalition conventional units and Special Operations forces was 

initially provided by each unit’s organic Role 1 and 2 medical assets, with very limited 

surgical capabilities.13 Special Operations forces were the first units to deploy in the war, 

with their organic medical personnel, which included Special Forces medical sergeants 

(military occupational specialty 18D) and Special Operations combat medics (68WW1), 

assigned to Special Forces Groups and Ranger regiments, respectively, as well as physician 

and physician assistant providers. These healthcare providers had received significantly 

advanced training in tactical combat casualty care (TCCC) and could perform limited 

surgical procedures to stabilize patients or avoid preventable causes of death. These medical 

soldiers also had advanced training in all aspects of the military, allowing some to enter the 

theater by airdrop parachute-forced entry (airborne units), air-assault entry via rotary wing, 

or air-land entry via fixed wing aircraft. Very limited numbers of US Special Operations 

Command surgical elements were forward deployed.14 These teams had various compositions of traditional trauma team members and could provide advanced surgical operations 

on individuals with lethal injuries. However, they could care for only a very limited amount 

of patients.8,14,15 These small teams provided life-saving resuscitation and surgery for the 

initial Special Forces soldiers in OEF. The patients were then evacuated from Afghanistan 

to surgical facilities located in surrounding countries and oceans.

A US Marine medical detachment with surgical capabilities was established at Camp 

Rhino, approximately 190 km southwest of Kandahar, Afghanistan, on 25 November 

2001. Its mission was to support the Marine Expeditionary Force, Army Ranger units, 

Army air assault units, Navy SEAL (sea, air, and land) units, local national forces, and 

enemy prisoners of war in their area of operations.16 The detachment was made up of a 

standard battalion aid station and shock trauma platoon, along with an operating room 

section from a different element. In total, it was staffed with 32 members, including two 

general/trauma surgeons, two anesthesiologists, three emergency physicians, two emergency 

nurses, one critical care nurse, one perioperative nurse, one physician assistant, one general 

medical officer, one medical regulator, one independent duty corpsman, three surgical 

technicians, and one general duty corpsman.8,16 The medical-surgical detachment provided 

initial resuscitative and surgical care to soldiers. Patients would then be evacuated to a Role 

2 facility on a CRTS (the USS Peleliu or USS Bataan), located in the Arabian Sea, or to the 

Role 3 theater hospital in Seeb, Oman, for continuing care. 

The detachment was operational on 4 December 2001 and received a total of 48 

casualties over a 6-week period. The first group (and largest number) of patients arrived one day after activation. When a NATO-fired Joint Defense Attack Munitions was 
CHAPTER TEN • 359

dropped too close to friendly forces, 21 US and 20 local national forces were injured. Due 

to the distance from point of injury to the medical facility, communication issues, and 

aircraft mechanical issues, patients arrived 5 to 6 hours after their initial injuries. Of the 

41 patients, 19 US casualties were taken immediately to Seeb, while two US and 20 local 

nationals remained at Camp Rhino. One of the US casualties was actually killed in action, 

and the other was moribund on arrival and deemed expectant secondary to a massive head 

injury, requiring only catastrophic injury management. Of the 20 local national casualties, 

one required surgery for a neck injury, two required chest tubes for thorax injuries, six had 

open fractures, and the remainder had superficial injuries. The following day the detachment received four additional patients, but none required surgical intervention. 

Ten days later, the detachment received the last group of patients during its rotation. 

Three US Marines were injured by an antipersonnel land mine located near Kandahar. 

Injuries included a hand-degloving injury to one Marine, a near complete lower-extremity 

traumatic amputation to a second Marine, and minor injuries to the third. The casualties 

arrived at Camp Rhino about 1.5 hours after their injuries. The patient with the leg injury 

was sent directly to Seeb, while the other two were treated at Camp Rhino. The patient 

with the hand injury underwent surgical debridement and washout.16

This medical-surgical detachment set-up, consisting of a shock trauma platoon and 

operating room section, along with a surgeon and anesthesiologist from the 2d Medical 

Battalion and personnel from a health service support detachment from the 15th Marine 

Expeditionary Unit, overcame many challenges early in the US war in Afghanistan. Its lessons learned helped ensure that future missions were better supported by leadership, staffing was improved, units were issued enhanced equipment and supplies, and pre-mission 

training was significantly enhanced.

The first US Army FSTs to deploy in the GWOT and treat surgical wounds were the 

250th FST (Airborne) from Fort Lewis, Washington, and the 274th FST (Airborne) from 

Fort Bragg, North Carolina.11,17 Both the 250th and 274th were among the initial set of 

modern FSTs officially activated in 1997. Both had the prestigious and challenging additional capability of being an airborne deployable FST, trained and equipped for early entry 

missions.18 In addition, the 274th was the final version of one of the initial surgical squads 

developed in the late 1980s that had participated in Operation Just Cause and Operation 

Desert Shield/Storm. Both FSTs supported the Combined Joint Special Operations Task 

Force-Afghanistan (CJSOTF-A). They would successfully perform numerous doctrinal and 

nondoctrinal tasks and missions, setting the tone for all others to follow. 

274TH FORWARD SURGICAL TEAM (AIRBORNE)

The 274th FST (Airborne) was assigned to CJSOTF-North and initially set up at 

Karshi and Khanabad Air Base (K2) in Uzbekistan between 14 October and 27 December 

2001.11,12 Major (MAJ) Brian S Burlingame had recently taken over as the team commander. During their deployment, in addition to saving the lives, limbs, and eyesight of 

numerous soldiers, Burlingame and his team created several innovative tactical solutions 

used as foundational methods by many follow-on units. The 86th CSH arrived at K2 on 

17 October 2001, but was not fully functional until 27 December. During these months 
360 • FORWARD SURGERY

the 274th cared for over 100 patients requiring surgical evaluation and treatment. K2 was 

many hours from the point of injury for some patients injured in Afghanistan and not the 

ideal place for an FST to perform its primary mission. To stabilize patients with preventable 

causes of death within the “golden hour” prior to evacuation to a higher role of care, the 

FST needed to be closer to the actual combat. 

Once the battlefield was more mature, with basic force protection and logistic channels better established, the FSTs could move farther forward. On 5 December 2001, the 

274th sent a small slice of their 20-person team into southern Afghanistan to help treat 

US casualties injured in a friendly fire incident near Kandahar. Once there, this five-person 

team joined and assisted the local Marine medical-surgical detachment team at Camp 

Rhino taking care of both US and Afghan Militia Forces casualties. Patients were evacuated to supporting Navy ships or to the surgical facility at Seeb Air Base. The five 274th 

personnel accompanied the patients on two C-130 Hercules aircraft, performing in-flight 

surgical procedures on some casualties. Two days later, the 274th was again asked to 

send a five-person surgical team into Afghanistan. This time the five-person team set up at 

Bagram Airfield and supported ongoing combat operations in eastern Afghanistan (Figure 

10-1). This move placed surgical assets much closer to the point of injury and improved the 

potential of survival and salvage. The remaining 15 team members and equipment stayed 

FIGURE 10-1. This area inside an abandoned building at Bagram Airfield was used for surgery by the 

274th Forward Surgical Team in 2002, initially with only a litter, litter stand, and a few medical equipment 

set chests. This rudimentary operating room slowly became more advanced as better facilities and equipment became available in theater. Photograph courtesy of MSG John Dominguez, former operating room 

specialist 274th FST.
CHAPTER TEN • 361

operational at K2 until the 86th CSH became functional and assumed surgical care for that 

area of responsibility. 

On 27 December 2001, the 274th FST main element left K2 and joined their colleagues in Bagram. The 274th FST would stay at this location until the end of their 

deployment on 8 May 2002, caring for over 130 casualties. A few days earlier, on 24 

December, a British Role 3 unit, the 34th Field Hospital Troop, set up at Bagram approximately 300 meters from the 274th FST forward echelon, and quickly established a mass 

casualty incident plan. On 20 January 2002, the 34th and 274th had their first opportunity to work together, caring for US Marines injured in a CH-53 (Sea Hawk) helicopter 

crash. On 28 January, a US Army CH-47 (Chinook) helicopter from the 101st (Airborne) 

Division crashed during a night mission with 26 personnel on board. Fortunately, no one 

died on impact, but 16 sustained injuries. Two other CH-47s on the mission collected the 

26 passengers and patients and transported them to Bagram, approximately 1 hour away. 

Unit medics provided en route care. Seven patients went directly to the 34th Field Hospital 

Troop. The 274th FST provided care for 12 of the patients with assistance from medical 

staff from the 10th (Mountain) Division. Three patients were later transferred to the 34th 

Field Hospital for continuing care. Patients requiring further treatment went on to the 

86th CSH in Uzbekistan. In the end, all of the patients from this mass causality incident 

survived their wounds. The 34th Field Hospital and the 274th FST would again work 

together during the care of multiple patients from a US Air Force C-130 Hercules crash 

on 13 February.19

The 274th and 34th experienced their largest number of casualties during Operation Anaconda. Operation Anaconda, the largest and longest US military operation since 

the Vietnam War, began on 1 March 2002 and was staged out of Bagram Airfield. It also 

occurred at the highest altitude ever recorded for combat engagement by US forces.11,12,20

The operation involved multinational forces, including the Afghan Militia Forces, with the 

aim of destroying the largest stronghold of Taliban and al-Qaida terrorists residing in the 

Shah-e-Kot Mountains in southeastern Afghanistan. The enemy was well entrenched and 

trained, and American and coalition forces met strong resistance. During the second day 

of the mission, the 274th cared for 50 casualties, performing five minor and eleven major 

surgeries with the collaboration of British and Spanish field hospitals in the area. The next 

day only three casualties arrived at the FST’s location. On mission day four, a CH-47 was 

shot down by enemy fire along with a search and rescue helicopter that went out to assist 

their colleagues. Eleven of the survivors had injuries requiring care at the FST, with six 

undergoing surgery. 

By the end of Operation Anaconda, 119 soldiers had been seen at the 274th FST, with 

32 major and minor surgical procedures performed. In total, the 274th provided trauma 

care to over 200 casualties and performed 103 surgeries.11,12 Without the FST’s presence 

during the initial invasion, many soldiers would have died. The staff’s collaboration with an 

allied force medical unit was unique at the time, but such collaboration would become common as the conflict in Afghanistan, and then Iraq, evolved. The FST’s personnel recognized 

the benefits of collaborating and worked through protocol and equipment differences. Their 

documentation of this partnership helped others who found themselves in similar situations 
362 • FORWARD SURGERY

over the years. The 274th’s professionalism and willingness to perform surgery in a highrisk and immature theater set a high standard for all who followed.

250TH FORWARD SURGICAL TEAM (AIRBORNE)

Providing an equally important mission and high level of care in the southern region of 

Afghanistan was the 250th FST (Airborne). It was assigned to CJSOTF-South and initially 

set up at Seeb Air Base, from 20 October 2001 to 24 December 2001.17 Lieutenant Colonel 

(LTC) Clifford Porter led the 250th during this important initial deployment. He and his 

unit overcame numerous obstacles and worked alongside many joint and allied colleagues, 

ensuring the unit successfully provided the necessary surgical and resuscitative support to 

the combat and support personnel in southern Afghanistan. While in Oman, they cohabitated with an EMEDS unit from the US Air Force 320th Expeditionary Medical Group.17,21

Within 24 hours of arriving at Seeb Air Base, the FST and EMEDS unit were ready to 

receive patients. The combined units had four trauma/resuscitation beds; eight emergency/

acute beds; seven intensive care beds with ventilators; 10 medical/surgical beds; a laboratory; digital radiography, angiography, and computed tomography (CT); and four fully 

functional operating tables.17 This joint facility took care of casualties from southwestern 

Afghanistan and areas near the Pakistani border. Similar to the situation with the 274th 

FST (Airborne), the location was many hours from the point of injury and not the ideal 

proximity for an FST to best perform its primary mission. Evacuation times from point of 

injury to the surgical facility could be as long as 6 to 12 hours.21 Soldiers with preventable 

causes of death requiring surgery might not make it to this location in time. Fortunately, 

combat forces were able to quickly secure the area around Kandahar. 

Once the area was secured, with basic force protection and logistic channels established, 

the 250th relocated. The team set up in a more forward position at Kandahar International 

Airfield on 25 December 2001 and remained there until 2 April 2002. These early teams 

would learn how to cope with the desert cold, snow and winds (Figure 10-2). On arrival, 

they briefly integrated with a Marine shock trauma platoon from the 26th Marine Expeditionary Unit. The team was fortunate to also spend a short period of time in late February 

2002 with the forward support medical company from the 3rd Brigade of the 101st Airborne (Air Assault) Division.17 Because the US Army FST is not designed to operate for long 

periods without Role 1 or 2 medical assistance, as well as other logistical and administrative 

support, these partnerships were welcomed while they lasted. The 250th spent its remaining 

time at Kandahar functioning independently without the doctrinal support of a battalion aid 

station, forward support medical company (also known as “Charlie Med” and now referred 

to as a brigade support medical company), or area support medical company.7–9,22–26

Evacuation times from Role 2 to Role 3 early in OEF were far from the approximately 

1-hour evacuation period for combat casualties of the mature theater during the Vietnam 

War.11,12,27 While patients were seen by their Role 1 providers to address their injuries and 

some of the preventable causes of death within minutes to hours, the surgical facilities in 

K2 and Seeb Air Base were hours away for many casualties, so patients were held longer 

prior to evacuation to definitive care. During this period (October 2001 to May 2002, 

when the 274th FST was the primary medical treatment facility for combat casualties in 
CHAPTER TEN • 363

Afghanistan), these facilities were not in an ideal geographical location to provide life-saving surgical intervention to the approximately 10% of casualties with surgically correctable 

torso injuries, the 9% with significant extremity vascular injuries, and all patients needing 

advanced resuscitation management or care from other lethal injuries.11,12,27 However, these 

early OEF prolonged evacuation times to Role 3 facilities were comparable to the 3- to 

4-hour evacuation times that the Soviets experienced during the occupation of Afghanistan 

in the 1980s.28

Once the 250th was established at Kandahar and the 274th at Bagram, evacuation 

times from point of injury dropped to a maximum of approximately 3 hours, significantly 

improving the chances of a soldier’s life or limbs being saved.21 During this deployment, 

the 250th cared for 50 surgical patients, conducted 68 surgical procedures, and established 

a surgical resuscitative care facility that served as the model in terms of the types of injuries and treatments provided by FSTs in Afghanistan for a brigade-sized unit.29 Like the 

274th, the 250th proved that a small group of highly motivated and properly trained and 

equipped medical providers could save the lives, limbs, and eyesight of patients no matter 

where they were called to duty.

FIGURE 10-2. A Blackhawk helicopter takes off on a MEDEVAC mission at Forward Operating Base 

Orgun-E in the Afghanistan winter, 2011. The 250th and 274th Airborne Forward Operating Teams (FSTs) 

were the first US Department of Defense surgical teams to carry out combat trauma resuscitation and 

surgery in Afghanistan. Their personnel learned to work in extreme cold, strong winds, rain, and snow. The 

1980th and 947th FSTs replaced the 250th and 274th in spring 2002, and were the first to experience the 

opposite extremes of high temperatures, sand storms, and very dry conditions. Photograph courtesy of 

LTC Dean Felldabaum, former commander of the 2nd FST.
364 • FORWARD SURGERY

1980TH AND 102ND FORWARD SURGICAL TEAMS

As combat continued, President George W Bush made it clear that the conflict would 

be much different from previous wars and that it would last for many years, and possibly 

decades. The US Army Reserves would become very active in supporting the GWOT. The 

1980th FST from Fresno, California,30,31 was activated in February 2002 and arrived in 

Kandahar that April to conduct a handover of surgical coverage from the 250th FST (Airborne). A few days later 1980th personnel found themselves saving the lives of six Canadian soldiers injured by a 500-pound laser-guided bomb, secondary to a friendly fire mishap 

from a US Air National Guard F16 aircraft.32 By the end of their 6-month activation, the 

1980th FST had cared for over 70 cases of combat trauma, including gunshot wounds and 

blast injuries, to all regions of the body in adult and pediatric patients.33

In August 2002, the 1980th passed on their experiences and trauma responsibilities to 

the 102nd FST, another forward surgical team from Fort Lewis, Washington, commanded 

by LTC Robert Handy.34 The 102nd FST deployed for 7 months, from August 2002 until 

March 2003. Their primary mission was to provide damage control resuscitative surgery 

in support of combat actions by the 101st and 82nd Airborne Divisions, Special Operations forces, and Afghanistan militia forces. The vast majority of the casualties were trauma 

related and consisted of a mix of US soldiers, Afghan militia and civilians, and coalition 

forces. The FST performed 112 surgeries on 90 patients during this time period.34 

947TH AND 909TH FORWARD SURGICAL TEAMS

The 947th FST, a Reserve medical unit from West Hartford, Connecticut, was notified 

on 11 March 2002 that it would mobilize and deploy to Afghanistan in support of OEF. 

LTC Robert W McAllister and his team arrived at Bagram Airfield on 28 April and began 

proceedings to relieve the 274th FST (Airborne).30 Under the CJSOTF-A’s command and 

control, the 947th FST would continue the hard work of the previous FST. However, in 

May 2002, the team was unable to save the life of an American Special Forces soldier who 

had been injured many hours from their location. 

The FST commander, LTC McAllister, coordinated with CJSOTF-A and explained that 

an FST could function even closer to the point of injury to provide high-quality life-saving 

resuscitation and surgery to injured soldiers if other support measures were taken by higher 

elements. The Alpha echelon of the FST jumped forward to Camp Harrison in Orgun-E to 

be closer to the current area of enemy engagement. The Bravo echelon stayed at Bagram 

and received additional support from members of the 405th CSH (Reserve) stationed in 

Kuwait. 

In July 2002, the 339th CSH (Reserve) was established (see below for more details), 

providing a more robust theater Role 3 facility. This allowed the 947th Bravo echelon to 

move forward to Orgun-E and reunite with the rest of its team. When not seeing patients, 

947th FST members assisted with other camp activities, including working with local 

national police forces and supporting various requests by the local US civil affairs units. 

The unit cared for, and saved, numerous combat trauma patients in its area of responsibility, and was well respected by its CJSOTF-A leadership. On 28 October 2002, the team left 

the theater and was replaced by another Reserve unit, the 909th FST, from Fort Sheridan, 
CHAPTER TEN • 365

Illinois, commanded by Colonel (COL) Dirk Wassner.35,36 With a little over half of the US 

Army’s FSTs in the Reserve, teams such as the 1980th, 947th, and 909th would be key in 

the success of forward resuscitation and surgery on the modern battlefield. 

The 1980th and 947th FSTs also represented other “firsts” in this war. They were the 

first US FSTs to perform combat trauma management in the sweltering heat of an Afghanistan summer. Their ability to overcome the environmental conditions, combined with other 

logistical, communication, and evacuation challenges, set a new standard. They also continued to build the FST’s strong reputation; their combatant colleagues and leaders soon came 

to consider the FST as the new “gold standard” of casualty care on the battlefield. 

555TH FORWARD SURGICAL TEAM

The last of the initial FSTs during the early period of OEF was the 555th FST from 

Fort Hood, Texas. Commanded by MAJ Young Choi, the unit was deployed to Kuwait 

from 21 November 2001 to 31 March 2002 in support of US military stationed in Kuwait. 

The FST primarily supported the 1st Cavalry Division. The team worked out of the Kuwait 

Armed Forces Hospital, where they evaluated and treated US service members, including trauma evaluations and a few surgeries. During their deployment, the 555th FST was 

tasked with sending a small surgical element to Kandahar to support a temporary mission 

gap. The care provided by the 555th FST was not on the same scale as that of the 274th 

or 250th FSTs, but it demonstrated a different capability of a modern US Role 2 surgical 

team, working with an allied nation and deploying a split element to a different country 

thousands of miles away for a special support mission. This deployment would also help 

the 555th prepare for an unexpected deployment one year later.37

339TH COMBAT SUPPORT HOSPITAL

Department of Army doctrine for the employment of the various levels of military 

medical treatment is based on Army Techniques Publication 4-02.5, Combat Casualty 

Care.

38 FSTs are normally employed in brigade combat teams on the basis of one per 

maneuver brigade. They are usually attached to a CSH for general support. When operationally employed, FSTs are attached to medical companies. An FST may also be a part of 

a medical task force in support of Special Operations forces.22,24,38,39 CSHs are normally 

assigned to a medical brigade (support). CSHs were first deployed to Afghanistan and Iraq 

under the Medical Force 2000-designed table of organization and equipment (TOE) and 

consisted of two modules: a hospital unit base and a hospital unit surgical. Later deployments were under the Medical Reengineering Initiative design (corps CSH), consisting of a 

hospital company A (84-bed) and a hospital company B (164-bed). Hospital company A 

was capable of providing an early entry hospitalization element of 44 beds and a follow-on 

hospitalization augmentation element of 40 beds. Many of the CSHs conducted split-based 

operations utilizing the 84-bed and 164-bed hospital facilities to provide healthcare support 

in separate locations. Other CSHs conducted operations in more than two locations, using 

a variety of deployment manning documents, requests for forces, and requests for augmentation to add additional personnel needed to operate multiple locations. As both theaters 

matured, it became increasingly common for CSHs to operate in fixed facilities and to uti-
366 • FORWARD SURGERY

lize theater-provided equipment. If the CSH was within 1 hour of the point of injury, then 

taking a patient to an FST is usually not required because the patients can get advanced 

surgical care within the “golden hour” at the CSH. 

The 339th Reserve CSH, from Pittsburgh, Pennsylvania, was alerted on 23 April 2002 

that it would be the first US military hospital deployed within the borders of Afghanistan. 

On 24 June 2002, LTC James C Post and his CSH arrived in theater and established the 

first Role 3 facility within the country’s borders at Bagram Airfield. They set up their 44-

bed CSH element 4 days after arrival and were fully ready to accept patients on 1 July, 

4 days ahead of schedule.40,41 Due to their proximity to the combat operations, the CSH 

would receive numerous patients directly from the point of injury. On 2 July the first patients arrived. They included four Afghani children injured by crossfire between US military 

and opposition forces. The proximity of CSHs to the point of injury remained the same for 

over a decade, up to the writing of this chapter, allowing CSHs in various regions to be the 

initial recipients of numerous casualties and the FSTs to be located even further forward. 

The 339th medical staff performed trauma evaluation on 531 patients and treated 

hundreds of others for sick call and other disease and nonbattle injuries. Patients included 

337 US military troops, 26 troops from allied countries, 15 US civilians, 10 enemy prisoners of war, and 140 local nationals (90 adults and 50 children). The team performed 518 

life-saving or stabilizing surgeries and procedures over a 5-month period.40 The 339th CSH 

set up the first military CT scanner in theater and introduced many other technologically 

advanced pieces of medical equipment.40

48TH COMBAT SUPPORT HOSPITAL

On 6 December 2002, 6 months after its arrival in theater, the 339th CSH was 

replaced by the 48th CSH.11,30 The 48th, commanded by COL Alan L Beitler, had been 

reactivated less than 2 years before, on 16 October 2000, and was the US Army’s first multicomponent CSH. The 48th CSH was designed to function as a 44-bed hospital; however, 

as with most other medical and surgical units during the GWOT, it was employed in a 

different manner. The 48th CSH was set up as a 28-bed hospital with 12 intensive care unit 

and 16 intermediate care ward beds, not using the remaining 16 intermediate care ward 

beds. The staff consisted of two general surgeons, one vascular surgeon, one orthopedic 

surgeon, two oral maxillofacial surgeons, two anesthesiologists, two anesthetists, one emergency medicine physician, two family medicine physicians, one internal medicine physician, 

one pediatrician, one radiologist, one physician assistant, sixteen registered nurses, and 

numerous licensed practical nurses, technicians, and medics. Patients were seen in a sick call 

area for routine issues or in the emergency treatment section for urgent medical, surgical, 

and psychiatric needs. There were two operating rooms arranged to perform three procedures simultaneously. 

During their 6-month deployment, from 6 December 2002 to 7 June 2003, staff of the 

48th saw 10,679 patients, including US forces, allied forces, Afghan militia forces, Afghan 

civilians, and enemy combatants, performing 358 surgical procedures on 168 casualties. The CSH also received all of the patients from the two FSTs that were functioning 

as smaller, split elements. Combined, the FSTs treated 91 casualties prior to sending them 
CHAPTER TEN • 367

to the 48th CSH. Patients were sent from the CSH to either Landstuhl Regional Medical 

Center in Germany, their host allied nation hospital, the Afghan military hospital in Kabul, 

or local civilian Afghan hospitals, based on the type of patient. US soldiers were transferred 

to Germany via the Air Force CCATT.13,42

ROLE 2 AND ROLE 3 EXPANSION

The FST and CSH elements continued to expand their coverage over the next decade. As of late 2014, there were four regional commands (RCs) in Afghanistan. There 

was a NATO Role 3 facility at Mazar-i-Sharif in RC-North, an Army/Air Force Role 3 at 

Bagram in RC-East, a Navy Role 3 in Kandahar in RC-South, and another Army Role 3 

split between various locations in RC-West. Numerous Army, Navy, and Air Force Role 

2 surgical and resuscitative units were located within each RC under the command and 

control of the Task Force Medical Brigade or CJSOTF-A. Most functioned as split, 10-person elements, but some were full teams. All have faced tactical, operational, administrative, 

security, logistical, training, communication, information technology, and other challenges 

FIGURE 10-3. Far forward surgery holds risks for the providers. Here a forward surgical team at Camp 

Pannonia, Afghanistan, cares for a soldier during an offensive in which the compound came under direct 

and indirect attack. Team members continued to provide care while wearing their protective gear. Photograph courtesy of MAJ Christopher Vanfosson, critical care nurse, 541st FST. 
368 • FORWARD SURGERY

over the last 13 years (Figure 10-3). They evolved from split-based operations and working in tents to being mostly in fixed, semipermanent facilities. Most were located within a 

45-minute patient evacuation area, had reliable electricity, good communication equipment, 

and numerous morale opportunities. Their staff significantly contributed to the current 

95% survival rate from combat trauma, and have also been key in reducing the 10% died 

of wounds rate from truncal bleeding amenable to surgical correction.27,43–46 These medical 

units have become a necessity for the combatant commanders and are well respected and 

supported by combat leaders. 

However, most notable is the recognition of the importance of TCCC as the gold 

standard for combat medic training, which has brought about a revolution in casualty care 

through enhanced prehospital medical care. These enhancements emphasize hemorrhage 

control from extremity wounds by nonmedical personnel, either in support of combat 

medics or in their absence, and life-saving interventions such as application of tourniquets, 

maintaining airway and breathing, and control of shock at the point of injury. The combat 

casualty care experience of the 75th Ranger Regiment in Iraq and Afghanistan demonstrated how key life-saving interventions on the battlefield can be delivered by nonmedical 

FIGURE 10-4. An image of the split forward surgical team facility at Forward Operating Base Orgun-E, 

Afghanistan, in 2010. Surgical capability at Orgun-E was initially established in 2002. Note the significant 

difference from conditions in Figure 10-1, including powerful overhead lighting, walls of supplies, dedicated office space, refrigerator, and fluoroscopy machine. Not visible are oxygen lines providing flow to 

the facility from a large oxygen generator located outside. Photograph courtesy of LTC George Johnson, 

former certified registered nurse anesthetist, 541st FST.
CHAPTER TEN • 369

personnel or by combat medics. Both the Ranger Regiment and the Canadian armed forces 

identified their all-combatant TCCC training programs as key elements in their unprecedented success in reducing preventable death on the battlefield.47,48

FST leaders have developed new tactics, techniques, and procedures to address the 

austere environment they work in, as well as the changing enemy methods of attack. This 

has resulted in doctrinal and logistical changes that will be discussed later in this chapter. 

FSTs have been involved in many projects to support the Special Forces community, civil 

affairs community, Department of State, other US government agencies, and many nongovernment agencies. These include training local national military medical staff, working with 

local national civilian and military medical facilities, and other “winning the hearts and 

minds” types of projects.

As the war in Afghanistan evolved, medical assets grew from the first two FSTs to, at 

times, over 20 locations with established FST elements. All US services, as well as many 

NATO allies, have contributed to trauma care via their various versions of Role 2 surgical units and forward deployed Role 3 hospitals (Figures 10-4 and 10-5). On 1 January 

2015, the conflict’s name changed from OEF to Operation Freedom’s Sentinel as the US 

mission focuses more on training, advising, and assisting the Afghan security forces to take 

over protection of their own government, lands, and people.49 As the war draws to an 

FIGURE 10-5. Image of the new facility at Jalalabad, Afghanistan, after its opening in 2008. Providers of 

the 772nd Forward Surgical Team (Air Assault) and their patients enjoyed the enhanced amenities of this 

fixed facility, which are similar to those in a US hospital. Photograph courtesy of LTC Kyle Remick, former 

commander of the 772nd FST.
370 • FORWARD SURGERY

FIGURE 10-6. Early set-up (2007) of a non-doctrinal wheeled vehicle configured for forward surgical 

team (FST) missions in support of Special Operations forces. The vehicle would be transported via a 

rotary-wing aircraft to a far forward location. Photograph courtesy of LTC Kyle Remick, former 

commander of the 772nd FST.

end, the units are supporting more and more Special Operations forces as the number of 

conventional forces declines (Figure 10-6). As local national forces take over responsibility, 

these surgical units are closing down some areas while performing missions in new areas. 

Increasingly they are performing temporary missions outside of their large forward operating bases for short periods of time in support of Special Operations forces or for coverage 

in times and areas of need to conventional forces. FSTs have developed their own mobile 

mission concepts, using rotary wing aircraft to rapidly move a 6- to 10-person slice element 

around the battlefield. The passion and creativity of team members is impressive and will 

surely lead to even better care in the future (Figure 10-7). 

Operation Iraqi Freedom

Due to increasing concerns about the potential Iraqi use of weapons of mass destruction (WMDs), the United Nations Security Council passed Resolution 1441 in 2002.50

This resolution called for the country of Iraq to fully work with and support UN weapons 

inspection teams. Despite the UN resolution, Saddam Hussein and his staff failed to support the full disclosure of certain facilities and documents thought to provide evidence of 
CHAPTER TEN • 371

a WMD program. Due to the concerns that Iraq was developing WMDs, or could easily 

acquire them from another source, and intelligence sources indicating Saddam was supporting terrorist organizations, an invasion of Iraq was planned. On 20 March 2003, 

conventional forces entered Iraq and started the official ground war known as Operation 

Iraqi Freedom (OIF). This war would be supported by 40 different countries with different languages, combat trauma protocols, and skill levels, and occur simultaneously with 

OEF, creating unique challenges throughout the DoD and especially for the medical units.51

Combat maneuver units were under the command of US Central Command and operationally controlled by US Army V Corps. Just under 300,000 soldiers took part in the initial 

invasion. Of these, 248,000 were US troops split among elements of the 3rd Infantry Division, 4th Infantry Division, 82nd Airborne Division, 101st Airborne Division, 1st Marine 

Expeditionary Forces, and various Special Operations units.

FIGURE 10-7. MAJ Cleve Sylvester, MAJ Tyson Becker, MAJ Jacob MacGregor, CPT Suzan Laux, and SGT 

Keith Shackelford operate on an Afghan National Police officer at their facility in Farah, Afghanistan, in 

2014. Many forward surgical team members have deployed multiple times over the years. US Navy photograph by Chief Hospital Corpsman Josh Ives/Released. 
372 • FORWARD SURGERY

As in OEF, FSTs, as well as FRSSs, were deployed in support of combatant commanders.52 In total, nineteen FSTs and six Marine FRSSs participated in the initial phases of OIF. 

These units are listed in Table 10-1.52–54

Various Army, Navy, and Air Force Special Operations surgical assets were in place to 

support Special Operations forces already coordinating the invasion and subsequent overthrow of the Baath party, securing any potential WMDs, and disrupting any terrorist cells. 

One of these units would become the newly designed Air Force Role 2 surgical unit known 

as the Special Operations surgical team, which was usually accompanied with a Special 

Operations critical care evacuation team. Various NATO and allied forces also had Role 2 

surgical and Role 3 facilities that took care of combat injured soldiers.55,56

The conventional surgical units accompanied their assigned combat units as they 

moved north from Kuwait or as they moved south after being air deployed in the north. 

Some of the members on the 274th FST (Airborne), 250th FST (Airborne), and 555th FST 

TABLE 10-1. UNITS PARTICIPATING IN INITIAL PHASES OF OPERATION IRAQI FREEDOM

Unit Home Base

1st FST (Reserve) Brooklyn, NY

2nd Armored Calvary Regiment FST (Airborne) Fort Bragg, NC

126th FST Fort Hood, TX

160th FST Miesau, Germany

240th FST Fort Stewart, GA

250th FST (Airborne) Fort Lewis, WA

274th FST (Airborne) Fort Bragg, NC

555th FST Fort Hood, TX

624th FST (Reserve) Erie, PA

628th FST (Reserve) San Antonio, TX

745th FST Fort Bliss, TX

782nd FST (Airborne) Fort Bragg, NC

801st FST (Air Assault) Fort Campbell, KY

912th FST (Reserve) Cranston, RI

915th FST (Reserve) Vancouver, WA

932nd FST (Reserve) Indianapolis, IN

934th FST (Reserve) Salt Lake City, UT

936th FST (Reserve) Paducah, KY

945th FST (Reserve) Minneapolis, MN

1st Medical BN-FRSS Alpha Camp Pendleton, CA

1st Medical BN-FRSS Bravo Camp Pendleton, CA

1st Medical BN-FRSS Charlie Camp Pendleton, CA

2nd Medical BN-FRSS Alpha Camp Lejeune, NC

2nd Medical BN-FRSS Bravo Camp Lejeune, NC

2nd Medical BN-FRSS Charlie Camp Lejeune, NC

BN: battalion

FRSS: forward resuscitative surgical system

FST: forward surgical team
CHAPTER TEN • 373

had memories of serving in Afghanistan during the early phases of OEF still fresh in their 

minds. These units would again be initial deployers and help lead the way with their lessons 

learned.17,57 During the initial invasion phase and the early period of the follow-on security 

and stabilization phase, most of these units remained in theater. While some FSTs stayed 

as little as a few months, most stayed 12 months, with a few extended to 15 months. Over 

this time, FST personnel would care for thousands of friendly military, local civilian, and 

enemy combatant patients, resulting in hundreds of surgeries performed. The FSTs would 

set up and tear down their facilities multiple times using various configurations, including 

their organic tents as well as abandoned buildings. The 2nd Armored Cavalry Regiment 

FST (Airborne) acquired an expandable surgical shelter like the ones used at CSHs, which 

remained set up on the back of a 5-ton truck. The unit was able to keep up with the 

FIGURE 10-8. The 2nd Armored Cavalry Regiment (ACR) Medical Company and Forward Surgical Team 

accept patients at Camp Muleskinner via CASEVAC after the 19 August 2003 bombing of the UN headquarters at the Canal Hotel in Baghdad, Iraq. The bombing caused at last 22 deaths and over 100 casualties. The 2nd ACR was the closest medical/surgical facility in the area, located approximately 6 miles 

southeast of the incident, and received many patients. Photograph courtesy of COL Kim Smith, former 

perioperative nurse, 2nd ACR FST.
374 • FORWARD SURGERY

FIGURE 10-9. LTC Thomas McCorey, LTC Alexander Stojadinovic, and MAJ Kim Smith perform surgery on 

victim of the UN headquarters bombing. The 2nd Armored Cavalry Regiment Medical Company and Forward Surgical Team occupied the Al Rasheed Military Hospital in the southeastern area of Baghdad early 

after the initial phase of the invasion of Iraq. Photograph courtesy of COL Kim Smith, former perioperative nurse, 2nd ACR FST.

cavalry’s quick advancements and could rapidly be ready to conduct surgery without setting up all the tents or much equipment. 

Coordination for unit movement and patient transfers was complex due to the vast 

number of medical units on the battlefield; however, the resourceful and passionate FSTs, 

medical companies, various surgeons’ cells, and MEDEVAC units were able to function 

fairly well. As the mission converted from the first to the second phase after 1 May 2003, 

the unit movements slowly stabilized and the type of patients and types of injuries changed 

(Figures 10-8 and 10-9). 

Injury patterns early on were as expected for a ground war with dismounted and 

mounted troops taking on a force with conventional weapons. The majority were gunshot wounds, blast injuries, and burns. Due to the protection of armored vehicles and 

body armor, many injuries were to the limbs. Vehicle armor and individual body armor 

would significantly improve in quality and increase in quantity early on in this theater. The 
CHAPTER TEN • 375

enemy’s method of attack would also change to reliance on improvised explosive devices 

(IEDs) and indirect fire, with much less gunfire. The combination of improved armor and 

change in the enemy’s tactics caused a shift in injury patterns to more isolated extremity 

wounds or polytrauma including the extremities. Role 2 surgical teams were flexible and 

able to continuously provide the care needed to save many soldiers.

FORWARD RESUSCITATIVE SURGICAL SYSTEMS

Other innovations being introduced at the time included the new Navy and Marine 

Corps surgical unit, recently added to address injured service members in this type of 

conflict. Like the Army, the Navy and Marines had been working with various small and 

mobile surgical platforms to meet the needs of their new combat missions to prevent the 

problems that occurred during Operation Desert Shield/Storm. With news of the upcoming 

potential war in Iraq and ongoing war in Afghanistan, the Navy Bureau of Medicine and 

Surgery solidified its plans and created the FRSS. The Marine FRSS was a new surgical unit 

that had only been in prototype development prior to January 2003. It was designed to 

augment medical units already in the Marine inventory, including the battalion aid station 

and shock trauma platoon, or to boost capability on a Naval vessel when increased surgical 

capability was required. Like the FST, the FRSS could be moved by its own ground tactical 

vehicles, via military aircraft, swing-loaded under a rotary wing, or (unique to the Navy) 

it could also be moved on air-cushion vehicles. The unit was manned by eight personnel, 

including a general surgeon, orthopedic surgeon, anesthesiologist, critical care registered 

nurse, independent duty corpsman, two operating room technicians, and one general duty 

field medical technician. The team could be augmented with additional critical care or 

emergency care nurses to assist with the transport of critical patients. There were two prototype FRSSs, one stationed on the east coast and one on the west coast. These units would 

become official FRSSs after January 2003.

Between February and March 2003, four additional FRSSs were rapidly assembled and 

prepared for deployment to OIF under the leadership of Captain HR Bohman and Commander Robert Hincks.58 In April and May, four additional Reserve FRSSs were stood up 

from the 4th Medical Battalion so they could relieve their active duty colleagues that summer. The six primary units moved with the 1st Medical Expeditionary Force along the eastern side of southern Iraq toward Baghdad. During a bad sandstorm, one of the teams had 

vehicle problems and lost the ability to move its equipment. The personnel were reassigned 

to a different FRSS so their skills could still be used. This consolidated team traveled with 

the combat service support element in support of the 1st Medical Expeditionary Force. 

The remaining four teams moved far forward of their two parent surgical companies. After 

bounding forward, they would set up surgical capabilities and then meld in with the full 

surgical company once it arrived. During the period from 22 March to 1 May 2003, the 

FRSSs treated 34 Marines and 62 wounded Iraqi soldiers and civilians, performing 151 

surgical procedures, with a zero died of wounds rate.53,59 The FRSSs performed 14% of all 

surgeries while functioning as jump elements and assisted in many other surgeries when 

they cohabitated with the surgical company. FRSS staff performed in an exemplary manner 

while providing care to their fellow Marines. 
376 • FORWARD SURGERY

212TH MOBILE ARMY SURGICAL HOSPITAL

Another key combat surgical team that contributed to the initial phases of the war was 

the 212th Mobile Army Surgical Hospital (MASH). Commanded by LTC Ken Canestrini 

and based out of Miesau, Germany, the 212th was the Army’s only remaining MASH. The 

212th MASH initially co-located with the 86th CSH at Camp Udairi, in Kuwait, prior to 

the war. Once the invasion began, the unit of 160 soldiers, including 9 physicians and surgeons, 29 nurses, and a mixture of pharmacy and operating room technicians, laboratory 

and radiology technicians, medics, licensed practical nurses, nutritionist, administrators, 

logisticians, computer and communication specialists, laundry and motor pool staff, and 

others moved north. Over a 3-day convoy, they encountered combat action as they moved 

toward Objective Rams and set up at the logistics support area (LSA) Bushmaster near 

An Najaf. Personnel were able to rapidly assemble tents and surgical shelters to provide 

an emergency medical treatment area, three operating room tables, and 36 recovery beds 

divided into three 12-bed areas.60,61

During the early phases of OEF and OIF, Role 2 surgical unit members had to conduct many other duties, such as field sanitation and area security, in addition to their jobs 

as medical care providers. While not pleasant and often time consuming and disruptive to 

work-rest cycles, these duties were necessary to ensure that the unit functioned and was 

secure. The 212th MASH, as did their sister surgical units, would also experience something they never saw in the United States or Europe, massive sand storms. Personnel had to 

ensure that their equipment was not damaged and then decontaminate as best they could to 

provide the cleanest facility possible.60,61

After a few weeks of operations at LSA Bushmaster, the team moved farther north, to 

LSA Dogwood, located just south of Baghdad. There they conducted capabilities assessments of area Iraqi medical clinics and hospitals. The 212th returned to Germany in June 

2003. Of the 701 patients treated during the deployment, 132 orthopedic procedures were 

performed on 74 patients, while an additional 33 patients required abdominal, thoracic, 

or neck explorations. This was the final combat mission for the 212th MASH because it 

was converted to a CSH in 2006. The team members demonstrated one last time that the 

MASH, designed after World War II, was still a capable surgical unit.60,61 

COMBAT SUPPORT HOSPITALS 

In addition to the 212th MASH, three combat support hospitals deployed into Iraq 

during the initial phase of OIF. The 21st CSH from Fort Hood, Texas; the 28th CSH from 

Fort Bragg, North Carolina; and the 86th CSH from Fort Campbell, Kentucky, all crossed 

the border and entered Iraq, while the 47th CSH from Fort Lewis, Washington, and 10th 

CSH from Fort Carson, Colorado, provided medical care and support from Kuwait.61–64 As 

with their Role 2 surgical colleagues, these Role 3 units would care for initial wounded due 

to the nonlinear aspect of the war after phase one was competed. They would also receive 

all casualties from the numerous Role 2 facilities. These casualties’ injuries were caused by 

direct and indirect contact with the enemy, IEDs, helicopter crashes, suicide bombings, and 

nonbattle trauma. Casualty evacuation rarely occurred with only single patients. Many of 

their patients arrived in groups or as part of a true mass casualty incident, such as the 
CHAPTER TEN • 377

attack on the United Nations headquarters building in Baghdad on 19 August 2003.65

From January to July 2003, the 86th CSH was deployed in support of preparations 

for and during the invasion of Iraq.60,66 After its initial staging in Kuwait, the 86th was split 

into multiple elements once OIF began. These elements included a 44-bed hospital at Tallil 

Air Base near An Nasiriyah and two FSEs in the V Corps headquarters area. An additional 

84-bed primary element remained in Kuwait to provide medical care to support elements 

that remained in Kuwait, and to receive initial patients from the invasion phase from various FSTs, FRSSs, and the 212th MASH.60,61

The 28th CSH supported the 3rd and 101st Infantry Divisions’ area of responsibility 

during the initial ground invasion.63 Personnel established a 44-bed hospital while en route 

to Baghdad. Once the city was in the control of US and allied forces, the 28th CSH split 

and established two facilities. The main element was a large facility in the “Green Zone” 

just east of Baghdad International Airport. A second, smaller hospital was established 

in Tikrit. While many medical-surgical facilities came under attack during the war, the 

28th’s location in the Green Zone made it a target of opportunity, and the area was shot 

at routinely with rockets and artillery. While no CSH members died of wounds during this 

rotation, a few years later, in 2006, the 28th CSH would return to this location and lose a 

team member to indirect fire.67 

The 21st CSH convoyed from Kuwait to sites in northern Iraq.64 The unit had the 

furthest convoy from its starting point in Kuwait of all the initial CSHs that moved into 

theater. Their 3-day drive ended about 100 miles north of Baghdad, where they established 

a 44-bed hospital at the airfield in Balad. The 21st would establish two sites, known as 

“Bear North,” located in Mosul, and “Bear South,” located in Balad. The Bear South site 

was expanded to a larger 164-bed facility, while Bear North was enlarged to the 84-bed 

configuration. These sites became very busy as the war transitioned. Two periods of significant patient inflow were during the Battle of Mosul and the Battle of Fallujah.68,69

The 47th CSH, from Fort Lewis, Washington, also played an important role in the 

initial phases of the invasion, but its primary mission was to provide hospital support in 

Kuwait.70,71 The unit would provide combat support and combat service support, and 

treat DoD civilians who ran the massive logistical and support mission for the troops who 

advanced across the border into Iraq. Support personnel in Kuwait were often victims of 

job-related injuries and accidents while working with heavy and dangerous military equipment and supplies. The 47th also received combat trauma cases from Role 2 surgical teams 

during the initial invasion phase until the various other Role 3 facilities were established 

during phase two of the war. The unit’s efforts provided care for numerous battle and 

nonbattle injuries and served as a safety net for the military service members conducting the 

fighting to the north.

The 10th CSH, from Fort Carson, Colorado, had prepared to accompany and support 

the 4th Infantry Division as it moved through Turkey into northern Iraq, but was not able 

to conduct this mission when the Turkish Parliament denied the US and British forces use 

of its ground or air space for the invasion.72 After the mission was scrapped, the 10th CSH 

was notified that it would go to Kuwait and advance north into the area it had previously 

been tasked to support. However, upon arrival in Kuwait, the mission changed again. The 
378 • FORWARD SURGERY

10th CSH established itself there to provide support for local military and associated civilians, and prepared to receive patients from Iraq, if needed. At one point, team members 

were told they might move to northern Iraq for a humanitarian mission, but again they 

were selected to stay and provide care in Kuwait. After approximately 4 months, the 10th 

CSH returned to Colorado and prepared for a return mission to Iraq in 2005. While the 

unit never entered the combat zone, it was prepared to do so, and it did provide essential 

care to support personnel in Kuwait.68,72

AIRBORNE INSERTION OF FORWARD SURGICAL TEAMS

Of the initial modern FSTs stood up in 1997, five were designated as airborne capable: 

the 782nd FST (Airborne) within the 82nd Airborne Division at Fort Bragg, North Carolina; the 274th FST (Airborne) and 2nd Armored Cavalry FST (Airborne) within the 44th 

Medical Brigade, also at Fort Bragg; the 250th FST (Airborne) within the 62nd Medical 

Brigade at Fort Lewis, Washington; and the 67th FST (Airborne) within the 30th Medical 

Brigade in Germany. Other FSTs would also receive the prestigious airborne designation 

and the challenging mission capability during the GWOT era (see Chapter 11 for details). 

The mission of airborne FSTs was to jump into combat along with their combat arms colleagues. Personnel would then assemble to provide advanced trauma care alongside their 

fellow medical company paratroopers. Approximately 1 to 4 hours after the jump, with 

the area secured, the FST’s Alpha echelon could set up for more advanced resuscitation and 

surgery, functioning separately for 6 to 48 hours while awaiting reconstitution with the 

Bravo echelon once the airfield was repaired and aircraft could air-land the second wave of 

soldiers.73,74

The 250th FST (Airborne) was the first conventional modern US Army FST to execute 

this mission during the initial invasion of Iraq in 2003. The team was led by LTC Harry 

Stinger, a long-time leader in the FST community, especially in the airborne FST units. In 

1996 he had been the commander of the 82nd Airborne Surgical Squad, which was converted to an official FST, the 782nd FST (Airborne), in 1997. While with the 782nd, Stinger 

and his unit supported the Defense Readiness Brigade mission, now known as the Global 

Response Force mission. He led the development of many administrative, logistical, training, and operational concepts used by airborne FSTs today. The 250th FST (Airborne) thus 

had the most knowledgeable airborne FST commander, along with other highly trained and 

qualified surgical soldiers in the Alpha and Bravo echelons.

FSTs usually train with their local brigade combat teams for the Global Response Force 

mission. This facilitates development of standard operating procedures and supports unity 

as a combined Role 2 medical-surgical trauma team. Unfortunately, in 2003 the 250th 

FST (Airborne) had limited information on the mission and associated details. Its mission, 

originally for a possible airborne assault, was changed first to an air-land mission and later 

back to an airborne assault mission. Also, the 250th would support an infantry brigade 

that it had never trained with, one on the other side of the world. Team members joined the 

173rd Airborne Infantry Brigade in Vicenza, Italy, only 5 days before the mission, without 

taking part in the initial medical planning. Because the 173rd did not have a dedicated 

FST stationed with it, its members were not familiar with the integration concepts of FSTs, 
CHAPTER TEN • 379

which were not part of their airborne medical standard operating procedures. Fortunately 

LTC Stinger had years of experience with airborne FSTs and was able to coordinate with 

the 173rd brigade surgeon, MAJ Richard Malish, and other organic medical staff on how 

to best employ their assets. These leaders had to make hard decisions on short notice that 

could have a huge impact on soldiers’ outcomes a few days later. 

LTC Stinger and MAJ Malish developed plans on who would jump versus be air-landed.75 Due to limited space on the initial heavy drop aircraft, the vehicles carrying the FST’s 

equipment and supplies replaced two previously loaded vehicles from the medical support 

company. The 173rd Brigade Medical Company would now be short their patient-hold 

capability for the initial phases of the mission. It is not uncommon for some vehicles to be 

bumped during training, so airborne FSTs know that two vehicles’ worth of equipment is 

the minimum they must bring to provide advanced resuscitative and surgical care to up to 

10 severely initial injured patients. It is also not uncommon for the number of FST jump 

personnel to be changed to nine or even eight from the planned ten. 

The 250th FST (Airborne) experienced this situation when its members executed their 

airborne forced entry mission into Iraq on 26 March 2003. The exact makeup of the Alpha 

echelon is mission dependent, based on many factors. The following members of the 250th 

made this first, and to date only, jump of a modern FST into combat: LTC Harry Stinger 

(general surgeon and 250th FST commander), MAJ John Devine (orthopedic surgeon), 

MAJ Brad West (nurse anesthetist), CPT Glen Carlsson (emergency room registered nurse), 

Sergeant First Class (SFC) Robert Novak (licensed practical nurse and FST detachment 

sergeant), SFC Luke Fullerton (healthcare specialist), Staff Sergeant (SSG) Robert Burns 

(healthcare specialist), SSG Abel Tavarez (operating room specialist), and Specialist (SPC) 

William Goldsworth (operating room specialist). (See previous chapters for information 

about early surgical squads and detachments that air-landed into Operation Just Cause and 

air-dropped during World War II.76,77)

The team heavy rigged and jumped two M998 highly mobile military wheeled vehicles 

(HMMWVs) loaded with a single deployable rapid assembly shelter; one 5-kw diesel 

generator; multiple medical equipment sets with enough equipment and supplies to set up 

and care for approximately 10 surgical patients; and 20 units of packed red blood cells.78,79

Blood products were acquired from DoD resources in Europe. The team also requested 

nonstandard fresh frozen plasma (FFP) and platelets, but these were not provided. Of 

note, later in both theaters FFP was provided to all FSTs, but, due to their short shelf life, 

platelets are still not available. The packed red blood cells the team acquired were packed 

in two standard commercial Styrofoam coolers with ice, with one cooler placed in the front 

of each vehicle.80 The issued blood refrigerators were not loaded because they took up valuable space in the back of the HMMWVs. The Bravo echelon carried the remainder of the 

unit’s military and medical personnel, equipment, and supplies. 

Over 950 paratroopers exited the airplanes that night and jumped not only into the 

pitch darkness over Iraq, but also into history.79 Not since the British Army’s 1st Surgical 

Team, led by Lieutenant Charles Rob, parachuted into Souk-el-Arba, Tunisia, in World 

War II had a similar event occurred.81 The jump made by the 250th FST (Airborne) is 

considered the first of its type by a US military conventional surgical unit (see Chapter 9 
380 • FORWARD SURGERY

for further details). Fortunately, the 250th’s patient load was much less than what Dr Rob 

experienced. A total of 18 patients were injured on the drop zone and treated by the 173rd 

Medical Company and 250th FST (Airborne). Injuries ranged from mild jump injuries to a 

possible leg fracture. Luckily, there were no life-threatening injuries due to jump complications or initial combat action. 

Contributing factors to this success included an intense pre-mission parachute-training 

regimen, a large drop zone that was free of obstacles, favorable wind conditions, soft terrain 

secondary to recent rainfall, and no enemy contact. The FST Alpha echelon helped with the 

evaluation and management of many of the initially injured soldiers, including minor extremity injuries, a soldier with bilateral dislocated shoulders, and a jumper with a presumed 

tibia-fibula fracture (later diagnosed as a grade III sprain).78,82 After the initial air insertion, 

the team linked up with the Bravo echelon to establish the full FST (Figure 10-10). 

Members of the 250th supported numerous medical and surgical needs of US and 

allied personnel, civilians, and enemy prisoners of war in their area of responsibility. They 

also assisted other unique support missions during their deployment. These included 

FIGURE 10-10. Members of the 173rd Infantry Brigade (Airborne) Medical Company and the 250th 

Forward Surgical Team (Airborne) care for patients on the airfield they occupied in Northern Iraq in 

March 2003. These paratroopers were trained to perform triage, resuscitation, medical management, 

and surgery with minimal assets after jumping into a combat zone. The unit would later have better tents 

and facilities as the battlefield matured. Here they are evaluating a patient in an outside care area with 

a portable x-ray machine. Photograph courtesy of COL Richard Malish, former brigade surgeon, 173rd 

Infantry Brigade.
CHAPTER TEN • 381

medical civil affairs mission support, in which they worked with the local surgical community to help with numerous projects. The 250th provided much needed support to the 

local population and showed the Iraqis in this area what the Americans could provide. The 

surgical staff was able to coordinate with the American College of Surgeons to provide 

valuable training material for the local national surgeons to use. They also worked with the 

Air Force EMEDS unit at Kirkuk Military Airfield on a few occasions. 

By the end of their 1-year deployment, 250th staff had performed 59 surgeries on 48 

patients (including US troops, allied troops, and enemy prisoners of war). An additional 

16 patients with nonoperative trauma were treated. The patients had an average revised 

trauma score of 7.0 +/- 2. Approximately 25% of injuries were nonbattle related, 35% 

were blast injuries, and 40% were gunshot injuries. These various mechanisms caused torso 

injuries in 21% of patients, head and neck injuries in 28%, and extremity injuries in 51%. 

Four patients died in the FST’s triage area or facility, including three from nonsurvivable 

head injuries and one secondary to exsanguination from a superficial femoral artery and 

vein injury.17,83

Overall, the unit had a very successful mission and provided high-quality care to the 

soldiers in its area of responsibility. In addition, it validated that the airborne FST concept 

could be executed, from loading the proper equipment, jumping the equipment and surgical team out of a plane, and set-up on the drop zone, to providing care prior to the main 

body’s arrival. The 250th’s lessons learned have been passed on to other airborne FST 

members via various publications and word of mouth. Their actions were recognized with 

the Bronze Star, Combat Parachutist Badge, and Arrow Head Device.77,78,82

TRANSITION FROM MANEUVER BRIGADES TO AREA SUPPORT MISSION

Once the linear battlefield was no longer present, the management of various support 

elements in theater became complex for a period of time. Coalition forces were spread 

throughout the country, and small pockets of friendly forces and anticoalition groups were 

mixed in between. Units might live and work next to other units that could not support 

their administrative and logistical needs due to differences in branch of service or chains of 

command. This was also true for the FSTs.52

The FSTs at this time were attached to maneuver brigades, except for three unique 

FSTs that were direct reporting units permanently assigned to a regiment or division. These 

were the 2nd Armored Cavalry Regiment FST (Airborne), 801st FST (Air Assault), and 

782nd FST (Airborne), which always fell under the 2nd Armored Cavalry Regiment, 101st 

Airborne Division (Air Assault), and 82nd Airborne Division, respectively, even in garrison. 

The location of surgical assets was determined by the combatant commander, based 

on recommendations of his or her medical staff, which did not always take into account 

the needs of the entire theater of operations. To solve the problem, administration, tactical, 

and operation control of FSTs was transferred from brigade combat teams to a medical 

task force. This change allowed for one governing body to oversee the placement of Role 2 

surgical assets and Role 3 assets to best meet the need of the theater commander’s mission, 

regardless of which combat and support units moved in and out of the region. 
382 • FORWARD SURGERY

As the mission transitioned to counterinsurgency operations, the entire system was 

able to manage the needs of a mobile and difficult adversary. FSTs were placed in areas that 

better met the needs of a region, instead of the unit they were first assigned to. Future FSTs 

would come into theater under this arrangement but, by virtue of location, would still support the combat unit in their area of operations. Some units were able to collaborate with 

local facilities and providers (Figure 10-11). Some FSTs augmented the CSH in their area 

and could rapidly move to an area that required additional support for both conventional 

and Special Operations soldiers. This change had an impact on the garrison management of 

the three direct reporting FSTs. 

Between late 2004 and 2006, these three units were deactivated and then reactivated 

under new command. First, the 2nd Armored Cavalry Regiment FST (Airborne) left the 

2nd Armored Cavalry Regiment in 2004 and became the 759th FST (Airborne), under 

the 44th Medical Brigade, while under the command of LTC Richard Ellison.84,85 Next, in 

2005, the 801st FST (Air Assault) left the 101st Airborne Division and became the 772nd 

FST (Air Assault), also under the 44th Medical Brigade, while under the command of LTC 

Kirby Gross. Lastly, in 2006, the 782nd FST (Airborne) left the 82nd Airborne Division 

and became the 541st FST (Airborne), again under the 44th Medical Brigade, while under 

the command of LTC Shawn Nessen. The 772nd stayed at Fort Campbell, Kentucky, and 

the 541st and 759th stayed at Fort Bragg, North Carolina, continuing the traditions of 

their former units while also setting new standards and developing proud reputations for 

their new designations.84,86,87

THEATER CLOSURE

Beginning 1 September 2010, OIF officially ended and became the new mission known 

as Operation New Dawn. The focus of this operation was to finalize the training of the 

Iraqi military and police forces, finalize other stabilization efforts, and transition the future 

assistance of the Iraqi government and people to the Department of State. The US Army 

XVIII Airborne Corps performed command and control duties of US Forces-Iraq during 

the final phases in 2011. One of the main focuses of the deputy corps commander, Lieutenant General (LTG) Frank Helmick, was the maintenance of the advanced surgical capability that the United States and allied countries had become accustomed to.88,89 Plans were 

developed to ensure that this would be possible. The medical task force coordinated with 

their assigned FSTs to create a method of coverage and evacuation. 

There were three basic types of facility closures involving FSTs. They included 

(1) smaller outpost or station closures, (2) large operating base closures, and (3) medicalsurgical unit transitions of authority from DoD to the Department of State. The FSTs 

were often already functioning in their 10-person split capacity, but would need to function 

with even less personnel and equipment for a short period just prior to leaving their sites. 

Instrumental in these closures was the 912th FST.

Commanded by COL Timothy Counihan, 912th personnel knew that high-quality 

surgical care could be provided by four to six skilled members for short periods of time, 

based on their experience from early OEF deployments and knowledge of published and 

unpublished sources. However, due to operational needs during the closure of Contingency 
CHAPTER TEN • 383

Operating Station (COS) Gary Owen, 912th team members had to limit their final “jump” 

team to four members. This jump team would remain as the only real trauma management asset for damage control resuscitation and surgery for the final 2 days that COS Gary 

Owen was open. The jump team ensured that all 1,200 soldiers leaving the area during 

those last few days would have combat surgical coverage, and departed by rotary wing 

only 4 hours before the final American soldiers left.88

The next closure was slightly different from COS Gary Owen. Through careful planning and availability of assets (including nearby fixed and rotary wing service), the split 

912th was able to function as a complete 10-person team for the closure of the much larger 

Camp Adder. The team provided coverage until 18 hours prior to the final ground convoy 

departure time. This gave them 6 hours to tear down their facility, pack it, palletize their 

equipment, and deliver it to the convoy area. They then moved to the airfield and were 

transported by C-17 Globemaster aircraft.88

FIGURE 10-11. Partnership training and care became commonplace early in Afghanistan and Iraq as part 

of winning the hearts and minds of local citizens. Here a local national patient receives surgical care from 

members of the 2nd Armored Cavalry Regiment Forward Surgical Team and a local surgeon. These collaborations included local providers conducting joint medial training with US and allied staff. Photograph 

courtesy of COL Kim Smith, former perioperative nurse, 2nd ACR FST.
384 • FORWARD SURGERY

The other half of the 912th split FST was responsible for the transition of medical 

coverage to a new Department of State medical unit at Contingency Operating Base (COB) 

Basrah. The United States had taken over responsibility of this area in 2009 from British 

medical units that had been there for most of OIF. The 912th FST provided training and 

mentorship to the new Department of State medical-surgical staff. The old and new team 

collaborated for a short period of time and provided capabilities and capacity similar to a 

20-person FST. Once the final US convoy was beyond the area of coverage and closer to the 

combat support hospital in Kuwait, the 912th broke down its equipment and supplies and 

the team members said their final good-byes. They left Basrah in the hands of the Department of State team and flew via rotary wing to Kuwait.88

Leaving bases like Gary Owen, Adder, and Basrah is much different than moving to 

a new site, as some units had done earlier in the war. Instead of having a large amount 

of support locally to move somewhere that may or may not be mature, FSTs that close 

or transition bases are leaving an area with minimal support and possibly heading home 

(Figure 10-12). The positive and negative emotional impact of these missions can adversely 

affect a team if not managed well. The 912th did an exemplary job of maintaining high 

morale, staying as long as they operationally could to provide coverage, and remaining 

FIGURE 10-12. MAJ Ronald Kembro and MAJ Timothy Placket of the 772nd Forward Surgical Team (Air 

Assault) perform surgery at a newly established location in Iraq in 2015 in support of Operation Inherent Resolve. While the facility is brick and mortar, the team is using standard field equipment. The return 

to Iraq is a new beginning in a traditional immature theater of support, which is developing at this time. 

Photograph courtesy of MAJ Timothy Placket, trauma surgeon, 772nd FST.
CHAPTER TEN • 385

focused on their core mission: to be far forward, possibly in harm’s way, to stabilize casualties for further transport along the continuum of care, with the final destination being home 

with friends and family.88

US ARMY SURGEONS GENERAL CONTRIBUTIONS TO THE 

SUCCESS OF THE FORWARD SURGICAL TEAM

The significance of the FST was clear to the Army surgeons general since their initial 

inception in the late 1980s. Lieutenant generals Ledford, LaNoue, and Blanck had the 

vision to realize that the old field and general hospital and MASH systems were dated and 

needed to be replaced. Their collaboration with subordinate units’ recommendations and 

surgical subject matter experts, along with analysis of lessons learned from various US and 

NATO units in the 1980s and 1990s, led to development of a sound platform and mission 

for future FSTs.90 During the GWOT, four Army surgeon generals maintained strong support for the FST community. 

Just prior to the GWOT, LTG James B Peake became the 40th US Army surgeon 

general.91 As a general/thoracic surgeon, he truly appreciated that the FST was the Army’s 

premier medical-surgical unit of the future. His vision and timing were paramount to the 

success of FSTs for the next 15-plus years. Before becoming surgeon general, LTG Peake 

was the Army Medical Department (AMEDD) Center and School commander from 1996 

to 2000.92 While there, he ensured that a new dedicated FST field manual and Army Training and Evaluation Program-Mission Training Plans were published in 1997 and 1999, 

respectively, to help guide FSTs to the highest level of combat medical readiness.23,93 He also 

played an essential role in establishing the Joint Trauma Training Center at Ben Taub Medical Center in Houston, Texas, and the FST Commanders Course at Fort Sam Houston, 

Texas.94,95 After becoming surgeon general, Peake was the senior Army medical officer as 

the wars in Afghanistan and Iraq began. During this time, LTG Peake successfully finalized 

the new training partnership with the Ryder Trauma Center in Miami, Florida, to establish 

the Army Trauma Training Center (ATTC), initiated the Joint Trauma Theater Registry, 

and supported the increased number of active and Reserve FSTs to meet the needs of a war 

being fought in multiple theaters.96–99

In 2004, LTG Kevin C Kiley succeeded LTG Peake.91 He too was an advocate of the 

FST, starting before he became the 41st Army surgeon general. As the AMEDD Center and 

School commander from 2000 to 2002, LTG Kiley helped update the FST field manual in 

2003, which improved guidance in the new types of battlefield engagement.24,100 He also 

worked with LTG Peake in the approval of the Joint Trauma Theater Registry and the 

ATTC.96–98 Once he became surgeon general, Kiley supported the transformation of all 

FSTs into medical brigade assets, as well as decreased deployment time for certain FST and 

CSH providers to help prevent surgical skills degradation. LTG Kiley was also instrumental 

in the establishment of the formal Joint Trauma System (JTS) in 2006,98 and he pushed 

for all deploying FST personnel to attend predeployment trauma training at the ATTC for 

clinical validation.101
386 • FORWARD SURGERY

In 2007, LTG Eric B Schoomaker became the 42nd Army surgeon general.102 Like his 

predecessor, Schoomaker understood that the FST was the most essential element to saving 

lives on the current battlefield and worked hard to ensure their success. Under his leadership, the old Army Training and Evaluation Program-Mission Training Plans system was 

converted to the newer Combined Arms Training Strategy System, giving teams a clearer 

and more complete training program to use throughout their Army Force Generation 

Cycle.103,104 In 2009, he finalized a policy started by LTG Kiley to ensure that all medical and surgical units attended their appropriate predeployment trauma training.105 LTG 

Schoomaker also ensured that four FSTs would be assigned to support the Homeland 

Security Defense Chemical Biological Radiation Nuclear Response Force mission. Near the 

end of his tenure, he supported a force design update for the FST to meet the needs of the 

next decade and future conflicts. His contributions to the FST community provided them 

with the proper manning, equipment, and training to save the maximum amount of lives 

on the battlefield. 

Most recently, LTG Patricia D Horoho has maintained strong support for the Role 2 

surgical team after becoming the 43rd Army surgeon general in 2011.106 She supported the 

radical redesign of the FST into the new forward resuscitative surgical team, and continued 

to ensure that funding and personnel were available for an optimal clinical training experience at the ATTC as well as the Combat Extremity Surgery Course. In 2013, a new Army 

training publication replaced the previous FST field manual.107 This new document consolidated the past medical company, FST, and CSH manuals into one brief publication.

INJURED AND FALLEN FORWARD SURGICAL PROVIDERS 

Performing surgery far forward is a challenging mission for many reasons. Providers often do not have all the equipment and supplies they are accustomed to in stateside 

practice or at a CSH. Resupply, communication, Internet connectivity, and basic electricity 

are also challenges. Often the living conditions and basic morale, welfare, and recreation 

options are much more limited than at the larger bases. Also, the forward setting is a much 

more dangerous place to work. Because there is more manual labor involved, FST members 

are known to have more disease and non-battle injury conditions than colleagues working 

elsewhere. Even more dangerous is that personnel are physically closer to the conflict, both 

during initial ground or air assaults and later, as the FST occupies more austere forward 

operating bases and combat outposts closer to the enemy. 

Many FST members have sustained combat wounds while deployed. At the time of 

this writing, injured FST personnel notably include members of the 915th FST (Reserve), 

274th and 250th airborne FSTs, and, most recently, the 628th FST (Reserve).84,108–112 In 

addition, four medical personnel—from the 782nd FST (Airborne), 1st FST (Reserve), 

274th FST (Airborne), and the 848th FST (Reserve)—have died during combat while 

deployed with an FST.113–116 Personnel assigned to CSHs endured combat injuries and 

some fatalities too. 
CHAPTER TEN • 387

On the evening of 3 July 2003, the members of the 915th FST, from Vancouver, Washington, were set up in Balad, Iraq, finishing up work and relaxing for the night. Without 

warning, a volley of mortars came into their compound, and one round hit their facility. Of 

the team’s 20 members, 14 sustained some level of injury from the blast, and many of them 

required medical treatment and surgery. The injured received evaluation, resuscitation, 

and surgery at the 21st CSH and the newly arrived 1st FST, from Fort Trotten, New York, 

which were both located nearby at Balad. Fortunately, all team members survived their 

injuries.108,110

On 20 March 2004, US forces came under attack from insurgents in Fallujah, Iraq. 

This coordinated attack included the use of rockets fired from a distance at the US military 

compound. One of the rockets detonated near the location of MAJ Mark D Taylor, MD. 

Mark was a Professional Filler System (PROFIS) surgeon in the 782nd FST (Airborne) out 

of Fort Bragg, North Carolina. His fellow FST members were unaware of his location and, 

needing his assistance as other casualties arrived, frantically asked for someone to find him. 

Then a casualty arrived whom they recognized. It was Mark. His good friend, Womack 

Army Medical Center colleague, and fellow PROFIS surgeon on the 782nd, MAJ Sean 

Montgomery quickly realized that Mark’s injuries were too severe to survive. MAJ Taylor, who was 41, became the first FST member killed in action. He has been recognized in 

numerous ways. At Fort Bragg, a street and a simulation training center, the Taylor-Sandri 

Medical Training Center, were named after him, as was a trauma lecture series at the Gary 

Wratten Army Surgical Symposium.113

The second FST member to die in combat was another surgeon, MAJ John P Pryor, 

DO. Previously a trauma surgeon at the University of Pennsylvania Medical Center, MAJ 

Pryor joined the Army Reserves in 2004 and deployed to the medical facility at Abu Ghraib 

in 2006. For his second deployment, he wanted an even more challenging assignment and 

volunteered to deploy with the 1st FST from Fort Trotten, New York. He was killed at age 

42 on the morning of 25 December 2008 during a mortar attack on his compound in Mosul, Iraq. John was highly respected in the civilian and military medical community, and his 

loss had a significant impact on many. He, too, was recognized and remembered in numerous ways, including in articles and stories in the American College of Surgeons’ Journal of 

Trauma and the General Surgery News. He also had a memorial lecture series named after 

him. On 4 February 2015, the John P Pryor Shock-Trauma and Resuscitation (STAR) Unit 

at Pennsylvania Presbyterian Medical Center opened. The unit was named in Pryor’s honor 

by his former mentor, US Naval Reserves Commander C William Schwab.114

The third FST member to die in combat was SSG Ronald J Spino, the senior licensed 

practical nurse for the 274th FST (Airborne) from Fort Bragg, North Carolina. Ron started 

his 1-year deployment in Iraq and then moved with his unit to Afghanistan to provide much 

needed surgical support in Bala Murghab. This northwestern region of Afghanistan near 

the Turkmenistan boarder was underdeveloped and a challenging location with minimal 

assets. The team performed well and maintained its morale. With only 1 month to go on his 

deployment, SSG Spino was shot and killed on 29 December 2009 by an Afghan National 

Army soldier while both were on a helicopter landing zone. (Additional tragedy happened 

a few weeks later, in January 2010, when the site was hit by indirect fire as the 274th was 
388 • FORWARD SURGERY

conducting a site handover to the 250th FST from Fort Lewis, Washington. Multiple team 

members from both units sustained significant injuries, including the operating room nurse 

from the 274th and both the senior surgeon and orthopedic surgeon from the 250th. Fortunately, there were no lethal injuries.) SSG Spino was 45 years old. He was recognized and 

remembered like his fallen comrades. A large commemorative plaque hangs in the 274th 

FST (Airborne) team house at Fort Bragg.111,115 In addition, the main training room at the 

Army Trauma Training Center in Miami, Florida, has been dedicated in his honor, reminding all deploying FST members of the risks and challenges that await them.115

The fourth FST member to die to date in combat was another Army Reservist, CPT 

Joshua M. McClimans, RN. After a 2005 tour to Iraq in 2005 with the 256th CSH, 

CPT McClimans was the critical care nurse for the 848th FST, from Twinsburg, Ohio, 

while the unit was deployed to FOB Salerno. On 22 April 2011, FOB Salerno received 

indirect fire attacks. At 30 years old, Joshua was fatally injured by one of the munitions 

that entered the FOB and detonated. Joshua’s grandmother, the mayor of his hometown of 

Jamestown, Pennsylvania, ensured that he was honored for his service and actions.116

The most recent injuries sustained to FSEs by combat action occurred during the 7 

August 2012 attack on FOB Shank, which was attacked by insurgents early that morning. 

The attack involved a vehicle-borne IED with approximately 3,000 pounds of explosives. 

The explosion caused a large breach, approximately 75 feet long, in the base’s thick outer 

wall. The attack killed four individuals on the base and injured another 28, including one 

of the surgeons assigned to the 648th FST.84

All of these FST members volunteered to take on the challenges of combat trauma so 

they could share their knowledge, skills, passion, and empathy with the combatant soldiers. 

None truly believed they would one day become one of the many patients seen at their 

surgical facility. None actually thought they too would die in combat rather than return 

home in the manner they had planned. The four fallen soldiers, the other providers with 

injuries, and fellow FST members who have deployed since 2001 are part of a unique family of eclectic medical staff dedicated to saving lives beyond what many noncombat medical 

providers can comprehend. 

LTC Robert Blease, SSG Ronald Spino’s commander at the 274th FST (Airborne), 

served at the ATTC after their deployment. He ensured that SSG Spino’s spirit and memory 

would live on as all deploying Army FSTs saw his name and story during their predeployment trauma training in Miami. The training center named after Spino also includes a 

“wall for our fallen FST heroes” with the photos, names, and units of the four who gave 

their lives while trying to save lives. The wall is pointed out on the first day of training to 

ensure that all students take their training seriously and understand the risk they are volunteering to take. 

The US Role 2 surgical teams described in this chapter faced the challenges of forward 

deployment and did everything they could to improve the lives and outcomes of their 

fellow soldiers on the battlefield. Afterward they shared their lessons learned and worked 

toward process improvement back in garrison. Amid the chaos of war, they found opportunities to improve their patients’ outcomes and the trauma system as a whole. This is an 

accomplishment of which each and every one of them is right to be proud.
CHAPTER TEN • 389

TOPICS AND ISSUES AFFECTING FORWARD 

SURGICAL CARE

Military Working Dogs Cared for by the Forward Surgical Team

During this era, a new type of patient started showing up at the doors of the FST. FSTs 

were well trained and prepared to take care of US soldiers, NATO soldiers, enemy prisoners 

of war, and local nationals; however, when military working dogs (MWDs) began to arrive, 

providers had to adjust their medical-surgical knowledge and skills to help these new “soldiers.” Typically, veterinarian medical detachments are co-located or near Role 3 facilities, 

a distance from the outposts where most of the animals worked and were injured (Figure 

10-13). A significant number of these animals would not have survived if they were sent on 

the long journey to Role 3 facilities, so they were taken to the area Role 2 or FST instead. 

[Left] FIGURE 10-13. A canine is cared for at the 772nd Forward Surgical Team (Air Assault) during 

Operation Inherent Resolve after receiving multiple lacerations from concertina wire. Military working 

dogs are considered soldiers and receive care within the Department of Defense (DoD) system. Often 

they receive initial care by forward surgical teams because they are further forward than the DoD veterinarian assets. Photograph courtesy of MAJ Tmothy Plackett, former trauma surgeon, 772nd FST.

[Right] FIGURE 10-14. A NATO military working dog being cared for in the postoperative setting. This 

explosive ordnance disposal canine was cared for by a conventional forward surgical team supporting 

NATO in Regional Command–North, Afghanistan. The canine became hyperthermic after surgery. Medical 

management was coordinated for via cell phone with US veterinarians stationed in Bagram. Photograph 

courtesy of MAJ Christopher Vanfosson, former critical care nurse, 541st FST.
390 • FORWARD SURGERY

FIGURE 10-15. Trauma care not only saves the patient, but also strengthens partnerships. While most 

partnership building during the war was between allied countries and local nationals as part of the 

counterinsurgency doctrine, many times it also occurred within allied personnel. Thousands of coalition 

patients have been cared for at US Role 2 and 3 facilities. Here the collaboration at a multinational camp 

can be seen, as multiple combined and joint conventional and Special Operations units arrange for a 

military working dog to be transported to Bagram for further care. 

Although veterinary clinical medicine officers had been assigned to deployed veterinary 

units since 2005 to ensure high-level care for MWDs in theater,117 and MWD management 

has been detailed in military veterinarian and Special Operations doctrine for many years, 

veterinary trauma management was sparsely documented in the peer-reviewed literature.118

During the GWOT era, Dr Wesley M Taylor, MAJ Janice L Baker, and a few others began 

publishing detailed articles addressing gaps and lessons learned in managing MWDs with 

combat injuries.117,119–122 However, this information was not in mainstream medical literature or presented to the surgical staff members on FSTs. Additionally, MWD management 

was not part of the FST’s mission essential task list and few team members ever imagined 

they would one day be looking at an MWD lying on a stretcher with combat injuries and 

in extremis. As the dogs arrived, individuals from various FSTs began documenting their 

experiences treating the dogs so that lessons learned could be passed on. 

One of the first places where this care was documented and distributed in the conventional military medical community was in “First to Cut: Trauma Lessons Learned in the 

Combat Zone,”123 a collection of case scenarios from OIF and OEF sponsored by the US 

Army Institute of Surgical Research (ISR) and edited by COL Lorne Blackbourne. Chapter 

14, titled “Military Unique,” described an MWD with a gunshot wound to the abdomen 
CHAPTER TEN • 391

and laid out a basic pathway to manage these types of patients. After reading this case scenario or hearing about MWDs as FST patients, some units asked for additional predeployment training from their local conventional or Special Operations veterinarian units.

This training proved valuable. One FST, the 541st from Fort Bragg, was provided a 

canine surgery standard operating procedure by the veterinarians prior to deployment, and 

later performed multiple urgent and emergent procedures and surgeries on NATO MWDs 

in their area of responsibility. One patient was an explosive ordinance MWD with an acute 

gastric dilatation volvulus that was extremely sick on presentation. The dog had just arrived in-country and was lethargic and tachycardic, with significant abdominal distension. 

Asked to help, the FST first contacted NATO veterinarians at the Role 3, approximately 2 

to 3 hours away by rotary wing, but these veterinarians did not have surgical training. The 

541st then contacted US veterinarians in Bagram, and performed the surgery via phone 

consultation. The veterinarians in Bagram provided advice on a different way to perform 

a gastropexy that was slightly different from the technique used in a human patient, and 

later they provided postoperative advice when the dog became hyperthermic and needed 

intervention (Figure 10-14). Otherwise, the case was similar to human laparotomy and 

foregut surgery, and a few questions were answered by the canine surgery standard operating procedure. After the surgery, the MWD patient was transported to Bagram and had a 

full recovery (Figure 10-15). He had in-country convalescence and was ready to go out on 

missions with his handler a few weeks later. 

The 541st documented this case in a peer-reviewed journal with collaboration from the 

US veterinarians in Bagram,124 which sparked interest and controversy within the veterinarian and surgical community. The final consensus was that in certain situations, initial 

stabilization of MWDs with resuscitation and surgery, if indicated, could be performed by 

a nonveterinary surgeon if the dog could not be sent to a veterinarian in a timely manner. 

The 541st also provided initial care to two NATO search-and-rescue MWDs that were 

severely lacerated after becoming entangled in concertina wire. These interventions saved not 

only the MWDs’ lives and limbs, but also thousands of dollars in transportation costs and 

unnecessary risk to an aviation crew, while strengthening relationships with NATO allies.

A clinical practice guideline titled “Canine Resuscitation” was approved and published 

on 15 April 2011 by the Joint Theater Trauma System under the ISR.125 As part of the 

annual review process, the clinical practice guideline was updated on 19 March 2012 and 

renamed “Clinical Management of Military Working Dogs.”126 All medical providers 

deploying to the Central Command area of responsibility are expected to be familiar with 

this guideline and all clinical practice guidelines, and the topic is covered at the ATTC, 

Navy Trauma Training Center, Centers for the Sustainment of Trauma and Readiness, and 

Joint Forces Combat Trauma Management Course, as part of the mandatory predeployment trauma training. Various other military units have also adapted doctrine for MWDs; 

for example, the US Army Special Operations Command has a canine TCCC guideline for 

its medical staff,127 providing basic information to Role 1 and Role 2 providers. Additionally, it is recommended that units train in advance with their local military veterinarian 

center and MWD handlers as part of their routine annual training to ensure the best 

possible patient outcomes.
392 • FORWARD SURGERY

Unexploded Ordnance Embedded in Patients

FST members deployed to OEF and OIF often found themselves in unexpected situations, for instance, how to manage a patient with embedded unexploded ordnance (UXO). 

Also referred to as retained or impaled UXO in the literature, embedded UXO occurs very 

rarely. Cases of embedded UXO have involved rocket-propelled grenades (RPGs), largecaliber explosive bullets, mortar rounds, and grenades such as M79 and M203 rounds. 

Patients with embedded UXO usually have significant blunt injury but no true blast injury. 

Most medical providers know to check for any type of ammunition and ordnance 

patients may have in their pockets, known as “loose” UXO, before the patient is brought 

into a treatment facility, especially when treating unknown local patients or known enemy 

patients. Loose UXO is equally or more dangerous than embedded UXO because it may 

be missed, and it could detonate if dropped or stepped on during patient transport or care. 

However, few providers were trained to handle the mental, emotional, logistical, or clinical 

aspects of caring for a soldier with embedded UXO. 

In 1999, “Removal of Unexploded Ordnance From Patients: A 50-Year Military 

Experience and Current Recommendations,” by LTC Brian Lein, LTC John Holcomb, 

CPT Scott Brill, COL Steven Hetz, and MAJ Thomas McCrorey, was published in Military 

Medicine.

128 The authors found cases of 36 patients with retained UXO dating from World 

War II, either in the global literature or identified by verbal communication with living military physicians. Four of these patients were noted to be moribund upon arrival and died 

before surgery could be provided. The remaining 32 patients all survived the removal of the 

UXO, with no injuries sustained by the medical or explosive ordnance disposal (EOD) staff 

who took care of them. In these 36 cases, 4 injuries were located in the head or neck, 14 in 

the extremities, and 17 in the trunk; the remaining injury had no clearly documented location. This landmark article also laid out a basic plan for safely performing surgery on these 

patients with minimal risk to the surgical team. 

This article was the only available guidance on the subject until the more widely distributed Emergency War Surgery–Third United States Revision handbook was published 

in 2004.8

 However, neither the article nor the handbook were required predeployment 

reading, and embedded UXO was not covered in any of the official predeployment training 

early in the wars. Although official guidance has evolved slightly since these two sources 

were published, they included a number of basic principles that have endured: notify the 

local command and the EOD team immediately, evacuate all nonessential personnel from 

the area, and require essential medical personnel to don individual body armor or EOD 

blast gear (if they have trained with it). Another recommendation is to avoid using the main 

care facility because valuable equipment could be lost if the UXO explodes. Instead, move 

the patient to a pre-designated safe area to ensure force protection and crowd control, and 

utilize a predetermined and prepackaged set of essential equipment and supplies that have 

no effect on munitions. These strict policies and procedures were created to ensure provider 

safety and best patient outcome. 

Because fuses are armed and triggered by different methods (impact, electromagnetic, 

laser, rotational/centrifugal forces, acceleration, etc), these two documents recommend 

caution to avoid inadvertently arming or detonating the device by rotating the UXO or the 
CHAPTER TEN • 393

patient, avoiding contact with electrical tools or monitoring equipment, avoiding metal-tometal contact, and always gently moving the patient, thus avoiding sudden movements or 

impact to the device. Oxygen can safely be provided to the patient, but the oxygen canisters 

or oxygen generator should not be near the patient to prevent a secondary explosion if the 

primary UXO detonates.

Most patients with this type of injury will require general anesthesia. Totally intravenous anesthesia (TIVA) should be used instead of inhaled gases, which are contraindicated. 

If necessary, TIVA can be provided from a distance with an extension tube, allowing the 

anesthesia provider to remain in a safe location behind sandbags or a blast wall. If general 

anesthesia is not required, a spinal or regional block can be used. Other points to consider: 

radiography use is safe, but ultrasound, CT scans, and other studies should be avoided. 

The device should be removed en bloc, if possible; amputation should be considered if 

other methods fail. Once the UXO is removed, the patient should be rapidly transported to 

the main operating room to receive the highest level of surgical and resuscitative care.9,128–134

In any situation requiring triage, providers must do the most good for the most 

patients, so a casualty with embedded UXO should be the last individual to receive care. 

Also, the patient should be triaged as expectant if their injuries are too severe or the risk of 

UXO removal is too high (eg, in cases of embedded chemical and biological UXO).

 Units should practice UXO management in garrison. Every part of managing a patient 

with embedded UXO will go better if it is planned for and practiced ahead of time. The 

set-up of an ancillary surgical site, creation of a blast wall and sandbagging, and the “do’s” 

and “don’ts” of embedded UXO treatment cannot be safely or effectively done if performed strictly on the fly.

At the time of this writing, there have been five known cases of embedded UXO in 

combat casualties during the GWOT. Three occurred in OEF and are published and well 

known; however, very little has been published about embedded UXO in OIF and Operation New Dawn (OND). The two known OIF/OND cases will be formally documented 

here. One of these, the first known case of a soldier surviving embedded UXO during the 

GWOT, occurred in Iraq in the spring of 2005.135,136 An RPG went through the door of 

an HMMWV and penetrated the thorax of a soldier, entering through the open side of his 

body armor. The soldier was treated in the field and transferred to the 86th CSH, where he 

underwent surgery. Unfortunately, he was nearly moribund on arrival and died. The device 

was removed and taken to the large surgical equipment sterilizer until the EOD team was 

able to remove it.

This case of embedded UXO was not well documented. Individual interviews of 86th 

CSH staff members indicate that the grenade entered the soldier’s thorax in the axillary 

area and began exiting the anterior chest. It was also stated that the presence of embedded 

UXO was not clear until the patient was in the operating room, where he was immediately 

transferred because he was in extremis in the emergency room, before the x-ray had been 

developed and read. Many standard steps to ensure the safety of the medical providers and 

equipment were probably not taken, apparently due to the initial lack of knowledge of the 

embedded UXO. Because of limited documentation in this case, it is unclear whether the 

explosive part of the RPG was in the soldier’s chest, or whether only remnants of the tail 

section and warhead detonator were embedded. 
394 • FORWARD SURGERY

The best-documented and most well-known UXO case occurred in OEF and involved 

a 23-year-old active duty male soldier, Private (PVT) Channing Moss, in 2006.87,129,137–139

An RPG entered PVT Moss’s left side, with the tip lodged in his right hip. The extensive 

surgery performed on Moss by the 759th FST (Airborne) in Orgun-E, under the supervision of MAJ John S Oh, was videotaped. MAJ Oh and three enlisted medical providers, 

along with their EOD support personnel, performed this dangerous life-saving surgery. The 

surgery began with an initial incision at the right anterior hip around the tip of the RPG. 

Next, a standard trauma laparotomy incision was made. With the assistance of the EOD 

experts, the grenade was stabilized and the tail section extending out of Moss’s left side was 

safely cut off. The remaining components of the grenade were then advanced forward from 

left to right, following the projectile’s original path, and out the initial right hip incision. 

The UXO was removed and handed safely off to the EOD team. Additional surgery and 

resuscitation was performed to stabilize the patient and transport him to Role 3 for further 

management. Moss survived his wounds after undergoing numerous additional operations 

at Landstuhl Regional Medical Center, Walter Reed Army Medical Center, and Dwight D 

Eisenhower Army Medical Center.137,138

Numerous news interviews, textbooks, journal articles, and blogs mention this unique 

case, primarily because of the videotaped surgery. While the cameraman was not an 

essential member of the surgical team, his presence was not a violation of guidelines. 

Clinical evaluation and consultation with EOD personnel early on revealed that the warFIGURE 10-16. (a) An image from a pager used at the surgical 

facility in Tikrit, Iraq, in 2007, detailing information about an 

inbound patient with a live M203 round embedded in his leg. 

(b) The removed and still live M203 was placed in an ammunition can lined with medical gauze to create a soft packing. It was removed from the facility and disposed of by the 

local explosive ordnance disposal team. This was one of the 

earliest cased of an embedded unexploded ordnance in Iraq 

War and the first ever documented case of a live M203 round 

being embedded in a live patient. Photographs courtesy of 

MAJ John Chovanes, former trauma surgeon, 325th Combat 

Support Hospital.
CHAPTER TEN • 395

head was no longer connected to the sustainer motor. The casing for the base of the warhead detonator was seen on x-ray and possibly intact, but it was mechanical and did not 

have combustibles in it. Lastly, it was assumed that the rocket propellant in the sustainer 

motor was completed consumed. Due to this proper initial evaluation and consultation, the 

UXO was assumed to be stable and therefore fairly safe for removal and video documentation. This case and its detailed documentation spurred additional publications discussing 

these situations and providing guidance on how to properly address them.

A third known case occurred during OIF in 2007. A US Marine was injured and 

transported to the 325th CSH in Tikrit. The patient was stable, so hospital staff had time 

to prepare for the situation, setting up an ancillary surgical site and developing a safe plan 

for the UXO removal (Figure 10-16). MAJ John Chovanes, a trauma surgeon; CPT 

Michael Hawkins, CRNA; an unknown medic; and an unknown Navy EOD team 

member donned their personal protective gear and performed the procedure without 

complications.140–144 The embedded 40-mm round was disposed of, and the patient was 

eventually transported to Landstuhl Regional Medical Center and then on to the United 

States. Fortunately for the patient, Dr Chovanes had discussed this exact scenario with 

his trauma surgery colleague, MAJ John Pryor, before he deployed (see the preceding discussion of Dr Pryor’s death a year later as the second surgeon killed in action at an FST 

facility during the GWOT). This is the first documented case of an M203 round being 

embedded in a patient. While 18 of the 36 cases reported in Lein et al’s article involved 

the M79 grenade launcher round, its replacement weapon, the M203, had not been seen 

previously in embedded UXO cases.

In 2008, War Surgery in Afghanistan and Iraq, edited by COL Shawn Nessen, COL 

(Ret) Dave E. Lounsbury, and COL Stephen P Hetz, was published, soon followed by 

“First to Cut” in 2009 (see discussion above).123,129 Both publications included case 

scenarios of embedded rocket-propelled grenades in soldiers and described what the team 

did to address them. These scenarios reinforced the procedures recommended by Lein et 

al’s paper, with some additional recommendations, which assisted the providers in managing the next two cases of embedded UXO. 

At times UXO may be embedded so deeply that it is not recognized until the patient 

is inside a treatment facility, as with the first case discussed, and also the fourth reported 

case. This case occurred in 2010 at the Craig Joint Theater Hospital in Bagram. An Afghan 

National Army soldier presented with an embedded high-explosive incendiary 14.5-mm 

(.57 caliber) bullet from a Russian-made machine gun145 that had not exploded on impact. The soldier had been involved in an IED attack and was brought to the facility as a 

standard trauma patient. It is unclear if the round was a component of the initial IED or 

from secondary gunfire during an ambush after the initial blast. The patient underwent a 

standard trauma evaluation, initial adjuncts, and radiology studies including a CT scan. He 

was then taken to the operating room for surgery. At this time, a second, more thorough, 

evaluation of the CT scan revealed something odd embedded in the patient’s scalp. When 

the radiologist, Air Force LTC Anthony Terreri, realized what the CT was showing, he 

immediately notified Air Force MAJ John K Bini, the 455th Expeditionary Medical Group 

trauma director. 
396 • FORWARD SURGERY

The operating room was then cleared of all nonessential personnel while essential 

personnel removed the UXO from the patient. After removal, the high-explosive incendiary 

bullet was passed on to EOD staff for proper disposal. Remaining surgeries were completed 

on the patient, and he survived the injury.77 This case highlights how UXO can be embedded so deeply it can threaten medical staff and equipment inside a medical facility, and also 

how proper planning and quick thinking can lead to a successful resolution. 

The fifth known incident of embedded UXO occurred in 2012 when an undetonated 

RPG injured Marine Lance Corporal (CPL) Winder Perez.146–148 The RPG tip became 

lodged in Perez’s leg, pelvis, and lower abdomen, creating life-threatening wounds. As often 

occurs in a combat zone, communication and coordination among responders was difficult. 

The medical evacuation (MEDEVAC) crew initially believed they were picking up a local 

national girl with a leg injury, but soon realized their patient was a US service member with 

an embedded UXO device. As in all such situations, the medics, ground MEDEVAC teams, 

air MEDEVAC teams, and surgical staff had to decide whether to take on this dangerous 

challenge. 

While the literature provides guidance on the safest ways to manage these situations, it 

also states that sometimes the risk can be too high and the patient should be categorized as 

expectant. However, in this case, the pilot, copilot, crew chief, and flight medic collectively 

agreed to not leave the patient to die, but to take on the risk of injury and death, and the 

destruction of their UH-60 Blackhawk, if the round were to detonate during transport. 

Their decision resulted in Perez arriving at FOB Edinburgh alive. 

Once there, he was evaluated by Navy nurse Lieutenant Commander (Lt Cmdr) 

James Gennari and his surgical staff from the Marine Corps 2nd Supply Battalion, Surgical 

Company, Bravo. Initial surgery was performed at an offsite location per published recommendations and the battalion’s internal protocol. The RPG was removed without injury to 

the surgical staff or damage to any equipment. The grenade was given to EOD staff, and 

the surgical team was able to provide additional damage control surgical and resuscitative 

procedures to stabilize Perez. He was then safely transported to Role 3 for further management of his wounds.

The 1999 article written by Lein et al, the case scenarios in War Surgery in Afghanistan

and Iraq and “First to Cut” books, descriptions in the Emergency War Surgery Handbook

and the Defense Medical Training Institute’s Combat Casualty Care Course Handbook,

25,26

a few other journal articles, and local standard operating procedures provide guidelines 

that are not part of mandatory military training but were sought out by the surgeons and 

surgical staff and used extensively during deployment training rotations of FSTs at the 

ATTC. In all known GWOT embedded UXO cases, the surgical team had some preexisting 

knowledge of these potential situations and possibly a basic plan for who would perform 

the surgery, what procedure to perform, where they would perform it, why they would 

choose to do so, how they would function as a team, and how they would interact with 

other groups such as EOD staff to ensure that the patient and the surgical team survived 

the procedure. Some teams had more standardized plans and had practiced these scenarios 

in garrison. 
CHAPTER TEN • 397

Because of these embedded UXO cases and the lack of training on the topic, the Joint 

Theater Trauma System branch of the ISR published the “Unexploded Ordnance Management” clinical practice guideline in 2012. Once this guideline became official, the proper 

medical management of both loose and embedded UXO became part of mandatory predeployment training. As the GWOT/Overseas Contingency Operations continues to transition, these situations will likely continue. With the additional preparation from mandatory 

provider training, most soldiers will survive and medical staff may be able to maintain their 

100% success rate of avoiding embedded UXO detonation in surgery. 

Advances In Concepts, Technologies, and Care 

TACTICAL COMBAT CASUALTY CARE

US Army FSTs, and similar small surgical units, were designed to address the need for 

proximity and mobility of forward surgical assets, as noted in Chapter 9. One important 

factor in patient treatment at these facilities is the condition of the patient upon arrival, 

which largely depends on the quality of care rendered between the point of injury and the 

surgical facility. COL Ronald F Bellamy’s landmark 1984 paper, “The Causes of Death in 

Conventional Land Warfare: Implications for Combat Casualty Care Research,” published 

in Military Medicine, reviewed historical data and used complex analysis to demonstrate 

that a significant number of casualties’ lives could be saved if proper emphasis was placed 

on field medical care.27 In 1995, Bellamy presented a refined version of this data in the 

first chapter of the Borden Institute’s Anesthesia and Perioperative Care of the Combat 

Casualty, noting that of those killed in action, 44% died from exsanguination, 31% from 

central nervous system injuries, and 13% from combined injuries. Additionally, 5% died of 

wounds due to central nervous system injury, 4% from multiple organ failure/sepsis, and 

3% from shock. Twenty percent of those casualties who exsanguinated on the battlefield 

died as a result of bleeding from an artery in an extremity (femoral and brachial injuries 

were the most common locations) that could have been controlled by prompt first aid such 

as application of a pressure dressing or a tourniquet.43

COL Bellamy advocated for increased numbers of medically trained individuals, 

improved medical training for initial responders, and improved adjuncts at the point of 

injury to stabilize patients. This recommendation led to better training of combat medics, 

including instruction on emergency cricothyrotomy, improved resuscitation, simpler and 

more secure intravenous access, and evacuation of trapped air for the management of pneumothorax. Bellamy also strongly advocated for better hemorrhage control. He believed that 

better point-of-injury management, coupled with faster evacuation times, might save at 

least 26% of these causalities: those with surgically correctable torso injury, extremity exsanguination, and blast injuries.27,149,150 Bellamy went on to state that, “To save lives, there 

is no substitute for prompt and effective surgery. Either the casualty must be evacuated to 

surgical facilities or the surgical facilities must be brought to the casualty. With helicopter 

evacuation of questionable feasibility, surgical care in Army 21 [the 21st century Army] will 

be possible only if the facilities go with the soldier. That is not possible with the large and 
398 • FORWARD SURGERY

cumbersome hospitals of today, but the answer found forty years ago—small surgical/shock 

teams attached to unit level medical assets—might still be applicable.”149(p410)

In the 1990s, US Army Rangers and Navy SEALs developed what became known 

as TCCC, taking point-of-injury care to the next level.151,152 TCCC standards have been 

codified by the DoD Committee on Tactical Combat Casualty Care (CoTCCC). These 

techniques and practices have significantly increased the number of wounded soldiers to 

arrive at the forward treatment facilities. An important consequence of this improvement, 

however, is that on average the casualties were arriving with more severe injuries. Patients 

who previously would have been killed in action (ie, died before arrival at a surgical facility) were being saved. 

Proximity became more important. Combat surgeons needed to be closer to the point 

of injury to ensure that more of these soldiers, now surviving to reach Role 2 with central 

nervous system injuries, torso hemorrhage, and airway and chest wall or lung injuries, 

could be stabilized beyond the capabilities of the line medic. The modern FSTs provide initial surgical care of lethal head and torso injuries, as well as continuation of care rendered 

at the point of injury for airway, extremity, and some chest injuries. Once stabilized, patients can be transported to higher levels of care. The significant success of forward surgery 

is the continuing historically high survival rates, despite the increasing severity of patients’ 

condition on arrival. 

HEMOSTASIS

FSTs have embraced or helped develop numerous technology advances since the 

GWOT’s beginning. Improved body and vehicle armor have provided enhanced soldier 

protection compared to previous combat engagements. Many blast injuries that historically would have caused lethal central nervous system, torso, or extremity injuries are now 

more survivable. Solders are living after the immediate blast, but with significant extremity 

injuries with involvement of one to all four limbs. While use of extremity tourniquets had 

been taught to every soldier for decades, only medics and combat lifesavers were issued 

tourniquets or had the components, cravats and dowels, to actually apply them. However, 

even when available, the classic strap tourniquet or the cravat and dowel tourniquets never 

worked as well as desired. 

During the GWOT, new commercial tourniquets became available, and in 2005 they 

began appearing in various medical units’ medical equipment sets as well as soldiers’ individual first aid kits.153–155 The most commonly used extremity tourniquet was the combat 

application tourniquet (CAT), followed by the Special Operations forces tactical tourniquet 

(SOFT-T). With the availability of these new tourniquets, soldiers with previously lethal 

extremity injuries were now arriving alive in larger numbers to Role 2 facilities.155–158 

Combat surgeons had to quickly develop new protocols to meet the challenges of these 

very sick combat trauma patients.

Once extremity tourniquets became mainstream and liberally applied, extremity exsanguination was no longer the most common cause of preventable death from a nonsurgical 

source of bleeding. Instead, pelvic bleeding in the inguinal area from distal iliac and proximal femoral vessels became a leading cause of lethal bleeding. Military providers were very 
CHAPTER TEN • 399

aware of this problem, especially those familiar with the death of CPL James Smith, killed 

in action in Somalia in 1993.159 Smith died of a gunshot wound and groin hemorrhage that 

was too proximal for a tourniquet application. The US Army Institute of Surgical Research 

recognized and addressed this issue in 2008 by developing the Combat Ready Clamp 

(CRoC), which can apply pressure to areas of the body where traditional tourniquets cannot be used.

 TCCC management of junctional hemorrhage now includes training materials for three 

commercially available pelvic binders: the Pelvic Binder (Pelvic Binder Inc, Dallas, TX); the 

T-POD (Bio Cybermetrics International, La verne, CA); and the SAM Sling (SAM Medical 

Products, Wilsonville, OR). Additionally, two other types of junctional tourniquets may also 

serve as pelvic binders, the SAM Junctional Splint (SAM Medical Products) and the Junctional Emergency Treatment Tool (JETT; Chinook Medical Gear, Durango, CO).160–162

In addition to tourniquets, new hemostatic agents for external hemorrhage control 

were developed. Products such as QuickClot Combat Gauze (Z-Medica, Wallingford, CT, 

Celox Hemostatic (Chinook Medical Gear), and Chito Gauze (Tricol Biomedical, Portland, OR), to name the primary ones, filled the aid bags of medics and the traumatic cavity 

wounds of patients.163,164 Not all products developed for the military are still used, due to 

various problems. 

Combat Gauze became a frequently used and favorite supply of military medical providers. Beyond its traditional use to control significant soft-tissue bleeding, combat surgeons 

were known to pack it into liver injuries, retroperitoneal hematomas, and complex paraspinal injuries instead of using the traditional nonimpregnated plain gauze. When used in this 

manner, Combat Gauze is removed during a second surgery at the Role 3 facility. 

The success of these hemostatic agents prompted additional research and testing so 

that third-generation products are used currently, with ongoing research into future products. These will possibly have different chemical agents and structural enhancements of 

current designs.

DAMAGE CONTROL RESUSCITATION AND BLOOD PRODUCTS

Early in the war, military physicians and surgeons began using a new technique known 

as damage control resuscitation.165,166 This type of resuscitation was an attempt to limit 

excessive administration of intravenous fluids, to prevent their acute side effects and later 

sequelae, while focusing on the positive aspects of giving blood products. Also as part of 

this concept, combat providers were taught to be comfortable with permissive hypotension 

(a systolic blood pressure of 90) instead of the higher values normally taught. 

In addition to reduced overall volume of transfusion, damage control resuscitation 

emphasized early blood replacement. FST and CSH personnel began following protocols 

to give 1:1 ratios of packed red blood cells (PRBCs) to plasma or 1:1:1 ratios of PRBCs to 

plasma to platelets, based on availability of each product at their location. Traditionally, 

FSTs stocked PRBCs only, but for most of the GWOT they also had fresh frozen plasma. 

CSHs also stocked platelets. Following these ratios, instead of those used in garrison and 

civilian trauma centers, resulted in increased survival rates. Of note, although FSTs did not 

have prepackaged platelets, they had the ability to acquire platelets via fresh whole blood. 
400 • FORWARD SURGERY

Fresh whole blood transfusion for combat casualties was not new to the combat surgeon. The technique had been developed during World War I and was the primary type of 

transfusion throughout the world until the 1960s. The DoD continued to use fresh whole 

blood transfusion into the GWOT. Although no longer approved by the Food and Drug 

Administration for primary use in the United States, the technique is authorized for combat 

use due to logistical needs, and it has been found to be a better resuscitation product than 

component therapy. FSTs collaborated with their medical company colleagues to help 

develop robust fresh whole blood collecting systems.167 Many soldiers are alive today due 

to the generosity of their fellow soldiers who lined up to donate warm fresh whole blood at 

a moment’s notice. Currently, the US military is looking into the use of freeze-dried plasma 

and liquid plasma to allow for easier delivery of a resuscitation colloid at the point of 

injury, in transport, and at the FST facility. 

Additionally, since 2001 air MEDEVAC units have slowly increased their use of blood 

product transfusion.152 En-route transfusion in these “vampire” missions, commonplace 

since 2012,168 have helped improve patient condition on arrival at the FST for further 

resuscitation and surgery. Lastly, component blood therapy, as well as fresh whole blood, 

is currently being considered by the CoTCCC as the primary resuscitative fluid at point of 

injury for future missions. Overall, damage control resuscitation was practiced throughout 

the second half of the GWOT and has shown significant improvements in initial and longterm outcomes. 

HEMOSTATIC PHARMACOLOGICS

Hemostatic pharmacologics were also widely used at the FST and CSH during this 

period. Starting around 2003, recombinant Factor VIIa was being used to help address 

noncompressible bleeding in some trauma patients.169,170 While British military surgical 

personnel were the first to use the product, the United States followed shortly after.171 Initial 

findings demonstrated that recombinant Factor VIIa decreased bleeding; however, data on 

long-term outcomes showed a concerning increase in deep vein thrombosis and pulmonary embolism. Due to the nature of combat casualty care along the continuum of care, it 

has been difficult to determine whether the use of recombinant Factor VIIa offered a true 

benefit or a risk.172

Tranexamic acid, an antifibrinolytic, is the current standard of care for individuals 

deemed to require damage control resuscitation with massive blood transfusion (defined as 

10 units of PRBCs within the first 24 hours of care).163 Its benefits were proven in two major studies published in 2012, CRASH 2 (Clinical Randomization of an Antifibrinolytic in 

Significant Hemorrhage)173 and MATTERs (the Military Application of Tranexamic Acid 

in Trauma Emergency Resuscitation study).174 Both showed that tranexamic acid decreased 

coagulopathy and improved outcomes, leading to the CoTCCC recommendation for its 

use. The earlier it is administered, the better the outcomes for severe combat casualties. In 

August 2011, the CoTCCC recommended that TCCC guidelines include tranexamic acid 

and make it available for advanced level field medics to ensure that it would be in the 

patient’s system and have effects as soon as possible.175 It quickly replaced recombinant 

Factor VIIa, and new protocols were implemented.176,177
CHAPTER TEN • 401

HYPOTHERMIA 

Hypothermia management is another area in which FSTs have had a positive impact 

on patient outcome. All FSTs, from mobile to semipermanent facilities, have environmental 

control units to help ensure that trauma patients stay warm. In addition to wool or cotton 

blankets, these units also carried a variety of space blankets or other advanced passive and 

active products.178 Patients arriving at the FST’s facility have the remainder of their clothes 

removed, but stay warm in the operating room and recovery sections due to increased 

ambient air temperatures and quick placement of a space blanket or active warming device 

such as a Bair Hugger (3M, St Paul, MN). When patients are prepared for transport, FSTs 

are trained to package them using products such as the Hypothermia Prevention and Management Kit (HPMK [North American Rescue, Greer, SC]), or Blizzard Survival blankets 

(Blizzard Survival, Bethesda, Gwynedd, UK).179 The HPMK is the most widely used. This 

device fits the patient like a sleeping bag, has access areas for lines and patient care, and has 

an oxygen-activated warming pad.

PAIN MANAGEMENT 

Other advances in managing combat trauma pain had an impact on combat surgeons. 

Early on, soldiers received morphine for almost all combat injury pain. While usually 

effective, morphine had numerous shortcomings. It required intramuscular, intravenous, 

or intraosseous access; could cause additional blood pressure decreases in patients with 

hypotension; had to be administered by medics or higher-level providers; and was subject 

to abuse or theft. Intramuscular administration caused delayed effects, which could lead to 

accidental overdosing. Morphine’s effects can also cause challenges with evaluation, resuscitation, and respiration. 

In response to these problems, a new, tiered strategy for managing pain was developed. 

The system began (for mild to moderate pain) with administration of the combat pill pack, 

which contained 1,300 mg of acetaminophen and 15 mg of meloxicam for pain control, as 

well as 400 mg of moxifloxacin for initial antibiotic control of mild injuries. After taking 

these medications, soldiers could continue performing combat operations or await routine 

transport. Moderate to severe pain was managed with a lozenge of 800 μg of oral transmucosal fentanyl if the patient was not in hypovolemic shock, unconscious, suffering from 

a severe head injury, or in respiratory distress before arrival at a surgical facility. A second 

lozenge was authorized if the patient was hemodynamically stable and still having pain. 

The lozenge, commonly referred to as a fentanyl lollipop, could be taped to the patient’s 

index finger to ensure it was not dropped or misplaced; also, if the patient went into shock, 

developed respiratory problems, or became unconscious, it would fall out of the mouth. 

Ideally the patient should be sitting up when the lozenge is administered. 

Ketamine, a dissociative anesthetic medication, was added to the TCCC guidelines as a 

recommended alternative to morphine in 2012.180 In October 2013, TCCC guidelines were 

changed to make ketamine the primary medication for patients with moderate to severe 

pain. Ketamine worked reliably by multiple routes (intramuscular, intranasal, intravenous, 

and intraosseous). Morphine could still be used, in moderation, as an adjunct in certain 

situations.181 As the guidelines changed, the type of pain management the arriving patients 
402 • FORWARD SURGERY

had received in the field might be unclear, especially if treatment documentation cards 

were missing or incomplete. If it wasn’t known whether the patient had received ketamine, 

neurological evaluations would be inconclusive. This problem led to improvements in care 

documentation (see the section on patient medical records, below). 

Additionally, many patients received TIVA or regional blocks, based on their condition and injuries. Patients with isolated limb injuries often left theater surgical facilities with 

catheter-directed pain pumps. These devices provided excellent pain management control 

without the side effects of oral or parenteral narcotics, and numerous soldiers made positive comments about them.

RADIOGRAPHY, BLOOD COLLECTION, AND ANESTHESIA EQUIPMENT 

Throughout the war, FSTs received numerous intratheater equipment upgrades. Some 

locations had fluoroscopy for vascular and orthopedic repairs, and some received their own 

radiography machines if they were not co-located with a medical company. All received 

equipment to perform fresh whole blood drives if they were not co-located with a medical 

company. Many had improved operating room lighting, civilian-style patient beds, and operating room tables instead of the traditional litter-based systems. The standard draw-over 

system used for providing anesthetic gases at the FST was difficult to use and maintain. 

Eventually, many FST sites received field-style Drager (Louisville, KY) Narkomed or Fabius 

anesthesia machines to provide better quality general anesthesia. 

DAMAGE CONTROL SURGERY

In addition to damage control resuscitation, FSTs routinely employed damage control surgery. Damage control surgery was usually performed in the best interest of a cold, 

acidotic, and coagulopathic patient, but it was also used at times to stabilize a patient while 

surgeons treated another patient, or to meet a MEDEVAC opportunity that might not be 

available later due to missions or weather. After damage control surgery, numerous patients 

were left with packed abdomens, with bowel in discontinuity, or with vascular shunts to 

temporize their potentially lethal injuries. Soft-tissue wounds and laparatomy incisions 

were commonly left open, with follow-on surgery provided by a Role 3 facility. Improvised 

open-abdomen dressings were initially used, but many surgeons ended up using the preferred vacuum-assisted closure abdominal dressing system to control fluid losses. 

MEDICAL EVACUATION 

During the wars in Afghanistan and Iraq, most patients were transported by air 

MEDEVAC (primarily US, British, and German assets). On occasion patients who were 

injured on base, or near base, especially in large urban areas, were transported by ground. 

The primary aircraft supporting US medical transport was the UH-60 Blackhawk. The 

United Kingdom initially used the CH-125 Sea King, but switched from this aging aircraft 

to the CH-47 Chinook about 2006. German MEDEVACs initially used the CH-53 Stallion and then, starting in 2013, the NH-90. Ground transport occurred via many different 

ambulances. US field ambulances included the M113, M996, M997, various versions of 

the MRAP (mine-resistant ambush protected), or CASEVAC (casualty evacuation) vehicles. 
CHAPTER TEN • 403

At first MEDEVAC flights took a long time (as noted in the discussion of OEF above), but 

they were slowly reduced to under an hour. 

In 2009, Secretary of Defense Robert Gates mandated that a surgical unit and affiliated air medical support be available within 60 minutes for all conventional forces, so that 

patients had a better chance of being seen with in the “golden hour” of trauma.182 This 

requirement applied to Role 2 surgical teams and CSH FSEs, as well as their supporting 

air evacuation units, throughout both theaters. Previous 2-hour evacuation times rapidly 

dropped to under 45 minutes for most flights due to the assets dedicated to meet the secretary of defense’s policy. By reducing evacuation times, surgical stabilization, via damage 

control resuscitation and surgery, could more rapidly be provided. 

As the war evolved, patients also began to get better care before being picked up 

by MEDEVAC, and while en route to the FST. TCCC became the theater standard and 

helped ensure that the latest in concepts and equipment were pushed out to the front lines. 

However, the air and ground evacuation units had more patients to manage as the conflict 

continued. Some casualties in very critical condition would have died in the absence of 

advanced body armor or TCCC concepts. Air MEDEVAC units had to increase their ability to manage these critical patients better than they had in the past. Teams began adjusting their protocols, for example, by giving blood products while en route to surgical units. 

Known now as “vampire” missions, MEDEVACs with blood transfusions began early in 

OEF and became very common.183,184

The combination of improved body armor, better point-of-injury care, and faster 

MEDEVACs with better en-route care meant that the FSTs had more patients arriving in 

extremis than in the past, often with devastating injuries that would have caused death 

before the casualties reached surgical care in all previous wars. FSTs were now saving 

patients with catastrophic injuries who might be difficult to keep stable for further transport. Some FST sites were enhanced with additional critical care equipment and staff to 

provide limited extended care times to further stabilize the patients. 

Additionally, early on in the war many patients who survived their initial surgery at the 

FST were packaged and ready to be medically evacuated to the Role 3 with ongoing challenges. While many patients had numerous injuries and adjuncts to address these injuries, 

sometimes junior flight medics were asked to care for patients with complex injuries they 

had no experience with. Only stabilized patients were transported. However, these patients 

might have a head injury; an open abdomen; missing limbs; an external pelvic or limb 

fixator; nasogastric tubes; multiple chest tubes, peripheral intravenous lines, central venous 

catheters, or intraosseous lines with numerous drips and blood products running into each; 

or any combination of these injuries. 

MEDEVAC crews and combat surgical teams knew that some patients were beyond 

the scope of most flight medics’ skill set. To ensure patients’ best chance for survival, two 

major changes occurred. The first was a paradigm shift for the US Army: the recognition 

that within a trauma care system, the best medical staff to care for especially complex 

patients are in-flight critical care nurses. US civilian air rescue and some allied countries’ 

military had this capability. However, the US Army previously did not. The AMEDD Center and School rapidly developed a program to train new en-route critical care nurses: the 
404 • FORWARD SURGERY

Joint En-route Care Course, which provided the additional unique skills that already highly 

qualified nurses needed to help keep patients stabilized during air transport to Role 3.185

These providers, who had extensive backgrounds in managing patients in a hospital-based 

intensive care unit, received additional flight and patient transport training. They helped 

increase the number of patients who arrived to the Role 3 warmer, in better physiological 

condition, and more stable overall. 

In tandem with the deployment of en-route critical care nurses, the flight paramedic 

program was created to produce and maintain flight paramedics with more advanced 

training than earlier flight medics received.162,186 Both en-route critical care nurses and the 

new flight paramedics provided improved transport care to patients, improving the level 

of care provided from point of injury to the FST, as well as from the FST to the CSH.187 

In response, FSTs began creating better ways to address mass casualty incidents via planning, patient flow, and clinical management.188 For example, it was shown that in certain 

circumstances, with motivation and training, a two-surgeon FST could run two operating 

room tables.189

The new US air MEDEVAC model slightly resembled the German and British 

MEDEVAC platforms also used in Afghanistan at that time. The German CH-53 Stallion and NH-90 aircraft were usually staffed by a four-person medical team consisting of 

an emergency care physician, anesthesiologist or anesthetist, and two paramedics. Good 

outcomes with this platform were reported for movement from Role 2 to Role 3.190 The 

United Kingdom deployed a unique MEDEVAC concept known as the medical emergency 

response team, or MERT, midway through the war. Initially stood up in 2006 by LTC 

Andy Griffiths, a British anesthesiologist, MERTs have saved many patients who would 

have otherwise died en route.191,192 MERTs used CH-47 Chinook rotary wing aircraft 

staffed with a four-person medical team made up of an anesthesiologist or emergency care 

physician, an emergency care nurse, and two paramedics. Initially the team was an integral 

part of the hospital staff and rotated on shifts, performing on the MERT as an additional 

duty. Now the medical team is specifically selected, trained, and equipped for this role and 

is dedicated to it for the deployment. 

The advanced level of care in larger aircraft provided by MERTs has been shown to 

improve the patient’s condition on arrival to a surgical unit through advanced procedural 

skill sets, ability to transfuse blood products, and, most importantly, the decision-making 

expertise of a highly skilled and trained team. The MERT concept is now integral to future 

United Kingdom operational medicine. The United States has shown interest in the advanced provider concept used by the German and British, but has not committed to taking 

a larger aircraft with more equipment and providers with a higher level of training to the 

point of injury. 

Institute of Surgical Research and the Joint Trauma System

The US Army Institute of Surgical Research (ISR), located at Joint Base San Antonio–

Fort Sam Houston, Texas, has a long and proud history of supporting the medical and 

surgical needs of combat surgeons via extensive research efforts. During the GWOT, ISR 

staff worked to get information and products to Role 2 and 3 surgical teams on the battle-
CHAPTER TEN • 405

field and to their colleagues at the Role 4 hospitals in Germany and the continental United 

States. In 2005, the Battlefield Health and Trauma Research Institute was formed. This new 

consortium co-located all combat casualty care research leaders within the DoD at the ISR 

for enhanced collaboration. The ISR also ensured that the latest discoveries in initial burn 

management were rapidly provided to Role 2 surgical units.193

A few years into the war, the DoD recognized the need for better management of the 

vast amounts of trauma data pouring in, which could be used to analyze patient outcomes 

and effect process improvements.194 This led to the creation of the JTS in 2004. Efforts 

were focused on three areas for the much needed feedback to the field: data acquisition, 

automation, and analysis. The JTS evolved to provide unequalled shared knowledge and 

impacts on patient outcomes. Also created in 2004 was a subordinate unit, the Joint Theater Trauma System (JTTS). This element, which resided in the Central Command area of 

responsibility, was established to ensure the JTS was actively engaged in combat trauma, 

primarily by establishing the Joint Theater Trauma Registry (JTTR) to improve collection 

of patient management and outcomes data for near-term and future analysis. Role 2 and 

3 surgical units were provided a very detailed form to fill out on each patient, designed to 

collect specific information in a simple and concise manner using TCCC cards and afteraction reports. The information is then input via Medical Communications for Combat 

Casualty Care (MC4) handheld devices. 

JTS staff have conducted very successful data acquisition, provided data analysis, coordinated for performance improvement, and developed and conducted education and training programs that far exceeded anything done in the past. Performance improvement came 

in the form of clinical practice guidelines based on the data collected and the education and 

training led by the weekly Combat Casualty Care Conferences held by the JTS and ISR. 

While the JTS was originally stood up to meet the needs of the Role 2 and Role 3 trauma 

teams within the Central Command area of responsibility, its value has been recognized 

and addresses all roles of care and will likely be the model for all combatant command 

areas and theaters in the future. 

Patient Medical Records

Another first during this period was the use of electronic medical records for documenting and tracking patient care. Early on, all documentation was done on standard 

field casualty care forms, followed by notes handwritten on hospital-based forms such as 

the Standard Form 600. At times patient data was written directly on the patient’s skin or 

on strips of silk tape with a permanent marker. Research-oriented surgeons and nurses at 

many of the initial FSTs collected data on their patients. These local databases were used 

for early OEF and OIF analysis and publications until a better system was established by 

the DoD via the JTS. To improve individual patient care, the DoD procured a new electronic patient care system for the field. The system, called the Medical Communications 

for Combat Casualty Care, or MC4, provided an array of useful patient care software 

products. Deployed in 2003, MC4 was used in Afghanistan, Iraq, Kuwait, and Qatar.195 It 

used a semi-ruggedized laptop as its primary hardware and could communicate to various 

servers via a satellite dish. 
406 • FORWARD SURGERY

In addition to tracking and logistical software, the DoD’s Armed Forces Health Longitudinal Technology Application (AHLTA) software program for soldiers’ electronic medical 

records could be used in a special “theater” version known as AHLTA-T. Using AHLTAT would ensure that all patient encounters could be entered into a permanent electronic 

medical record. As the patient moved from Role 2 to Role 3 to Role 4 care at Landstuhl 

Regional Medical Center in Germany to a continental DoD medical treatment facility, all 

records could be seen due to daily system-wide updates. This system provided a better trail 

of patients’ care, incorporating quality assurance for medical documentation accuracy and 

accountability.196

One of the final challenges to battlefield patient records was at the point of injury. 

At the beginning of the war, medics were issued DD Form 1380, a standard field medical 

card dated December 1991. Although the card had areas to document many of the basics 

needed for initial patient care, it needed improvement. Because 87% of casualties die in the 

prehospital setting, analysis of the reasons for each death, via proper documentation, was 

strongly sought after.46

With the change in basic point of injury care being rapidly advanced by the CoTCCC, 

committee members also pushed for an improved field medical card.195 They wanted a 

card that followed their three-phase system of care under fire, tactical field care, and tactical evacuation care and that was easier and faster to fill out. The CoTCCC developed the 

TCCC Casualty Card in 2007, based on a casualty card developed by US Army Rangers a 

few years earlier. The TCCC Casualty Card was initially printed as a DA Form 7656 and 

became the standard format for documenting prehospital care by all US Army providers.197

Even with an improved card, a 2011 study revealed that only 14% of casualties had 

care documented upon arrival at a Role 2 or Role 3 surgical unit.198 (pp44–47) Part of this 

problem was due to a lack of enforcement and poor understanding of the importance of 

point-of-injury documentation. Another problem was that the new TCCC Casualty Card 

was an Army form, so many Air Force, Marines, and Navy units could not easily acquire it 

or use it.199

Two things were done to address the underutilization of the new card. First, the 

CoTCCC had the DA 7656 converted to a DD form in 2014. It was again called DD 1380, 

but the nomenclature was changed from “field medical card” to “TCCC Card.” Second, 

an innovative initiative to inspire young medics, physician assistants, and physicians at Role 

1 to increase compliance and accountability was developed. Individual soldiers and medical units received recognition and awards for having the highest card turn-in rates. Both 

of these changes have significantly increased point-of-injury care documentation, resulting 

in better follow-on care at FSTs and valuable data for analysis of the 87% who die in the 

prehospital setting.

Forward Surgical Team Training and Readiness

Various FSEs within the US military train using a similar format of individual and collective military and medical training. Army FSTs prepare for mission readiness and combat 

deployments via a number of standard and nonstandard training techniques. The Army 

technique will be discussed here, with major differences in the Air Force, Navy, and some 
CHAPTER TEN • 407

NATO units noted when appropriate. Please refer to the referenced documents for additional details and specific facts. 

INDIVIDUAL AND COLLECTIVE, COMMON MILITARY, AND MILITARY MEDICAL TRAINING

Throughout the late 1980s and 1990s, the early surgical squads and detachments, 

which had no official doctrinal instructions, followed medical training formats that their 

sister medical companies were using and created additional training on their own to fill 

recognized medical-to-surgical gaps. Field Manual (FM) 8-10-5, Brigade and Division 

Surgeons’ Handbook: Tactics, Techniques and Procedures (published 10 June 1991) briefly 

mentioned the structure and employment of surgical elements, but included no formal 

guidance on training.200 When they could, team members performed surgery at their local 

military treatment facility with staff surgeons. 

Once the modern FST was established in 1997, the Department of the Army provided 

detailed guidance on how to lead, employ, and train an FST in numerous doctrinal materials. These included basic Army references such as FM 25-100 and FM 25-101, Training the 

Forces and Battle Focused Training, respectively, and FST-specific references such as FM 

8-10-25, Employment of Forward Surgical Teams: Tactics, Techniques and Procedures (30 

September 1997), and Army Training Evaluation Program (ARTEP) 8-518-10-MTP, Mission Training Plan for the Forward Surgical Team and Forward Surgical Team (Airborne), 

dated 9 February 1999.22,93,201,202 The basic Army publications provided FST leadership 

and their reporting commands with the same structure that the entire Army used to ensure 

high-quality training for unit readiness. However, the specifics came from the new FST field 

manual and ARTEP, which clearly stated the duties and responsibilities of individual team 

members and sections, and also the units’ capabilities and capacities to perform specific 

tactics, techniques, and procedures. 

Individual military tasks, known at the beginning of the war as Common Task 

Training or CTT, and now referred to as Army Warrior Tasks or AWTs, were found in 

manuals such as the Soldier Training Publication-Soldier’s Manual of Common Tasks 

(STP-SMCT).203–205 These manuals listed tasks for the four different enlisted levels needed 

to perform soldier basic skills properly in a combat environment. Officers were expected to 

know up to skill level four to be equal to their sergeant first class and higher colleagues in 

each of these skills. Specific individual military occupational skills for enlisted soldiers were 

found in various editions of the Soldier Training Publication-Soldier’s Manual and Trainer’s 

Guide (STP-SM-TG).206–208 These manuals listed the specific skills essential to performing duties as a healthcare specialist (91W, later 68W), licensed practical nurse (91C, then 

68WM6 and 68C), or operating room specialist (91D, then 68D). 

Likewise, officers had specific tasks they were expected to know at the company and 

field grade level, in addition to the soldier common tasks. These tasks, conditions, and 

standards were found in the military qualification standards level I, II, and III manuals 

for precommissioning, lieutenants and captains, and majors and lieutenant colonels.209–211

Lastly, a publication for individual medical officer training was the Military Qualifications 

Standards II for Medical Areas of Concentration,212,213 which covered specific medical tasks 

for field medical providers. 
408 • FORWARD SURGERY

These manuals also included information about where each task is first learned and 

how often it needed to be repeated as part of the training cycle. The manuals were guides 

for setting up routine scheduled training and evaluating individual performance levels. They 

also often had information on the collective tasks and group training, including situational 

training exercises, field training exercises, culminating training events, certifying exercises, 

and validation exercises. The ATEP manual was the primary guide for unit collective training. FSTs also accompanied their supported units during rotations at the National Training Center at Fort Irwin, California, or the Joint Readiness Training Center at Fort Polk, 

Louisiana, for complex training events.

Military doctrinal manuals were updated over the years to keep up with the changes 

in battlefields, equipment, and overall goals. In the early 2000s, FM 25-100 became FM 

7-0, Training the Forces; FM 25-101 became FM 7-1, Battle Focused Training; and FM 

8-10-25 became FM 4-02.25, Employment of Forward Surgical Teams: Tactics, Techniques 

and Procedures.

24,214–216 In 2011 the Army chief of staff began a complete remodeling of 

the Army doctrine system.217 Fundamental principles are now found under Army doctrine 

publications, while detailed information on fundamentals is found in the Army doctrine 

reference publications, and remaining FMs contain tactics and procedures only. Previously 

used FMs were replaced by Army techniques publications (ATPs). The FST field manuals 

were superseded by a new Army techniques publication, ATP 4-02.5 Casualty Care, in 

May 2013.107 The original 1999 ATEP manual for the FST was modernized and eventually 

evolved into the newer combined arms training strategy.103,218 Similar to the previous ATEP 

manual, units would use the combined arms training strategy as a guide for developing 

mission-essential task lists and supporting routine individual and collective training. Both 

the standard Army manuals and the combined arms training strategy were now electronic 

and more easily updated.

MEDICAL PROFICIENCY TRAINING/BORROWED MILITARY MANPOWER

An addition to task training, medical soldiers and officers had to perform their jobs 

in a clinical setting to maintain their overall skill set. Individuals who were professional 

fillers (PROFIS) to the FST performed their regular hospital jobs throughout the year and 

trained with their assigned FST for 2 weeks out of the year. Organic FST personnel worked 

at the hospital under the medical proficiency training program and the borrowed military 

manpower program. 

The medical proficiency training program provided soldiers with an opportunity 

for uninterrupted work at their local or partnered medical treatment facility, usually in a 

30-day rotation annually in which soldiers worked in various parts of the hospital correlating with their individual military occupational specialty. The borrowed military manpower 

program was used to ensure that all medical personnel with non-Medical Command 

assignments assisted with the hospital’s patient load while staying clinically active to ensure 

skill retention. Although the program varied between stations and units, FST nurses generally worked 4 days a week at the local medical treatment facility and spent the other day 

training at the FST facility. The senior nurse might work 2 to 3 days at either facility, while 

surgeons spent a few days per week at the medical treatment facility in clinics and the oper-
CHAPTER TEN • 409

ating room. Surgeons also participated in academic programs and had “on-call” duty at the 

hospital a few times every month. Enlisted personnel primarily participated in the medical 

proficiency training program because of other military obligations, although many units 

attempted to have their soldiers work in the local medical treatment facility more routinely, 

as well as having all personnel perform surgery as a team, in preparation for deployment 

(Figure 10-17). 

PREDEPLOYMENT TRAUMA TRAINING 

Throughout the majority of the GWOT, most FSTs attended what is now called 

predeployment trauma training. This was done near the end of the unit’s training phase 

of the armed forces generation training cycle prior to transition into the mission/available 

FIGURE 10-17. LTC Michael Yaffe, COL Colleen Klohen, and others from the 402nd Forward Surgical Team 

(Reserve) practice their roles during initial patient assessment and treatment prior to working together as 

a team on live patients. By knowing their specific tasks, working on a common lexicon, and gaining motor 

memory, forward surgical teams are able to cut their primary and secondary survey times by up to 50% 

while decreasing miscommunication and increasing provider and patient safety. Photograph courtesy of 

the US Army Recruiting Command. 
410 • FORWARD SURGERY

phase.103,104,218,219 Army Role 2 surgical units trained at the ATTC, while Navy and Air 

Force Role 2 surgical units trained at the US Navy Trauma Training Center and the Centers 

for the Sustainment of Trauma and Readiness Skills (C-STARS). These programs were 

originally established due to DoD Inspector General and General Accounting Office reports 

after Operations Desert Shield and Desert Storm, which found that many deployed medical 

providers were not clinically active at an acceptable readiness level, and most were not specifically trained in trauma assessment and resuscitation, trauma surgery, or trauma critical 

care. Those trained in trauma often did not perform these duties on a routine basis.220–226

In 1996, Congress passed legislation as part of the National Defense Authorization 

Act requiring the DoD to create military-civilian partnerships to provide opportunities 

for DoD personnel to sustain an acceptable level of trauma skills.94,227 The act established 

a DoD group of subject matter experts, which became known as the Combat Trauma 

Surgical Committee, to consider the trauma personnel, equipment, and training needs of 

the military to meet future deployment readiness requirements and address past failures.228

Many preexisting programs brought military trauma providers into civilian hospitals, but 

they were not universally available, had no standardized curriculum, and lacked consistent 

funding.94

In 1997, the Navy established a pilot program through the Naval Medical Center in 

Portsmouth, Virginia, and Eastern Virginia Medical School. Training was conducted at 

Sentara Norfolk General Hospital. The military also established a partnership with Ben 

Taub General Hospital in Houston, Texas, to provide a training center for all DoD Role 

2 surgical teams. This program, finalized in 1998, became known as the Joint Trauma 

Training Center.229 The 30-day training rotations alternated between Army and Air Force 

teams.230 The program trained numerous military medical providers for 2 years prior to its 

closure.231–233 Based on the overall positive feedback from rotating surgical team members, 

the Combat Trauma Surgical Committee sought alternative training sites that could accommodate a larger volume of rotating teams, provide an even better clinical experience, and 

resolve administrative issues.234

In 2001, the Air Force established the first of three current programs under C-STARS 

with Baltimore Shock Trauma. Focused on Air Force Role 2 and 3 team members, the 

program developed an excellent reputation.235,236 The second C-STARS was set up with the 

University of Cincinnati in August 2001, focused on training for critical care air transport 

teams. A third program was established at St Louis University in December 2002, focused 

on training Reserve unit Role 2 and 3 team members.237

With recommendations from military personnel who trained at the Ryder Trauma 

Center, the ATTC was established in August 2001. This program became the model for 

austere resuscitation and surgery refresher training and team roles development.238,239 The 

2nd FST from Fort Carson, Colorado, was the first official team to rotate through in January 2002. Since then, numerous FSTs have participated in over 130 rotations; more than 

3,000 students have attended the course (Figure 10-18). 

In July of 2002, the US Navy formalized its training program in collaboration with the 

University of Southern California School of Medicine, providing training for Navy forward 

and fleet surgical units.240–242 
CHAPTER TEN • 411

FIGURE 10-18. (a) A civilian trauma resuscitation 

unit bay after a patient 

was cared for with an 

emergency thoracotomy 

and went on to survive his 

surgery. High-volume Level 1 civilian trauma centers 

like those at the Ryder 

Trauma Center in Miami, 

the Shock Trauma Center 

in Baltimore, and the Los 

Angeles County Medical 

Center provided predeployment trauma training 

for Role 2 and some Role 

3 surgical teams. Their 

high volume of trauma, 

world-renowned staff, 

and dedicated personnel 

ensured all trauma team 

members had the best 

training prior to deploying. (b) Army Trauma 

Training Center senior 

nurse instructor LTC 

William White works with 

forward surgical team 

members at the Ryder 

Trauma Center during 

their 6 days of clinical 

rotations. All three trauma 

training centers worked 

with embedded military 

trauma experts along with 

the host facilities staff to 

hone the skills of rotating military personnel. 

Photographs courtesy of 

the US Army Recruiting 

Command.
412 • FORWARD SURGERY

All three programs focused on basic and advanced trauma knowledge, skills refreshers, and combat-unique trauma considerations based on injury patterns, equipment, and 

supplies available. There were also varying levels of interprofessional team development at 

the training centers. While all three programs were conceptualized prior to the GWOT to 

ensure prewar readiness, they were well-placed to meet the ongoing need for predeployment trauma training throughout the conflict. They are considered centers of excellence 

staffed with subject matter experts in the areas of operational medicine, resuscitation, and 

surgery. In addition to didactic lectures and labs, and hands-on real life trauma training for 

skills sustainment, the combat trauma-specific curriculum ranged from blast and highpower rifle physics to large total body surface area burns to management of severe injuries 

with limited resources. Unique surgical training far in advance of residency or fellowship 

training included performing external fixator placement for long bone and pelvic fractures, 

lateral canthotomy and cantholysis for retrobulbar hematomas, and craniotomy for damage control neurosurgery.243–247

Various articles and numerous testimonials by surgeons have stated the significant 

value of being initially taught or refreshed on the most current patient care guidelines, and 

receiving training with their dedicated team.245,248–253 Midway through the war, each service 

surgeon general made attending these courses mandatory for a certain percentage of each 

deploying team,105,254,255 ensuring that personnel had the funding and opportunity for refreshing their skills and knowledge, were current on combat clinical trauma guidelines, and 

could work together as a team to excel in patient care.

ADDITIONAL AND OPTIONAL FORWARD SURGICAL TEAM TRAINING

Some FST members and teams attended additional training opportunities, including 

other Army predeployment trauma training courses for Role 2 medical units or Role 3 surgical units, as well as many other optional military medical courses. Other predeployment 

trauma training courses included the military transition team, brigade combat team trauma 

training, tactical combat medical care with a focus on Role 1 and 2 medical team providers, and the Joint Forces Combat Trauma Management Course for Role 3 CSHs. Many 

FST personnel attended these courses to enhance their knowledge of the overall continuum 

of care on the modern battlefield, gaining a better understanding of the capabilities and 

standards at sending and receiving units that work with the FST. 

Another course attended by some FST members was the Emergency War Surgery 

Course sponsored by the Defense Medical Readiness Training Institute, mostly attended by 

Air Force and Navy surgical team members. The course provided Army FST staff another 

chance to receive the latest information on combat casualty management in a formal 

setting. As with the mandatory predeployment trauma training courses, the curriculum 

has changed over the years, but remained focused on current standards of cared based on 

TCCC and the clinical practice guidelines. 

Because many combat injuries involve the extremities, and are often severe and different from those seen in civilian trauma centers, additional training was needed in this 

field. A preexisting Extremity War Surgery Course (created in the mid-1990s) evolved into 
CHAPTER TEN • 413

the Combat Extremity Surgery Course in 2004. This course focuses on the initial combat 

trauma management of extremities, including completion amputation, proper debridement, 

fasciotomies, vascular shunting, and placement of external fixators to the long bones and 

pelvis. The course’s focus audience is general surgeons and orthopedic surgeons preparing 

to deploy. It provides foundational knowledge of the current ways to address these injuries to help improve limb salvage or expedite patient care and transfer to the next medical 

treatment facility. The course is embedded into the Army Trauma Training Course, so that 

all deploying Army Role 2 surgical teams gain this knowledge, and is also taught multiple 

times a year at off-sites for others to attend.

When it became evident that some patients being transported from the forward medical and surgical facilities to the next higher level of care were having complications en 

route, the Army addressed this in two main ways. One was to provide improved training and hands-on experience back in garrison to all flight medics, including a new flight 

paramedic course. The second step was assigning advanced skilled providers to assist with 

MEDEVAC of complex patients. These providers were usually emergency care and critical 

care nurses, aeromedical physician assistants, and flight surgeons. The military developed 

the Joint En-route Care Course to train flight medics, licensed practical nurses, registered 

nurses, physician assistants, and physicians, with a focus on having nurses and flight surgeons better prepared to assist with transport care.256

The ISR Burn Center offered courses throughout the GWOT to help give Role 1 

through Role 4 providers a better understanding of current concepts for treating burns and 

polytrauma in theater. One Burn Center course was the Management of Burn and Multiple 

Trauma Casualty Course, which provided didactic training and hands-on experience with 

burn and polytrauma patients at Brooke Army Medical Center/San Antonio Military Medical Center. Students at the course could see how proper management at the point of injury, 

and throughout the continuum of care, had resulted in improved outcomes. 

Other courses attended less often by FST members include the Field Management 

of Chemical and Biological Casualties or the more advanced Medical Management of 

Chemical and Biological Casualties, provided by the US Army Medical Research Institute 

of Chemical Defense and US Army Medical Research Institute of Infectious Diseases. These 

courses covered general and specific chemical and biological concerns in the battlefield or 

stateside due to attacks or accidents. Those who wanted to further their understanding of 

trauma management in a radiation-exposed patient could also take the Medical Effects 

of Ionizing Radiation Course taught by the Armed Forces Radiobiology Research Institute. Another course some personnel reported attending was the Infection Control in the 

Deployed Environment Course held at San Antonio Military Medical Center. As in other 

units, a specified number of FST members needed to be Field Sanitation Course graduates. Additionally, operating room specialists and executive officers needed to complete the 

Combat Lifesaver Course. 

The FST TO&E also formally assigned the position of FST Chief to the 61J general 

surgeon or 61M orthopedic surgeon who was organic to the team. The AMEDD Center and School’s Department of Healthcare Operations developed the FST Commanders 
414 • FORWARD SURGERY

Course in 1998 after a need for the training was noted by a surgeon, LTC Steve Swann, 

with the support of another surgical leader, LTC Brian Allgood, and the AMEDD Center 

and School’s commanding general, MG James Peake.257 LTC Allgood was a former commander of the 82nd Airborne Surgical Squad in the early 1990s and the first commander 

of the official modern 274th FST (Airborne) in 1997.77,95 COL Allgood is one of the few 

physicians who paid the ultimate sacrifice during this era when he died in a helicopter crash 

in Iraq on 20 January 2007.258

First conducted in July 1999,259 the FST Commanders Course provides surgeons, 

nurses, and others who took on the role of FST commander with appropriate administrative, intelligence/security, training/operations, logistical, information technology, budgeting, legal, and other related knowledge needed by successful commanders. The week-long 

course is conducted in a small group with lectures provided by subject matter experts and 

former FST commanders. The FST Commanders Course is held at the same time as the 

Brigade Surgeons Course and Division Surgeons Course, so universally useful lectures are 

held jointly, and students of all three courses can interact, network, and better understand 

how their roles interact in garrison and while deployed. When FSTs assigned to brigade 

combat teams were realigned to be exclusively under medical brigades, this interaction became even more important because past interactions at the home station were significantly 

FIGURE 10-19. Exercise, entertainment, and group development are not just for the movies. Soldiers in 

combat zones need to stay fit and also deal with the realities of life and death. Here a friendly game of 

volleyball provides all of these and more. Photograph courtesy of LTC Dean Fellabaum, former commander, 2nd FST.

FIGURE 10-20. Sometimes forward surgical team members find it necessary to “recharge their batteries” 

by adding a little color (green fake grass) and familiar activities, like this member of the 160th FST shown 

in Naray, Afghanistan. Photograph courtesy of LTC Dean Fellabaum, surgeon, 160th FST.
CHAPTER TEN • 415

reduced. FSTs worked with the brigade combat teams’ medical staff and units during some 

contingency missions and many deployments, so getting an understanding of various unit’s 

capabilities, gaps, and standard operating procedures made mission success easier (Figures 

10-19 and 10-20).

Other Missions and Changes During Time of War

In addition to the theater and garrison transformations mentioned above, the Medical 

Command and Forces Command changed FST locations and numbers in other ways. Additional Role 2 surgical teams were established after the GWOT began in September 2001. 

As the battlefield changes, FSTs now perform more Special Operations forces support missions. FSTs have also worked with local national medical facilities while deployed to both 

Iraq and Afghanistan. And at the time of this writing, the US Army FST is preparing to be 

transformed into the forward resuscitative surgical team (FRST), with many changes in 

personnel. US Army Special Operations Command is working on acquiring up to three of 

its own FRSTs by fiscal year 2017. 

Another major change during the GWOT was the airborne status of various units. Due 

to the ever-changing nature of the conflict, the Army alternated the number of FSTs that 

could perform their duties as part of an air-deployable joint forced entry package. A brief 

description follows, with more details on these changes noted in the next chapter. 

The 8th FST was one of the original surgical teams that existed before the official 

designation of the FST in 1997. It was activated in 1986 at Schofield Barracks, Hawaii, as 

the 8th Medical Detachment (Forward Surgical) to support the Role 2 surgical needs of the 

Pacific Command. While the team members were stationed in Hawaii, they participated in 

OIF twice and OEF twice. In 2010, the unit relocated to Fort Richardson, Alaska, and was 

designated an airborne unit. While deployed in 2014, the unit was notified that it would 

lose its newly assigned airborne status upon its return to Alaska as part of a Department of 

the Army realignment of assets.260

The 240th FST was activated in 1997 at Fort Stewart, Georgia. The unit had two successful deployments to Iraq while based at Fort Stewart. In 2009, the 240th was relocated 

to Fort Bragg, North Carolina, and was designated an airborne FST. The unit deployed to 

OEF twice, supported the Northern Command Defense Chemical Biological Radiological Nuclear Response Force mission, and supported the XVIII Airborne Corps’ Global 

Response Force mission multiple times. The 240th FST lost its Airborne designation as part 

of the same realignment in 2014.261,262

The 67th FST was another of the original surgical teams in existence before the FST’s 

official designation. The 67th Medical Detachment (Forward Surgical), as it was known, 

was stationed in Vicenza, Italy, since its activation in 1993. This European Command FST 

would be one of three in Europe, including the 160th FST activated in 1999, and the 130th 

FST.261 The 67th was an airborne unit that could support the 173rd Infantry Brigade, also 

stationed in Vicenza. In 1994, they both relocated to Giebelstadt, Germany. The 67th FST 

participated in numerous support missions throughout Europe and Africa, including Bosnia, Kenya, Macedonia, Kosovo, Nigeria, and the Republic of Georgia, making them one 

of the most highly utilized FSTs in the DoD.263
416 • FORWARD SURGERY

In 2002, the team was disappointed when it lost its prestigious airborne status. In 2005 

it deployed to OIF, and on its return in 2006, relocated to Wurzburg, Germany. The 67th 

relocated again in 2007 to Miesau, Germany, and regained its designation as airborne. 

Since that move, it participated in OEF twice, supported the XVIII Airborne Corps’ Global 

Response Force mission, and again provided support within the Africa Command area of 

responsibility in Tanzania and other locations. The 67th FST again lost its airborne status 

in 2013. This FST has been to more places, in garrison and on support missions, than any 

of its peers, and has changed its mission profile multiple times. Throughout this period 

the 67th maintained a strong reputation as a team much in demand for assignments and 

deployments.264

The number of US Army FSTs increased during the GWOT. At the time of this writing, there were 16 FSTs on active duty and 22 FSTs in the US Army Reserves. The Air 

Force and Navy/Marines have also increased the number of their Role 2 surgical teams, or 

developed new ones, in both the conventional and Special Operations communities. However, there have also been deactivations. In addition to those previously mentioned, other 

deactivated units include the 130th FST, which was part of European Command, stationed 

in Camp Darby, Italy, until 2009. However, the unit never deployed, and it probably was 

never stood up due to transformations going on at the time. Another deactivated unit was 

the 127th FST, stationed in Yongson, Korea, which was stood up in 1997 and maintained 

readiness for its enduring potential mission of providing Role 2 surgical care in the event of 

a conflict in the region.265

While the GWOT was the primary focus of FSTs during this era, they supported other 

missions outside of the Central Command area of responsibility. Some units were assigned 

to support DoD conventional and Special Operations forces combat units, while other 

missions supported disaster relief and humanitarian assistance missions. Units still rotated 

to various partner countries to support European Command medical needs, while others supported missions in many countries throughout the Southern, African, and Pacific 

Commands areas of responsibility. Additional mission assignments included the Northern 

Command Defense Chemical Biological Radiological Nuclear Response Force mission, the 

Forces Command Global Response Force mission, and presidential support missions. More 

information on these topics will be presented in the following chapter.

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426 • FORWARD SURGERY

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428 • FORWARD SURGERY

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INTRODUCTION

AS DISCUSSED IN THE PREVIOUS CHAPTER, the post-9/11 Global War on Terrorism represented a significant era for military medicine in general, and military surgery in 

particular. As in other times of armed conflict, significant advancements were made: the 

concepts of damage control surgery and damage control resuscitation, the application of 

tourniquets and hemostatic agents, improvements in mechanical protection, and the institution of casualty tracking systems and data collection all helped reduce battlefield mortality 

to historically low levels, while the “modular” concept of forward surgery brought surgical 

assets closer than ever to the point of injury.1–14

The accomplishments of surgeons, nurses, physician assistants, medics, and other 

medical officers and enlisted personnel treating life-threatening injuries in Iraq and Afghanistan over this period were nothing short of heroic. Also during this timeframe, the armed 

services were engaged in the tasks of homeland defense, responses to severe weather and 

natural disasters, support of allied militaries, and the posture of readiness to support any 

new potential theater of operation—all the while maintaining a steady deployment cycle in 

support of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New 

Dawn. This resulted in an unprecedented operational tempo for the US military’s medical 

personnel.

This chapter will discuss the US military’s surgical contributions with respect to the 

Global Response Force (GRF) mission, homeland defense, responses by US Northern Command (USNORTHCOM) to natural and manmade disasters, terrorist threats including the 

Defense CBRN (Chemical, Biological, Radiological, and Nuclear) Response Force (DCRF) 

mission, readiness to support contingency operations other than Iraq and Afghanistan, and 

other missions. Force design updates and future directions for military surgical assets will 

also be discussed.

Chapter Eleven

Homeland Defense, 

Contingency Operations, and

Future Directions

DAVID C. LYNN and JASON M. SEERY
430 • FORWARD SURGERY

HOMELAND DEFENSE AND CONTINGENCY OPERATIONS

Operation Noble Eagle

Immediately after the 9/11 attacks on New York and the Pentagon, thousands of 

National Guard and Reserve personnel were mobilized to perform security missions at 

military installations, airports, power plants, bridges, ports, and other potential terrorist 

targets. As military assets were used for homeland defense and to support federal, state, 

and local agencies, Operation Noble Eagle rapidly expanded to include search and rescue, 

engineering operations, forensics, medical support, and various other missions.15–17

Numerous federal entities were mobilized, including USNS Comfort, battalion aid 

stations, volunteer-run first aid stations, Veterans Administration hospitals, and aid stations 

operated by the Federal Emergency Management Agency (FEMA). The 344th Combat 

Support Hospital (CSH), a Reserve unit, provided personnel, logistical support, and supplies to Jacobi Hospital in the Bronx. The unit also loaned everything from cots to weapons 

to other military units and fire departments. Unfortunately, Jacobi Hospital, like many 

others in the New York area, was waiting for patients that would never arrive. According 

to Dr. Sheldon Teperman, director of Jacobi’s trauma center:

We cleared out patients, we cleared out the emergency room, we set up teams of 

trauma doctors and emergency medicine doctors that were volunteers that came from 

all over the campus and then we waited, and no one came, because as everybody 

knows now, close to 3,000 people died at Ground Zero, and almost nobody was 

pulled out of that rubble.18

Instead, medical care focused on combat stress and the treatment (long- and shortterm) of respiratory illness secondary to exposure. Individuals at Ground Zero were 

exposed to falling debris, fire, smoke, toxic chemicals, dust (including pulverized asbestos), 

and various biohazards. Mental trauma, stress, and fatigue also took a toll on rescue workers, many of whom labored for extended periods of time.

In her book Attack on the Pentagon: The Medical Response to 9/11, Condon-Rall 

describes in vivid detail the harrowing events of that day, and the heroic efforts of numerous military and civilian personnel in Washington, DC.19 While 126 lives were tragically 

lost, the outcomes could have been much worse. 

Before the attack, portions of the Pentagon building had been modernized with blastresistant windows, steel-reinforced weight-bearing columns, and penetrant-resistant outer 

walls. The Anthony DiLorenzo Tricare Health Clinic routinely prepared for emergencies 

and always had two five-person teams (each with a physician, a registered nurse, and three 

medics) on standby. These teams systematically prepared for emergencies in conjunction 

with the Air Force Flight Clinic, the Navy Dental Clinic, the Washington Headquarters Services, the Arlington County Fire Department, the Federal Bureau of Investigation, FEMA, 

the Defense Protective Service, and the Department of Defense (DoD) law enforcement organization for the Pentagon (now the Pentagon Police Department). Condon-Rall describes 

how Major (MAJ) Lorrie Brown (DiLorenzo clinic chief nurse), Captain (CPT) Jennifer 
CHAPTER ELEVEN • 431

Glidewell (acute care nurse), and Sergeant (SGT) Matthew Rosenburg (medic) immediately 

took action following the attack by organizing casualty collection points, conducting triage, 

providing point of injury care, and coordinating evacuation.

With their emergency bags already packed, and only the length of the hallway to run, 

the teams, according to Major Brown, had all of the triage areas operational by 0943, 

5 minutes after the plane hit the Pentagon.19(p10)

In the end, 125 patients were evacuated to 12 different surrounding military and civilian 

hospitals. The preparation, decisive action, and teamwork of those who responded that day 

has since served as an emergency preparedness model for healthcare systems and providers.

The Global Response Force Mission

The GRF mission, formally referred to as the Division Readiness Brigade (DRB) 

mission, includes military assets on 24/7 standby, ready to deploy anywhere in the world 

within hours of notification. The capabilities of these assets, if called, include forcible entry 

and seizure of a defended airfield, followed by the buildup of combat power to support 

follow-on military operations.20–22 GRF is a joint military operation led by the Army’s 

XVIII Airborne Corps. The Army’s airborne forward surgical teams (FSTs) continuously 

FIGURE 11-1. US Army medical providers with the 240th Forward Surgical Team at Fort Bragg, NC, complete a simulated leg amputation during a joint service field exercise, 15 October 2012, at the Joint Readiness Training Center at Fort Polk, LA. (US Air Force photo by Tech Sgt Joselito Aribuabo/Released)
432 • FORWARD SURGERY

TABLE 11-1. ROLES OF MILITARY MEDICAL CARE

Role 1 Point of injury (self-aid, buddy aid, and combat lifesaver)

Army/USMC: Battalion Aid Station

USMC: Shock Trauma Platoon

Role 2 Army: Medical Company

Forward Surgical Team

Air Force: Mobile Field Surgical Team

Small Portable Expeditionary Aeromedical Rapid Response

Expeditionary Medical Support (EMEDS, Basic or +10) 

Navy: Casualty Receiving and Treatment Ship (CRTS)

Aircraft Carrier Battle Group

USMC: Surgical Company

Forward Resuscitative Surgical System

En Route Care Team

NATO: Any facility that provides damage control surgery

Role 3 Army: Combat Support Hospital

Air Force: EMEDS +25

Air Force Theater Hospital

Navy: Expeditionary Medical Facility

Hospital Ship

Role 4 CONUS-based hospital or other “safe haven”

Adapted from: Emergency War Surgery. Fourth US Revision. Fort Sam Houston, TX: Borden Institute; 2013.

USMC: United States Marine Corps

CONUS: Continental United States

TABLE 11-2. US ARMY AIRBORNE FORWARD SURGICAL TEAMS AND THEIR LOCATIONS

2nd ACR FST Fort Bragg, NC (airborne 1997 to 2004, when unit deactivated)

8th FST Joint Base Elmendorf Richardson, AK (airborne 2011 to 2013)

67th FST Miesau, Germany (airborne 2007 to 2013)

240th FST Fort Bragg, NC (airborne 2009 to 2014)

250th FST Joint Base Lewis-McChord, WA (airborne 1997 to 2009)

274th FST Fort Bragg, NC (airborne 1997 to present)

541st FST Fort Bragg, NC (airborne 2006 to present; formerly the 782nd FST)

759th FST Fort Bragg, NC (airborne 2004 to present; formerly the 2nd ACR FST)

782nd FST Fort Bragg (airborne 1997 to 2006, when unit deactivated)

ACR: Armored Cavalry Regiment

FST: Forward Surgical Team
CHAPTER ELEVEN • 433

train with the 82nd Airborne Division’s brigade combat teams and are prepared to support 

this enduring mission (Figure 11-1).23,24 The FSTs are organized to conduct both airborne 

(parachute) and air-land insertions.25,26 Capabilities for this mission are trained on a regular 

basis through the Joint Operations Access Exercise,27,28 and FSTs are routinely co-located 

with their brigade support medical company counterparts to evaluate, treat, and evacuate 

casualties (Table 11-1).29–32

The concept of the airborne surgical team was developed by a British vascular surgeon, 

Dr Charles Rob, during World War II. As a result of Rob’s work, the Royal Army Medical 

Corps conducted two combat jumps into North Africa, validating the ability of airborne 

surgical assets to decrease combat deaths.33 In the 1990s, the first US Army airborne 

FSTs were established: the 782nd and 274th Medical Detachments and the 2nd Armored 

Calvary Regiment FST at Fort Bragg, North Carolina, as well as the 250th Medical 

Detachment at Fort Lewis, Washington.34 In 2015, three Army FSTs retained the airborne 

designation (Table 11-2). These highly mobile, well-trained, and disciplined surgical units 

can be deployed anywhere in the world on short notice. They are designed to parachute 

into combat, allowing for the early treatment of casualties (Figure 11-2). During an airfield 

seizure operation, a team parachutes part of its personnel and equipment (Alpha echelon), 

then air-lands the other portion of the team (Bravo echelon). Alpha echelon equipment 

is heavy-dropped (parachuted) in one to two military vehicles, while Bravo echelon 

equipment and personnel is air-landed approximately 12 to 24 hours later. Thus, these 

FIGURE 11-2. Team members from forward surgical teams at Fort Bragg, NC, aboard a C-17 aircraft, 

about to complete a nighttime combat parachute jump, 18 October 2011. Fort Bragg FSTs regularly 

conduct airborne training operations with the 82nd Airborne Division’s brigade combat teams on the 

Global Response Force mission. On the right is MAJ William Vanasse, Chief Nurse, 759th FST. (Photo by 

MAJ David Lynn)
434 • FORWARD SURGERY

units enhance the brigade medical team’s ability to perform advanced trauma resuscitation 

during the initial phases of a mission, and conduct surgical interventions approximately 30 

to 45 minutes after their heavy-dropped or air-landed equipment is recovered. Army FSTs 

employed in this manner are capable of performing approximately 30 life-saving surgeries 

over the course of 72 hours before reconstitution is required. 

The personnel and equipment makeup of the Alpha and Bravo echelons, as well as their 

method of employment, are variable and flexible. During the 250th FST’s combat jump into 

Northern Iraq, the Alpha echelon included one general surgeon, one orthopedic surgeon, 

one certified nurse anesthetist, one emergency medicine nurse, three combat medical 

specialists, and two operating room technicians.35 Once on the ground and operational, the 

FST may stand alone, but capabilities are greatly enhanced when the team is combined with 

its brigade support medical company (or “Charlie Med”) Role 2 counterparts.31 Surgical 

and medical capabilities may be established in a cleared building (preferred if available). If 

FIGURE 11-3. Team members from Fort Bragg’s airborne forward surgical teams set up their Bravo echelon next to their Alpha echelon on the tactical air field after a night mass tactical jump as part of a Joint 

Operational Access Exercise, August 2009. Note the small 5-kw non-military generator used to provide 

power for the Alpha echelon shortly after parachuting onto the landing zone, enabling advanced resuscitation and surgical capabilities. (Photo by MAJ David Lynn) 
CHAPTER ELEVEN • 435

a building is unavailable, the medical teams will set up their respective tents (generally best 

if co-located and interconnected) to begin advanced resuscitation and surgical intervention. 

After the runway is cleared and the air-land option is available, the Bravo echelons of the 

medical units arrive and augment their Alpha counterparts.24

An FST vastly improves its capacity by quick assembly and establishment of a footprint 

within the medical company area, which is composed of an administrative section, treatment 

platoon, patient holding squad, and ambulance platoon.30 By combining personnel, this 

robust “Role 2-plus” medical team can greatly increase capability while improving the 

quality of care; it has ambulance support for patient evacuation to awaiting ground or 

air assets. This crucial integration increases the speed of care, improves patient flow and 

tracking, and enables medical resupply operations, as well as providing radiographic and 

laboratory capabilities. It also allows for damage control surgery and resuscitation to 

occur beyond the 30 patients in a 72-hour period limit. This method of forward surgical 

employment is validated on a regular basis through participation in Joint Operations Access 

Exercises, which include one brigade combat team from the 82nd Airborne Division, 

members of the US Air Force, various international partners, and multiple other enablers, 

including one airborne FST (Figure 11-3). Over 1,000 paratroopers conduct static-line 

jumps, projecting combat power into a hostile environment, and units conduct various 

follow-on missions over the ensuing weeks as they would in a GRF mission. 

As was demonstrated after Hurricane Katrina in 2005 and the Haiti earthquake in 

2010, military medical assets that stand ready on this short notice mission may be utilized 

for a wide variety of operations other than war.

US Northern Command and Homeland Defense

After the terrorist attacks on 11 September 2001, USNORTHCOM was created to 

deter, prevent, and defeat threats and aggression aimed at the United States, its territories, 

and its interests. This marked the first time a single military commander was charged with 

protecting the US homeland since the days of George Washington. Activated on 1 October 

2002, USNORTHCOM’s mission now includes defense support for civilian authorities. 

When approved by the president or secretary of defense, it may direct military resources 

(Army, Navy, Air Force, Marine Corps, or Coast Guard) to support federal, state, and 

local entities. Its area of responsibility includes all air, land, and sea approaches to North 

America, encompassing the continental United States, Alaska, Canada, Mexico, and the 

surrounding water areas out to approximately 500 nautical miles.36

USNORTHCOM’s assigned missions for military medical units include the Joint Task 

Force Civil Support Defense CBRN (Chemical, Biological, Radiological, and Nuclear) 

Response Force (DCRF), formerly known as the CBRNE Consequence Management 

Response Force. DCRF assets were increased to improve its ability to assist the federal 

response more rapidly and reduce the impact of a homeland CBRN incident, providing 

critical life-saving capability. Including over 5,200 service members, DCRF is structured in 

two force packages that are prepared to deploy at 24 and 48 hours, respectively. The medical task force portion of the force is currently composed of Role 3 assets (three Air Force 

expeditionary medical support [EMEDS] units) and Role 2 assets (four FSTs and four area 
436 • FORWARD SURGERY

FIGURE 11-4. [Top] Members of the 759th Forward Surgical Team set their tents up adjoining 

the 550th Area Support Medical Company just 

north of Normandy Drop Zone, Fort Bragg, 

NC, 17 January 2012. Teams conducted a 5-day 

unit-level field training exercise in preparation 

for assuming the Defense (Chemical, Biological, 

Radiological, Nuclear) Response Force Mission. 

(Photo by MAJ David Lynn)

FIGURE 11-5. [Bottom] Fort Bragg Forward 

Surgical Team (FST) commanders attend the 

Medical Management of Chemical and Biological 

Casualties course at Aberdeen Proving Ground 

and Fort Detrick, MD, in preparation for the Defense CBRN (Chemical, Biological, Radiological, 

Nuclear) Response Force mission, 25 October 

2011. Left to right: MAJ David Lynn, 759th FST; 

MAJ Jason Seery, 541st FST, and MAJ John 

Detro, 240th FST. (Photo by MAJ David Lynn)
CHAPTER ELEVEN • 437

support medical companies [ASMCs]), in addition to medical logistics, preventive medicine 

and ground ambulance units, combat and operational stress control, and veterinary services. FSTs and ASMCs are geographically “paired” for employment at or near an incident 

site, providing a relatively rapid, robust medical-surgical element (Figure 11-4).37,38 

Preparation for medical units assigned to the DCRF mission consists of both individual 

and collective unit-level training with a renewed emphasis on CBRN threats, as well as a 

focus on legal aspects of military employment within the United States. All individuals are 

required to take courses related to antiterrorism, FEMA, and the defense support of civil 

authorities, as well as the Posse Comitatus Act, in order to ensure that soldiers and leaders 

understand their roles and limitations as they interact with civilians. CBRN training is 

variable and may be limited due to new restrictions on centralized funding, and is often at 

the discretion of unit commanders. The US Army Medical Research Institute of Chemical 

Defense and US Army Medical Research Institute of Infectious Diseases host numerous 

useful courses. These include Medical Management of Chemical and Biological Casualties, 

designed for nurses and providers; Field Management of Chemical and Biological 

Casualties, for medics and enlisted personnel; and Hospital Management of Chemical, 

Biological, Radiological, Nuclear, and Explosive Incidents, geared toward senior leaders 

and medical planners (Figure 11-5). The Armed Forces Radiobiology Research Institute 

hosts Medical Effects of Ionizing Radiation, a valuable course that can be tailored for 

physicians and nurses or medics and first responders.

Unit-level training includes medical and surgical treatment of all casualties, including 

pediatric and geriatric patients, animals, and CBRN victims. Training also includes the use 

of personalized protective equipment and specialized CBRN equipment needed for hasty 

decontamination and detection. These skills should be reinforced and validated regularly 

during field training exercises, preferably with regional ASMC units. Training culminates 

FIGURE 11-6. US Army 

MAJ Kelly Blair (right), 

commander of the 

250th Forward Surgical 

Team, 62nd Medical 

Brigade, Joint Base 

Lewis-McChord, WA, 

instructs soldiers as they 

perform mock surgery 

on the Chloe Surgical 

Simulator during the 

Vibrant Response exercise at Camp Atterbury, 

IN, 2 August 2012. (US 

Army photo by SGT 

Mark Cloutier/Released)
438 • FORWARD SURGERY

in the annual Operation Vibrant Response exercise, in which units respond to a simulated 

large-scale CBRE incident (Figure 11-6).

To date, USNORTHCOM has not had to respond to a large-scale threat calling for 

military support. The Robert T Stafford Disaster Relief and Emergency Assistance Act 

(Public Law 100-707), signed into law in 1988, authorized the federal government to help 

state and local governments alleviate the suffering and damage caused by disasters. USNORTHCOM has frequently been called upon to respond to requests from civil authorities in these situations, and on at least two occasions the response included provision of the 

military’s unique medical and surgical assets.36

Hurricane Katrina

Hurricane Katrina first made landfall as a Category 1 hurricane on 25 August 2005 in 

Florida, where it caused approximately $2 billion in damage and killed 14 people. Katrina 

then crossed the Gulf of Mexico, making landfall again on 29 August as a Category 3 

hurricane, inundating New Orleans and inflicting widespread damage as levees protecting 

the city failed, killing more than 1,800.

At the request of civilian authorities, USNORTHCOM forces deployed to the region 

under the direction of Joint Task Force Katrina commander Lieutenant General Russel 

Honoré.36 More than 22,000 personnel from every branch of the US military participated 

in the effort, which included health and medical support; search and rescue; security; 

evacuation; recovery of deceased persons; debris removal; restoration of infrastructure; 

logistics including distribution of food, water, and ice; temporary shelter; and long-range 

communications.39 The first medical unit to arrive was the 782nd FST (Airborne) under the 

command of MAJ (P) Shawn Nessen.40

The 782nd FST was assigned to the 82nd Airborne Division and supported the DRB 

mission. As part of the DRB mission, the team represented one of the world’s few surgical 

assets ready to deploy at a moment’s notice. The 782nd left Fort Bragg and was on site in 

New Orleans within 18 hours of notification (Figure 11-7). At the direction of the Medical 

Task Force Commander, the FST set up in the baggage claim area of the New Orleans 

airport and was ready to receive surgical patients within 1 hour (Figure 11-8). The 782nd 

maintained operations until the 14th CSH from Fort Benning, Georgia, arrived and set 

up almost 2 weeks later. Unfortunately, by the time either of these units was activated and 

operational, most people in need of medical attention had already been evacuated from the 

city. With few civilian patients, focus shifted to support of the 82nd Airborne Division and 

other military units.

When Hurricane Rita threatened the city in late September that same year, the 14th 

CSH was disassembled, moved, and reassembled inside the convention center in downtown 

New Orleans, closer to the remaining civilian population in need of assistance. The 14th 

CSH, an 84-bed hospital, included an emergency room, operating room, computed 

tomography and radiograph capability, and dental and specialty clinics. The 14th CSH 

continued to provide support for both military and civilian populations until being replaced 

by the 21st CSH from Fort Hood, Texas, on 10 October. Operations were eventually taken 
CHAPTER ELEVEN • 439

FIGURE 11-7. [Top] The 782nd Airborne Forward Surgical Team was the first Department of Defense 

medical asset to arrive and be ready to accept patients due to the organic mobility designed into the unit 

and it being on the Global Response Force Mission. Prepacked vehicles were loaded on C-17 aircraft at 

Pope Air Base and arrived at New Orleans Airport shortly after. (Photo by COL Shawn Nessen)

FIGURE 11-8. [Bottom] MAJ(P) Nessen team’s set up next to baggage claim area 13 in a secure and powered location. Taking advantage of the enclosed facility, triage, initial trauma assessment, and resuscitation were conducted adjacent to the erected tent, saving it to be allocated as an operating room with 

two tables. (Photo by SFC Leonel Cubias)
440 • FORWARD SURGERY

over by New Orleans Charity Hospital on 14 November, bringing US military medical 

operations to a close.39

Although the care of surgical patients during this time was minimal, the operation 

was still important for two reasons: (1) it again validated the FST as a rapidly deployable 

unit within the United States, and (2) it yielded powerful lessons learned for future 

incidents. The fact that the 782nd FST was able to reach New Orleans with all necessary 

personnel and equipment within 18 hours of alert speaks to the military’s truly unique lift 

capability, as well as the FST’s training, motivation, and state of readiness. While limited 

in the number of surgical patients that can be treated, few other military or civilian assets 

exist that can be employed with such expediency. It also validated the DRB/GRF medical 

support mission: both the need for highly trained units (including medical and surgical 

units) on 24/7 standby, and the possible employment of these units for missions other than 

overseas combat operations.

Lessons learned reinforced the known challenges regarding timeliness of employment.41,42 Even if the decision was made to deploy surgical assets immediately, and these 

elements are on standby, surgical units will arrive well beyond the “golden hour” for 

treatment. Even after the team’s arrival, obstacles exist to informing those in need about 

the availability and location of medical assets. Patients with life-threatening injuries from 

the initial event may already have died of wounds, survived without intervention, or 

received care elsewhere. If any surrounding infrastructure exists, as it did in the suburbs of 

New Orleans (and in the greater New York area during Operation Noble Eagle), patients 

generally find their way via ambulance or personal means to existing hospitals and medical 

facilities. Unless units are pre-positioned, expectations regarding the treatment of patients 

with life-threatening injuries from the initial event should be tempered. While individuals 

with new injuries sustained during post-event search and rescue missions, recovery 

operations, or other actions would be treated during the “golden hour” timeframe, 

these casualties are historically far fewer in number. Focus instead shifts toward true 

civilian support, an important lesson that should not be forgotten by units that currently 

support DCRF and other contingency missions. Surrounding hospitals may be staffed 

with surgeons, nurses, and technicians who have been awake and working for days, and 

facilities may be running low on medical supplies. Military medical units may be employed 

to reinforce existing medical systems with personnel and Class VIII medical supplies, while 

other military assets assist with food, water, fuel, security, and logistical support.43

Operation Lifeline and Task Force 212

In the early morning hours of Saturday, 8 October 2005, the Kashmir area of Pakistan 

suffered a 7.6-magnitude earthquake with its epicenter near the densely populated city of 

Muzaffarabad.44 The event would claim the lives of over 86,000 and displace over 4 million. Within 48 hours, various US military assets began to mobilize, including the 212th 

Mobile Army Surgical Hospital (MASH), based in Miesau, Germany. The 212th was supported and augmented by the 160th FST and 123rd Main Support Battalion, also stationed 

in Germany, and the 240th FST from Fort Stewart, Georgia.45,46 The first elements of Task 

Force 212 left Ramstein Air Base, Germany, and arrived in Pakistan on 17 October 2005. 
CHAPTER ELEVEN • 441

FIGURE 11-9. US Army 2LT Kristy Bischoff (left) and MAJ Tom Knisely treat a patient at the 212th Mobile 

Army Surgical Hospital at Muzaffarabad, Pakistan, during Operation Lifeline on 5 January 2006. Operation Lifeline was a Pakistani-led relief operation designed to aid victims of the devastating earthquake 

that struck this region on 8 October 2005. (US Air Force photo by Airman 1st Class Barry Loo/Released) 

Medical efforts began in earnest around 29 October as part of what would be dubbed 

Operation Lifeline: transportation, engineering, medical, and logistical support provided 

by more than 1,200 troops.46–49 Task Force 212 faced unique logistical challenges due to 

the region affected. Harsh weather (snow), difficult terrain, and lack of security (because of 

nearby Taliban forces) were constant concerns, particularly for the 240th FST, which was 

located several miles away from the main body at higher elevation.44 Unlike after Hurricane 

Katrina, Pakistani patients walked for miles to be seen. By the end of the operation, the 

212th MASH treated over 32,000 host nation patients, performed 484 surgical operations (mostly for orthopedic or extremity wounds), and provided over 13,000 vaccinations 

(Figure 11-9).50 The 212th was the last active MASH in the Army prior to its conversion to 

a CSH, and after the operation, the US State Department purchased all $4.6 million of its 

equipment and donated the entire hospital to the Pakistani military.48 The 212th MASH’s 

sign now resides at the Army Medical Department (AMEDD) museum at Fort Sam Houston, Texas.
442 • FORWARD SURGERY

Operation Unified Response 

On the morning of 12 January 2010, a catastrophic 7.0-magnitude earthquake struck 

Haiti. The epicenter was approximately 10 to 15 miles west of the capital, Port-au-Prince, 

and it eventually killed over 200,000 people, injuring hundreds of thousands more and 

displacing over one million individuals. The quake destroyed Haiti’s main port and caused 

major damage to its infrastructure. Later that night, the president of Haiti declared a 

national state of emergency and requested humanitarian assistance and disaster relief aid. 

Military aid from the United States was coordinated through US Southern Command 

(USSOUTHCOM). The USCG Cutter Forward arrived off the coast the next morning, on 

January 13th. Military personnel established a liaison team with the Haitian Coast Guard 

to conduct damage assessments, establish command and control, and begin providing humanitarian assistance. Shortly thereafter, two USCG C-130 aircraft arrived to help the most 

seriously wounded and evacuate injured American citizens. During the course of the day, 

an Air Force South assessment team landed in Port-au-Prince to survey the airport, while 

elements of the First Special Operations Wing arrived to reopen Port-au-Prince International Airport. US Navy P-3 aircraft from the Cooperative Security Location of Comalapa, 

El Salvador, conducted aerial reconnaissance of the area. DoD officials ordered the aircraft 

carrier USS Carl Vinson and the USS Bataan Amphibious Readiness Group (with the 22nd 

Marine Expeditionary Unit embarked) to make best speed to Haiti. The first US urban 

search and rescue team, a 72-member unit from Fairfax County, Virginia, arrived in Haiti 

before 24 hours had elapsed. On January 14, four more USCG cutters and the USS Higgins

arrived offshore. An engineering assessment team determined the pier and wharf at Portau-Prince port too badly damaged to allow for ship-borne efforts to make land, making 

them effectively inoperable. On January 15, key personnel from USNORTHCOM, the 

XVIII Airborne Corps, and the 82nd Airborne Division arrived along with the USS Carl 

Vinson. Additional medical assets were dispatched, and the Joint Task Force Bravo (JTF-B) 

Medical Element (stationed in Honduras) and the USS Bataan arrived on January 18, 

followed by the USNS Comfort on January 20 and the 24th EMEDS on January 24. Military units were augmented by Red Cross translators and support personnel, DoD assets, 

and civilian physicians, nurses, and medical students from across the United States. By the 

end of January, JTF-Haiti controlled over 22,000 military personnel both on the ground 

and offshore, 1,100 of which were medical.36,49–51

A worldwide outpouring of support led to the arrival in Haiti of additional military units, civilian personnel, and nongovernmental organizations (NGO) from multiple 

nations. Numerous field hospitals were established by entities from Argentina, Canada, 

China, Colombia, Cuba, France, Israel, Italy, Jordan, Mexico, Russia, Spain, Sri Lanka, 

Turkey, and other nations. Coordination of these assets became the main focus of the military leadership. From a medical standpoint, the three main tasks now became: (1) working 

with engineers to find out which Haitian hospitals were standing, safe, and functional; 

(2) distributing medical assets across the disaster area; and (3) informing the populace 

about the location of various assets. In all, six Haitian hospitals remained operational, and 

another nine were partially operational. While coordinated through the US State Department, these efforts relied heavily on the expertise of medical planners from USSOUTH-
CHAPTER ELEVEN • 443

COM, led by Captain Miguel Cubano (a general surgeon and the first naval officer to hold 

this command), and the XVIII Airborne Corps surgeon cell, led by Colonel (COL) Richard 

Ellison (a general surgeon by training and former commander of the 759th FST).52

Unlike the situations encountered during Operation Noble Eagle or Hurricane Katrina, 

what little surrounding infrastructure that existed before the earthquake was decimated. 

Thirteen of Haiti’s 15 government ministry buildings were completely destroyed. Nearly 

half of all buildings sustained significant damage in Port-au-Prince and surrounding 

villages. The airport control tower was rendered inoperable, and more than half the seaport 

was left in ruins. In contrast to previous humanitarian operations, medical units found 

no shortage of patients. Due to the sheer volume of patients, as well as the potential for 

ongoing injuries due to aftershocks, the initial units to arrive became rapidly overwhelmed. 

Potentially dangerous situations were encountered when medical units set up without 

proper security in place.53

Once again the US military was able to utilize its unique capabilities to employ its 

medical assets for circumstances other than combat operations. However, the scale of these 

operations was unprecedented, and never before did a noncombat operation rely so heavily 

on military leaders and medical planners. The effort required international and interagency 

coordination and communication, not only among medical counterparts, but also among 

engineering, logistical, and security personnel, as well as various governing bodies.54 By 

the end of February, DoD personnel were directly responsible for treating nearly 10,000 

patients and performing over 1,000 surgeries, as well as evacuating approximately 189 

Haitian citizens in need of higher levels of care to US facilities via military aircraft. Seventy 

thousand prescriptions were filled, and countless additional lives were saved by preventive 

medicine units that worked energetically to thwart the spread of communicable diseases 

among the displaced.

Other Foreign Operations

US military medical and surgical assets continue to have a presence throughout the 

world, providing both humanitarian relief and strategic support. To serve as an academic 

resource, the Center for Disaster and Humanitarian Assistance Medicine was chartered 

in 1999 at the Uniformed Services University of Health Sciences in Bethesda, Maryland, 

through congressional funding. According to the Center’s director, COL Charles Beadling, 

“Healthcare is a bridge that permits non-threatening interactions between parties that otherwise would not communicate,” contributing to regional stability and global security.55 

In fact, current DoD directives place priority on security, stability, transition, and reconstruction operations equal to combat operations.56 Most of these initiatives and projects 

fall into the category of primary care and preventive medicine, although surgical units play 

a support role. One example includes the US Africa Command’s Natural Fire exercise. 

Although the exercise is largely an academic endeavor involving forces from Uganda, Chad, 

Kenya, Tanzania, Rwanda, and Burundi, US forces also provide medical care at rural clinics (Figure 11-10). In 2009, the 629th FST, from Columbus, Ohio, along with the 7225th 

Medical Support Unit, saw approximately 700 patients a day at the Pajimo Clinic in rural 

Uganda (Figure 11-11).57,58 Numerous surgical units in Iraq and Afghanistan have also 
444 • FORWARD SURGERY

FIGURE 11-10. A joint team of Chadian and US military medical professionals work together during a 

surgery 14 April 2015, at the Military Teaching Hospital in N’Djamena, Chad. They performed a procedure 

on a Chadian soldier who sustained a gunshot wound that fractured his right femur and left tibia. The US 

and Chadian medical teams were working together as part of a joint exercise called Medical Readiness 

and Training Exercise, known as MEDRETE 15-3. The exercise was a joint effort between the Chadian government, US Army Africa, the Army Reserve Medical Command, and the 7th Civil Support Command. 

MEDRETE 15-3 served as an opportunity for US and Chadian forces to hone and strengthen their lifesaving skills as well as reinforcing the partnership between the countries. (US Army Africa photo by 

SSG Andrea Merritt)
CHAPTER ELEVEN • 445

FIGURE 11-11. MAJ Scott Armen, a surgeon from Gainesville, FL, and other soldiers of the Columbus, OH, 

629th Forward Surgical Team, examine a Ugandan soldier hit in the head by a steel beam. 1LT Matthew 

Boyer (not shown), a nurse, was the medical officer-in-charge at the site, and having no neck braces, 

improvised and stabilized the injured man’s neck with a pair of boots. The Ugandan soldier was quickly 

flown by helicopter to a hospital in Kampala, 200 miles south. (US Army photo by MAJ Corey Schultz/

Released)

conducted humanitarian relief projects, as well as providing training for host nation’s civilian and military medical assets.59,60

USSOUTHCOM’s JTF-B, established in August 1984 at Soto Cano Air Base, Honduras, conducts joint operations to enhance security and stability in Central America. Its personnel have ranged from 500 to 2,000 over the last 20 years and currently number about 

600. The JTF-B has a medical element with an organic seven-person mobile surgical team 

(MST) manned with a mixture of Air Force and Army medical staff. The MST works with 

other Army, Navy, and Air Force medical personnel (dental, pharmacy, laboratory, veterinary services for military working dogs, preventive medicine, physical therapy, radiology, 

medical maintenance, medical supply, emergency medical technicians, aviation medicine, 

and patient administration).61
446 • FORWARD SURGERY

While its primary mission is to support the service members of JTF-B, the unit’s 

medical element has a secondary mission to remain “field ready” for any emergency 

requiring medical or surgical support. Personnel conduct quarterly medical readiness 

exercises to prepare for this mission. In an effort to support the local community and build 

international goodwill, the forward surgical element assists local surgeons with operative 

cases in nearby villages twice a week (Figure 11-12). The JTF-B also provides air assets and 

resuscitative surgical care in response to local trauma cases.61–64 Personnel were dispatched 

to Peru in 2007 under the command of Lieutenant Colonel (LTC) Esmeraldo Zarzabal in 

response to a severe earthquake, arriving approximately 20 hours after notification (Figure 

11-13).64–67

As mentioned earlier, the JTF-B medical element deployed to Haiti in support of 

Operation Unified Response in 2010 under the command of Colonel (COL) Marie 

Dominguez with 23 personnel: the MST an emergency medical team and a 20-cot holding 

capability. It was one of the first surgical units to have “boots on the ground” (Figure 11-

14). JTF-B personnel conducted inpatient and surgical operations for 20 days, working 

hand-in-hand with counterparts from the Haitian Coast Guard, the Mexican Navy 

FIGURE 11-12. US Army MAJ Lisa Coviello, Joint Task Force Bravo Medical Element general surgeon, 

performs a gallbladder removal with Dr Jose Mejia and Dr Guillermo Saenz, Honduran general surgeons, 

12 July 2011, at a community hospital in Comayagua, Honduras. (US Air Force photo by Tech Sgt Matthew 

McGovern/Released)
CHAPTER ELEVEN • 447

FIGURE 11-13. Army MAJ Richard Malish, a physician from Soto Cano Air Base, Honduras, listens as a patient describes his condition during the Joint Task Force-Bravo medical humanitarian relief mission 17–21 

August 2007. Members from the JTF-Bravo deployed to provide medical care to the citizens of Pisco, 

Peru, following the 8.0-magnitude earthquake that devastated the region on 15 August. In addition to 

the medical assets sent, the mobile field surgical team, led by COL Rob Rush, was deployed too. (US Air 

Force photo by Senior Airman Shaun Emery)

and civil service, the Columbian Army and Navy, the Sri Lankan infantry, and other US 

military units. This unique multinational team saw over 2,000 patients, conducted 64 

surgical procedures, and evacuated over 400 patients to the USS Comfort, Sacre Coeur 

Hospital, Italian and Russian military hospitals, NGO facilities, and medical facilities in the 

Dominican Republic.62–64

Perhaps the US military’s most notable medical and surgical humanitarian efforts are 

the biennial missions conducted by the Navy ships Comfort and Mercy. Both Role 3 facilities include 1,000 beds and 12 operating rooms, with 80 to 100 intensive care unit bed capabilities. During odd years, USNS Comfort embarks from Norfolk, Virginia, and conducts 

Operation Continuing Promise, spending several months at various ports in the Caribbean 

and South America. Similarly, the USNS Mercy conducts Operation Pacific Partnership on 

even years, traveling to places such as Vietnam, Cambodia, and Indonesia. Utilizing various 

partnerships, on-site NGOs and local physicians identify potential surgical cases. The first 

day at port typically includes an evaluation day, when patients are examined, decisions are 

made based on complexity and time constraints, and cases are scheduled for the upcoming 

5 days; more complex cases will be “front loaded” to maximize the ability for follow up. 

Patients are issued numbered tickets, and barges ferry patients to and from the ship. Gen-
448 • FORWARD SURGERY

eral surgeons, orthopedic surgeons, otolaryngologists, urologists, and other specialists then 

perform hundreds of procedures ranging from the simple to the complex. Civil engineers 

concurrently perform various projects ashore, while outdoor medicine clinics see patients 

numbering in the thousands.68–70

These noncombat surgical support missions are vital in enhancing US national security 

strategy, using “soft power” as a means of influence. They also provide challenging and 

unexpected situations that keep various forward surgical elements prepared and ready to 

execute their mission at a moment’s notice. The experience and skills sustainment obtained 

during these missions are difficult to replicate in training, and benefit not only team members, but also future patients who will be treated by these units.

Other Forward Surgical Elements

Operational security limits the amount that can be written about many covert operations and units. However, military surgeons, anesthesiologists, nurse anesthetists, surgical 

FIGURE 11-14. Members of Joint Task Force-Bravo Medical Element, led by COL Marie Dominguez, 

completed a 28-day deployment to Haiti 14 February 2010 in support of Joint Task Force Haiti and 

relief efforts stemming from a 7.0-magnitude earthquake that struck the country a few weeks prior on 

12 January. (US Army photo by CPT Isabel Ramirez/Released)
CHAPTER ELEVEN • 449

technicians, nurses, and medics continually support the president and vice president of the 

United States and other high-level dignitaries, both in the United States and overseas. Army, 

Navy, and Air Force surgeons and their teams are also embedded with Special Operations 

Forces units across the globe, providing surgical and resuscitative care to the nation’s most 

lethal and versatile fighting forces.71

FUTURE DIRECTIONS

After many years of garrison and combat experience, the keys to a successful forward 

surgical element are now known. These include highly motivated surgical personnel who 

are skilled in their profession and understand the unique needs and structure of a surgical 

team; durable and mobile medical equipment for performing damage control resuscitation 

and damage control surgery; reliable military field communication and information technology equipment to support the team’s administrative, logistical, and operational needs; 

high-quality, consistent training that is team-oriented and patient-focused; and proper 

tactical employment.

The wars in Iraq and Afghanistan have validated the capabilities of smaller forward 

surgical units.72 While small size undeniably places a greater strain and more training 

requirements on deployed personnel, data have shown that mortality rates of patients 

treated at Role 2 facilities are nearly identical to those at Role 3 elements, even when these 

small surgical teams were “split” and deployed to two different locations.13 This data has 

driven much of the thought process behind the Army FST Force Design Update: current 

concepts for teams in the future would be composed of two mirrored “halves” that can 

be employed together or separately depending on mission requirements. Each half would 

include one orthopedic surgeon and one general surgeon. These halves could be divided 

even further, with a “resuscitative” unit that includes an emergency medicine provider, 

as well as an “operative” unit. The resuscitative unit would have the ability to “jump” 

forward on occasion and provide care nearer to the point of injury, as well as conducting 

preoperative and postoperative care when attached to the rest of the team.73

Ideal equipment for the forward surgical element includes items that are small, light, 

and durable, and have multiple functions. Much of the equipment needed is also electrical, and needs a long battery life and dual-voltage capability so it can be used in areas 

where only 220 voltage is available. With the establishment of the modern Army FST in 

1997, units were fielded with standardized equipment that was agreed on by a working 

group of subject matter experts. The large amount of attention and funding this endeavor 

received ensured that the best equipment was provided. However, with time the missions 

that FSTs perform changed from those originally conceived: the length of time patients 

were held at the FST, the length of time the FST was supported by a towable generator for 

electrical power, and the length of time an FST was deployed (at times up to 15 months) 

all increased. In addition, there was a new expectation for Internet capability to complete 

reports, track patients, and maintain electronic medical records. At the same time, technology has rapidly advanced and patient outcome expectations have increased.
450 • FORWARD SURGERY

The AMEDD Center and School Capabilities Development Integration Directorate 

and the US Army Medical Materiel Agency, an AMEDD Research and Materiel Command 

agency, have endeavored to ensure that the proper tools are in the hands of the forward 

surgical elements working to save the life, limbs, and eyesight of those with combat injuries. 

During their triennial meetings, staff of these agencies query numerous subject matter 

experts and develop working groups to discuss the need for additions, deletions, or modifications to the FST medical equipment and supplies. Recently, a working group was able to 

capture useful data collected by the AMEDD Center and School Lessons Learned Division 

during FST postdeployment out-briefs. Dedicated individuals such as MAJ (R) David Cannon and others have consolidated this valuable feedback and published it in the “Forward 

Surgical Team Handbook: Guide to Lessons Learned and Recommended Practices for 

Deployment Operations.” The working group has used this reference, along with feedback from the MilBook website, to make numerous recommendations, including the most 

recent changes. Ensuring that all equipment is dual voltage, acquiring newer technology for 

providing anesthesia and airway management (such as the formal addition of video-assisted 

laryngeal scopes to the standard equipment), and improved surgical lights are just a few of 

the many improvements made to the basic issue equipment and supplies.

Modern forward surgery also relies on dependable field equipment to transport its personnel and equipment, to power its facility, and to house its life-saving medical equipment. 

Recent improvements include replacing some Army FST High Mobility Multipurpose 

Wheeled Vehicles (HMMWVs) with Light Medium Tactical Vehicles, which have more 

space and power to transport the team and its equipment. Vehicles are fielded with modern, 

secure communication and global positioning satellite devices that enable them to move 

more freely and securely on the battlefield. The original 5-kw generators are now augmented with 18- to 20-kw generators that have onboard 5-ton environmental control units 

to ensure that patients will stay warm or cool, based on the medical and tactical situation. 

There have also been improvements in tents and related items. However, equipment unique 

to the GRF and DCRF missions has not been provided by the Department of the Army 

Headquarters, and it is left to local units to purchase such equipment, currently creating 

variability among units and occasional shortcomings. These issues are being aggressively 

addressed by the XVIII Airborne Corps and US Army North, respectively.33

Training for forward surgical units while in garrison remains a challenge. Newly assigned Army FST chiefs (aka “commanders”) are expected to attend the FST Commanders 

Course taught by the AMEDD Command and Staff Branch at Fort Sam Houston, Texas. 

This is to ensure that Army Medical Corps and Nurse Corps officers appointed to this special assignment are equipped with foundational knowledge in the areas of administration, 

personnel, legal issues, security, tactics/operations, training, planning, logistics, maintenance, communication, information technology, and budgeting.

Today’s forward surgical units perform weekly military and medical training during 

“Sergeant’s Time,” guided by their unit mission-essential task list and the supporting soldier 

training publications, including the Soldier’s Manual and Trainer’s Guide and Soldier’s 

Manual of Common Tasks for various military occupational specialties. These individual 

and collective training tasks are reinforced at numerous situational training exercises and 
CHAPTER ELEVEN • 451

field training exercises. Individual team members participate in patient care at their local 

military treatment facility as part of the Borrowed Military Manpower program, in which 

they serve as part of the clinical schedule on a routine basis to ensure skills sustainment. In 

addition, medical proficiency training is provided as soldiers are relieved from their normal FST military duties for a period of time (30 days, for example) and work exclusively 

in their local military treatment facility. All deploying FSTs, and some FSTs assuming the 

DCRF or GRF mission, are also required to attend the US Army Trauma Training Center 

(ATTC) at Ryder Trauma Center in Miami, Florida. This 2-week, team-training, traumafocused event has been the premier predeployment trauma training exercise within the 

DoD since 2001. The ATTC training curriculum is based on Advanced Trauma Life Support principles, the Team Strategies and Tools to Enhance Performance and Patient Safety 

(TeamSTEPPS) program, combat-specific instruction based on the most recent US Army 

Institute of Surgical Research Clinical Practice Guidelines, and Tactical Combat Casualty 

Care Guidelines. Once teams complete the training at ATTC, they usually conduct a culminating training event at their home station, where their reporting unit certifies or validates 

that they are ready to deploy or assume a special mission.

As the focus shifts from combat operations to homeland defense, surgical teams still 

need to be prepared to care for critically injured patients.74 Command teams will continue 

to balance the requirements for individual training, soldier development, collective military 

training, and time spent engaging in actual patient care. Coordination with local military 

and civilian hospitals will therefore become even more important.75–77 Currently, there 

exists a high degree of variability among surgical units and their opportunities for such 

training. Some military treatment facilities struggle to meet required personnel needs, and 

individuals from surgical units are “tasked” to meet these shortfalls, making collective team 

training difficult. Other units’ garrison requirements make any hospital training minimal 

to nonexistent.78 Airborne units have the additional challenge of added individual and 

sustainment training because parachutists are required to conduct one or more jumps every 

3 months.23 While the validity of this airborne requirement has been challenged, no other 

option exists for providing surgical support to paratroopers during the initial phases of a 

forced entry mission. According to COL Shawn Nessen, former commander of the 782nd 

FST and current Deputy Commander for Clinical Services of the 212th CSH, “As long as 

there is a need for airborne operations, there exists a need for airborne forward surgical 

teams.”40 

Future forward surgical elements supporting DCRF, GRF, humanitarian assistance, 

disaster relief, and other missions will be successful only if the unit is properly staffed, 

equipped, trained, and employed. To ensure the best patient outcomes, operational and 

medical commanders must fully understand an FST’s abilities, requirements, and limitations. It is up to the subject matter experts to keep their commands informed regarding 

the units’ capabilities and readiness level, and the responsibilities of the commands to take 

the advice of the highly specialized leaders of these units. Instructors of the Basic Officer 

Leadership Course, Captains Career Course, Brigade Healthcare Provider Course, Division 

Surgeons Course, and similar courses must ensure that thorough discussion of forward surgery is provided. Simply stating that the FST is a Role 2 asset that can work with a medical 
452 • FORWARD SURGERY

company or augment a CSH at the Role 3 level is insufficient. Recent curriculum changes at 

the Brigade Healthcare Provider and Division Surgeons courses added a 1-hour lecture on 

FST capabilities, tactics, and other vital information to ensure that future staff advisors and 

medical unit commanders are able to properly support and employ forward surgical units. 

Subject matter experts must continue to work with and educate the brigade combat team 

and division leadership to ensure that lessons learned, especially during Operation Enduring Freedom and Operation Iraqi Freedom, are not forgotten.

CLOSING

This chapter is by no means comprehensive. Without a doubt units from all branches 

of service, many of which are also on 24/7 standby, have also accomplished great tasks and 

touched many lives. Highlighted here were only some of the units and events that demonstrated FST capability and important lessons for the future, as well as emphasizing the 

training, manning, and equipment needs for the next, unknown mission. Their efforts have 

saved lives, provided comfort and a sense of safety to Americans and others in need abroad, 

strengthened international relations, and proved to the DoD leadership that the Role 2 

surgical team is flexible, adaptable, extremely capable, and a very valuable asset. 

ACKNOWLEDGMENTS

Mr James P Brown; Dr Dominic Storto, MD, FACS; COL James D Frizzi, MD, FACS; COL Richard 

Ellison, MD, FACS; COL Shawn Nessen, DO, FACS; LTC John V Salter; LTC Francis Cannizzo, 

MD, FACS; LTC John F Detro, PA-C; MAJ Paul Brewer, MD; MAJ Rebecca Lesemann; CPT Chris 

Parker; Dr Miguel Coello; and Dr Ricardo Aviles.

REFERENCES

1. Nessen SC, Cronk DR, Edens J, et al. US Army two-surgeon teams operating in remote 

Afghanistan—an evaluation of split-based forward surgical team operations. J Trauma. 

2009;66:S37–S47.

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