THE ORIGINS OF M.A.S.H.
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| Richard Hornberger at his MASH unit (Wikipedia) |
Care of the wounded had concerned armies for years, especially since the introduction of firearms and canons, weapons that shatter flesh and bone. In earlier times, armies retrieved the wounded at the end of a battle, or, if in retreat, perhaps not at all. During the Napoleonic wars, the French military surgeon, Dominique Jean Larrey, sought to rescue wounded rapidly. He advocated early amputation to avoid infection, gangrene, and excess bleeding. He 
Artist rendition of Larrey's "flying ambulance"
(Wikipedia)
created a “flying ambulance” service, employing horse-drawn wagons to transport the wounded to nearby surgical stations close to combat. His prompt surgery improved survival rates and, knowing that rescue was available, troops felt protected.
The American Civil War saw an extension of this concept. In early battles, wounded Union soldiers received almost no medical attention. A new Surgeon General, William Hammond, appointed Joshua Letterman, a physician with several years of experience in the west, Medical
Letterman, seated, left, at camp (Wikipedia)
Director of the Army of the Potomac. Letterman established a system of ambulances, similar to that created by Larrey, to transport wounded to nearby hospitals. Importantly, he insisted that the ambulances be strictly under the medical services to avoid any requisitioning of horses and supplies by regular army officers.
When the U.S. entered World War One, the military organized “evacuation hospitals” 9-15 miles behind the fighting for major surgery and “field hospitals” closer to the lines for lighter injuries and immediate life-saving measures. Before long the Americans noticed a French innovation, consisting of two mobile units, the auto-chir and the groupe complémentaire. These were mobile surgical and hospital units transported by trucks that could be assembled (and disassembled) rapidly near fighting areas, forerunners of MASH. The Surgeon General of the Army approved the units for American use and Yale’s medical center staffed the first functioning one, Hospital #39, in late 1917. It included X-ray and sterilization equipment, generators, surgical instruments and personnel. Other units followed.
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| U S Mobile Hospital #39, Yale Unit, WWI (National Library of Medicine) |
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| U S Mobile Hospital #2, WWI (from The Medical Department of the United States Army in the World War, vol 8. Internet Archive) |
During the interwar years the country lost interest in military affairs and the army medical service dwindled. When America entered WWII the relatively immobile field hospitals, requiring lengthy evacuation of wounded soldiers, were reestablished. The surgeon general asked the surgeon, Col. Michael DeBakey, and other consultants to devise a better system. Their recommendations gave birth to “auxiliary surgical groups” (ASGs), mobile units that resembled WWI units but were more mechanized and rapid, saving more lives. The first ASG supported troops in North Africa, and several were deployed during the Normandy invasion.
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| Setting up field hospital, WWII (Medical Department, United States Army: Surgery in WWII, v. 1, Internet Archive) |
After WWII, the Army organized five similar units, now named Mobil Army Surgical Hospital (MASH), three in the U.S. and two in Germany. Though most were still on paper, the plans called for 60-bed hospitals with greater mobility, equipped with radiology, pharmacy, operating rooms, a post-op area, and adequate personnel.
In June 1950, the Korean War suddenly exploded. Both U. S. and U.N. troops from other nations suffered severe casualties. The semi-functional MASH units swung into action, the 8063rd arriving in Korea first. Overwhelming numbers of wounded forced the units to enlarge bed capacity from 60 to over 200 beds. Triage was instituted in battalion aide stations near the combat zone followed by a second triage at the MASH units. Inexperience at the aide stations cost lives at first, relieved by assigning more experienced medics who could place tourniquets and chest tubes. Another innovation accelerated evacuation even more: helicopters. The H-13 was the workhorse, on which the wounded were placed on skids outside the helicopter for “medevac” to MASH units or to hospitals further back, sometimes giving transfusions during flight.
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| M.A.S.H. unit, Korea. Note multiple operating tables. (from The Medics' War, public domain) |
As Hornberger put it in an interview, the work was “meatball surgery,” patchwork operations to save a life or limb, with further repair/rehabilitation to be done further away. Dr. Otto Apel left a memoir of his time with the 8067th MASH. Although he relates humorous moments, he found little joy (and much satisfaction) in working around the clock with mangled bodies and broken bones, followed by periods of idleness. His fellow surgeons generally entered as draftees from internships or residencies and learned battle surgery “on the job.” But they learned quickly and the MASH system saved many a life and limb.
Important innovations germinated in MASH units. Because of hemorrhage and unstable blood pressure, ether and chloroform for anesthesia gave way to nitrous oxide, thiopental, and opiates. Blood remained the main stabilizer of blood pressure. An extensive blood bank system developed to meet the high demand. Winter subzero temperatures made frostbite a serious problem, stimulating improved methods of care to save feet. Nonsurgical problems, such as dysentery, malaria, and hemorrhagic fever (from Hantaan virus, a new disease to U.S. medics) filled many beds and required new therapies and preventive measures.
Probably the greatest surgical advance in MASH units was the repair of torn blood vessels, seldom performed in the past. Talented surgeons close to the action, using instruments designed for less delicate procedures, sectioned veins to repair severed arteries and restore vital blood to arms and legs that in prior wars would have been lost from delay. A new specialty, vascular surgery, was born.
Rescue and treatment of the war wounded began over 200 years ago, eventually developing into the MASH units of the 1950s, and has continued to evolve in more recent conflicts.
H 13 Helicopter. Note runners on which patients were placed for flight (Wikipedia)
SOURCES:
Apel O F and Opel P, MASH: An Army Surgeon in Korea. 1998, University Press of Kentucky.
King B and Matoi I, “The Mobile Army Surgical Hospital: A Military and Surgical Legacy.” 2005; J Nat Medical Assoc 97 (5): 648-56.
DeBakey M, “Military Surgery in World War II: A Backward Glance and Forward Look.” 1947; New Eng J Med 236 (10): 341-50.
Robb J C, “Baron Larrey (1766-1842): Napoleon’s Chief Surgeon and His Times.” 1952; Ulster Med J21 (2): 101-13.
McGaugh S, Surgeon in Blue: Jonathan Letterman, the Civil War Doctor who Pioneered Battlefield Care. 2013; Arcade Publishing, NY
Hooker R, M*A*S*H* A Novel about Three Army Doctors. 1996; Harper Collins.
Planer R, “MASH: Advances in Treatment and Triage during the Korean War.” 2024; Chronos: The Undergraduate History Journal 5 (1): 69-88.
Woodard C, “Forward Surgery in the Koren War: The Mobile Army Surgical Hospitals.” Chapter 7 in: Steahly, L P and Cannon, D W, eds, The Evolution of Forward Surgery in the U.S. Army. 2018; Borden Institute, Fort Sam Houston.
Helling, T S, “First World War Catalyzes Forward Surgical Care.” 2023; Bull Amer Coll Surg 108 (11). Accessed at: https://www.facs.org/for-medical-professionals/news-publications/news-and-articles/bulletin/2023/november-december-2023-volume-108-issue-11/first-world-war-catalyzes-forward-surgical-care/
Lynch C, Ford J H, Weed F W, eds, The Medical Department of the United States Army in the World War. Vol 3, chap 5, pp 184-207.
Cowdrey, A E, The Medics’ War. 1987; Center of Military History, U S Army, Washington.
A full index of past essays is available at:https://museumofmedicalhistory.org/j-gordon-frierson%2C-md
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