A history of neurosurgical capabilities in the United States Pacific Command: from World War II to present

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  • 1 Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland;
  • | 2 Uniformed Services University of the Health Sciences, Bethesda, Maryland;
  • | 3 Icahn School of Medicine at Mount Sinai, New York, New York;
  • | 4 Darnall Medical Library, Walter Reed National Military Medical Center, Bethesda, Maryland; and
  • | 5 Department of Neurosurgery, Naval Medical Readiness Training Command, San Diego, California
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Neurosurgery has benefited from innovations as a result of military conflict. The volume and complexity of injuries sustained on the battlefield require medical teams to triage, innovate, and practice beyond their capabilities in order to treat wartime injuries. The neurosurgeons who practiced in the Pacific Command (PACOM) during World War II, the Korean War, and the War in Vietnam built upon field operating room knowledge and influenced the logistics of treating battle-injured patients in far-forward environments. Modern-day battles are held on new terrain, and the military neurosurgeon must adapt. War in the PACOM uniquely presented significant obstacles due to geographic isolation, ultimately accelerating the growth and adaptability of military neurosurgery and medical evacuation. The advancements in infrastructure and resource mobilization made during PACOM conflicts continue to inform modern-day practices and provide insight for future conflicts. In this historical article, the authors review the development and evolution of neurosurgical care, forward surgical teams, and mobile field hospitals with surgical capabilities through US conflicts in the PACOM.

ABBREVIATIONS

EH = evacuation hospital; ICP = intracranial pressure; L+1 = 1 hour after troops landed; MASH = Mobile Army Surgical Hospital; MEDEVAC = medical evacuation; MTF = military treatment facility; MUST = Mobile Unit Self-Contained Transportable; PACOM = Pacific Command; TAMC = Tripler Army Medical Center; USNHO = US Naval Hospital Okinawa; USNHY = US Naval Hospital Yokosuka; WWI = World War I; WWII = World War II.

Neurosurgery has benefited from innovations as a result of military conflict. The volume and complexity of injuries sustained on the battlefield require medical teams to triage, innovate, and practice beyond their capabilities in order to treat wartime injuries. The neurosurgeons who practiced in the Pacific Command (PACOM) during World War II, the Korean War, and the War in Vietnam built upon field operating room knowledge and influenced the logistics of treating battle-injured patients in far-forward environments. Modern-day battles are held on new terrain, and the military neurosurgeon must adapt. War in the PACOM uniquely presented significant obstacles due to geographic isolation, ultimately accelerating the growth and adaptability of military neurosurgery and medical evacuation. The advancements in infrastructure and resource mobilization made during PACOM conflicts continue to inform modern-day practices and provide insight for future conflicts. In this historical article, the authors review the development and evolution of neurosurgical care, forward surgical teams, and mobile field hospitals with surgical capabilities through US conflicts in the PACOM.

Neurosurgery has seen saltatory advancements in both surgical technique and the transfer of critically ill, battle-injured patients during periods of military conflict. The process of stabilization and evacuation has evolved concurrently with the evolution of transport technologies and supply lines.

In World War I (WWI), 7% of casualties resulted from cranial injuries.1 This conflict coincided with the development of contemporary neurosurgery as a discrete surgical specialty, pioneered by Lieutenant Colonel Harvey Cushing. As one might expect, the care for head and spine injuries in the Belle Époque period and early stages of WWI yielded exceedingly high mortality rates.2 WWI catalyzed an evolution in all of surgical care, including neurosurgery, with new techniques in surgical stabilization for previously fatal wounds and an accelerated transfer to definitive neurosurgical care. Initially, US military neurosurgery was born in the European theater; this foundation was built upon technological advancements in wound care and yielded a tiered training program to increase the number of trained neurosurgical specialists.2,3

Military operations in the Pacific Command (PACOM) presented new challenges that could not be addressed using previously employed strategies. The conflicts in PACOM led to higher volumes of neurosurgical trauma, and unique geographic isolation and course terrain added significant challenges to neurosurgical care. In this historical review, we recount the evolution of military neurosurgery in the Pacific theater from World War II (WWII) to present day.

World War II

On December 7, 1941, the reality of WWII was brought to American soil in Pearl Harbor, Hawaii, with an unprovoked aerial assault by the Empire of Japan and its First Air Fleet. Shortly after the US entered WWII, Lieutenant Colonel Roy Glen Spurling organized the first neurosurgical service in the US Army.2 Notably different from the practice in the European theater, neurosurgical care within the PACOM presented a new set of challenges. Operations on the geographically isolated archipelagos during pivotal battles, including the Battles of Wake Island, Midway, Guadalcanal, the Philippine Sea (Operation Musketeer I, II, and III), Saipan, Guam, Iwo Jima, and Okinawa (Operation Iceberg), required military medicine to modernize methods to evacuate casualties or to provide neurosurgical services closer to conflict (Table 1).411

TABLE 1.

Pivotal battles during WWII in the Pacific theater

Battle/CampaignOperation NameDatesSignificanceCasualties
Pearl HarborAI & Z by Imperial Japanese NavyDecember 7, 1941An unprovoked, surprise attack by the Japanese spurred the US to enter WWII.3,601
Wake IslandNot applicableDecember 8–23, 1941The US suffered fewer losses than the larger Japanese force in 2 battles at Wake Island. Served as a rallying point for the US.1,324
MidwayMI by Imperial Japanese NavyJune 4–7, 1942The US Navy demonstrated the ability to defend major bases. This historic battle became a turning point for the war.3,364
GuadalcanalWatchtowerNovember 12–15, 1942Thwarted Japanese control of airfields that would reach New Guinea & New Caledonia32,852
The Philippine SeaNot applicableJune 19–20, 1944Greatest carrier battle of the war, the Japanese suffered losses of 480 aircrafts & 3 aircraft carriers.3,096
SaipanForagerJune 15 to July 9, 1944The US gained a crucial air base allowing for the launch of long-range B-29s to mainland Japan.64,790
GuamForagerJuly 21 to August 10, 1944The US gained access to harbors & airfields in Guam. In addition, the US liberated Guam from Japanese rule.27,981
Iwo JimaDetachmentFebruary 19 to March 26, 1945The US captured 3 airfields, which were potential staging areas for an invasion of mainland Japan.45,446
OkinawaIcebergApril 1 to June 22, 1945Provided allied powers w/ a strategic air base to both increase air strikes & block supply lines for Japan.309,000

From the beginning, neurosurgeons demonstrated their resourcefulness in WWII. Dr. Ralph Cloward, Hawaii’s only neurosurgeon (a civilian) at the time, reported to Tripler Army Medical Center (TAMC) immediately upon hearing news of the attack in Pearl Harbor. There, he set up a neurosurgical operating room in a small obstetrics delivery room. With the assistance of an Army Lieutenant, he performed 42 craniotomies in the 3 days after the Pearl Harbor attack. He performed large craniotomies with meticulous debridement and sprinkled sulfonamide antibiotics directly on brain tissue. He later received a presidential plaque recognizing his patriotic service.12

Later in the conflict, the Philippines campaign saw the benefit of paved roads and aircraft runways, which enabled expedited medical evacuation (MEDEVAC) by air via C-47 and L-5 airplanes (Fig. 1), a novel idea.13 The use of roads decreased the time to evacuation and thus reduced the mortality rates of brain and spine patients. Evacuation of patients, however, was often interrupted secondary to poor travel conditions, and neurosurgical patients often remained at forward surgical hospitals that were minimally equipped or capable of handling these injuries.13 Despite these obstacles, the majority of patients arrived at an evacuation hospital (EH) within 18 hours of injury.13

FIG. 1.
FIG. 1.

Pacific operations in WWII. A: A map of Asian-Pacific operations throughout WWII from 1942 through 1945. Reproduced from Condon-Rall ME, Cowdrey AE. The Medical Department: Medical Service in the War Against Japan. Center for Military History; 1998. B: Behind enemy lines on Bougainville Island, Papua New Guinea, in an underground "operating room," a US physician performs surgery on a US soldier injured by a Japanese sniper. Photograph from December 13, 1943. Department of Defense. Defense Audiovisual Agency. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/531177). C: A wounded US soldier is transported via an L-5 plane from Quezon City, Luzon, Philippine Islands. Photograph from February 14, 1945. Department of Defense. Department of the Army. Office of the Chief Signal Officer. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/80660842). D: US medical personnel treating casualties on Saipan Beach during the invasion in 1944. Department of Transportation. US Coast Guard. Office of Public and International Affairs. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/205586589).

Patients from the Philippines campaign transferred to an EH were immediately examined by a neurosurgeon. A systematic resuscitation approach was used for neurosurgical patients that included 2 U of plasma, 100 ml of 5% sodium sulfadiazine, and 50,000 U of penicillin sodium. Upon re-evaluation, anteroposterior and lateral roentgenograms (i.e., x-rays) were taken, and if necessary whole blood was transfused.13 X-ray technology, although antiquated by modern standards, allowed physicians to evaluate for retained foreign bodies and calvarial injuries, which allowed for intervention in the acute postinjury period.

Captain Kenneth H. Abbott, an Army neurosurgeon deployed to the southwest PACOM including the Philippines campaign of WWII, observed and treated all cranial trauma, including bullet injuries, other high-velocity fragment injuries, and open depressed skull fractures due to bayonets and hatchets.13 He emphasized early resuscitative efforts, as well as water-tight dural closure and use of perioperative and postoperative antibiotic therapy as means to decrease the risks of cerebrospinal fluid fistula and infection, respectively.14

The early arrival of neurosurgical patients to EH allowed for optimization of wound care unique to cranial injuries. The care of traumatic cranial wounds was approached in phases that included debridement of the scalp, exposure of cranial defects, and craniectomy or craniotomy, followed by debridement of devitalized cerebral tissue and subsequent closure. Scalp debridement was often accomplished by enlisted personnel, such as an Army field medic or a Navy hospital corpsman. These procedures carried a high risk of infection due to the nature of the wound. In addition, they were frequently complicated by increased intracranial pressure (ICP) and neurological deterioration secondary to agitation during these poorly anesthetized procedures.13 Captain Abbott wrote, "Occasionally the patient was restless while his head was being shaved. Rather than allow straining to cause more herniation of brain tissue, it was then necessary to anesthetize the patient before continuing the preparation of the scalp."13 Later, elevations in ICP were mitigated using intratracheal ether with oxygen, which was the preferred anesthetic for pain control during scalp debridement. If no personnel trained in the administration of intrathecal anesthesia was available, local anesthetic with 0.5% procaine solution was co-administered with pentothal sodium.13 The latter had more complications such as respiratory depression and inadequately controlled pain increasing ICP.13 In addition to careful layered debridement, antibiotics were utilized for infection prophylaxis. Due to penicillin’s poor penetration of the blood-brain barrier, an injection of 50,000 U of penicillin sodium was given locally into the traumatic cerebral defects or underneath the dura mater after dural closure. Local antibiotic administration was combined with regularly scheduled systemically administered antibiotic therapy in the postoperative period.13

During the Battle of Okinawa, military medical leaders were able to construct mobile neurosurgical units, a strategy used in the European theater. It was determined that by moving surgical care units to a far-forward setting, patients could be rapidly assessed for medical and surgical care, including neurosurgery, without being transported long distances.15 In Okinawa, an initial team arrived 1 hour after troops landed (L+1) and consisted of a neurosurgeon, assistant neurosurgeon, anesthetist, 1 nurse, and 3 noncommissioned officers. The team’s equipment was delivered in two 160-pound crates. They were prepared to see patients by L+5 and received their first referral at L+12. The team was positioned within 8 miles of combat, so critically injured patients could be treated within 24 hours of injury.15 Despite the far-forward, mobile nature of these small portable surgical hospitals, they were equipped with enough resources to care for complex battle injuries. Devine and Farr described these operating tents as having a physical setup equivalent to those found in most civilian hospitals.15

Despite the advancements in delivering far-forward medical and surgical care to combat casualties, Operation Iceberg remains the bloodiest campaign of the Pacific Offensive in WWII with over 309,000 casualties.16 Estimates state that US forces saw between 75,000 and 82,000 casualties and 20,195 deaths, including that of Pulitzer Prize–winning war correspondent, Ernest "Ernie" Pyle (Fig. 2).16 Although Mr. Pyle famously spent 3 years embedded with US forces while covering WWII in the European theater, he tragically suffered a fatal gunshot wound to the head and was killed less than 2 days after arriving on the beaches of Okinawa with the marines.17 At the conclusion of nearly 3 months of ground, naval, and aerial fighting (April 1, 1945, to June 22, 1945), 24 US service members went on to receive the Medal of Honor, including Corporal Desmond Doss, a combat medic who famously received the award for heroism in battle while remaining a conscientious objector.17

FIG. 2.
FIG. 2.

Battle of Okinawa. A: A map demonstrating the strategic location of field hospitals and portable surgical hospitals. Reproduced from Condon-Rall ME, Cowdrey AE. The Medical Department: Medical Service in the War Against Japan. Center for Military History; 1998. B: One of the last photographs of Ernest Pyle, taken days before he was killed during the invasion of Okinawa. Photograph from April 8, 1945. Department of Defense. Department of the Navy. US Marine Corps. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/74251954). C: A profile photograph of Private First Class Desmond Doss, a combat medic who would go on to receive the Medal of Honor while serving as a conscientious objector. Photograph from May 15, 1945. Department of Defense. Defense Audiovisual Agency. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/593452). D: Transfer of wounded from USS Bunker Hill to USS Wilkes-Barre who had been injured during a fire aboard the carrier after a Japanese suicide dive-bombing attack off Okinawa in Ryukyus. Photograph from May 11, 1945. Department of Defense. Department of the Navy. Naval Photographic Center. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/520682).

The Korean War

The Korean War began on June 25, 1950, when nearly 75,000 soldiers from Democratic People’s Republic of Korea crossed the 38th parallel into the Republic of Korea to the south.18 Although a war in all but name, the involvement of the US military was technically declared a "police action." This provocation represented the first action of the Cold War between the communist Soviet Union and their backed countries and the prodemocratic, Western-backed countries. The war raged for 3 years and ended on July 27, 1953. During this time, approximately 1.8 million American troops served in the theater and estimates suggest nearly 4 million deaths among all participating belligerents, more than half being North and South Korean civilians.1821

In the early stages of the Korean War, the military medical community had minimal resources to manage neurosurgical casualties. As a possible byproduct of rapid demobilization after WWII, the initial medical corps response was inadequate. As a result, the first casualties with cranial injuries were evacuated from Korea to Japan without definitive debridement and closure.22 Inadequate wound care led to an increased incidence of complications such as meningocerebral infections, fungating cerebritis, and decubitus ulcers.22 The high rate of infections—as high as 41%—signaled a departure from previous successes seen in the Battle of Okinawa and other late WWII conflicts; this, in part, led to action by military planners to bring definitive neurosurgical care closer to the conflict’s front lines.23

The USS Consolation, a hospital ship, was reactivated for the Korean War to aid in providing specialized medical care, including neurosurgery.24 The planning of assaults, such as the amphibious assault at the Battle of Incheon in September 1950, prioritized access to triage facilities and care early during the battle. During the Battle of Incheon, the Consolation served as the preferred transfer site for all patients with injuries requiring specialized treatment.24 The Consolation and 2 other hospital ships, equipped with nearly 2500 hospital beds altogether, were assigned to berth close to the conflict during the assault phase, so specialty surgical capabilities would be available when casualty rates peaked.24

Despite early use of hospital ships with neurosurgical capabilities, it was not until February 1951 that the first provisional neurosurgical detachment was established in Taegu.22 The detachment was led by Lieutenant Colonel Arnold M. Meirowsky, whose team performed 108 operations in the first 3 weeks of the spring offensive.25 A graduate of University of Cologne medical school in 1937, Lieutenant Colonel Meirowsky completed his residency in neurosurgery at Albany Hospital and a fellowship at Barnes Hospital and Children’s Hospital of St. Louis.26 While in the Korean theater, Lieutenant Colonel Meirowsky educated line medics and other medical providers on the care of neurosurgical patients.26 As a measure of the carnage created by the Korean War, Lieutenant Colonel Meirowsky reported his experience of treating 540 penetrating head injuries in just a 2-year period.27 His teachings also included reduced sedation to monitor for complications, as well as techniques for efficiently turning paralyzed patients to prevent bed sore infections.25

The neurosurgical team functioned in collaboration with Mobile Army Surgical Hospital (MASH) units to ensure that neurosurgical injuries received care in specialized silos (Fig. 3).22 The idea of the Auxiliary Surgical Group or MASH unit was conceptualized by Colonel Michael E. DeBakey and surgical consultants in 1946.28 The partnership with MASH units signaled a transition from the mobile neurosurgical unit framework employed by Colonel George Finney during the Okinawa campaign to provide smaller far-forward surgical teams with a larger network of resources.9 The first of these teams was deployed for the Korean War in October 1951 in Kumsong.9 The detachment then partnered with the neurosurgical center at the 8167th US Army Hospital in Tokyo, Japan, to have an outlet for tertiary operations, as well as prolonged management of critically ill brain and spine patients.22

FIG. 3.
FIG. 3.

War in Korea. A: A map demonstrating the change in fronts as the war progressed. 2015 WGBH Educational Foundation and Public Broadcasting Service. Map of South Korea downloaded from PBS LearningMedia, https://www.pbslearningmedia.org/. Rights to use this asset do not expire (https://vpm.pbslearningmedia.org/help/full-license-for-section-3d-of-terms-of-use-download-share-and-modify/). B: A photograph depicting a helicopter evacuation of a wounded marine from the front lines. Photograph from September 18, 1947. Department of Defense. Department of the Navy. US Marine Corps. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/74241285). C: A wounded US soldier is brought into Japan for definitive care via C-47 from the forward Korean airstrip. Photograph from July 28, 1950. Department of Defense. Department of the Air Force. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/542217). D: An operation is performed on a wounded soldier at the 8209th Mobile Army Surgical Hospital, just 20 miles from the front lines. Photograph from August 4, 1952. Department of Defense. Defense Audiovisual Agency. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/531425).

Another advancement in neurosurgical care was the expanded use of MEDEVAC directly from battle. Although the first evacuation with a helicopter occurred in 1941 during WWII, it was not popularized not until the Korean War.29 In 1950, former Army pilot Captain Leonard A. Crosby demonstrated using helicopters for MEDEVAC in Taegu. Within a week, the Fifth Air Force Commander authorized helicopters for frontline evacuations. Major General George Armstrong later advocated for and successfully created dedicated medical department air ambulance units with the Army and Air Force to provide frontline evacuation support.23

In Korea, evacuation of casualties from the front lines was accomplished using the H-13 Sioux helicopter (Fig. 3).22,30 After stabilization and preliminary neurosurgical care, casualties were evacuated to the nearest airport and then to the neurosurgical center in Tokyo. Evacuation to Tokyo’s 8167th US Army Hospital was accomplished by C-54 planes within 8 to 10 days of injury depending on the condition of the casualty and the tactical situation.22 The 8167th US Army Hospital performed tertiary operations and managed critically ill patients before arranging transport stateside.22

Overall, the 2-echelon system and use of air evacuation during the Korean War effectively allowed military medicine to reduce complications associated with neurosurgical injuries. From September 1950 to September 1952, the mortality rate for all penetrating craniocerebral trauma was 7.8% and the rate for penetrating spinal wounds was 3.6%.6 Nearly half (46.2%) of casualties who presented to a neurosurgeon within 3 to 8 hours of penetrating cranial injury had confined intracranial hematomas that were evacuated.22 Whereas early reports in the Korean conflict found a rate of meningocerebral infection as high as 41% after head trauma, the institution of early neurosurgery at MASH units with definitive backup at the 8167th US Army Hospital in Tokyo reduced such infections to 1% of injuries.22

The Vietnam War

The second of the Indochina Wars, the War in Vietnam began on November 1, 1955, as the US and allies attempted to support the prodemocratic South Vietnamese against the communist North Vietnamese and its allies, the Soviet Union and China. Spanning nearly 2 decades (1955–1975) and without many discrete military strongholds, the guerrilla, attrition-style warfare of the War in Vietnam was a departure from prior military engagements seen in the PACOM. Despite the lack of large-scale military conflicts, this long, arduous war produced staggering casualties with estimates exceeding over 3 million people.20,31,32

Due to the long, defensive nature of the conflict, the War in Vietnam resulted in a shift from MASH units to semipermanent and permanent hospitals. To provide frontline, far-forward care, the War in Vietnam saw the introduction of expandable Mobile Unit Self-Contained Transportable (MUST) shelters that could be divided with inflatable ward sections. These were designed to accommodate laboratories, pharmacies, radiology suites, and kitchens. The perioperative equipment was comparable to that of a hospital in the US at the time and included respirators, Stryker bed frames, and hypothermia units.33 Neurosurgeons had access to cerebral angiography, ventriculography, and pneumoencephalography.33 In 1968, the PACOM general surgeon dictated that all MUST units remain in a mobile capacity, effectively replacing the MASH units.34 Further care after initial stabilization and treatment was performed after transfer to Japan or a US military treatment facility.33

Neurosurgeons in Vietnam benefited from the development of whole blood banking.35 Other technologic improvements included new MEDEVAC air assets. With more power and a larger frame than the helicopters used in the Korean War, the UH-1D "Huey" transported 6–9 patients, with most patients evacuated within 35 minutes after injury.2 Improvements in MEDEVAC paradoxically increased hospital deaths, as expectant patients who would have previously died at the point of injury were now able to arrive at hospitals with injuries incompatible with life. Lieutenant Colonel William "Dr. Bill" Hammon described this finding in a series of 455 patients with craniocerebral trauma who were managed nonoperatively due to the severity of the injuries at the 24th Evacuation Hospital. A total of 165 patients (32.26%) sustained cranial gunshot wounds.36 Lieutenant Colonel Hammon graduated neurosurgical residency from Walter Reed Army Medical Center under Colonel Ludwig Kempe and was assigned to the 24th Evacuation Hospital of Long Binh, where he served as chief of neurosurgery and hospital commander in 1968.37

The 24th Evacuation Hospital of Long Binh was the largest and most active of the US Army medical centers with neurosurgical capability in the Republic of Vietnam.36 During a 26-month period, the center received 2187 patients with penetrating wounds of the head. Of these patients, 95% were evacuated by helicopter and typically received some form of emergency care either at the point of injury or in transit (Fig. 4).36 Initially, patients were brought through the emergency department for further resuscitation and evaluation of surgical priority before undergoing appropriate roentgenographic imaging. At the time, a roentgenographic series of the skull included anteroposterior, lateral, and Towne projections. Penetrating cranial injuries were treated with debridement, and a cone of cerebral tissue was resected along the missile tract. Debridement was continued until the brain was no longer tense and hemostasis was obtained.33 The most common complications were retained bone fragments (4.61%), postoperative hematoma (1.1%), superficial wound infection (0.81%), cerebrospinal fluid fistula (0.63%), and postoperative meningitis (0.63%).36

FIG. 4.
FIG. 4.

War in Vietnam: Part I. A: A map of the early years of the war in Vietnam, illustrating the northern and southern borders of Vietnam. Map of the beginning of the Vietnam War 1957 to 1960 (https://commons.wikimedia.org/wiki/File:Vietnam_war_1957_to_1960_map_de.svg) by Don-kun, NordNordWest. CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0/). B: US Army Bell UH-1D helicopters airlift members of the 2nd Battalion, 14th Infantry Regiment from the Filhol Rubber Plantation area to a new staging area during Operation Wahiawa, a search and destroy mission conducted by the 25th Infantry Division, northeast of Cu Chi, South Vietnam. Photograph from May 16, 1966. Department of Defense. Department of the Army. Office of the Deputy Chief of Staff for Operations and Plans. Training Directorate. US Army Audiovisual Center. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/530610). C: Major General Louis B. Robertshaw, commanding general, 1st Marine Aircraft Wing, wipes the brow of a marine wounded during Operation Hastings, Long Ha Airfield, Vietnam. Hospitalman Daniel J. Breton, attached to the 3rd Marine Division, holds a bottle of glucose that is being administered to the wounded man. Photograph from September 18, 1947. Department of Defense. Department of the Navy. US Marine Corps. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/100310811).

Cerebral abscesses were an infrequent (3%) but severe complication that carried high morbidity (82%) and mortality (54%) rates.36 Typically occurring in the 2nd or 3rd weeks after injury, these complications were attributed to incomplete debridement of retained bone fragments.38 Gram-negative infections were the cause of the majority of severe infections (56% of fatal cases) because there was a dearth of antibiotics that could cross the blood-brain barrier and inhibit these organisms at the time.38 Because of this, extensive and vigorous debridement of penetrating craniocerebral trauma was the mainstay of infection control. Bone fragments remained after debridement in 3%–5% of cases; upon discovery, the patient was taken back for subsequent debridement.33,39

Due to the complete replacement of ground evacuation with MEDEVAC by helicopter, it was common for patients to receive neurosurgical care within 1 hour of injury.33 Despite the increase in expectant injuries seen by definitive treatment teams, the faster evacuation times also led to more patients evaluated for potentially lifesaving procedures. In just 1 year of deployment, Captain Calvin Early, a US Navy neurosurgeon, performed 631 surgical procedures in Da Nang, Vietnam, the most of any deployed US Navy neurosurgeon during this conflict (Figs. 5 and 6).39,40 One of the 21 neurosurgeons deployed to the War in Vietnam, Captain Early received his medical degree and doctorate of philosophy and completed his neurosurgical residency at The Ohio State University in Columbus, Ohio.40 After his tour in Vietnam, Captain Early was assigned to the National Naval Medical Center (now Walter Reed National Military Medical Center) in 1968. There, he served as director of surgical services and established the neurosurgery residency training program.40,41

FIG. 5.
FIG. 5.

War in Vietnam: Part II. A: An aerial photograph of the US Naval Support Activity (NSA) Station Hospital in Da Nang, Vietnam, in 1967. From US Naval Support Activity: Da Nang, Vietnam 1966–67. Courtesy of the Naval History and Heritage Command. B: An officer photograph of Captain Calvin "Cal" B. Early, a naval neurosurgeon, who performed more than 600 surgical procedures in 1 year while deployed to Da Nang. Photograph courtesy of the Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland. C: Members of Company B, 4th Battalion, 12th Infantry, 199th Infantry Brigade carry a wounded member of the company from the field during a firefight in Lhu Duc District. Photograph from October 14, 1967. Department of Defense. Defense Audiovisual Agency. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/531461). D: Medical personnel treat patients and perform rounds in the facilities of the NSA Station Hospital, Danang. From Naval Support in I Corps 1968. Courtesy of the Naval History and Heritage Command.

FIG. 6.
FIG. 6.

US Military Hospitals of the PACOM. A: The first US military hospital in Okinawa, Ryukyus Army Hospital on Camp Kue. Photograph courtesy of Department of Defense. Defense Health Agency. B: The hospital was eventually replaced in 2013 by the current hospital, which was relocated to Camp Foster. Photograph courtesy of Department of Defense. Defense Health Agency. C: Ambulances and buses of the 1453rd Medical Air Evacuation Squadron, a component of the Pacific Division of the Military Air Transport Service, transport combat casualties and military patients from Hickam Air Force Base to Tripler Army Hospital on Oahu, Hawaii, in March 1953. Department of Defense. Department of the Air Force. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/204977939).

Military Hospitals of PACOM

The US military currently has hospitals, or military treatment facilities (MTFs), in South Korea, Japan, and Hawaii. The only MTF in South Korea—Brian D. Allgood Army Community Hospital—was originally established in 1967 and serves more than 65,000 beneficiaries of American service members, their dependents, and civilian contractors.42 The oldest MTF in PACOM is in Yokosuka, Japan, near Tokyo.43 US Naval Hospital Yokosuka (USNHY) was established on September 11, 1950, during the early stages of the Korean War. Interestingly, this hospital was built on the original grounds of a hospital compound for the Imperial Japanese Navy in 1881. The hospital command received a Navy Unit Commendation Award for treating over 5800 casualties during the Korean War. Currently, USNHY serves over 43,000 service members and authorized beneficiaries with a wide range of emergency, outpatient, and inpatient services.43 Despite the wide-ranging capabilities of these MTFs, the only hospitals with neurosurgery capability reside in Okinawa, Japan, and Hawaii.

In 1958, the US Army Hospital of the Ryukyu Islands was created at Camp Kue in Okinawa.44 This hospital provided close deployed neurosurgical support for all US forces in PACOM. During the Vietnam War, the hospital boasted a 700-bed capacity. This facility was renamed Camp Lester in 1977. The hospital—US Naval Hospital Okinawa (USNHO)—relocated to Camp Foster, also in Okinawa, in 2013 where it continues to provide neurosurgical care for over 55,000 marines and over 100,000 beneficiaries in the PACOM region.44,45 Currently the neurosurgical practice at USNHO is maintained by an active-duty Navy neurosurgeon, with an average of 120 neurosurgical procedures performed annually. Although most procedures are elective spine surgical procedures aimed at maintaining unit readiness, the hospital is capable of treating complex neurosurgical emergencies.46,47

The only tertiary care hospital in PACOM with expanded medical and surgical capability is TAMC. Tripler General Hospital existed prior to the attack on Pearl Harbor, but the present-day structure was created after the 1941 attack in preparation for the Pacific conflict. At the height of WWII, the large coral-pink hospital boasted an average census of 2000 patients per day.

Today, TAMC is the only military tertiary care hospital in the Pacific basin, supporting 264,000 military personnel, dependents, and veterans with a referral network of 171,000 patients.48 Currently, TAMC is a certified level II trauma center that performs, on average, more than 500 neurosurgical interventions annually with positions for 4 staff neurosurgeons.

Conclusions

Wartime neurosurgical care has undergone significant adaptations due to the inherent difficulties presented by the distance, terrain, and climate in the Pacific theater to treat patients efficiently and effectively. As demonstrated, the adaptability of surgeons, coupled with increased emphasis on MEDEVAC techniques, helped to bridge the gap and ensure access to early neurosurgical intervention. This highlights the importance of an adaptable military medical force to positively influence patient care and outcomes.

With the contemporary geopolitical climate and in preparation for a potential future conflict at multiple locations, troops are again training to serve in a variety of novel tactical environments compared with those of the last 20 years. With this shift, military medicine will again need to adapt to effectively treat casualties. In future conflicts, in anticipation of near-peer conflicts where air superiority is not guaranteed, there will be a continued need to locate definitive neurosurgical care close to the battlefield, while still balancing the need for continual training and skill reinforcement for surgeons. Ultimately, the future of military neurosurgery may not have the benefit of frequent, efficient mobility for both surgeons and patients. Through careful study of past conflicts, we hope to build upon these adaptations to provide efficient and effective neurosurgical care for patients in future conflicts to come.

Disclaimer

The views expressed are solely those of the authors and do not reflect the official policy or position of the US Air Force, US Army, US Navy, the Department of Defense, or the US Government.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Ikeda. Acquisition of data: Yokoi, McGovern, Fetherston, Clarke. Analysis and interpretation of data: Yokoi, McGovern, Fetherston, Ikeda. Drafting the article: Yokoi, McGovern, Fetherston. Critically revising the article: Yokoi, Clarke, Ravindra, Hooten, Ikeda. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Yokoi. Administrative/technical/material support: Yokoi, Clarke, Ikeda. Study supervision: Ravindra, Hooten, Ikeda.

Supplemental Information

Videos

Video Abstract. https://vimeo.com/738606616.

References

Captain Benny Brandvold stands "at the ready" outside of Dhahran, Saudi Arabia, during the early phase of Operation Desert Shield, fall of 1990. © Benny Brandvold, published with permission. See the article by Martin et al. (E16).

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    Pacific operations in WWII. A: A map of Asian-Pacific operations throughout WWII from 1942 through 1945. Reproduced from Condon-Rall ME, Cowdrey AE. The Medical Department: Medical Service in the War Against Japan. Center for Military History; 1998. B: Behind enemy lines on Bougainville Island, Papua New Guinea, in an underground "operating room," a US physician performs surgery on a US soldier injured by a Japanese sniper. Photograph from December 13, 1943. Department of Defense. Defense Audiovisual Agency. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/531177). C: A wounded US soldier is transported via an L-5 plane from Quezon City, Luzon, Philippine Islands. Photograph from February 14, 1945. Department of Defense. Department of the Army. Office of the Chief Signal Officer. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/80660842). D: US medical personnel treating casualties on Saipan Beach during the invasion in 1944. Department of Transportation. US Coast Guard. Office of Public and International Affairs. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/205586589).

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    Battle of Okinawa. A: A map demonstrating the strategic location of field hospitals and portable surgical hospitals. Reproduced from Condon-Rall ME, Cowdrey AE. The Medical Department: Medical Service in the War Against Japan. Center for Military History; 1998. B: One of the last photographs of Ernest Pyle, taken days before he was killed during the invasion of Okinawa. Photograph from April 8, 1945. Department of Defense. Department of the Navy. US Marine Corps. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/74251954). C: A profile photograph of Private First Class Desmond Doss, a combat medic who would go on to receive the Medal of Honor while serving as a conscientious objector. Photograph from May 15, 1945. Department of Defense. Defense Audiovisual Agency. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/593452). D: Transfer of wounded from USS Bunker Hill to USS Wilkes-Barre who had been injured during a fire aboard the carrier after a Japanese suicide dive-bombing attack off Okinawa in Ryukyus. Photograph from May 11, 1945. Department of Defense. Department of the Navy. Naval Photographic Center. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/520682).

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    War in Korea. A: A map demonstrating the change in fronts as the war progressed. 2015 WGBH Educational Foundation and Public Broadcasting Service. Map of South Korea downloaded from PBS LearningMedia, https://www.pbslearningmedia.org/. Rights to use this asset do not expire (https://vpm.pbslearningmedia.org/help/full-license-for-section-3d-of-terms-of-use-download-share-and-modify/). B: A photograph depicting a helicopter evacuation of a wounded marine from the front lines. Photograph from September 18, 1947. Department of Defense. Department of the Navy. US Marine Corps. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/74241285). C: A wounded US soldier is brought into Japan for definitive care via C-47 from the forward Korean airstrip. Photograph from July 28, 1950. Department of Defense. Department of the Air Force. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/542217). D: An operation is performed on a wounded soldier at the 8209th Mobile Army Surgical Hospital, just 20 miles from the front lines. Photograph from August 4, 1952. Department of Defense. Defense Audiovisual Agency. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/531425).

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    War in Vietnam: Part I. A: A map of the early years of the war in Vietnam, illustrating the northern and southern borders of Vietnam. Map of the beginning of the Vietnam War 1957 to 1960 (https://commons.wikimedia.org/wiki/File:Vietnam_war_1957_to_1960_map_de.svg) by Don-kun, NordNordWest. CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0/). B: US Army Bell UH-1D helicopters airlift members of the 2nd Battalion, 14th Infantry Regiment from the Filhol Rubber Plantation area to a new staging area during Operation Wahiawa, a search and destroy mission conducted by the 25th Infantry Division, northeast of Cu Chi, South Vietnam. Photograph from May 16, 1966. Department of Defense. Department of the Army. Office of the Deputy Chief of Staff for Operations and Plans. Training Directorate. US Army Audiovisual Center. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/530610). C: Major General Louis B. Robertshaw, commanding general, 1st Marine Aircraft Wing, wipes the brow of a marine wounded during Operation Hastings, Long Ha Airfield, Vietnam. Hospitalman Daniel J. Breton, attached to the 3rd Marine Division, holds a bottle of glucose that is being administered to the wounded man. Photograph from September 18, 1947. Department of Defense. Department of the Navy. US Marine Corps. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/100310811).

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    War in Vietnam: Part II. A: An aerial photograph of the US Naval Support Activity (NSA) Station Hospital in Da Nang, Vietnam, in 1967. From US Naval Support Activity: Da Nang, Vietnam 1966–67. Courtesy of the Naval History and Heritage Command. B: An officer photograph of Captain Calvin "Cal" B. Early, a naval neurosurgeon, who performed more than 600 surgical procedures in 1 year while deployed to Da Nang. Photograph courtesy of the Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland. C: Members of Company B, 4th Battalion, 12th Infantry, 199th Infantry Brigade carry a wounded member of the company from the field during a firefight in Lhu Duc District. Photograph from October 14, 1967. Department of Defense. Defense Audiovisual Agency. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/531461). D: Medical personnel treat patients and perform rounds in the facilities of the NSA Station Hospital, Danang. From Naval Support in I Corps 1968. Courtesy of the Naval History and Heritage Command.

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    US Military Hospitals of the PACOM. A: The first US military hospital in Okinawa, Ryukyus Army Hospital on Camp Kue. Photograph courtesy of Department of Defense. Defense Health Agency. B: The hospital was eventually replaced in 2013 by the current hospital, which was relocated to Camp Foster. Photograph courtesy of Department of Defense. Defense Health Agency. C: Ambulances and buses of the 1453rd Medical Air Evacuation Squadron, a component of the Pacific Division of the Military Air Transport Service, transport combat casualties and military patients from Hickam Air Force Base to Tripler Army Hospital on Oahu, Hawaii, in March 1953. Department of Defense. Department of the Air Force. National Archives at College Park-Still Pictures (RDSS) (https://catalog.archives.gov/id/204977939).

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