Download PDF

At 0530, the gunfire support started, and over the next 3 hours 100,000 projectiles hammered inland. There would be 25 rounds for each 100-yard square under bombardment. At 0745, air attacks hit with bombs, napalm, and machine gun fire. At 0830, the initial waves of landing craft crunched ashore, and within an hour 16,000 men were fanning out.

It was L-day (landing day), April 1, 1945, and the United States had massed 1,300 ships to cover the initial landing of four divisions and seize Okinawa as another stepping stone toward Japan. Forces had converged from many bases, and supply convoys were already in motion to sustain momentum.¹ Operation Iceberg was underway.

The invasion of Okinawa was an example of joint forcible entry in an anti-access/area denial environment. Ground, maritime, and air forces played their roles, with supply lines stretching back to the United States and Australia. Support also went front to back, as medical care involved evacuation as well as support flowing forward. It was long before joint operations had anything like their current meaning, but the successes and challenges can still enlighten us about best practices in medical support and command.²

Planning

Planning for Operation Iceberg had started in the autumn of 1944. Fifth Fleet would handle maritime operations, but there was no land component headquarters of sufficient size to handle the ground forces that would be needed to secure a large island against fierce resistance. Thus, the Joint Chiefs of Staff ordered the activation of Tenth Army headquarters to provide dedicated planners for the land operation. Initially, Tenth Army planned Operation Causeway—the invasion of Taiwan—but when the target changed to Okinawa, its experience allowed for quick adjustment. The land fighting would include III Amphibious Corps (the 1st, 2nd, and 6th Marine divisions) and XXIV Corps (the 7th, 27th, 77th, and 96th Infantry divisions).

Tenth Army surgeon was Colonel Frederick Westervelt, U.S. Medical Corps, who had recently served on Admiral Chester Nimitz’s staff and thus had experience in both Army and Navy medicine.³ Westervelt and his small staff were based in Hawaii but had to coordinate with the two corps headquarters; XXIV Corps was in action in the Philippines, while the III Amphibious Corps was forward-deployed and had units engaged in the Mariana and Palau Islands campaign and also commanded ground operations at Iwo Jima. Fifth Fleet staff were based at Ulithi (an atoll in the Pacific Ocean), over 4,000 miles away from Hawaii, and were concurrently in operations or planning them. For Tenth Army to focus on the battle, an Island Command (ISCOM) was created to handle the buildup of logistical units on Okinawa for its role in the intended invasion of Japan. ISCOM was also headquartered in Hawaii, allowing close coordination. But with none of the other headquarters nearby and all engaged in operations, there was limited bandwidth for planning Iceberg.

That seems to have affected the planning. There were joint aspects, but there were also substantial elements that each Service handled for itself. Some responsibilities were handed to one Service to provide for both. This caused aspects of medical care to differ substantially. Starting at the plan, there was limited medical intelligence about Okinawa, which was something of a backwater within the Japanese Empire. Apparently, the existence of poisonous snakes was the only data point, and the planners could do little more than recommend checking vaccinations and being prepared for malaria and tropical diseases with insecticide and other countermeasures.⁴ (Both of these assumptions proved to be faulty but with no negative consequences—the lack of snakes and malaria was hardly a problem.)

At a lower level, the surgeon for 1st Marine Division looked at both Army and Navy experience in island fighting in making his plans.⁵ Intelligence on enemy forces was hard to pin down, and since enemy resistance would drive the friendly casualty estimates and thus the medical plans, it was hard to be sure whether the plans for hospitalization and evacuation were adequate. Unfortunately, the estimates of enemy strength kept rising as L-day grew closer. It turned out that the final prediction was roughly correct, and the rising numbers were largely Okinawan natives who were being conscripted into the Japanese forces. They contributed more numbers than combat power. An unknown was the substantial artillery strength of the Japanese 32nd Army, which affected casualty patterns.

Colonel Westervelt seems to have been limited in his ability to coordinate some medical aspects. Army and Marine divisions had their own organic medical support, and the Tenth Army did not try to dictate medical support within the two corps. Both the Army and Navy provided hospitals to support Operation Iceberg, and it is unclear how much control the Tenth Army had over those. Army doctrine of the period would have given Westervelt control over all hospitals, which he could then attach to corps but still retain control over.

In the joint situation, he assigned Navy hospitals to support the Marines and Army hospitals to support the Army. Perhaps he believed neither Service would be more flexible and “joint.” Other medical responsibilities were assigned to the Army or Navy. For instance, the Army was supposed to handle all medical supplies, including the subtask of supplying fresh whole blood and the time-sensitive cold supply chain that it entailed (since blood must be kept cold and has a shelf life).⁶ On the other hand, the Navy had responsibility to provide medical support to the civil affairs/military government personnel on the island. Evacuation off Okinawa was coordinated by Tenth Army’s 96th Medical Battalion but was executed by Army or Navy sea or air assets, with the 645th Medical Company handling all patients at airfields.⁷

There were also elements that were substantially different between the two corps. During World War II, the Army created portable surgical hospitals (PSHs), with 4 physicians and about 30 personnel total. These performed a role like today’s Forward Resuscitative Surgical Detachment (Army) or Forward Resuscitation Surgical Team (Navy), but at the time the Navy formally had nothing similar. However, both 1st and 6th Marine divisions had procured some leftover equipment (trailers and amphibious tractors), fitted these with operating room equipment, and improvised staff for forward surgery.⁸

The Army did not have enough PSHs even to support the divisions of XXIV Corps (some regiments had PSHs attached, and others had to make do with less mobile surgical support), so III Amphibious Corps units had none attached and thus entirely lacked forward surgical capability.⁹ Similar, the Army organized auxiliary surgical groups, with a variety of specialty surgical teams to augment hospitals. The few teams that were available were attached to the Army hospitals.¹⁰ Moreover, the Army found a few psychiatrists and attached one per Army hospital, and some Army divisions conducted short courses for their medical personnel (and in one case, for line unit commanders) on psychiatric reactions to combat. At least one Navy psychiatrist arrived during the battle.¹¹ The Navy, in contrast, found enough corpsmen to provide two per platoon in the Marine infantry battalions, and the 1st Marine Division trained some troops as litter bearers.¹²

Outside Tenth Army, both the Army and Navy undertook some similar medical preparations. The obvious base to sup- port Operation Iceberg was the Mariana Islands, and both Services expanded their hospitals there to a combined 16,000 beds. Also, both cleared patients from the existing hospitals in the Marianas back to hospitals in Hawaii and the continental United States so that maximum beds would be available on L-day.

The final medical plan anticipated 30,000 casualties, with 6,600 dead. (Disease cases were expected to be 41,000 in the first 60 days, but far more of them would return to duty as long as there were enough hospital beds for them to recover.¹³) In case the landing was opposed on the beaches, the landing forces would have their unit medical support, with casualties evacuated as soon as possible by landing craft back to a landing ship, tank (hospital) (LST[H]), an ordinary landing ship, tank that had been augmented with medical personnel (some Army, some Navy) and equipment to provide blood transfusion and emergency surgery capabilities. (The Navy provided four to each landing corps.) As the landing forces pushed inland, medical support would increase in capacity and capabilities. If all went well, by the end of L-day there would be slices of every medical function ashore. Medical companies would provide low-acuity care, surgical teams would be ashore along with medical supply elements, and a medical illustration detachment would document patient care.

Meanwhile, offshore the LST(H) not only could treat urgent patients but was also seaworthy enough to ferry all patients out to the hospital ships steaming farther away from Okinawa. Both the Army and Navy sent hospital ships to provide adequate capacity. Both also had hospital transports, which were ordinary transport ships with modest augmentations of medical personnel to transport lower-acuity patients. Scarcer hospital ships could then provide more complex care to higher-acuity patients. This was part of a shift from using hospital ships mainly as highly capable medical evacuation platforms to using them as mobile medical treatment platforms. A shortage of Navy surgeons meant another joint requirement: some Army surgical teams were provided to expand capability and capacity on Navy hospital ships.¹⁴

Air evacuation was also used, but it was for less acute patients (hospital ships and even hospital transports had far more capabilities than cargo aircraft with one nurse and one medical technician on board) and of course required having a working airfield. The planners were cautious and did not expect to have an airfield operational before L+11. Correlating that with casualty estimates, some 7,000 casualties might be wholly reliant on waterborne evacuation. Thus, the hospital transports were required, and patients who could usually return to duty in only a few days would likely be evacuated much farther, and their return to units would be substantially delayed. Hospital ships would be needed to both treat and evacuate patients, but hospitals would be landed early and were expected to be operational after about a week. Westervelt had wanted 8,000 hospital beds (total of Army and Navy) to get patients stable for evacuation (not only stabilized, as modern high-acuity en route care can handle, but also fully stable) and to heal many so they could return to duty.15 Replacement troops were scarce in the Pacific theater, and having combat-ex- perienced troops returning to duty close to the fight would sustain combat power. However, only 4,500 beds were available, including some new special augmented hospitals from the Navy.¹⁶ The final plan had Navy hospitals supporting III Amphibious Corps while Army hospitals were behind XXIV Corps. This approach also aligned with the operational plan: the Marines landed on the left and were to turn north, while the Army landed on the right and turned south. Each force would have its own support rather than intermingled or joint support.

Operations

The landing was unopposed. Scuttlebutt had been that landing units might take 80 percent casualties (projections were for only 300, rising to 600 per day), but there was so little opposition on L-day that troops were spooked and scouted cautiously.¹⁷ Gaining confidence the next few days, troops quickly moved across the island to the east coast. Then the Marines headed north and the Army moved south. While there was resistance in the north, the main Japanese forces were in the south, and Tenth Army reorganized. After clearing the north, the Marines took the western flank and the Army the eastern. Again, Service hospitals supported their own troops. It took until June 22, 92 days of action, to secure the island.

Total battle casualties were close to predictions, but there were problems. The Japanese had substantially more artillery on Okinawa than U.S. forces had faced in the Pacific. This gave the Japanese the ability to at least harass U.S. forces at greater depth. The duration of the campaign, likely exacerbated by the Japanese artillery, also led to substantial numbers of psychological casualties, which were not documented if they responded to treatment at an aid station and did not go to a hospital.¹⁸ The reasonably accurate prediction camouflaged problems, however: instead of a smooth slope of casualties, there were days of fierce fighting (battalions might take more than 350 casualties in a day) that briefly overwhelmed the medical system, at least locally. Taking a single hill might cost almost 4,000 casualties.¹⁹

The fleet also took unexpected casualties resulting in Okinawa becoming the Navy’s bloodiest battle of World War II.²⁰ The Imperial Japanese Navy had no ability to drive the Fifth Fleet away from Okinawa, but the prolonged ground campaign meant the fleet had to stay around Okinawa for months. That exposed the ships—and their Sailors—to relentless air attack, both conventional and kamikaze. Thousands of air sorties caused heavy losses in the Fifth Fleet, with about 250 ships and more smaller craft hit. Most of the ships hit were small, and even a few casualties could overwhelm the limited medical support aboard. Without helicopters to move casualties to care, the damaged ship had to come alongside another ship, and thus there could be several hours’ delay before patients could get more than rudimentary care. The length of the campaign and repeated attacks also caused psychological casualties afloat, something for which the Navy had not prepared.

Medical support on land was generally good. Elements of every medical function were ashore on L-day, and the lack of early opposition meant that hospitals could easily be landed and be ready by L+5, before there was much fighting. (The period without much fighting also allowed air spraying against insects, which reduced disease incidence.²¹) Air evacuation was also available sooner than anticipated, with both Army Air Forces and Navy aircraft ferrying casualties back to the Marianas by L+6. It is not clear whether the Services would not cooper- ate, or whether, since both would be flying cargo forward, it made sense for both to evacuate as well.

Hospital ships were effective, although the USS Comfort was hit by a kamikaze that plunged into an operating room be- fore exploding, killing patients and Army surgical personnel who were augmenting their Navy colleagues. The hospital transport USS Pinkney was hit the same day, after it had unloaded the combat troops that it brought forward. Total casualties on the two ships were 65 dead and 60 wounded. After that, hospital ships turned off their lights at night, relying on concealment rather than the protections of the Geneva Convention. Ultimately, about half the patients were evacuated by air and half by water. Just as the Army and Navy worked together to evacuate patients from Okinawa, movement around the island was sometimes joint: heavy rains made ground evacuation dangerously slow for several days, and LST(H) and other amphibious craft were used to move patients to hospitals and clear those hospitals to others in the rear.²²

Meanwhile, ground forces pushed aggressively, and there was not enough hospital support available on Okinawa when heavy fighting started. The wounded took priority over psychiatric casualties for hospital beds, which meant combat fatigue patients were evacuated off the island.²³ That was known to cause worse outcomes to the patients (“fixing” their symptoms before therapy could ameliorate them) and meant that troops who would have been likely to return to combat if they received prompt care could not do so. Thus, lack of hospital capacity cost combat power. Some lightly wounded were also evacuated without any hospitalization. Had more convalescent facilities been available, those 5,175 patients might have been returned to combat.²⁴ Later, more hospitals and other medical units were repurposed to care for psychiatric casualties, which provided adequate capacity if little more capability. Even with few psychiatrists available, forward treatment proved extremely effective, with approximately 73 percent of patients returning to frontline duty, and a further 7 percent returning to rear-area duty.²⁵

There was some joint support, with Army ambulance units attached to III Amphibious Corps and some Marine patients treated at Army hospitals. Two Army hospitals were temporarily subordinated to III Amphibious Corps.²⁶ Some improvements to care were implemented. Fresh whole blood was widely available— first, flown to the Marianas and then shipped forward, and later, flown straight to Okinawa. With iceboxes available, blood was pushed forward to regimental and even battalion level, an echelon or two closer to the front than previously.²⁷ Quantities were also greater than earlier in World War II, forecasting 1 pint per casualty as opposed to 1 pint for every 3 casualties in 1943, and about 41,000 units of blood were used, slightly more than 1 unit per surgical patient.²⁸ (A unit of blood is roughly equivalent to a pint.)

Oxygen apparata were apparently provided to regiments and on ambulances, but no reports of use have been found, and training may not have been synchronized with issue.29 The Army’s auxiliary surgical teams were effective in augmenting hospitals designed for low-acuity care, so they could handle battle casualties. The Army reported a rate for “died of wounds”—patients who arrived alive at a hospital and subsequently expired—of 3.4 percent, which was below the World War II average of 4.5 percent. (Surgeons still thought more could be done if more hospitals with more surgical capacity were available, and they were probably right; perhaps more surgical teams should have been improvised from units in the rear.³⁰) The hospitals also proved their value not just in treating patients to get them stable for evacuation but also in returning troops to duty, and both the Army and Navy improvised convalescent centers.³¹ The Army suffered 34,500 casualties on Okinawa, of whom about 15,000 returned to duty before the battle was over. More Soldiers were returned to duty than were evacuated from Okinawa. Considering this was counting only inpatients, the medical system was truly supporting the fight.

There was a potential problem with command of the medical effort. The Tenth Army was supposed to secure Okinawa, while ISCOM would establish and run the logistical base that would support the invasion of Japan. ISCOM units would be coming ashore while the fighting was continuing (although none of ISCOM’s 10,800 hospital beds would be functional during the fighting), creating potential tension between the headquarters. The Tenth Army surgeon’s office was understaffed to handle operations, while the ISCOM surgeon, Brigadier General Earl Maxwell, and his staff came ashore on L+10. Colonel Westervelt recognized he was not going to pull personnel from Maxwell and sensibly merged his staff into Maxwell’s.³² Maxwell oversaw medical support for the fighting and building the ISCOM medical infrastructure. These two functions might well be dual-hatted today, but in 1945 they had to adjust on the fly.

Implications

Planning was difficult in a low-band- width environment. Current operations rely on rapid and reliable communica- tions to compensate for distances and to coordinate among Services and forces. One mitigation for operating in a denied, disrupted, intermittent, and limited bandwidth environment could be the sort of deconfliction and setting up parallel operations that the Tenth Army did rather than operating fully joint operations. It took 6 months to plan the invasion of Okinawa, with many of the (highly experienced) headquarters involved in the planning also executing other operations. Keeping a plan simple could speed the operational tempo.

Medical support in Operation Iceberg was good despite not meeting modern concepts of jointness. Despite effective medical support, it was a bloody battle: 43 percent of the combat strength were casualties, with roughly equal numbers of battle and nonbattle casualties.³³ Medical support in future operations with even 10 percent of the casualties suffered at Okinawa would challenge medical sup- port at every step—forward surgery and hospitalization, evacuation to the United States, and care in military hospitals in Marble 79 the United States.³⁴ Better command and coordination to use theater assets can mitigate some of the problems, and theater medical commands should help in the future. Current doctrine is certainly more joint than that of 1945, and our capabilities are far greater, but our capacity is far less. Let us hope deterrence works and the enemy does not get a vote. JFQ

¹ On the battle, see Roy E. Appleman et al., Okinawa: The Last Battle (Washington, DC: U.S. Army Center of Military History, 1948), https://web.archive.org/web/20241212210948/https://www.history.army.mil/html/books/005/5-11-1/index.html.

² Joseph Caravalho, Jr., and Enrique Ortiz, Jr., “The Future Joint Medical Force Through the Lens of Operational Art: A Case for Clinical Interchangeability,” Joint Force Quarterly 101 2nd Quarter 2021), 55–8, https://ndupress.ndu.edu/Portals/68/Documents/jfq/jfq-101/jfq-101_55-58_Caravalho-Ortiz.pdf.

³ Main sources on medical support are Mary Ellen Condon-Rall and Albert Cowdrey, Medical Service in the War Against Japan (Washington, DC: U.S. Army Center of Military History, 1998), chap. 12, https://web.archive.org/web/20241207064919/https://www.history.army.mil/html/books/010/10-24/CMH_Pub_10-24-1.pdf; “Medical Service in the Asiatic-Pacific,” chap. XIV, unpublished draft, U.S. Army Medical Service Historical Unit, ca. 1965, U.S. Army Heritage and Education Center; U.S. Navy Bureau of Medicine and Surgery, The History of the Medical Department of the U.S. Navy in World War II—A Narrative and Pictorial Volume, vol. I (Washington, DC: U.S. Government Printing Office, 1953), https://archive.org/details/HistoryOfTheMedicalDeptInWWIIV1/mode/2up.

⁴ United States Navy Medical Department at War, 1941–1945, vol. 2, Organization and Administration (draft) (Washington, DC: Bureau of Medicine and Surgery, Navy Department, 1946), 29–30, https://digirepo.nlm.nih.gov/ext/dw/14321920RX4/PDF/14321920RX4.pdf.

⁵ United States Navy Medical Department at War, 1941–1945, 3.

⁶ Office of the Surgeon, Headquarters U.S. Army Forces Middle Pacific (HUSAFMIDPAC), Administrative History of Medical Activities in the Middle Pacific (Washington, DC: U.S. Army Heritage and Education Center, 1946), 110. This Army subtask did not work well, although medical supplies were interchanged among the Army, Marine Corps, and Navy.

⁷ Office of the Surgeon, HUSAFMIDPAC, Administrative History of Medical Activities in the Middle Pacific, 16; Condon-Rall and Cowdrey, Medical Service in the War Against Japan, 408.

⁸ U.S. Navy Bureau of Medicine and Surgery, The History of the Medical Department of the U.S. Navy in World War II, 106, 110.

⁹ Office of the Surgeon, HUSAFMIDPAC, Administrative History of Medical Activities in the Middle Pacific, 14.

¹⁰ See John W. Devine, Jr., and Hollon W. Farr, “The Neurosurgical Management of Wounded in the Okinawa Campaign,” Military Surgeon 103, no. 3 (September 1948): 202–7.

¹¹ On psychiatric aspects, see Oscar B. Markey, “Tenth U.S. Army,” chap. XVIII in Neuropsychiatry in World War II, vol. II, Overseas Theaters, ed. William Mullins and Albert Glass (Washington, DC: Office of the Surgeon General, 1973), 639–80, https://apps.dtic.mil/sti/pdfs/ADA295201.pdf; United States Navy Medical Department at War, 1941–1945, 26.

¹² U.S. Navy Bureau of Medicine and Surgery, History of the Medical Department of the U.S. Navy in World War II, 106–7. The First Marine Division alone would have 478 casualties among Hospital Corps personnel, with 49 killed, 226 wounded, 17 injured, and 186 sick.

¹³ Office of the Surgeon General, “Medical Aspects of the Ryukyus Campaign: Noneffective Rates,” in Health (Washington, DC: Headquarters, Army Service Forces, War Department, September 30, 1945), 2–10, 18, https://collections.nlm.nih.gov/pdf/nlm:nlmuid-22310600RX32-leaf.

¹⁴ David A. Lane, “Hospital Ship Doctrine in the U.S. Navy: The Halsey Effect on Scoop-and-Sail Tactics,” Military Medicine 162, no. 6 (June 1997): 388–95.

¹⁵ Office of the Surgeon, HUSAFMIDPAC, Administrative History of Medical Activities in the Middle Pacific, 24.

¹⁶ U.S. Navy Bureau of Medicine and Surgery, The History of the Medical Department of the U.S. Navy in World War II, 37.

¹⁷ Office of the Surgeon, HUSAFMIDPAC, Administrative History of Medical Activities in the Middle Pacific, 35–36.

¹⁸ Office of the Surgeon General, “Medical Aspects of the Ryukyus Campaign,” 6.

¹⁹ Condon-Rall and Cowdrey, Medical Service in the War Against Japan, 394–95.

²⁰ U.S. Navy Bureau of Medicine and Surgery, The History of the Medical Department of the U.S. Navy in World War II, 107–9.

²¹ Tenth Army Surgeon, Essential Medical Technical Data for the Okinawa Campaign, August 29 1945, on file at the Army Medical Department Center of History and Heritage, San Antonio, TX; National Archives, Record Group 319, entry A1-145, box 4.

²² Tenth Army Action Report: Report of Operations in the Ryukyus Campaign (Washington, DC: Tenth Army, September 80 Recall / Medical Support at Okinawa 3, 1945), chap. 11, “Staff Section Reports,” 11-XV-13, https://cgsc.contentdm.oclc.org/digital/collection/p4013coll8/id/600/rec/1.

²³ Office of the Surgeon, HUSAFMIDPAC, Administrative History of Medical Activities in the Middle Pacific, 93.

²⁴ Office of the Surgeon, HUSAFMIDPAC, Administrative History of Medical Activities in the Middle Pacific, 126.

²⁵ Historical Sub-Section G-2 HUSAFMIDPAC, History of United States Army Forces Middle Pacific and Predecessor Commands During World War II, vol. XII., ca. 1946, 2708.

²⁶ United States Navy Medical Department at War, 1941–1945, 14; Tenth Army Action Report, II-XV-12.

²⁷ United States Navy Medical Department at War, 1941–1945, 27.

²⁸ Historical Sub-Section G-2 HUSAFMIDPAC, History of United States Army Forces Middle Pacific and Predecessor Commands During World War II, vol. XII, ca. 1946, 2704; Edward D. Churchill, Surgeon to Soldiers: Diary and Records of the Surgical Consultant, Allied Force Headquarters, World War II (Philadelphia: Lippincott, 1972); Office of the Surgeon General, “Medical Aspects of the Ryukyus Campaign,” 10.

²⁹ Historical Sub-Section G-2 HUSAFMIDPAC, History of United States Army Forces Middle Pacific and Predecessor Commands During World War II, vol. XII, ca. 1946, 2709.

³⁰ John Flick, Forrester Raine, and Robert Robertson, “Pacific Ocean Areas,” in Surgery in World War II, vol. II, Activities of Surgical Consultants, ed. B. Noland Carter (Washington, DC: U.S. Government Printing Office, 1964), 645–50, 675–82, https://apps.dtic.mil/sti/tr/pdf/ADA286769.pdf.

³¹ Office of the Surgeon, HUSAFMIDPAC, Administrative History of Medical Activities in the Middle Pacific, 78; Appleman et al., Okinawa, 414; U.S. Navy Bureau of Medicine and Surgery, History of the Medical Department of the U.S. Navy in World War II, 110.

³² Office of the Surgeon, HUSAFMIDPAC, Administrative History of Medical Activities in the Middle Pacific, 71–72.

³³ This source apparently includes combat exhaustion and other psychiatric casualties with noncombat losses.

³⁴ Matthew Fandre, “Medical Changes Needed for Large-Scale Combat Operations: Observations From Mission Command Training Program Warfighter Exercises,” Military Review, May-June 2020, 36–45, https://www.armyupress.army.mil/Portals/7/military-review/Archives/English/MJ-20/Fandre-Medical-Changes.pdf; F. Cameron Jackson,“Don’t Get Wounded: Military Health System Consolidation and the Risk to Readiness,” Military Review, September-October 2019, 141–51, https://www.armyupress.army.mil/Portals/7/military-review/Archives/English/SO-19/Jackson-Military-Health.pdf.