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SGRD-RMS 

Mrs. Patricia A. Madigan -~ 

SGRD·RMS/USAMRDC "-. 

Fort Detrick, Frederick, MD 2170f 

o.,OA 95-01242 

'JMIIIIIIIII 

~CQU~IN~E~D6 

----------------····--·-·--······· .... ··- .. 
MEDICAL DEPARTMENT 

UNITED STATES ARMY 

IN WORLD WAR II 

-

\ 

Accesion For \. 

NTIS CRA&I tA 

OTIC TAB 0 

Unannounced (] 

Just.t&catton ··-----------------

By ·-·--··------··------·-------.1 

Distribution I 

A-' 

Avaifabilit¥ Cod~s 

Avail and I or 

Special 
Br·i!!. (;I'll. llut:h ,J. \lor·t:an .. \{':0: (H•·t.), ('ld•·f ('on-ult:lrlt irt \IPdil'inP 

to Tilt' :O:urw·or1 ( ~t·lt!'l':tl. 
~IEDICAL DEPART~IE~T, UNITED STATES AR~'IY 

IJVTERNAL MEDICINE IN WORLD WAR II 

Vohnne I 

ACTIVITIES OF MEDICAL CONSULTANTS 

Prepared and published under the direction of 

Lit•utt·nant General l.Eo~ARD D. IIEATO~ 

The Surgeon General, United States Army 

Editor in Chief 

Colonel Jou~ BoYD CoATEs, Jr., \IC 

Editor for lnternal1\ledicine 

W. PAUL 11 .. \XE~s, Jr., M.D. 

OFFICE OF THE SL-RGE01V GESERAL 

DEPART1\IE1VT OF THE ARJil' 

rVASHINGTON, D.C., 1961 
INTERXAL ~lEDICINE IN 'YORLD 'VAR II 

.-tdm:.~ory Editorial Board 

(;ARHELD G. Dn;cAX', :\LD., Chairman 

W. PAt'L II.HEX~ . .Tr .. :\LD., Editorial Direrlor 

W.u.TER RAt:ER, :\LD. HowARD P. LEWIS, :\f.D. 

HERRMAN L. BLl::>.tGART, :\LD. E~:-.toxo R. Loxa, :\T.D. 

WoRTH B. DAxiELS, :\LD. PF.RRrx II. Low;, :\J.D. 

En;ExE C. EPPIXGER, :\LD. WILLI.UI H. :\hoDLETo:-., :\J.D . 

. Jo~~:PH :\!. IIAniAX', :\J.D. DoxALD 11. PILL~Bl'RY, :\LD. 

YAL•; K:o;E•:r.Axo, .Tr., :\LD. :\!At'RicE C. PI:-.con~, :\LD. (dPe.) 

II EXRY :\[. Tnml.\._, .Tr., :\f. D. 

Colonel DAN CRoZIER, :\[C (ex officio) 

Colmwl .Jou:'\i BoYD CoATES, .Jr., :\[C (ex officio) 

The Historiral Cnit, Cnited States Army .llerlical Ser1ice 

Colonel .Jon:-. BoYD CoATES, .Jr., MC, Duedor 

Colonel OrnMAR F. GoRIUP, :\ISC, Executive Officer 

Colonel R. L. PARKER, l\IHC, Special Assistant to Director 

Lieutenant Colonel R . .J. BER:->rccJ, l\IC, Sper·ial Assistant to Direr·tor 

LiPutt•nant Colonel 1\IATTHEW GI!'\ALicK, :\I~C. Chief, Special Projects Branch 

CHARLES M. WILTsE, Ph. D., Litt. D., Chief, Historians Branch 

ER:o;EsT ELLIOTT, .Jr., Chief, Editorial Branch 

LicutPnant Colonel LEo:o;ARD L. CoLLIER, :\ISC, Chief, Promotion Branch 

Major ALB•:RT C. Ruw~ .. Jr., MSC, Chief, Genrrnl Reference and Rf'srnr,.h Rranch 

II An:t. (;. IIrsE, l'hie.f, Administrative Branch 
Volume I 

ACTIVITIES OF MEDICAL CONSULTANTS 
MEDICAL DEPAR'T',IENT, l'NITED STATES AR~IY 

Th£' volumps comprising th£' ofli<"inl history of tht> :\[t•di<"al Dt>partmt•nt 

of til{' C.S. Army in World War II an• prt>part>d h.'· Tlw Historical l'nit, C.S. 

Anny :\INlicnl St·t·vie£', and puhlislwd umlPr thP dirP<"tion of Tlw Surgpon 

Gt>twrnl, U.S. Arm~·. Tlwst• volunws an• dividt•d into two st>riPs: (I) Tht> 

ndministrntiv£' or opt>mtionnl st>rit•s; nnd (2) thP proft>ssional, or dinicnl and 

t l'eh nical, S<•ri£'s. This is mw of t ht> vohutH'S pu hlislu•d in tlw la ttt>r series. 

VOLUMES PUBLISHED 

AD\11:\"ISTH \TIYE SERIES 

lio8pital i :at iu11 and /<..'racuat ion. Zunr r~f Intr-rior 

CLL'aCAL SERIES 

Pr£'nntiw :\ft>di<"ill<' in 'Yorld Wnr II: 

l~o/. II. Enrironmnlfal llyaienr 

l·o/. III. Per.wmal 1/ealth JlelPIIJre.o;; and Immunization 

ll'ol. IF. f'ommunicable Disease.<; Transmitted f'hie.fly Throu!lh Ue8piratonJ and Alimentary Tracts 

l"ol. V. Communicable Di:;;eases Tram~mitted Through rontact Or By 

f"nknown Jfeans 

Surg£'ry in World War II: 

General Surgery, tol. II 

/land Surgery 

Xeurosurgery, ml. I 

Neurosurgery, rol. I I 

Ophthalmology and Otolaryn(!ology 

Orthopedic Surgery in the European Theater l~f Operation.<; 

Orthopedic Surgery in the .\/editerranNl·n Thcata of Operation.<.: 

The Phy.'liologic Effect . ..; of lrollll(/8 

Fa ... rular Surgery 

1\liscPlhuwous: 

Cold Injury, Ground Type 

f'n ited States Army Dental Sen-ice in lrorld War I I 

VI 
Contributors 

T1n:ouoa~: L. BAIHa:R, :\I.D. 

,\:..;,.:i:-;tant Clinical l'roft-ssor of :\ledicinc, Harntrd :\ledical School, Roston, :\lass. 

FormPrly Colonel, .:\[ C, A t·s. 

lh;:-1.1.\:\IIX :\I. BAKER, :\I.D . 

. \:-::-:ociatt- Profpssor of :\lerlicine, .John:-: Hopkins rnin•rsity, and Ph~·sician, .John,.: Hopkin:-: Hospital, BaltirnorP, :\[d. ForrnPrly Colonel, :\IC, Al'S. 

lh:RR:\1.\X L. BLt'WURT, :\1. D. 

Profp,.;:-:or of :\lprlicinP, Harv:trd :\lPdical School, and Physician in Chicf, Beth lt't·:wl 

llo.-pital, Boston, :\Ia>'>'. Fornwrly Colond, :\IC, ACS. 

(;.\RFIEI.I> (;, l>t::-.II'AX, :\I.l>. 

Profp:..;sor of :\h•dirirw, rnin•rsity of l'PIIIll;yh·:mia, and Director of the :\Icdiral I>h·i:;ion,_; 

of tlw l\•n11s~·lvania Hospital and the Benjamin Franklin Clinic, Phila<IPlphia, Pa. 

Fornwri~· Colom·l, :\IC, At'S. 

Y.\I.E 1\::•o;.:r..\:->I>, .Jr., .:\[,D . 

. b:-:oeiatP Profp,.;sor of :\ledicirw, Columbia rniversity; Attcnding Physician, l'rt•sh~·­

tPrian Hospital; and Clinical DirPf'tor, Columbia HP.;Parch St-n·ice, Goldwater :\[cmorial 

llo:-:pital, :"Pw York, X.Y. Formerly Colonl'i, :\IC, An~;, 

PERRI:-; II. Lo:o;r;, :\I. D. 

Chairman and l'rofp,.;sor, Dcpartnwnt of :\ledicint-, State Cniversity of New York, 

I>ownstatp :\IPdical C'PntPr, Xew York, X.Y. BrigadiPr (;pnPral, CSAR. 

v~:R:'o;E R. :\[Asox, :\I.I>. 

Chairman, :\IPdical Addsory CommittN', Howard Hughes :\ledical Institute, and 

Enwritus Clinical Professor of :\Iedirirw, {'niversity of Southern Califoruia, Los AnJ!;des, 

Calif. Forml•rly Colond, :\J C, A l'S. 

WILLIA:II s. :\hDDLETO:'IO, .:'II.D. 

Chid :\lcdiral Director, Veterans' Administration, Washington, D.C. (on lea,·e of 

ahsencl' from Cniversity of Wisconsin :\ledical School, l\Iadison, Wis.). Formerly 

Colond, :\IC, ArS. 

Hnm .J ~IoaoAN, :\I.D. 

ProfPssor and fh•ad of the Department of :\fedirine, Vanderbilt Fniversit.r School of 

~IPdicinl', and Physician in Chid, Vanderbilt Cniversity Hospit:tl, :\'ashville, Tl•nn. 

Formerly Brigadier f:eneral, A l'S. 

GEoRnE ~1. PIKE, :\1.1>. 

Instructor in ~INlirilw, Han·ard :\Iedical School, and Asl"istant Visiting Physician, 

BPt h Isr:wl Hospital, Boston, :\lass. Formerly :\Iajor, :\IC, A CS. 

Do:\'AJ.I> ;\I. PILJ.SB!'RY, :\LD. 

Chairman, I>Ppartment of Dermatology, l'niversity of Pennsylvania Hospital, Phil-

:l<l<'lphia, Pa. Formerly Colonel, l\tC, Al.'S. 

HE:\'RY :\L THoMAs, Jr., :\J.D. 

Associate Prof!'ssor of Medicine, Johns Hopkins :\fedical School, and Visiting Physician, 

.Johns Hopkins Hospital, Baltimore, :\ld. Formerly Colonel, l\IC, Al'S. 

LJ.oYI> .J. Tno:~~Pso:-.r, :\1.1>. 

Director, Child (;uidancP Clinic of Forsyth County, Inc., Winston-Salem, X .C. Formerly Colonel, :\IC, ACS. 

VII 
This ,·olunw. thP Sl'\'<'lllt'l'llth to ht• puhlislwd in tlw total ::wriPs <'Oil<'l'I'JH•d 

with tht> histm·~· of tht• t·.s ... :\1-my ~dt•dical Dt•pnrtmPnt in World War II. dP:ds 

with intpr·nnlrnl'dicirw nnd is thP first of a sPrit•s of tlu·t't' \'Olunwson thissuhjl'<'t. 

Its nirw chnptl'r·s \H'I't' writtPn hy thirtt•pn authors, nil of whom sJwnk with tht> 

nut hority of pt'IH'l'tirnl' tmining- and l'XJWriPIH'<' supph•nwntNl hy tiH•ir wurtinH' 

st•niel' as consultnnts in intt•nwl nH•dicirw. 

Bt•t·nust> this is t ht• first vohllrH' of t ht• history to I'Pla tt• t lw st or,\· of the 

eonsultnnt syslt•nr in \\'orld \\·nr II, SOJllt' <'omnwnts should ht> mndt• which, 

whih• sfwcifieaily applicnhlt• to intPI'nulnwdiein<', nr<' also npplienhlt• to nil otht>r 

SfH'Cinlt iPS. 

Wht>n t h<' first consult nn t I'<' port t>d for duty in the Office of the Surg<'oll 

fi<'IIPI'Ill, in l<'t•hi·unr·y Hl42. lw found no offirinl stnt<•nwnt of n consultant's 

functions. A Pmfpssionnl St•r·,·iet>s Di,·ision hnd t>xist<•d in this Offict• sinct> 

I !l2i). hut its S<'OfW wns limitt>d nnd its functions \Vt'l'l' ehit>tly ndministmtiv<'. 

Tht• org-nni;mtion and pott•ntinlitiPs of the eonsultnnt syst<•m hnd to lw <'Stnhlisht>d in Wodd Wnr II. nnd h~· trinl nnd <'ITor·. 

For n numlwr of n•nsons. t lw <'XtPnsion oft lw systt•m wns slow nnd ditlieult. 

Tlw \\·nl' Dt•pnr·trnt>nt. St•rTiet>s of Supply (lni<'I' liPadfJuni'tt'I'S, .AI·my St•n·iet' 

Foret•s), whieh had g't'tll'l'l\l eog-nizanel' of thPsP mnttt•r-s in tlw Zonp of lntN·ior, 

wns poody infol'llwd on, m· krww nothing nt all ahout, nwdicnl rweds. Tlwn• 

\HI'<' t hPr·t'foi'l' long- <h•lays i11 Sl't t ing- up n<'l'<'ssm·y posit ions. E\·en wlwn 

mnlnrin wns inenpncitnting thousnnds upon thousands of troops. it wns t•ig-ht 

months nft<•r t hP n•q ut•st. wns llliHl<' ht>fon• n eonsultnn t in t ropicnl nwdieirw 

wns n ppoin tPd in t lw Offici' of t lw Surgt•on Ot>nt•I·nl. Tlw mnnng<'lllt'n t of 

n•nt•rt>nl dist>nsp wns plnet•d undt•r prevt>ntin• nwdicirw offiet•rs. lllllll_\" without 

clinicnl PXJWI'iPIH'<' in this fi<•ld. whilt• the intPrnists. who nt>et•ssnrily ti't•ntt•d it. 

nctt>d ns tlwir· ng-<•Hts. Similndy, lnhomtorit•s. althoug-h tht>ir funetio11s W<'l'l' 

almost pxclusin•ly clinicnl, W<'I'<' plnct•d u11dt>r· pi'<•n•ntin• nH'dieirw control. 

This mndt• for pnrticulnr diflicultit•s in tlw Pacific Oct•nn IH'<•ns, wh<'I'P lnhomtory 

tPsts \H'l't' fn•qu<•ntl,\· PSS<'ntinl for dingnosis. Ineidt•ntnlly, in t'Vl'ry th<•nt<•r·, 

until tlw mPdical eonsultnnts stPpped in, tlwrc wns g<'IH'l'lllly nn excess of 

n•qtwsts for lnhomtot·y work. 

SirH't' eonsultnnts had not h<'t'n <'nvisllg<'d in pn•w11r nwdie11l plnnning-, 

both t.h<',\' nnd tht• colllllliiiHl surg<•ons und<'I' whom th(•y workt•d wert• plngtw<l. 

until tlw £'lid of tlw w11r, hy till' l11ek of position YIH'Hncit•s fm· them, ns \n'lllls 

hy <•mhnrrnssing qtwstions of rnnk. ~IOI'l'O\.l'I', thl' consultnnts, no mnttl'l' 

in whnt <'OIIllllllnd tlwy Wl'l'<' stntiorwd, str(•sst•d tlw incon\'t•nit•net' nnd indlieienc.\· <'llliSl'd hy l~tck of t'ff<•cti ve chltlltwls of eomnmnica t ion hl'hn>en themselns nnd th<• cowmltnnts in the Offict• of the Surgt•on Gl'IH'I'HL \rtwn such 

<'nil tIll' Is (•xist <'<l. t h<•y W<'I't' tmoffieinl. 

IX 
X Fom;wonn 

'Ylwn tlw first consultnnts wrrr nppointrd, thrrP \Yns a tneit. undPI'standing 

that. t hPy \H'r<' to eonfinr t hrir activit iPs to elinienl prohlPms. BPfon• t lw wnr 

PndP<l. thrsp activiti<'s had been BN'<'ssarily extPJHIPd to a variPty of othPr 

matt<•rs, ineluding pt•rsoJmel, supply, and hospitalization and pvacuation 

policiPs. 

P<•rsonnPl rPsponsi hili tiPs, next to dinieal n•sponsi hili tiPs, IH'eame th<• 

major cone<•rn of thP consultants, as might han• hPPn <'Xp<•et<•d. In wartinH•, 

just as in pPaCPtinw. the availability and prop<•r <'mplo.nm•nt of qunlifi<•d profpssional JWrsomwl dPt<'l'lllin('(l t hP quality of m('(lieal enr<'. Originnlly, t hP 

distribution of thr limitt>d llllllllH'r of such p<'I'sonnPl was UIWVPn nnd inPffiei<•nt. CorrPetion of thP mnldistribution wns 11ot t•as~·. o1w rpason ht>ing thP 

lnek of uny stnndnrds of elnssification. Tht> :\lilitar~· Occupational Sprcialty 

ruting, which would han• solved many qurstions of both nssignnwnt nnd promot ion, did not hPcome a vaila hh• until la tr in tlw war. X <'V<•rt hPl<•ss, in 

spitr of th<• handicaps undrr whieh tlwy first opPrutPd, thr consultnnts soon 

hPeiUIH' t hr lH'st infomwd officPrs in 1m~· command on t IH• profpssional p<•rsomwl 

in it, and ofli<'<'I'S in chnrg<' of p<•rsomw1 ussignnwnts soon l<'nrnrd not only to 

rrly upon tlwir advicr but to ask for it.. 

Tlu• magnitudP of tlw tusks of tlw eonsultants drprndPd upon a number 

of eonsidrrations, ineluding thr size of thr command, tlw number and type of 

installations in it, thr total troop strength, and, most of all, thr degr<'e of thPir 

ac<'<'ptan<'£' by th<' eommnnd surg£'ons und£'r whom they st•rvPd. This hook 

r£'lat£'s frnnkly and r£'alistica1ly the trouhl£'s which aros£' hr<·ause of th<• eonsultants' la<'k of £'Xperience in military matters and th<' initinl failurP of Regular 

.Army medieal offieers to appr<'eiat£' what they had to off<•r in the way of spPcializNl m£'dieal sprvic£'s. From thPir p£'acrtime experit>nee, most of thes<' 

consultants had a. correct concept of the funetions of a eonsultant, and, l><'-

C"ause they wer£' imaginative and resourceful, they W<'re soon a.hle to translat<• 

t h£'ir peac£'t ime concepts to military nec£'ssit ies. In most insta.nc£'s, t lw~· 

r£'adily adapt('(! tlwms£'1ves, as th£'y sonwtimes had to at first, to working in 

hPadquart£'rs tha.t W£'r<' a.t hrst indiffPl'Pnt and at WOI'St hostile, without losing 

thPir indt>p<•rHlencP and individuality. It is a. tribute to th£'ir tact as w£'ll as 

thPir comp£'tenee that the Parly opposition to tlwm graduall~· disappt>ar·pd a.nd 

thnt the eonsultant systpm sprt>ad from a fpw eommands in thP Zone of Interior to otlwr eommands in this eountry a.nd ovrrsPas, including field armit•s. 

Cntil the middlt> wall of partition was hrok£'n down, thP nwdiea.l care of the 

siek and wourulPd soldier did not rPaeh its full<•st effieiency. 

Tht> goal of tlw consultants in intemal medieine and its suhspt>eialties was 

prompt, aeeuratP diagnosis and optimum tlwmpy, in order to reduc<' hospitalization tinw and rPtum soldiPrs to duty without umwct>ssnry loss of tinw, 

in line with thP ~Jedicnl Dt>partmPnt's o\·rrall mission of maintaining an efft>C'tivP fighting foreP. Tht> rpsults WPl'<' surprisin~ly good, though thP d<•grPe 

of stH'ePss naturally varied aecording to ('Vacua t ion polieies and sp<•cial eireumstan<'<'S of tlw tiH•ntPrs. 

Although tiH• problems of Pnry thPatPr \Wr<' fundanwntally th<• snme, 
FtlHEWtlHJ) XI 

ilwy vnrit•d widPly in dPtnils. In thP Pncifie OcPnn ArPn, for instnnc(', prohh•ms \H'n' both organi?.ntionnl nnd physical. Fndlun~ hospitnls, on<"P huilt 

hnd to lw <•quippP<I. stnfft>d, and th<•n kPpt suppliPd. Basps \n>n• isolntl•d. 

Living conditions Wt'I"<' frpqupntly primitin•. LinPs of <'nwuntion W!'I"l' Ion~. 

Th<'I"<' was. ns Oil<' consultnnt put it, "n stn1·tling lnck of qunlifi<•d pPrsomwl," 

nnd ther<' wPn' fpw hil!hly qualifi<•d r<•plll<'enwnts or in<'l'<'lllt•nts during th(' 

<'OHI'SP of tlh' wt\1'. Tlw most sti·t-nuous t•fl'orts of thP consultants could not 

ovpn·omP nn unavoidnhl(' misusP of limitP<l J>l'l'son•wl. 

Th<•n• \H'I't' SJwcinl prohlPms in tlw Pacific Oc<•an al"<'as as wPll as in tlw 

lndin-Burma th<•ntl'l' <'V<'Il wlwn t}wre was no nctin• comhnt. 'l'hP st1·ess<•s 

nnd struins of tlw hot, humid climnt<', the torr<•ntinl mins, thP mosquitoes and 

otlwr· insPcts, tlw lack of n•ci'Pation, tht• sl'IIS<' of I'Pmot<'n<•ss, tlw mnn~· frustm.tions, nil prpspntPd the eonsultants with situations thnt ill\·oln·d human 

r<'lntions quit<' ns mtwh as profpssional matt<'rs. Thr·ir work hnd much to do 

with tlw fnet that nwdical officprs, frPsh from civilian pnwticP, to tlu•i1· <'VPrlasting crNlit, !H'<·t-pted uneong<'nial assignnwnts; adaptPd tlwms<'ln-s to environnwnts in which they \Vere neith<'l' eomfortahle nm· happy and to regulations with which thPy had little sympathy; and, withal, performed nn 

outstanding job of mPdical care. 

Visits to hospitnls nnd other installntions were the prineipnl m<'nns hy 

which tlw consultnnts controllNI dinical prndiel's. All of them SJWnt 7f> perc<'nt or morp of their time awny from their lwadquart<'I"S; the consultnnt for 

tlw Indin-Bunna tlwatpr traveled more than 40,000 mill's. Th<'y \WI'<' thus 

ahl<' to clu•ck compl<'t<'ly, or spot elwck, the car<' of pati<'nts; eorr<'ct PITors; 

OV<'r<·onw lll'ens of ignorance; dissPminat<' information; obs<'rvc and pvnluat<' 

tlw perfo1·numcP of inclividunl nwdieal offiePI"S; and g<'nPrnlly insur<' thnt the 

sick soldi<'l' was l'<'<·ei,·ing the best possihl<' enr<'. Tlw prnctic<' of nll consultants of rPviPwing and anulyzing all protocols had, as one of them noted, "a 

salutory nnticiputory pf}'('et" on m<'clical prnetie<' in nil hospitals. 

Tlw nwdical eonsultnnts hnd to dir<'ct th<' cnre of ev<'r.'· conceivable civilian dis('aS<'. ~lnny such dis<'HSPS upp('arNl in strang<' manif<'stutions outside 

of t h('ir usunl Pnvironnwnt. Others hnd long sincP hP<'n con t roll<'d in the 

United Stntes or did not o<·cur nt nil lwre. Spot survpys show<'<l tlw gPrwrnl 

accumcy of pn•i nd uct ion scrN'n i ng for tuh<'reulosis, hut sp<•cial situations a1·osp, 

as in t IH• EuropPan t hPnt PI', when SoviPt prisorwrs of wa I' nnd lat('r RN'OV<'I'<'d 

AlliPd ~lilitar~· Pprsomwl W<'l'<' rPI<•ns<'d or wh<•n tlw notorious Gennan conc<'n t mt ion camps, such ns Buch<•nwald, W<'re I ihPrat Pd. Tu herculosis was 

also always n poh•ntial prohlPm in th<' Cnited Kingdom, whPrc milk wns not 

pnstPmizPd, und it was tlw custom to k<'<'P men with minimal disl'aS<' in SPI'vicP 

on limit<•<l duty. Atypical pneumonia rpquil'<'<l sp<'cial consid<•mtion h<'cnuse 

it wns a rl'latively ll<'W disens<'. So wns infectious h<'patitis, which O<'<'III'I'Pd, 

often ulanningl_v, in cwry thpnter. 

ThP natiw smnllpox mh' in tlw India-Burma tlu•ntt•r was tlw highPst in 

tlH' world, hut thPn' WPI'(' only 40 enses in U.S. Anny personnel, all attributahiP to Prrors in vaccinnt ion. 
XII FOREWOllD 

.AllPt'!!i(' di~<'H~P~ rnn!!Pd from triYiul di~ord<·r~. su('h as <'<'rtnin d<'rmntologic eond it ion~. to t hosp which W<'J'(' \"<'1',\" S<'r·ious. sueh us hronchinl nst hmn. 

Th<'y tH'<'OIIIItt•d for m1wh irH'U)>H('ity. nnd it wns soon lPtu·rwd that in somP 

t I'O)>i('nl nr<'ns t h<' simpl<'st and most <>ffiei<>nt way to luuullP t lwrn was to s<>nd 

t h<' sold iPI' out of t h<• <'tWii'Ormwn t. DPrmatolo!!ic disPn~<'s foml<'d n highl~r 

SJW('inliz<>d fi<'ld, in which mo~t consultants in int<•r·nnl nwdi('ifl<' hnd little to 

<'Ontrihut<' <'X<'Ppt, as OIH' l'PillHI'kPd <'Undidly Ulld I'IIPfully, "<•ncour·agement 

nnd int<•rpst," plus thP finn rPsolw thnt th<' postwar tPaehing of d<'rrnatology 

must h<' im pron•d in all mPd icnl schools. A dPrmn t olo!!i(' consult nn t, along 

with t lw prop<•r nssi!!nnwnt of d<•rmntolo!!ists, proYPd n paying inn•stmPnt, 

for in 90 JWre<'nt of such conditions rPttrm to duty wns possihiP within a :30-day 

per·io<l. 

~lalarin wns no pi'OhlPm in th<' Emop<>an thPntPr until ti'Oops from the 

X ort h Africn n t h<•a t <'I' \H'I'<' l'<'<h'ploy<>d in t h<' full of 194:3 and t h<' win t <'I' of 

194:3-44. Similnrly. it was no pi'Ohl<'m in thP Zorw of Int<>rior until easunltiPs 

from th<' .\'orth African th<'al<'r and th<' ensualtiPs from th<' ti'Opienl theat<>rs 

began to r<'t urn. It was originally a mnjor prohlPm, of most serious proportions. in <'<'rtnin nr·pas of th<' Pneifie, whil<> in th<' India-Burma th<'ater, prohahly 

th<' most mnlnrious ar<'a in tlw world, 40,000 C.S. Army easlutlti<'s were tn•nt<'d 

l><'fOr<' th<' situation was hrou!!ht und<•r control. F.S. Army ml'dical officprs 

had had little prnet ieal experiPrwe with malnrin, and \vhat little PXJWri<'IH'<' 

th<'y had had was entir<'ly inapplienhl<' to tlw dis<>ns<' in th<>s<' arpns. New h'ssons of hoth diagnosis awl thel'apy Jwd to hP )pai'JI<'cl, particularly with respeet 

to <'<•rehml malariu, which U<'<'OlmtPd for most d<>nths from th<> disense. Relnps<'s eontimwd nn almost insoluhl<' pi'Ohl<'m until the <'tHl of th<' war. 

TIH• nurnlwr of dispns<>s <'IH'Ollllt<'r<>d in th<> tropical thent<'rs, in addition 

to malaria, ran a h<'wild<>rin!! !!arnut. F'<>Hr of undetermined origin furnished 

endll'ss diagnostic problrms. ~lultiple disrases in the same victim were common. Beeaus<' of the high natin ineidPtH'<' and its insidious charnd<'r, amebiasis was originally rampant, hut it was brought und<'r control by preventiv<' 

nwasures, prompt diagnosis, identifictttion of carriers, adequate therapy, and 

cnn'ful followup. Although cholera nnd plague were endemic in the IndiaBurma theat<>r, not n single authentic cusc oecurred in U.S. Army personnel. 

Other diseases encountered in tropicnl theaters included every variety of 

diarrheal nnd dysenteric diseuse; typical nnd atypical lichen planus; schistosomiasis; filariasis; dengue fever; hookworm; Jupnnese B enc<'phalitis; scrub 

typhus; sandfly fever; and typhoid and parntyphoid fever. A numher of cuses 

of lend poisoning occurred hefore it wus dinbrnosed nnd its origin traced to 

cureless exposur<'s to ll'uded !!nsoline. 

_\'puropswhiatry wns eonsider<'d originally a suhsp<'einlt~· of int<'rnal medi<"irw, und <'V<'Il wiH'n it hP<'Uill<' u sPplll'nt<' sppeinlt~· its mnnng<'nwnt wns alwnys 

most pff'pctiV<• wiH•n tlw <'Onsultunts for all sp<•cinlti<•s wor·k<•<l in close eootwr·ution. In <'V<'I'Y thPnt<'l' th<• pmhl<•ms W<'l'<' th<> sunw. In tlrP beginning, too 

many pn t i<>nts W<'l'<' hospi tnli;wd who would ha V<' lw<'n lwt t pr· off if t r·<•nt <>d at 
FOREWOHI) XIII 

tiH' outputit•nt lt•nl. As n t'<'sult, snlnlg<' wns disnppointing. It impt·ov<'<l 

wlwn mnjor <'mphnsis was pln<'Pd on prpn•ntion and tt'Pntnwnt in forwnrd lll'<'tlS. 

ThPn' was no ndminist rn t i w pmvision for research, n nd t h<' originnl policy 

was to discout·ng<' whnt could hnve h<><>n undNtak<>n. Of n<'<'<'ssity, this policy 

chnnged. ~<'W mPthods of thrt·apy hnd to he workt>d out for unfnmilinr dis<>US('S. 

New agents hnd to h<• tt>st<'d. sueh us Atah1·in<'. p('nicillin, and strPptomycin. 

Sulfonnmid('s in tropicnl ('limat<•s I'NJ.Hin•d ndjunet th<•t·apy. Prior to th<• nvailability of Jl<'nicillin, th<• dPcision to US<' mnssiH nrspnoth<•mpy in thP Emoppun 

thentPr in tlw mnrulgo<'nWnt of syphilis r<'quin•d hoth eoumg<' to institut<' it and 

clinicnl tPsting. In spit<• of all of th<>s<' Ptuh•nvors, th<'l'<' wns n regrPttab]p loss 

of vnlunhl(' clini<·nl nuttl'l'inl in ('Wry th('llt<•t·, as we'll ns a loss of stntisticnl 

du t n, h<'<'n us<' t hP mneh in('ry for t lwi1· eoll<•ct ion and p1'<'S<'ITH t ion simply did 

not <'Xist. 

An int<'I'Psting part of this hook is t II<' story of tlH' wnrm and )}('lpful relations of F .S. Army nwdienl offi<·<•t·s nnd t ht•i1· Allit•d opposi t<• n umh<'I'S. In 

th<• Eump<'nn th<'nt<'l', th('n' w<'r<' 24 Int<•t·-Allit•d conf<'I'('II<'('S, with 220 sp<'nk<'rs, 

utt<'IHI<'d by mon• thnn 6.i'i00 Allit•d nwdicnl officprs. und furnishing, us the 

chid consultnnt in medicin(' for tiH' tlwutt>t'r<•mm·kt•<l. "nn ohjP<'t lt•sson in intt•rnntionnl unwnitiPs." Tht'S<' urul oth<•r· conft•t'<'IH'<'S plnyt•d nn importnnt pnrt 

in th<• <•ducntionul ucti,·itiPs of tlu• t·onsultnnts. who follO\wd tl}(' C'ivilinn principh• t hnt wh<•n <•du<'ntionnl stnndnt·ds HI'<' high<•st. nwdicul <'HI'<' is h<'st. 

This hook is n n•conl of pnst wnrtinw <'Xp('ri<'ll<'<', hut it hns in it thP pluns 

and polici<•s mnny of tlwm hns<•d on th<' <'XJwri<'n<'<'S rP<·ord<•d in tlw history 

of th<' r.s. Arm.\· :\l<•dicnl D<•pnrtnwnt in Wmld Wur I -whi<'h must guid<' us 

in our pn•purntions for n possihlt• f;ttun• wnr. It shnul<l lH' I'Pnd with <'nhn 

reflection in JWUcPtinw, to dt>t<•t·mirw tlw lll<'HSlii'('S which <'fill most w;pfully h<' 

employ<'d in wurtinw. It <'ontuins u frnnk and n•nlisti<' n<'<'Ollnt of t•t·rors 

which must not h<' m1HI<' ngnin. Th<• consultunt syst<•m will h<• institutPd in 

toto on th<• nutht·<•nk of nnoth<'r wur. fnt· it is nnw nn intPgrnl part of nwdicnl 

<'Ur<' in th(' H('gulnr J><'H<'Ptinw Army. In World W11r II, tll<'re wns a st<•ady 

improvPment in nwdicnl <'Ill'<' from W<'<'k to WP<'k and fmm op<•ration to operation. If th<•n• is n ti<'Xt time, impt·nn•mpnt must com<' l'\·en fnstPr. 

Likl> otlwr clini<"nl volunws in this sPriPs, this volume has much in it of 

vnlue for p<'IH'<'tim<' rn<•dicin<'. 

Ewn to om• who knows th<' story of nlC'diciTH' in \Yorld \Ynr II hP<'UHS<' h<• 

wns par't of it, this hook mak<•s int<'l'<'sting, nnd freqtll'ntl_,. thrilling, rPading. 

I cxpi'<'SS m.'· g"l'ntitmiP to th<• consultunts in intPmal mPdicinP nnd ullit•d sp<'-

cialti<'S who IH'lp<•d to cr<•nt<• tlw fl<'hi<'V<'lll<'llts l'<'lnt<'d in it; to those who n•-

enrdNI thPm; nnd, ngnin, to thosp who HI'<' produeing tlwst' volunws. 

LEONARD D. lh:.\TOX, 

Lif11-fnmnt Gntrral, 

Tltf Sur!/f'OII Gcnn·al. 
Preface 

ThP hi~tory of intt•rnal rru•dit·inP in World \\"ar II wa~ ~tnrtl'd in l 945 

wht•n Bri~. (it•n. Alht•rt (i. Lon•, dil"t•clor of thP histnl'ical p1·o~rar11 of lht• 

\lt·di<'al Dt>pnrtnu•nt. l"t'<flll'~tt'd tlw wnrtirtu• chit>fs of tht• \"HI'ious diYisio11s 

and Sl'rYit•ps in I hP Ofli<'t' of t hl' ~lll"~t·on <iPnt>ml to JH'<'PHI"t' t ht• hi~torical 

n•t·o1·d of thl' al'li,·itiPs tlwt had hPt•n UIHIPI' tlu•ir· jurisdil'lio11. Bri~. (iPn. 

llu~h .J. \lor;!all, nt thnt tinu• ('hid. \lt•dit·:tl ('onsultants l>i,·ision, ()flit'<' 

of tlu• ~IIIW'OII (it'llt'l"lll. was ~iHII tht> rt•sponsihility of dil't•l'lin~ this projt>t•t. 

and IIIW'h is owt>d to his unfla~~ing spirit hy thost• who suhst•qtH'Iltly t•onll"ihlllt•d to this history. 

By I ht• t•nd of l !1-lli, a ~n·a I dPal had hPI'II a<'<'OIIl plislwd. Col. "·alt t'l' 

Ballt'r, \((', Capt. .John ~- Hunt. \I(', and Col. Fnlltl'is H. l>iPuaidt•, \I(', 

lllldt•rtool.; tht• PditOI'ial rt•sponsihilitit·~ for vnrio11s st•dions. ~onu• oflit'Prs 

had ht•Pn assi~nPd to tht• Otlit•t• of tht• ~111-gt'on (iPII<'I'alto t'Oillpl<'lt' tlu•ir· nwnllsnipts: olht'l"s Wt'l't' l'<'<pii'SIPd to s11hrnit tlu•ir nwnust•ripts promptly followin~ 

t lu·ir t't•lt•Hsl' front St'l"\"ict•. Howt•n•r. as is not tmusuHl in t ht> affairs of nwn. 

a ~a p ~r:u l11a lly widl'nt'd IH't Wl't'll I ht> pia ns and I ht>i1· fulfillnu•n I. Tl11• t•onfllsion a It <'lid a 11 t 11 pon 1"11 pid dt•ntohil iza t ion and t lw inntlltu•ra hlt• pmhlt•nts of 

JH'rsollal n•adjustrnt•llts to <'i,·ilian lift• tPndt•d to 111inirnizt• tht• ir11portant'<' of 

n•t·on\in~ PXJWrit•llt'<'S that o<·cupi<'tl quilt• Yarinhlt• positions in thl' hl'at·ts and 

rninds of nu•n .i11st o11t of thl' Army. It is, thl'l"t•fol"l', a trihutl' to tht> t>fl'orts 

of Drs. \lor~11n, Bntll't', Hunt. nnd Dit>tlllidt> that. in thP tm11hlous postw:~r 

JWriod, tlu•y wt•n• :~hlt• to oht:tin 111ost of thl' iru!i,·idllal t•onsult:lllts' rPports, 

IS JlllJl<'l"S on nontropi<'al dist•ast•s, and 12 dPalin~ with tropil'al dist•:tst•s. That 

I ht• wamH•st Pnt h11siasr11s of t hl'st• !Padt•t·s wt•n• insuflit•it•Jlt. lwwt•\"t•r. to OY<'I'-

t'Oilll' t lw itH•rt in that nat uml!_,. dt•\·Pioped is not surprisi11~. and hy l ~ti2 it 

was ,.,·ident that, if thl' history Wt•n• to hi' <'ontp!t•t<'d. a 11<'\\' apJH'Oal'h was 

n·< tu i , .•. ,I. 

Pn•vious t'XJWril'tH'I' with t'Prlnin prnh!t•rns t'llCOtlllll'l't'd in pr<'parinl! tiH• 

history of pt't'\'1'111 i, .•. IIH•di•·inl' lwd show II t h<' YlllrH• of 11ll 11dYisory t•ditori:d 

hoard. 'I'IH• Sll<'<'t'Ss of this approat·h 111ot ivatt'd ( 'ol. ( '11h·i11 II. <iodd:ml. 

\l<', tlw11 l>irt•t·lor of Tht• llistori<·nl l'nit, l·.~. "\rill_\. \lPdi<'al ~ .. ,.,-i,·t•, 

to Slll!~t·st t hi' for111nt io11 of n sirnilar hoHrd for intt•r·nalJlu•dil'int>. Dr. \lorg:rll, 

who h11d dPt·lillt•d I ht• l'hllil"lllllllship of this nt•w ~roup, \\"liS JH't'St'llt 111 I ht' first 

IIH'I'Iin~ on 2ii Octoht•r· 1\l;):! at tht• Ofli<·t• of thl' ~tuw·on (it>nt>ral. liP Olltliru•d t'<'l'tllin of th•• prohlt•flt~ PII('OUiltt•n•d up to tl111t tin11• and ~n\·t· his hJpssin~ 

on futurP al'li,·iti<'s. It is JlPrtirwnt to point. out hPn• that whalt'\'('1" stH't't•ss 

hus t'OIIH' of tht•:·w neti,·itit·~ owt·~ lllltch to tl11• sllslailiPd intt-rPst nnd Pnthusinst il' support of I k :\ ( or~n 11. 

Tlu• .\th·i~ory l•:ditorinl Bo:ml which \\·a~ suh~t'<JIIPiltly appointt•d hy 

Tl11• ~IIIW'OII (it•flt•r·al. Olltlint•d :1 plan for tht• t'Yaluntion of t•xisting llt:tllllSI'l"ipb, 

X\' 
XYI PRKF .-\ CE 

including tlw r<>visiOn of some and the rewriting of otlwrs. X<>w authors 

Wl'rt' invitNI to <'Ontrihuh• pap<>rs on suhjPcts not pn·,·iousl~· assigrwd or to 

r<>vis(• mnnus<Tipts that tht> original authors had almndorwd. An <'ditorial 

offic<> was t>stablislwd at tlw ,Jpffprson ~Iedical Colh•gt> in Philath'lphia, and a 

<'Ontmet lwtw<><'n this institution and the Office of the Surgeon Gerwral \\·as 

nutdP on I F<'hrunry 195:3. Dr. ~I organ's original plan for tlw history was 

<'hnngt•d to providP for one volume on the aetiviti<>s of m<>dical consultants 

and two vohma•s 011 various dist•ases. This hook, containing th<• rPports of 

th<' m<>dical <'ommltnnts, rt•prPsPnts the first fruits of tht• <'fi'orts of The Surg<'on 

Gt•rwrul to publish thP histor~· of int·<'rtwl mNiicine in 'Yorld War II. 

Eaeh chapt<'r was writtPn b~· tlw individual consultant (or consultants) 

conct•rtwd, with th<• t•xc<>pt ion of the onE' on the Europ<>nn t lwa tE'r. Dr. 

William S. ~Iidd1eton \\TOt.t• the op<>ning S<'ction of this ehnpt<'r from his own 

vit•wpoint as Chi<>f Consultant in ~l<'dieinP in thP Em·o,wan thPnt<•r and. 

without going into tht>ir activitil's at l<'ngth, showPd how his sPnior consulta11ts 

in tht>ir spt•eialitit•s fitt<>d i11to the patt<>rn. Subst•qut>Htly, C'ol. .John Boyd 

( 'oat('S, .Jr., ~1( ', JH'l'Sl'nt Din•etor of Tlw Histori<'al t•nit. r.s. Army ~I('(li<'al 

S<'n·iel', nssignPd ~laj .• Janws K. Arimu, ~ISC, Sp<'<'ial Proj<'<'ts Bmndt. Tilt' 

Historil'al l'11it, tlw task of dt•s<·rihing tlw lH'tivitiPs of tlw s('nior !'onsultants 

in mPdi<'iiH' in the Europ<•a n t lwa t <'I'. ~I ajor A rima ass<' Ill hied his 11arrn ti n• 

from tht• doeum<•ntary rPeord, a11d tlw mlllllls!'ripts W<'n' Pdit<•d by tht• st•nior 

eonsultants <'Oll<'<'t'llPd, hy Dr. ~liddll'ton, and by Colotwl Cont<>s. Dr. Esmond 

R. Long n•vi<•wpd thP portions pt•rtaining to tiH' s<•nim· consultant in tulwr-

<'lllosis. At t hl' PHd of their l'l'S}Wet in• S<'etions. t h<' fol'lll<'r sPnior consultants 

in d<'rmatology and syphilology, n('uropsyehiatr~·, infPetious dist•ast•s, and 

tulwrculosis summnriz<'d tlu•ir pres<'nt (1956) thinking r<'gnrding their end!:'n vors during t lw war-mon' than I 0 ~·<'ars <'nrli<>r·. 

Titer<' is itwvitahly SOIIH' OV<'rlapping of suhj<'ct matt<>r in this volume nnd 

the two thnt will follow. Tlw first dt•snil>l's tlw mor<' g<>Iwml asp<•ets 

of lll<'dical problems as seen in pt>rSJWCtin• by t ht> nwdieal consult un ts, t Itt• 

ot h<'rs will focus upon sp<'cific dis<'Hs<>s. For a eompl<'t <' picturl' of som<' of 

t h<' disl'HSPS toudwd on lwr<', tlw l'<'nd<>r should rl'f<•r to tlw volumPs on prt•-

YPntive medieirw, surg<'ry, Iwuropsychintry, and miscl'llmwous clinical suhjPcts in tlw History of tlw ~lNlicnl D<>pnrtment, P.S. Army, in 'Yorld 'Yar II. 

Of the misc<'llaneous clinical volumes, thos<' on cold injury, the Army Y <'tl'rinnry St>rvie<', and rt>conditioning Ill'<' t>Spl'einll,\· pertirwnt. 

C'l'rtnin administrntiv<•, logistical, nnd op<•rntional matters nre discussl'<l 

insofar us tlwy conePrrwd thl' prnetic<' of <'linicnl nwdieine. Thl' point of 

vi('W is p<'rsonal nnd profpssionul und do<'s not nl'cl'ssnrily coincide with tlw 

official position or policy of Thl' Surg<'on Gl'n<>rnl or of tlw 'Yar D<'pnrtment.. 

Administrntive, logistical, and op<>rntional matt<'I'S p<>r S<' ar<' discuss<>d in tlw 

vohlln<'s in t.hl' administrative Sl'ril's of thl' ~fPdical D<'pnrtnwnt historr or in 

tiH' volunws of tlw Army of tlw t•nitNl Stnt<>s in World War II, publishNI 

undPI' tlw nuspicPs of tlw Chil'f of ~lilitnry History, Dt•pnrtm<'nt oft ht• Army. 

Tht• statist i<'s prt'Sl'n t t•d are consid<'l'l'<l "pt•rsonnlly eoll<•etpd" and of "local 
XYll 

origin" nnd do not nlwnys represent official Army fi!!ures. X<'itlwr are they 

to I)(' considt•r<'d official ~Iedicnl D<'pnrtnwnt statistics sine<', for the histor·y 

of the ~[edicnl Department in \Yorld \Var II, only thosl' of Armywide significance are revi<'wed nnd elweked by the ~Iedicnl Statisties Division, Office of 

t hl• Surgeon Generul. Th<'y have, however, been clwckPd with the docunwntary sources indicated. The officiul nwdical statistics of the V.S. Army in 

\Vorld ·war II are scheduled for publication in the two statistical volumes 

planned for tlw ~l<'dical DPpar·tment history of that wnr. 

For convPnit•nce and clnrity, the t('rm "tlwuter" has b('('n used with some 

latitud('. A tlwuter of wnr is defirwd in the Dietionary of tlw Cnit('d Stutes 

Army Terms ns that ar('n of land, SPa, and nir which is, or· may hl•eonw, invohr('d 

dir<•ctly in tlw opl•rntions of war; n thent<'l· of opt•r·ations is that. pOI'tion of 1t 

tlll'nter of war IH'e('ssary for particular military opt•r·ations and for the administration incidental to them. Tht> t('rm "theatpr·" is used in this volunw in 

tlw lattPr sense. In till' Pacifie, the forces of the VnitNl States opernt<'d within 

what wer<' formnlly dPsignuted "areas," although tlwy WPrt' often rPft•rrPd to 

informally us t lwa t('rs. There was no singl£' "Pacific Then tt•r of Op('rn t ions" 

nt nny tinw dm·ing the wur. The wor·ds "nn•a" and "tlwatpr·" ar(' aecordingly 

used intN·chang('ably, exc£'pt when rwepssnry to r£'ft'r to thP propt•r nunu• of a 

command; for ('Xumph•, Soutlnnst Pacific Area. ld£'ntifieation of the t·.s. 

Army commands indient<•d hy the fr£'P USl' of tlw word "tlwnt('r" is d£'ar from 

the cont('xt in £'ach chaptN' or is made cl£'ar in footnoh•s. 

In \Yorld \Yar II, most tlwah•rs were occupied or about to be occupi('(l 

not only hy thP Army (including tlw Arm~· Air For·e£'s) and the Xn.vy of the 

l'nit£'d Stat<•s but also by tlw various nmwd s<'rvic<•s of tlw Alli<'s nnd of fril'ndly 

nations. Howen•r, in this volunw portrayal of actions nnd pl'rsons within a 

giwn th£'ntl'r usually hns r£'ferl'llCl' only to tlw Army of tht> Cnited Stah•s. 

TIH• tN·ms "tlwat<'r surgpon" nnd "chiPf surgl'on" havP similar rl'fl'rl'nCP. 

ThPrl' mny or mny not have hP£'n un individuul dPsignuh•d at tlw comhirwd 

(AlliP<l) stuff h•wl us t.lw surg('Oil of t lw t ht•u t<'r, und t lwrl' obviously Wl'l'C tlw 

chiPf nwdicul offic<•rs of the U.S. Xuvy und of the Allil's, whatever tlwir formul 

tith•s mny hnw hPPil. But. this is u history of tlw ~Iedical D('purtnwnt. of thl' 

Army of the Cnit('d Stnt£'S, nnd with no intl'ntion to slight others the t('rm 

"ehiPf surg£'on" und relntPd dl'signutions ure for eonvenil'lle(' usPd to rpfpr only 

to the chiPf smgeon of the highest U.S. Army commund within n. purticulnr 

tlwnter. 

Tlw lups<' of more thnn n decnde between the expl'riencl's rl'cotmtPd lwn• 

u nd t l)('ir publieation does not. detrnct from thl'ir vnluP or in tl'r(•st. Act unlly, 

thPrP is much to n•eomml'nd such n hintus sinel' it nllows opportunity for ('011-

sidt•rntion nnd r('nss£'ssment of sit.uutions in some historical pPrspl'ctivl'. It is 

indP£'d likl'ly thnt tlw pnssngl' of time did much to l'ncournge n more eontPmplntiV(' nppl'Onch to mnny of the problems that werl' l'neounterl'd. 

The Pditor wishPs to cxpr·pss his sincl're thnnks to tlw distinguislwd eontl'ihutors who huw writt<'n this history. It is obviously not l'US,\' to pick up 

t h<• t lu·(•luls of PX{}('l'i(•nct•s long sine<• rl'gurdPd us finislH•d. In uddit ion, t hunks 

:ili-t!fill" Ill---2 
xnn l'HEF.\CE 

HI"£' dtw to Dr. Gnrfil'ld G. Duncan nnd thl' mt>mbt>I'S of th<> Ach·isor.\· Editorial 

Bonrd for t hl'ir eon~t ant support nnd to Colorwl Con tPs for his many <·ourt Psit>s 

and vigorous assistatH'l'. In particular, appn•eiation is <'Xfll't'SSl'd to .\[iss 

Elt>tmor ~- CoopPr whos<• tirPIPss and painstaking attPntion to tht> JH"<•pamtion 

an<l t>ditin~ of tlwst• manuscripts was an invaluahl<• aid in tht• eompilntion of 

this history. .\Irs . .\la<h•lim• W. E\·ans. Editorial Assistant, and .\Irs . .\lar~arPt 

X. K<•mp and .\h'S. El<•anor ~PilPr, Sl'<'l'PtariPs. also eontrihutt•d substantially 

to tlw pn•pnmtion of this volumP. Tit<' Pditor also ~I'HtPfully neknowh·d~es 

tlw assistanel' of .\Irs. Paulin<' B. Yinttt•, publications Pditor of th<' Editorial 

Bmneh, Tlw Histor·icall"nit. who JH'rfornwd tlw final puhlieations Pditing and 

pr<•parPd the• indPx for this vohmu•. 

\Y. P.\l"L 11.\\"E:"\~ •• Jr .. .\I.D. 
Prologue 

Tlw initial assi!!nnwnt of commltnnts in nwdicitw, 

SUI'!!<'ry, nnd tu•uropsyehint ry in t hP C.S. Army d tn·in!! 

"·orld Wnr I I was to t lw Officp of t lw Smw•on GPtwral. 

1-fpr(l,Pach fmwtiont•d us( 'hiPf( 'onsultunt and Coordinatot· in mat tt•t-s pt•t·tninin!! to his fiPld of nwdieitH' t hrou!!hon t t hP Al'lny. Aftl·t· considl't'll hh• <h·li hPm t ion on t hP 

part of n fpw, t lw <·ommatulin!! !!l'JH'rnls of t lw nitw eorps 

nn•as (lntl't' sPrviet• eommnnds) in tlw ZonP of Intl•rior 

tH'<'PptPd t lw n•eornmPtuln t ion t hn t proft•ssionnl eonsultnnts lw nssi!!twd to tlw offict•s of t hl'ir chiPf sm-

!!l'Ons. As O\'PJ'Sl'a <·omrnmuls <'alllP into lwin!!. eonsultnnts \WI'<' d<•si!!nntPd for tlwm. Tlw conspicuously 

stH't'l'ssful performl\IH'P of tlwsP early consultant appoin tpes provided conclusi n• proof of t lwir ntlnt• to 

thl' ~h·dical Dt•ptu·tnwnt nt honw and owt'Sl'HS. By 

t lw l'nd of t hP wnt·, fairly eomplt't" <'OH'l'll!!<' hy eonsuit un t s lwd lweonw Psta hlislwd t hrou!!hou t t lw .\ IPdicul D<•ptu·t m<·n t, l'xt t'tulin!! from t lw Zmw of In tPrior 

to t h<• armi<•s in t lw fit> I< I. 

The mission of th<• ~lt>dieal DPpnrt llll'll t of t lw Army 

in timl' of wnr is to pt·<•n•nt dist•nst• nnd injury mad to 

prO\·idt• optimum t t'Pa tnwn t for t lwm wlwn t lwy oe<·m·, 

to thP Pnd of rnaintainin!! thP IO\wst nmwffl'ctin• ratP 

possihl<•. Th<· consultants, most of whom t•ntl•rt>d 

udiw sPJ'\"i<·<• direetl~· ft·om l'ivilillll lift• a11d posst>ssPd 

littlt• JWt-sonnl PXpt•ri<•tu·P with militnt·~· nwdi<·itu•, Pitht•t' 

elinicnl ct· udministrntiw, rt>lntPd tlwmsPlws to this 

mission in un t•xtmonlinurily t•ffPetiw fashion. Of 

tll'<'l'Ssity. t !wit· SIH'<'t•ssful pnfm·mtHH'PS dPf)('tHit•d lt•ss 

upon nuthoritutin• dit·t•ctiws nnd <'omrnnnds t hun upon 

J't•uson und ()('I'Stutsion. This volunw pt·ovidt•s a t'l'Vil'w 

of sonw of thPir netiviti<•s. It is not dt•si!!nPd to I't•eord 

all of tlu•ir contributions and tH'<·ornplislmwnts. Xor 

will it mon• than sU!!!!PSt. and this indit·Petly, tlw eomplt't<•tu•ss of tlH'ir loyalty to <·ountry and profpssion and 

th<• thot·ou!!hll<'SS of tlwit· dPdieution to tlw important 

nwdienl otfict•r ussignnwnt in which thl'y Sl't'Vl'd. 

lfn;H J. ~fOHf:.\X, 

BrirJadifr Gtmral, .. :lCS (fl,·f.). 

xrx 
Contents 

Page 

FORE\\"ORI)_ _-- -- _- __ ---------------------------------- _ ------ _____ ------- ix 

PH 1-:F -\C:t:_ ---------------------------------------------------------------- XV 

PRO I.OC. t' E xix 

t:hafiiPr 

I :\lPdil'al Con~ultant~ l>i\·i~ion, Offire of till' SurgPon (ft•npra) (llllgh J . 

II 

. \forgan • . li.D.)_ ________________ -·--------- __ 

Bt•ginning of tht• Con~ultant 8:-·stcm ______ . ___ . _ 

Evolution of :\ledieal Con~ultant~ l>ivi~ion_ _ _ _ _ _ 

ChL."-'~ifiration and A~~ignnwnt of Pt·r~omtPL .. 

Cliniral St'rviet·~ in Army llo~pital~ _ . _ _ 

Admini~tratiw and Clinieal Adv:mt•t·~ I )uring World War II 

Spt•<'ialization in Zom• of lntPrior llo~pital~ 

Exrhangt• of Proft'~~ional Information 

lntraoffit•t• and Intl'roffit·t' RPlation~hip~ 

Ht'~Par<·h __________ . __________ _ 

Yi~it~ to St.·n·i<'t' and ( )n•n-;pa Comnuuul~ 

Ci\·ili:w Con~ult:mt~ in :\lt>dil'inl' __ 

Plan~ for t ht• Po~t war Arm:-·_ .. _ 

Holt' of tht• Intt•rnist in World War II 

&·n·it-p Commands (Hugh .l .• Uor(lan, .lf.D.) ___________________________ _ 

Dutil'~ of :\lt•dit•al Consultant!'l ------------------------------

Pt·r~omu•l :\lanngPmt•nt __ 

Clinit•al Problems_. 

Lnhorutory Aetivitil'l'l . ___ . _____ . ___________________________ _ 

Autopsy Protorols _ _ _ ___________________________________________ _ 

Po:-;tgmdllatt• Edtl<'ational and Training Program!! ___________________ _ 

Adt'fiiiiU'Y of :\lt>dieal Cart• in Army llol'lpitals . __ . __________________ _ 

Clinit'al Ht·~P:trl'h . . _ _ _ _ _ _____________ _ 

Ht•eonditioning _ _ _____________ .. ________________________________ _ 

l>il'tl'tit•l'l ______ --------- -------- ··-------- ----------------------- :\ft>dit•al Supplit•:o~ ______ . __ _ 

~ ur:-<ing Curt• _________ _ 

Coordination With Otlwr Con~ult:mt~. _ 

St·rvirt• Command Instnllntion~ Otlll'r Than Htationand nt•m•ralllo .;;pitals_ 

Conl'lultnnts' Evaluation of th<• Consultant Hystt·nL ______ _ 

1 

2 

H 

16 

:!I 

.,-_, 

:l:! 

:J!) 

41l 

liO 

li:J 

6ti 

li7 

69 

71 

74 

8:! 

88 

!)8 

101 

10:! 

IOH 

110 

116 

IHI 

12:l 

1:!4 

12fi 

1:!7 

l:J5 

II I :\fPdit-,•rr:uwnn (Formerly North Afrit•:m) Tlwatt•r of Opt•ration" (Perrin 11. 

Long, Jl. D.)_ _ _ _ _ _ _ _ _ _ _ _ __ . 143 

Function and l>utiP!'I of a :\fNiiral Consultant in an Owr:-<t•a Tlll':ttPr of 

Opt•rnt ions _______ . . _ J.t:J 

Organization .... ____ 150 

Consultant Artivitit>s in Varioll!'l Tn)(•s of .:\ll'rlit•al lnl'ltHilation~ 154 

XXI 

---- -- -----------------------------------------' 
XXII 

( .'hllfJif>l Page 

I Ir :\IPditPrrmwan ( Fornwrly :'-1 ort h African) Tlwat~>r of Opt>ratiou,;-Coutiuued 

l't·r,;onnd :\lana~~;t•mt>nt _ _ _ _ _ _ _ _ _ _ _ _______ _ 

:\lt·dieal Supplil's _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . ___________ _ 

l >i,;t'llSl'S of l\lt•dical I ntPrp,;t ______________________________________ _ 

Pt•nieillin ____________ _ 

l>isposition of Patients to Zom• of lntt•rior __________________________ _ 

Laboratory Servicl's_ _ _ _ _ _________________________ _ 

Problems of Evacuation and IJo,;pitalization ________________________ _ 

l\lt>dical Care of Prisotlt>r,.; of War___ _ ______ . _____ . _. _ _ _ _ _ _______ _ 

XutritiotL ___________ _ 

Reconditioning____________ _ _ _ _. _ . 

Profl'ssioual Education ________ _ 

Ht•search Problems __________ . ___________________ . 

Editorial I>utiPs ______________ . ___________ _ 

l\INlieal IntPlli!!;eneP ________________________ _ 

157 

I() I 

WI 

185 

186 

1ll1 

Hll 

1 !I:{ 

208 

214 

215 

224 

22i 

z:m 

IV European Tlwatt•r of Opt•rations (WilliamS. Middleton, .ll.D.)____________ 231 

Part I. Chief Consultant in l\ledieinl' 

H i,;t orical N ott• _ _ _ _ _ .. ___________________________________________ _ 

Evolution of l\lt-diral Consult at ion 8Pn·ice ____ . ____________ • ________ _ 

Ot•neral !\forgan's Visit to Europt•an ThPlltPr _ _ _ . _________________ _ 

Conft>renct>s of Chiefs of l\IPdieal &•rvirPs _ _ _ _______________________ _ 

Inter-Allied Relationships______ _ _ _ _ _ _ _ _________ . _______________ _ 

Function of Medical Consultant____ _ ____________ . ________________ _ 

PPrsonnel Management_ _________________________________ . ________ _ 

Edurational Programs ____________________________________________ _ 

Proft>ssional Meetings ___________________________________ . ________ _ 

Supply and Use of I >rugs___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ______________ _ 

Hospital Facilities _______________________________________________ _ 

Evat•uation PoliciPs ____ . ___ . ____ . __ . _ . ___ .. __ . ___ .. ____ ... __ .... __ 

Clinical Studies _____ .. _______ ... _________ .. __ . __ .. ___ . __ . ____ ... __ 

Ph.rsicnl Standards __ .. ___ . _. ____ . ______________ . ___ . _. _____ .. ___ _ 

HPdeploymenL ___ . _ . __ . _ .. ____ . _____ . _ . ___ .. ___ .. __ .... _________ _ 

Su1n1nary ________ . ___ . _. __________________ . _. ______ . ___ .. _______ _ 

Part II. Senior Consultnnt in Dt•rmatolo!!;y and Syphilolo!l;y 

Evaluation of the Situation _ _ _ _ _ _ _ _______ .... _________ . ____ .. ___ • _ 

Formulation of Policit>s and ProcedurPs _____ ... __ .... ___ .. _. __ ... __ . _ 

Full-Scale O)X'rations __ .. __ .. _ . _________ ... ____ .. __ .. ___ .. _ . __ - - - . 

Summary in Retrosp;•ct .. _______ ... _ _ ________ . _ _ _ __ .. _-. ___ --.-- _ 

Part III. St>nior Commltant in XPuropsyehiatry 

2:H 

2:!2 

240 

241 

245 

246 

248 

252 

257 

264 

266 

271 

274 

277 

278 

280 

281 

2S:J 

295 

315 

Arrival and Evaluation .. __ ------------------------------------- 318 

From Buildup and 111\·a:-~ion to Victory_._-_. __ ... _______ .- __ ------ _ _ :J22 

Summary in Retrospt•t•t _ _ . _ _ _ _ _ _ _ _____ .. ___ ... _ _ _ :m-t 
XXIII 

Chapter Page 

IV European ThPatPr of ( lperation,.:-Continw•d 

Part IV. &•nior Con,zultant,.: in lnfeetious Diseas<>" and Tuberculosis, 

and :\INlieal Consultation in SuhordinatP Commands 

Buildup in t.he United Kingdom _________ ._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ :198 

Normandy In vas ion and Campaigns i 11 X ort lwrn FraneP _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 41!1 

Final Opt•rations_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ -t:J2 

From V-E Day to V -J Day_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 45 7 

Summaries in Rt-tro,.:p<•ct _______________________________ ----------- 4til 

V Southwest Padfic An•a (llenry 1\f. Thomas, Jr., .U.D.)___________________ 473 

Part I. Administrative Considerations 

Organization of the Medical Depart nwnt ___________________________ _ 

Fum•tions of the 1\ledical CommltanL ______________________________ _ 

AetivitiPs of thP :\fPdieal Consultant_ ______________________________ _ 

Hospitals and :\h•di<•nl St•rvi<·e _____________________________________ _ 

Lahomtoril•s ____________________________________________________ _ 

Convalt•scent Care in New Guine:L ________________________________ _ 

Evaeuation _____________________________________________________ _ 

Xurses ______ _ 

Visitors to thP ArP:L _____________________________________________ _ 

Blood Bank _____________________________________________________ _ 

SuppliPs _ _ _ _______________________________________________ _ 

Clinieal In wst igation ____________________________________________ _ 

Part II. Clinical Considerations 

General OhsPrvations ____________________________________________ _ ~lalaria _________________________________________________________ _ 

Dysentery __________ - ____ - _______ --- - - - - - - -- - - - - - - - - - - - - - - - - - - - - - I>engue _________________________________________________________ _ 

Scrub Typhus ___________________________________________________ _ 

Differential I )iagnosis of Acute Fewrs ______________________________ _ 

I nfeetious He pat it is_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 

Amebiasis _______________________________________________________ _ 

Diphtheria-------------------------------------------------------

Poliomyelitis ____________________________________________________ _ 

Dermatological Conditions ________________________________________ _ 

Filariasis ________________________________________________________ _ 

Achistosomia .. <~il'l 

Psy<·honeurosPs __________________________________________________ _ 

Part III. Conclu,.:ions and Rt•commendations 

47:3 

482 

485 

4H2 

501 

50:3 

506 

50!) 

510 

512 

514 

514 

515 

517 

52:3 

524 

524 

5:J4 

536 

5:J9 

54:3 

544 

547 

550 

551 

55!) 

Analyl'lis and Conclusions _____________________________ ------------- 564 

R<•commendations ___________________________________ ------------- 567 
XXIV COXTEXTS 

Chapter Paf!e 

VI South Pacific Area (Benjamin M. Baker, .U.D.)__________________________ 5ti\l 

VII 

VIII 

Factors in ~ledical Care ______ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5tm 

Consultant Aetivities at Headquartl'rs ____ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 575 

Commltant Activities in tlw FiPld ___ . ___ . _____________________ .. _ _ _ 580 

l\ledieine in the Forward ArPa__ _ __ . _______________________ . _ 586 

Diagnostic Difficulties____ _ _____________________________ . 5!l:J 

Morbidity Statistics______ _ _. ___________________ - _. _____________ . 5!l8 

~lalaria. _________ .. ________ . ___ - ____________ . - . _ .. _ . _ _ _ _ _ _ _ _ _ _ _ _ 60:J 

Other Diseases __________ . _______ . _________________ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ 618 

Central Pacific Area (l'eme R. ~lfason, J/.D.) . 

Expansion and Organization of the ~ledieal HPn·ieP 

The ~ledieal Consultant's FiPld __________ . 

~ledical Problems ______________ . __ 

The Assault on Okinawa_ ... _ _ _ ... __ 

Clinical A .. ~pects of the War. ____ .__ . _ _ _. . . .. _. 

Military Occupational Specialty Ratings_._._. ______ _ 

India-Burma Theater of Opt>rations (Herrman L. Blumgart, JI.D., and George 

J/. Pike, J/.D.) ________________________________________________ _ 

6:!5 

6:!7 

641 

643 

648 

667 

692 

6!15 

Scopt> of Consultant Activitit>s .. _ . __ . _____ ..... _____ ... _ .. _ _ _ _ _ _ _ 6!16 

ConsidPrations in Diagnosis of I list> asp _ . ____ ....... _ .. __ .. ___ . _. . . . 705 

Military Importance of Diseases EneountPred ___ ........ ___ . ___ ..... _ 707 

Evaluation of Consultant System __ .. __ .. ____ .......... __ .. __ . _. __ . _ 797 

IX Field Armies (Garfield G. Duncan . .1/.D.)________________________________ 79!} 

lnh•rnal ~ledirinc at thP Front._____ _ __ .. _____ .-.... ______ .. _____ . 800 

Medical Service in Forward ArPas ... __ .. ___ .. _ ....... _ .. _________ . _ 

Scope of Consultant ActivitiPs ______ ... _ ... _ .. _ .. --- ____ - ___ ------ __ _ 

Summary and Comment. __________ . __ . __ . _ ... ____ .. ____ . _. _______ _ 

APPENDIXES 

A Consultant!5 in Medicine in the Various Commands of the U.S. Army 

B 

c 

D 

in World War II ___________________ -- ___ _ 

Programs of Conferences of Medical Consultants in tlw Zorw of IntPrior _ 

Civilian Consultants in Medicine During World War IL __________ . 

Program of Conference on Internal ~ledicine in the Ninth St·rviee 

Command __ .. _. _______ -- _____ .-.- - _ .. -.----..... - - - -- --- -

INDEX--------------------------------------------------------------------

Illustrations 

Number 

812 

818 

826 

829 

8:n 

8:m 

841 

843 

1 Brig. nell. Charh·s c. HillmaiL.. -------------------------- 2 

2 Brig. Oen. W. Let' Hart and nwmlwrs of his l'ltaff __ . _. _ .. _ .... _ .. _ ___ ____ 3 

3 ArPas served by part-time nwdieal eon>'ultant_... _____ --------------------- 8 

4 Consultants in medicine, Office of the Surg .. on Ol•rwraL ________ . ___ . __ ... 14 

5 ~lobile and fixed hospitals owrsPas _. ______ .... __ . _.- _ .. _. ______ . _. _ _ 18 

6 Cardiac clinic, Lawson General HospitaL_ .. _. ______ ..... . __ .. _. _ _ 22 

7 Patient on neuropsychiatry ward, P<>rcy Jones Gem•ral Ho..,;pitaL__________ 22 

8 Scene on wards at neurology center, Ashburn C:eneral Hospital ___ . __ . ___ ._ 2:J 

9 Clinical laboratories overseas._. _____ . ____________ .... __ .. _ .. _ _ . __ . _. _ 28 
Number 

10 Convalescence and reconditioning in hospital:'! __________________________ _ 

11 8peeialty centPrs in general nwdieiru•_ _ ___ --------------------------- 12 Fitzsimons C:t•twral llo:o;pitaL _ _ _ _ _ _ _ ____________________________ _ 

1:3 l\loorP OenPral Ho~pitnL _ _ _ _ _ _ _ _ _ __________________________ _ 

H Tlwrapy usN! in tn•at ment of arthrit ie pat it•nts _ _ _ ______ _ 

15 ConfPrPHl'l' of consultants in nwdieirw, Offil'P of tlw SurgPon (;prwraL ____ _ 

16 ConfPrPnee of military and civilian eon~ultants in nwdieirw, A~hford ( ;PIIPral 

HospitnL _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ 

17 CoiiPeting mosquito Iarv:w in the fiPid for ~tudy _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 

18 Environnwntal conditions for Allied soldiPrs at pri,.;onPr:o~-of-wur eumps in 

19 

:.?0 

21 

22 

:m 

.lij 

41 

4.5 

·lti 

-!7 

-!8 

-l!l 

50 

Sl 

.Japan ____ -. _------------------------------ -- -- _- _- - ---- - - ----

Typieal picture of malnutrition in AmPriean pri:o~orwr of war rPeowrPd in 

.J u pan __ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Proc·p,.;~i ng rPeovPred Allied prisonPrs of war, -l2d ( ;PHPral II ospit a!, ,Japan __ 

TraiHiHg in triagP and evaeuation of woundPcL _ _ _____ _ 

PPrforming opPration under field eonditions in a mobilt• hospital unit, Lawson 

Cerwral HospituL ___________ _ 

Brig. ( ;Pn. Hugh ,J. l\lorgan \"i,.;iting Col. Frank W. WiisoH, ~~ C, ~loon~ 

(;prwral HospitaL___________ _ _______________________ _ 

~lanPII\'Pf,.; in California dPsPrt _ _ _ _ _ _________________________ _ 

:\IPdieal installation, Ni11th SPrvil'P Comma11d _ _ _______________________ _ 

Consultants in medicirw, sPrviee l'ommaHdl" _ _ _________________________ _ 

CoHsult:wts in medil'ine, spn·ice eomnHmds ____________________________ _ 

Typieal set•np at a port of embarkation_________________ _ _____________ _ 

fiardrwr {;pneral HospitaL ________________________ -------------------

AIIPrgy program, Fourth St•rviet~ Command_ _ _ _ _________ _ 

Pat it·nt brought to admis,.;ion tl•llt during s('('Oild U.H. Army IIHUIPII\'l'rs_---

O('eupat ion a! tlu•rapy, ~ludigan (;prwral Ho,.;pit al _______________ _ 

Ameri('an RPd Cro,.;,.; arts :md erafts program, Fort IluyPs_ --------------

Training \'OirllltPI'r a,; laboratory tPchnician _ _ _ _ ______________________ -

8Pet ion of Fourth H1·rvi!'e Command Laboratory ________________________ -

HPeOJHiit ion in~~:, PPrc·y .Jonps (;prwral Hospit a!. _______________________ _ 

·Food sPrVil'l', ~ladigan (;pru•ral HospitaL__ _ _____________ _ 

WPII-stol'kPd pharmaey, Pt-n•y .Jorws (;pneral HospitaL _________________ _ 

SP11ior eadet nurses in training __________________ _ 

XPwl:-· i11dnetPd :-~oldiPrs givi11g data for pPrsoHnPl and elassifieat io11 fl'l'ords __ 

NPw PiekPr portable X-ray equipment in tlw out pat iPnt sPrVil'<', Camp 

RuekPr _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _________ -

SPparation Ct•ntPr, Fort Dix ___________________________________ _ 

Ambulanel't-1 awaiting dol· king of ho:-~pital ship ___ . 

Col. PPrrin II. Long, ~~ C, Consultant in :\lt•dieirH', ~IPclieal Ht•etion, :'\AT( ll.SA-

~ITOUHA____ _________ _ ____________ ------------·-

OpPII storagl' of nwdieal suppliP:-~, X a piPs, Italy _____________ .. _ _ _ _ _ _ _ _ 

British hospital ship, Algil'r>~, Xorth Afriea _______ . ___________ _ 

Battle of ElC:ul'ttar, I!).J:J______ _ _________________ _ 

Admission of "Pxhaustion" easualtiPs to e!Paring station ______ -

TrPat IIH'nt of nPuropsyehiatric ea:o~ualt y undPr supNvision of psyl'hiat ri:-~t. 

Brig. (;I'll. FredPriek A. B!Pssl-_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . ______ _ 

HPio(haia swamp, AlgiPrs an•a, Xorth Afriea. l ~H:~ _ .. _ . _ _ _ _ _. ______ _ 

~I ala ria !'ontrol, AlgiPrs arPa, Xorth Afriea, l !1-t:J ___ . _ _ _ _. _ _ __ _ 

:\laking a blood smPar for Parly rpeognition of malaria, Xorth Afric•a, l!H:L-

:z:~d C:em•ral Hospital situatPd hetWl'Pn Bagnoli aiHI Xaplt•s _ _ _ _ _ _ 

Winter in Italy ____ .___ _ ________ .. 

XXV 

Page 

30 

34 

35 

36 

37 

41 

42 

51 

52 

55 

5G 

5!J 

60 

G-l 

G5 

66 

72 

n 

77 

88 

!H 

!Ia 

!).') 

!16 

100 

101 

120 

}'}') 

12-l 

125 

12!J 

l-t!l 

ltil 

Hi2 

Hi6 

167 

IG8 

Hi!l 

170 

171 

172 

178 

180 
xxn COXTEXTS 

.\"•tmher Page 

181 

185 

188 

1 !I:! 

1 \);~ 

I! 1-t 

I !I;) 

1\17 

:lli 

.')j 

.')8 

.')\1 

liO 

Iii 

li:.! 

(i;~ 

li-t 

ti5 

{Hi 

Iii 

li8 

li!l 

;o 

71 

7:.! 

i:~ 

i-t 

75 

j(i 

77 

iS 

i!l 

so 

81 

8:.! 

g;~ 

8-l 

85 

86 

8i 

88 

8!1 

!10 

!ll 

!I:! 

!l:l 

9-l 

!15 

!16 

97 

!18 

!)!I 

TrPnehfoot, Fifth U.S. Army. 1\1-t:L. _____________________ --------------

li-lt h ( :pm•ral llo.-pital, LP~horn, I !1-l;) ______ .. _______ . __________________ _ 

:\ir<·vacuation from It:tly to \'orth Africa____ _ .. _________________ _ 

Ho.-pitallahorator~·aeth·itip,- __________ _ 

\lohilP laboratory, FlorPIIl't' arPa, 1!1-!5 _ 

( ;.,rman and Italian pri.-onPrs of war, Xorth .-\fril'a, 1!1-t:~ 

I )pJou.-in~ of pri.-onprs of war_._______ _ 

Pri.-oru•r.- of war, Tunisia, I !1-t:~ _ _ _ _ _ _ _ _ _ 

t·.~. Arm~- trul'k loach·d with ( :Prrn:m pri.-oru•r:< arriving at pri.-orll'r-of-war 

l'amp, rwar \latPm, Tuni.-ia, 1!1-t:L __ _ 

GPrman nwdit•al oftiePrs in ho.-pital of P.R. prbonPr-of-war .-tol'kadP, H<·arHlirl'i 

arl'a, 1!1-l:l ___ . ____________ . 

GPrman pri.-orH•rs of war, Ita I,\·. I !I-t,')_ _ 

.-\mphihiou:< trainin~~: _____ . 

t·.~ .. -\rm~- FiPid Hat ion K and Brit i.-h Hat ion __ _ 

\IPdil'al J)ppartnH·nt .-oldiPrs of lOth lrrfantr,\· I>ivi.-ion. _____ __ 

Fr .. .-h lm•ad from llOth QuariPrtllastPr BakPry Co., .January 1!145 _______ _ 

lh'l'npational tlwrapy, 21.-t (;I'IIPralllo.-pital, Ita!~-. 1!1-t-L __ _ 

HPl'otHlitioHin~, 21st <:<·HPral llo.-pital, Italy, 1!1-l-t _. 

WPPkl~· III<•Pt i11~ of Fifth l~.H. Arnr~· nwdieal offie"r" at :~8th Ev:wuat ion 

Hospital, February 1!1-l-t_ _ _ ______________ . 

8th Enteuation Ho.-pital, Ita!~· • .January 1!1-!5 _________ _ 

Bri~. <:<•n. FrPdPriek A. B!Ps.-<; and ('.~.Army and '\'a\'y IIIPdieal offic•prs <'Xaminiu~ Tohruk spliuts, Xnrth ,\fril':t, 1!1-t:L _. 

15th \l<•<lieal C:PnPral Lahorator~·. Ita!~·. l!l-l5 __ . ______ _ 

Col. Willi:1m S . .\Iiddll'tou, :\IC, Chit·f Cousultmtt i11 \IPclieinl', I·:Ton·,A __ _ 

Col. .Janws C. Kimhrou~h. :\IC, and Col. WilliamS . .\lidclll'ton, \IC ____ . 

Col. Char!t•s B. Spruit, \I C _ .. _____ .. ____ . ____________ _ 

ETO ~as l'a.-ualty tn•ntnwnt kit_ ______ ---------- ______ . _____________ . 

Col. Halph H. \llrekpnfus.-, :\IC ___________________________ _ 

Staff of t lw \I!'Clieal S<·<·tion, IIPadquartNs, Unih•d Kingdom Bas<' ___ . _ 

AvPniiP Klt•llt'r, Pari.-, Franel', showing huilciin~s occupiPd hy ChiPf SurJ!:POn. 

ETOCS.-\ ______________________________________ _ 

Brig. CPn. Hu~~:h .J. .\lor~~:an on visit to ETO __________ _ 

ConvniPsrPnt patiPnt unrlPr~oing ohstarll' eoursP traininJ!:, 20:~c1 Htation Ho.--

pital, En~~:land ________ . ______ . . ___ . __________ _ 

Col. Edward \1. Curlp~·. VC, and Col. William S . .\licldh·ton, .\1(' 

Briti.-h J!:IIPst.- at n•~~:ular sPriP~ of hnnquPts lwld hy tlw Chit·f HurJ.(Pon. 

ETOURA. . ______________________ . _____________ _ 

:mth ni'IH'tal Ho.-pital, Enp;land_--- -------------------

Army :\IPclieal FiPid SPrviC'P School, ShrivPnhnm Barracks, England _____ . _ 

\INliC'al FiPicl RPrvi<'!' Sehool, France __ ---------------____ _ _______ . Lt. Col. .JamPs B . .\lason, .\IC _____________________________________ _ 

.\[aj. BPrn:ml.J. Pisani, .\[C __________________________ . 

.\laj. ( :Pn. Hir HPnry LPtlwhy Tidy, Prt>sidl'nt, Royal SoeiPt y of .\lt'dieirw, 

tn!'Pts with IIIPdil'al ron~ultants ____ . ____ .. ____ . ____ . _______________ _ 

RPar viPw of 108t h (;pnpral Ho~pital, Fr:mre ___ . _ _ _ _ _ _ . _______________ . 

Partil'ipants at lntPr-Aili('(l Consultants Conf<•rpnrP, 1!1-t.f __ . _________ _ 

Col. William H . .\fidcUPton, :\IC, prPsicling, lntPr-AlliPcl Corr,.;uJt:wts ConfPr<'lll'<', l !14-t. _ .. _. _. _- _____ .... ________ . __ 

Debility and malnutrition, eharacteristic of many rPco\'PrPd AlliP<l fwr.-onnPL 

Lt. Col. .John I>ou~Iu .. ~, RA .\I C ___ . ____ . ______ _ 

Typic·al examplp,; of hospital eonstruction in UnitPCl Kingdom for l'.::-i. Army. 

1!18 

20-t 

:!08 

:!10 

:! II 

:!I:! 

:! };~ 

:!IIi 

:!li 

218 

21\l 

:!:!!1 

221i 

2:t~ 

2:~-t 

2:~.) 

:.!:~; 

2:~s 

2:{!1 

2-ll 

242 

2-t:J 

2H 

247 

24!1 

25:~ 

254 

25;) 

2.')1\ 

25!) 

260 

261 

262 

21i4 

21\i 

:!t\8 
100 

101 

10:.! 

to:~ 

104 

10;) 

tot\ 

llli 

lOS 

I 0!1 

110 

Ill 

II:.! 

II:~ 

Il-l 

11;) 

llfi 

lli 

liS 

liB 

1:.!0 

I:! I 

t•)•) 

I:!:~ 

I :.n 

I:!;) 

l:.!(i 

l:!i 

1:!8 

I :!!I 

l·ll 

1-l:! 

14:~ 

144 

145 

Provi:-;ion of lwat in Xi:-;:-;pn-hut wards hy two t'oal ,.:lovps __ _ 

Lon~. opPn eorridors at hosp;t al of tPmporary :\ i""t'u-hut t'ou,.;t rnt't ion ____ _ 

:~8th 8tation Hospital, Enp;land __________ _ 

J·:stahlishnwnt of an ic!Pal, tPntt•d hospital fat'ility __ 

Troops of Fir,.;t :\lliPd :\irhorHP Arm~· in glidt>r cluriu~ Aruht·m opt·rat ion ___ _ 

Col. .TamPs C. Kimbrough's farPWPII party on thP t•n• of hi" dt·part nrP 

Col. Donalcl :\1. Pillsbury, :\lC_ _____ ____ __ __ _ _ _____ _ 

:\[pclit'al offit•t•rs dt•win~ display of lwnzyl bPrlzoatP prt•p:tratiou,.;_ _ ______ _ 

~l'fology :-\Pet ion, 1st :\lPdieal <fPnPral Laborat or.\·, En~la nd ________ _ 

Yt>JH'rPal clist•:tst' ward, :!cl (;pru·ral Hospit :tl. England __ 

lOth :\lt•dit'al Lahorator~·. Fir,.:t l'.H. Arm~·. Frant•t•, l!IH 

Col. David E. Liston, :\[ C, Col. Angvald C. \'it'kon·n, :\[ ( ', Col. l>onald :\[. 

Pilbhm~·. :\IC. and Col. Howard \\'. Poan, :\[C __ 

Htandard prPparat ion of pPnieillin _______ _ 

Consultants in nwdidrw, Europt•an tlwatPr ___________ _ 

:Hith Htation llospital, England__ _ _______________ _ 

Training >'Pet ion, :Wth Htation llo:-;pitaL ______________ _ 

ClosPcl ward, :wt h Htat ion llo,.;pitaL ______ . ____ _ 

Eval'uation in l'nitt•d Kingdom in support of Xormancly inva,.;ion _________ _ 

t:Wth(:PrH•ral Ho,.;pital, BPlgitmL_____ _________ _ ______ _ 

:\[Pclit·al ward, t:~Oth ( :PnPral Hospital ______ . _. _ _ _ ______ . ___ _ 

P,.;yehiatrit• ,.;N\"it•t•, t:Wth (;PIIPralllospital______ _ _ ________ _ 

IIPaclquartPrs, HPhabilitat ion ~pc·tion, 1:Wth ( :Prlt'ral llo,.;pital ________ . ___ _ 

~urgieal ward, t:~Oth ( :Prwral HospitaL _____ .__ _ ____________ _ 

Building,.: nnd ground,.:, 818th Hospital CPntt'r, Bl'lgium ____ -------------

Xt•urop:-;yl'hiatrit· program, l:~Oth < ;\'lwral Ho.,.pitaL__ _ ____________ _ 

.\t'ti\"itiPs, HPhabilitation HPt'tion, t:mth C:t'rwrnl HospitaL__ _ __________ _ 

!lh:.t :\h•dit•al (:as TrPatmcnt Battalion, ( it•rnuwy __ . _ 

HP,.:t t'PntPr for divi,.:ions of VI and XV Corps, SP\"Pnt h F .H. Army. Fr:IIH'<' __ 

I lr. Edward A. Ht rt•l'kPr viPwing t lw monumPnt,.: at HtorwhPngP, Englancl_ _ 

Enlist Pel t'linical p;;yehologist working with patient, 1 :mt h C:Prwral llo,.;pit al, 

BP!gilnn _______ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 

P,.:~·<'hiatrit• t rc•atnwr1t, I:~Ot h C:Pn<'rul llo,.:pitaL ______________________ ----

:\laj. Boward D. Fahing, :\lC ___________ . __ . _________________ .. 

Col. Lloyd .J. Thomp,.:on, :\IC, nwPts with di,.:tingui,.:lwd IIPurop,.:yehiatrie eon1-'llltants at thP lntPr-AlliNl Consultant,.: ConfPrPneP _______________ _ 

StanbriciJ~:P Earls, England, n·st ho11w for offirprs suffPring from flying fatiguPConsultants in mNliein<', EuropPan tlwatPr ____ . ____________________ -

bt :\INlieal ( :t•rwral Laboratory, En~~:lancl, 1 !IH __________ . ______ . 

ThP Washin~~:ton Club, pn•miPr A11wrkan H.Pd Cross dub, London, .Jut~· 1!14:! 

I )pmonstration of mobil(' X-ray unit a,.:semhlcd at 5th c:c·rwral llo,.:pital 

Col. TlwodorP L. BadgPr, :\IC, Pxamininjl; chest X-ray film,.:, 5th (;t•nt•ral 

Ho,.:pitnl, England_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ 

Col. KPnnPth D. A. All<'n's mobil<' auxiliary X-ray unit :-;£'t up in thP fil'ld __ _ 

Type of shoek ward Pnvh-•ion<'d by ColonPI :\lidd!Pton in opt'ration in tlw llOth 

Evaeuat ion Hospital, LuxPmhour~~: _ _ _ _ -- ___ - ___ -- -- ------------ - - - --

Hpc•eivin~~: arPa, 58th FiPld Hospital nPar \\'Pymout h, l!JH- ___ - ___ - . -.- -- -

HPePption of hospital trains and convoy,.:, En~~:Iand_----- . --.-.---.-.----

"\\'t't" e:t."ualtiP:-; of Xorm:mdv in\·asion rP:tl'lt English ,;horP, i .Jmw 1!1-!4 __ _ 

Typic·al shipload of walking wo;llldPd and nonhattlP t'asualti<'" arrivin~~: at \Yt•ymouth, .Jmw 1!14-l __ 

Xormandy bt•aehi>Pad at tim!' of Colonl'! :\liddiPtor•';; ,-j,;it, I .Jul~· I!IH_----

xxnt 

Paw 

:!70 

:!71 

:!i:! 

:!'77 

:!i!l 

:!81 

:!81i 

:!!HI 

:!!tS 

:w; 

;~I:! 

:H-l 

;{ l !I 

;{:,?;) 

;{:!li 

:{:!7 

:~:w 

:~:H 

u:w 

;~;); 

:~:{8 

a:~n 

:{40 

:~-l:.! 

;{.J5 

:{50 

:~51i 

:3i l 

ai5 

:{18 

3811 

as5 

:~8!1 

:w; 

-Hl:! 

405 

401 

40!1 

411 

4:!1 

·12:! 

424 

426 

42i 

4:!8 
XXVIII COXTEXTS 

N11mber Page 

1-!6 BrPakthrough at St. Lo, medical personnel and equipnwnt mow t hrou~h 

147 

148 

14!) 

150 

151 

152 

15:l 

154 

155 

15fi 

157 

158 

1.')!) 

HiO 

ltil 

162 

1 ();~ 

Hi4 

){)5 

Hili 

1(;7 

HiS 

16!1 

170 

171 

17~ 

17:l 

174 

17.') 

17ti 

177 

178 

17!1 

180 

181 

IS2 

1 s:~ 

IS-! 

IS5 

18{) 

187 

IS8 

18!1 

ruins ______________________________________________ _ 

A' ·men of 94th Division treating injured soldier on typieal cold and drt>ary 

day, rwar Tittingen, .January l!H5 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _____ _ 

Chest r1•spirator used in treatment of cold injury_____ _ _ _ _ _ _ _ _ _ _ __ _ 

Sovict soldiers, freed by Third U.S. Army, partaking of enwr~Pil<'Y ration:<, 

SarrPgucmines area ____________________ _ 

RPcowrPd French personnel flying the Trieolor a.., Ph•nu·nts of U.H. Army pn·-

parc them for return to France_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______ _ 

Can· of recoven·d Allit>d personnel, -Hith 0PnPral Hm;pitaL _ _ _ _ _ _______ _ 

Routilu• eontrol measurPs at 46th Gem•ral Ho:->pitaL _ _ _ _ _ _ ______ . 

Notorious Buclwnwald __________ . _ _ _ _ _ _ _ _ _ _ ______________ _ 

Anwrican and Brit i:-;h prisoners n•<·ovPrPd at a (iprman brick faetory __ _ 

:\1alnutrition in a rPcovPrPd AlliPd soldiPr _ _ __________ _ 

Typieal aRsPmbly area eonditions, Le Ha \TP ________________ _ 

NursPs undPrgoing medieal proePssing for rt•dpploynwnt, Camp CarlblP, 

Franec,.July l!l-!5___________________ _ ________ _ 

F.R.A.H.S. Mactan upon hPr rPturn to thP PhilippinP IRlands _____________ _ 

Consultants in medicinP, S\\'PA_ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _____________ _ 

Brig. Gen. Guy B. Den it.____ _ _ _ _ _ ____________________________ _ 

Consultants at mcdi<'al sPetion, Ht•adquartPrs, USASOS _______________ _ 

117th Station Hospital, NPw nuinPa_---- ------------------------------ 5th Station Hospital, Australia__ _ ___________________________________ _ 

124th Station Hospital, Xew Cuin('a _____________________________ . ____ _ 

Offiee of the Surgeon, Basp K, Philippine Islands _______________________ _ 

DDT dusting of :\fanila by C-H aircraft_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 

4!1th neneral Hmspital at the .Jockey Club, ~lanila ____________________ _ 

Santo Tomas U niV<•rsity, :\lanila _________________ _ 

Lt. Col. Homer K. Nicoll, l\1C, Commanding OffiePr, 1:Hh C:Prwral llo:<pital. 

N Pw Oui nea ______________ - - - - _____ - - - _______ _ 

!)8th Evaeuation Hospital, Philipnirw I:<lands _________ _ 

Dispensary No.2 opPratcd :1,V Philippine Civil Affairs Unit 21, ~lanila __ 

ColiPcting station JH'ar :rontlitH':-<, Philippine Islands ____ _ 

N ativPs n "l'i \'iug tn·a i mPnt in hospitals operatt>d by A X (I AU___ _ _____ _ 

8th '1Pclieal Laboratory, Australia_____________________ _ _________ _ 

t:mth Htatioll Hospital, ~ew (;uillea________________ _ _______ _ 

X ur>'!'S from :!:>I st ~tat ion Hospital, first to reach ~('W Britain ______ . _ 

X ursPs at :~01 h Evm·• tali on Hospital, Parang, ~lindanao 

:\Iaj. nen. ~orrnan T. Kirk, Thl' Surg<'Oil CPIH'ral, Ulld Brig. C:Pll .. Johll '1. 

Willis, Chief SmgPoll, USAFPOA ________________ _ 

Brig. C:e11 . .Janws S. Himmons, visiti11g 1!lth :\1Pcliral Laborator~· 

Whole blood ill rPfrigPrat('(l eontaillPr is ch•livPrl'cl to Parallg by L;')B li~ht 

ain·raft _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____ _ 

A mPrliPal snpply dPpot in tlw PhilippinP Islands__ _ _ _ _ _ _ _ _ _________ _ 

EIPvatPd llatin• honst• ill tlw Philippim• Islands___________ _ __________ _ 

Pushillg hark thl' junglc>. _ __ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______ • 

AtahriJtP publi!'ity c·ampai~~:n, :~fiad 1--\tati<Jn HospitaL ____ _ 

lllstructioll at :\lalaria Control Hehool, Sth ~IPdi!'al Lahorator~·. Australia __ 

Lt. CPJJ. WaltPr J(rtH'gPr'R Hixth F.R. Arm~· HPadquartPrs, C:oodPnough 

Isl:md _ _ _ _ _ _ _ _ _ _ __ - ___ - - - - - __ _ 

Bandicoot rat, host of mitPs translllitting s<'ruh t_vph11s. _ _ . -------

R<'ruh typhu:- c•oJJtrol, :~fillth Station Hospital, (:oodPnollgh J,..l:l'•rl ________ _ 

~Temlwrs of U.S.A. Typhus ComiJli,.;sion in Xew GuinP:L _ _ _ _ __ -- ______ _ 

4:?9 

445 

447 

448 

451 

45:l 

4.')4 

456 

45!) 

460 

474 

477 

47!1 

-!SO 

-~87 

488 

48!1 

4!10 

~!12 

4!1:3 

4!14 

4!15 

4!17 

4!1!1 

500 

502 

;)04 

501) 

510 

511 

512 

.')I:~ 

514 

.'iJ,'j 

.'l I f) 

51C 

.'i I !l 

.'):..!0 

.'i:?5 

.'i!?6 

.'l:?i 

il!?H 
COXTEXTS XXIX 

.Vumber Page 

1\10 F:wilitiP:-> of U.S.A. T~·phns Commi~:->ion_ ------------------------------- 5:m 

1!11 Tt>:->ting mite repPlll'llb------------- ---------------------------------- 5:m 

1!12 Troops of lst Cavalry Division imprl•!!;natP tlwir dothing_ ---------------- 5a2 

I !l:l PostPr urging prPVPnti Vf' mPasurPs against ,;eruh typhus_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5:l:l 

1!1-l Consultants in nwdieine, SWPA______ _ ____ _ _ __ ______________ 548 

1!15 Snail,; of tlw type harboring ePreari:u•, tr:wsmittPr,.; of ,.;ehi,.;tosomiasi,;__ _ _ _ _ _ 55:l 

1 !It} Sd1i,.;t osomiasi::; ex hi hit and dt>mmtstrat ion on LPytP _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 55!! 

1 !li PrPvalem·p of snails in Philippine strPams and poncb .. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 560 

1!18 HPst after tlm•e eontinuous days in batt it' without rPlit•f, Los X!•l<(ros_ _ _ _ _ _ _ 5tH 

1\1\1 nPogmphie and elimatie diwrsifieation, SPA___ _ _ _ _ ________ 572 

200 Chain of nwdieall•vaeuation, 2'\pw C!•orgia Island, .July 1!1-l:L _ _ _ _ _ _ _ _ _ _ _ _ _ 57 -l 

:.?01 1-l:.?d <1Prwral Hospital arPa, Fiji l,.;land:,;_ __________ .. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 575 

20:.? Con,.;ultants in nwdieinP, SPA ____________________ -------------------- 57fi 

:.!O:l ~lalaria control on New (korgia hland, OetohPr l!IH_ _ _ _ _ _ _ _ _ _ _ _ _ _ 581 

:.?0-l Laboratory, 48th Station Hospital, (:uaclaleanal, I>PePmiH'r l!IH_____ _ _ _ _ _ 58:! 

:.?05 Capt. :\lax Miehat'l showing his undPrground ineuhator on BouJ.?;ainvillP _ _ _ _ 5~-l 

:WH "Pa,.;h•ur Institute, Bougainvilll' Branch"_________________ 585 

20i Transfpr of woundt'd from Higgins boat to Navy sPaplam•, Solomon Islands, 

July 1!1-l:L- ____ --- __ -- _____________ --- __ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 588 

208 Forward arPa nwdiPal tn•atment faeilitiPs, Solomon Islands_______ _ _ _ _ _ _ _ _ _ 58!1 

20!1 Troop,; of tlw :nth Division pas,.;inf.{ vehielPs stalled in the muddy roads, Bouf.{ainvillP, NowmbPr Hl43_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5!!:.? 

210 Patrol shown 25 mill's beyond thP Anwrican lines, BougainvillP, I>cePmher 

1 !1-l-l. - - --- ------------------- - - - ---- ---------------- -- - - -- - - -- - -- 5!1:~ 

211 Ward tPnts, easual convalescent company, Bougainvill<', I>eeemlwr 1!!43____ 5!14 

212 Psyeholoj!;icalefft•cts of island warfa.n• seen on the weary and har:\1\>lt>d fare of 

one Anwrican soldi<'f, New Georgia Island, .July 1 !!4:3_ _ _ _ _ _ _ _ _ _ 5!!6 

21:3 :\IPn wa.'lhing up in jungle waters aftPr a four-day march, New C:Porgia 

Island_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5!17 

21-t !lth Station Hospital, -;\ew CalPdonia, SPptPmher 1943____________________ fiOI 

215 :\lalaria eontrol, BougainvillP, DecemhPr l!l-l:L _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 60-l 

2Hi Troops of the America! Division Pmharking, Fiji Islands__________________ fi08 

21 7 25th Infantry Divh;ion on C:uadalcanal, ,January Hl-t:L _ _ _ _ _ _ _ _ _ _ _ (j Hi 

218 UndPrground ward, 21st Evaeuation Hospital, BougainviUP, April I !lH _ _ _ _ _ _ (j I !I 

21!1 :l"ith Infantry Division, Bougainville. ________________ . _ _ _ _ _ _ __ _ _ _______ (i:!l 

220 l>Pstruetion at Hickam FiPld, Hawaii, 7 Deeemher l!l-lL_________________ ti:.?!l 

221 Consultants in medicine, CPntral Parilie________________________________ 6:{0 

222 Expaw..;ion of TriplPr C:enPral HospitaL_______________________ _ _ _ _ _ _ _ _ _ 6:J:l 

:.?2:{ :\l!•dieal l>Ppartment amhularH'PS awaiting tlw rPmoval of cnsualti!•s from the 

U.H.A.T. Willinm S. Clnrk__________________________________________ 6:~-t 

224 U.H. Army llospitnl Ship .llercy _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 6:{6 

2:.?5 Oeeupat ional thPrapy, 20-lth C:!•n<·ml Hospit nL _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 641 

22ti ~IPdieal Ward, l-l8th C:Prwral Hospital, S:dp:ut_ ------------------------- 64:.? 

227 :J!Ith 0Prwral Hospital, Saipan ______ .. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ fiH 

22S ~IPdieal officers on Okinawa, IIIPPting to PxehangP icl<•as and cliseuss problems_ 6-tfi 

22!1 ExpPriment condueted with mosquitoes, 21 !It h ~lalaria Hurwy I kt:H'hmenL 647 

2:JO Transfusion of whole blood during application of a tran,.;portation pla ... 'lter 

cast.-----------------------------------------------~-----------~- 651 

2:H <i!lth Fil'ld HospitaL _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 652 

2:l2 Landing orwrations on Okinawa___________________________ _ _ 66:~ 

2:l;J Clr•arinJ.?;station, IO:.?d :\IPdieal Battalion______________________ 66-t 

2:34 :\[Pn and tanks, ith Infantry IJivision, burning out enemy cave dPfPn,.;e,.; 666 

235 Enginpc•rs con,.;truct ing bridg<• across jungll' strP:t m_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 6 70 
XXX 

:.?:~8 

:!:W 

:!to 

:! ll 

:?I:! 

:!-n 

:.? ll 

:!-15 

:!Hi 

:.?17 

:.?18 

:.?-1!1 

:!50 

:!51 

:.?.'i:! 

:.?5:~ 

:!5-t 

:!5.=) 

25{i 

:!:i7 

:!•iS 

:!;)!) 

:.!1\0 

:!til 

:.!li:.? 

:.?li:~ 

:!(i-t 

:.!Iii) 

:.!liu 

2fi7 

:!(i8 

:.!li!l 

:!70 

:.!71 

:!7:! 

273 

274 

:.?7.') 

nr, 

:.?77 

~at in• ehild with I'JH't>J>haliti,.; __ _ 

Troop,; of :?7th l>ivi,.;ion tir,.;t to rl'l't>i\'t' pa,.;:-i\'~> irnrnunization of .Japalll'"'' B 

t'!ll't•phalit is_________ _ _ _ _ _ __ 

:.\IPmlwr of malaria eont rol unit ,.;praying wt•t•d,.; at t•dgt• of pond_ _ 

Col. llt·rrmau L. Blumg:u·t. :.\1('. Coli." lilt ant in :.\lt•di1·irw. CHI __ _ 

Ht•t•rt•at ion hall. 20th ( lt·rwral llo,.;pital. ___ _ 

Col. },.;idor t". Ha\'!lin. :.\IC. in,.;pt·eting \'t•gt>tahl"" grown undPr ,.;anitary eondition,;. :!Oth (l,•rwral Ho,;pital. _ _. ________________ _ 

Watl'r purifi('afion plant. 18th C:t•nt·r:tlllo,;pitaL _______________________ _ 

:.?Ot h ( :t·w·ral Ho><pitaL _ _ _ _ _ _ _ _ _ _ _ ___________________ _ 

( )utdoor firq>lat't'S, u!)th ( ;1'111'1':11 llo,..pital . _. __ - ___________________ _ 

:.\IPdieal ward. :!Ot lr ( :t•w•ral llo,..pital ________________ _ 

:\I ala ria eont rol __________ . ______________ _ 

Ht•t·l'iving offiee and mPdieal warcb. 7:~d EYaeuation llo,;pitaL ___________ _ 

Til'k-infp,.;tt'd jungll' along Lt>do Hoad ______ . ______________ _ 

Brig. <:I'll. Frank :.\ltorrill. l"R.-\. with intt>rprl'l t•r,; _ _ _ _ _ _________________ _ 

BiYotrat• an•a along Lt>clo Hoad _ _ _ _ _________________ _ 

Heruh t~·phu-:, t ypieal ~'"l'har . _________________ _ 

H('ruh t~·phus. rnaeular Pruption_ _ _ _ _ _ __________________ _ 

.-\ir-eondit iorwd t yphu,; ward>'. :!Ot h ( :l'rlt'ral llo,.;pit al .. ________________ . 

T~·pieal t rnpieal ult·Pr. _ _ _ _ _ _ _ _ _ _ _ _ _ __________ _ 

Pl't rolt>lllll pumping stat ion, 7081 h Engillt't'r Pt>t roiPIIIII lli>'t ril .ut iou Company ________________________ _ 

BurmPst' nur>"t' bandaging illft>l'!Pd It•!( of Chilli'S!' :<oldit·r ___ _ 

:.\laj. Clari'IH'I' S. Li\'ill!(OlHI. :\I C. :<tlllling flora, 20th ( lt>nt>ral llo,.;pital 

:\t,\·pieal lidwn pl:um,; of foot oh.o;t•rn•d :If 20th l:t•llt·r:!l Hospit:d 

Littt>r jt>t>p, Parly link iu el1:1in of mt'diral 1'\'aeuation. Philippi1w Islands. 

I !145 __ - _- __ . __ - - - - . - - - - . - - - - - - . - - - . -- -- - -- - - - - - -. - - --- ---- --- -. Fir:< I Pelwlon ml'dieal :<l'r\'il'l'. _________________________________________ _ 

I lOth E,·aeuation llo,.:pital. (;prmany, l!l-t5 ___________________________ _ 

Prm·t•:-;:-;iug lil)('r:ttl'd Ho\'h•t prbonPr:< of war, <:t•rnum~·. Hl45 ____________ _ 

-tl,.:t Inf:tlltr~· Di\'i:<ion. Australia _____ ------------------------------

Con,.:ultant,.: in nrPdieilll', fiPid armip,;_ _ _ __________ . 

4th Ca:<ual Compan~·. :~:.?d l>i\'i:<ion, marl'hing to lwaeh for ,.:uJwn·i,.:t•d ,..wimming . .-\u:-;tralia, 1!1-t:l ______________________ _ 

lntPn:-<i\'1' military training for :~d Ca,.;ual Compan~·. :~:.?d Dh+•ion . .-\u:<tralia. 

I !1-t:~ _ _ _ _ _ _ _ ________________________ _ 

Col. John H. Hall. :.\IC. SurgPon, X Corp:<, dPmon,..tratinJ?, dft>t•t,.: of atomit• 

homh.lliro~hima, l!l-ttL _________________ . 

Sho<·k tPnt in a forward nwdil'alunit. Fifth r.l". Army. Italy. IH.J.t _______ _ 

u~t' of hlood and blood ,ouhstit lilt':< in fip}d arm it"' ----------

Clinieallahoratory. 8th Evacuation Ho~pitaL _______ _ 

Crowd I'd fa<"ilit it":<, .J!lt h ( ;,.nPral Ho~pil :tl ___ _ 

Lt. (lt•n. WaltPr Knwgt·r, t;SA, visiting elParing :<tation of ith Infantry 

l>i vi:< ion _________________________________ .. 

Ext rPm PI~· hu:-;y 2-tt h FiPld Ho:<pital at rt'<'apt un·d Fort Stot,.:Pnhurg. Philippint• 1:-<lands ____________________________ .. . ______________ _ 

Con~ultant:< in nwdiri1w, fiPld nrmit-:; _____ . _ _ _ _ .. _- ___ -- _ 

Offit•Pr:< of tlw nwdi<'al :<t•t•t ion:< of ttw Third and Eighth r $. ArmiP:<- ____ - _ 

Arm~· lwarlquartPrs art•a. Sixth CS. Army, Philippi1w lslanrl:<, 1945 -. ·----

:\IPdil'al :-11ppl~· ><t·n·il',.,. in a fit>ld army _______ ----·----·-. --------

Page 

ui-t 

6i7 

liS() 

(j\lli 

iOu 

illS 

711 

II;) 

iii 

iiS 

i:.?~ 

i:~-t 

I -t:~ 

i-t;) 

1-W 

i48 

750 

i54 

757 

j'j() 

j'j.J 

i75 

177 

800 

801 

80:! 

so;J 

804 

805 

80{i 

807 

808 

80!1 

810 

811 

81:~ 

814 

815 

811i 

8:.?0 

s.,., 

8:.?5 
COXTEXTS 

Charts 

X11mher 

Orp;anization of ~[('(lical St•l't ion. :'\ ort h Afriean tlwatPr ______________ ----· 

·> llrg;aniwtion of ~[Pdi!'al St•(•tiou. :\IPditPrrarwan thPaiPr _________________ _ 

:~ Flow ehart of patiPnt,.; at I:mth ( :Prwral llo,;pital from adrni,.;,.;hm to di:o;-

XXXI 

Pugc 

15:3 

154 

po,.;it ion ____________________ . .. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3:35 

-t Simplifh•dor~~;:lllization ehart. SWP.\. l!H:! 45 -·------------------------ 475 

,j ~Iontlrly adrni,.;,.;ion ratp,;, all eau"""· India-Burma tlwatt-r. January 1\l-t:~-

:\ug;u,.;t I!l45._____________________ _____ ______ 70!1 

li :\Iont hly adrnb,.;ion ratp,;, all dbPa""· India-Burma tlwatt•r. Jauu:n·~· 1!14:3-

:\ ug;u,; t I !l4.j _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ______ . ____ . _________ . _ i 10 

i :\Ionthly ineidPneP ratP~. tliarrhPa and cly~t-ntPry. lndia-Burnta tlu·atPr. 

January I!J.l:3-.-\u~u,;t l!l4.'J ... ____ . _____________ .. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 71:! 

8 :'\ondft•(•tiYPnt'"" from all eau"""· from all diarrlwa and dy,.;PntPry, and from 

anwhir d~·,.;pntPr~·. India-Burma tlwatPr. I .January l!lH-15 July 1!145___ 71:3 

!) :'\orwffPeli\'Plll'"" for cliarrhPa and cly,.;pnt•·ry and for malaria, India-Burma 

t ht>a t Pr, I !lH _ _ _ . __________ . ______ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 71-l 

10 ~lonthly att:H·k ratP for malaria. India-Burma tlwatPr, January 1943-

Aug;u,.;t l!l45 __________________ .. ________________ -------------------- no 

II lneideuce and d£>aths duP to ,.;eruh typhu,.; [1'\'Pr. India-Burma theat£>r, 1 DeCI'rntwr 1943-:H July l!l45 ------------------------------------ 747 

I:! :\Ionthly ineidl'lH'P ratP,.;, undia~no,.;Pd fP\'t•r. India-Burma tlwater, January 

I !l-t:~- A ugu,; t I !l45 _________ .. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 7ti3 

1:{ :\Ionthly inridt'IH'I' ratp,; of common rp,.;piratory di,.;pa,.;p, India-Burma thmtcr, 

January 1!)4:~-Augu,.;t I !l45 ___________ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 780 

14 Xorwffpetin· ratp,.; for common rp,.;piratory dbPa,;p, India-Burma theater, 

January 19-l:\-July 1945. ________ . ____ . _____________ ---------------- 782 

15 ~Ionthly ineidPnrP rat1"' for primary atypieal prwumonia, India-Burma 

tlwatPr, January I!lH-.July Hl-t5_____________________________________ 783 

l(i lnrid1•nr£> of infl'etiou,.; ht>patiti,.;, India-Burma tlwatPr. January l!l4:J-Augu,.;t 

1!)45_____________________________________________________________ 787 

17 I ncidPnl'P and dPat hs duP to poliomydit i:<, India-Burma t lwat Pr, January 

194:J- Au~u,;t I!H5 .. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 78\1 

Maps 

St>r\'il'P Command,;, ZonP of lntPrior _ ____ _ _ _ ___ _ __ __ _ _ _ _ _ _ __ ___ _ __ __ ___ 7il 

2 Campaigns in :'\orth Africnn and ~IPditPrraiwan tlwatPrs. l!l4:!-45_________ I.'JI 

3 Ba:"P SPetion,.;, Xorth African thmtPr, July l!)H_________________________ J.jti 

4 Soul h Paeifie ArPa _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ,j 70 

5 Cmt ral Paeifie Arm_____________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ li:W 

6 U.S. Army ho,;pitals in India__________________________________________ fi!li 

7 U.S. Army ho,;pit:lls in As:o;nm, India nnd nortlwrn Burma________________ ti\18 
XXXII COXTEXTS 

Tables 

Y 11 mber 

Puhlirations prPpnr<'d hy :\lPdiral Con,.:ultant,.: l>h·i,.:ion __________________ _ 

:! .\utop,.:y rPport,.:-100 ca,.:ualtiP!< dyinJZ; from batt! .. wound,.: or "''\'t•rt· injuri!.,._ 

3 Wt'i~ht of lung.- and livPr in 100 autop:<it'<l womHIPd ___________________ _ 

4 l>i,.:m,.:l' and battle-ca,.:ualty rat'"'· Okinawa, 6 April through :?2 JmJP 1!1-15 __ 

5 Total ca:<t>,.: and attack rat l' for malaria, India-Burma t hPalt•r, l Sq>ll•mht•r-30 Junl' 19-15 _______________________________________________________ _ 

6 Typ<'!< of malaria ob!<PrVPd in 20th C:Ptwral Ho!<pital and in 7:~d Evaeuation 

Page 

4-l 

658 

6til 

@5 

7:!7 

Hm;pital. April to DeePml)('r I !H:~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 7:m 

7 Typt>,.: of malaria obsf'rVPd in :!Ot h nl'tlt'Tlll llo,.:pil al. April I !1-t:i-:\lareh 1 \1-li) 7:n 

8 Symptoms ob!<Pr\'Pd among ca,.:ps of hookworm inft>,.:lation, 20th { :l'nt•ral 

Ilo,.:pital, 1945. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 767 

9 Total cast-s, incidt•ncP ratPs, and notwffPcti\·c rat1-s, dbPa"I'S of n•spiratory 

tract, India-Burma tlwatPr, 1!)44-45_________________________________ 781 

10 Incir!Ptl<'l' of inft•ctiou,.: lwpatitis, India-Burma tlwatPr, January 1!1-t:~-Jul~· 

1945------------------------------------------------------------- 788 

11 

12 

13 

14 

IncidPnc£> of poliomyl'!itis. lndia-Bnrma tlwatl'r, l!l42--t5 __ _ 

IncidencP of typhoid fPVPr, India-Burma thPater, 1!14:?-45 

IncidPncc of parat~·phoirl fPvPr, India-Burma tlwatPr. I!l-t:!--15 

Incidt•ncc of smallpox, India-Burma theatPr, l!lH-4;) 

7!10 

7!11 

7\1:! 

7!1:~ 
CHAPTER I 

Medical Consultants Division 

Office of the Surgeon General 

Hugh ]. 1\lorgan, 1\I.D. 

The Army of the l'nited States in "Torld \Var II was by and large a <'itizen's army administt'red at the higher levels by a relatively small number 

of professional soldiers. This was true for practically all arms and servi<'es, 

including the ~[edieal Dept:u·tment whieh was primarily responsible for health 

services. A small gi'Onp of career officers of the Army ~h·dical ( 'orps administered the eomplieated afl'airs of the ~ledical Department. Consultants 

wN·e appointed by The Surgeon General and assigned to his offiee to develop 

medieine. surgery, and psyehiatr.\· in the ~ledical Department of the Army 

and, in a limited way, to supervise professional performance in thesP spe<'ial 

fields. \Yith few CX<'l'ptions, thC'Sl' mPn wPn' rC'cruited from civilinn life und 

were not from among tlw Regular Establishnwnt. 

The his to;.'· of the dcvdopnwnt of till' ~ledical Consultants Dh·ision, 

OTSG (Office' of the Surgeon General), and the projection of its influPnee 

throughout thP Arm.v is a story of eivilian participation in military medieirw. 

The eonsultant system, beginning in the Surgeon GPneral's Offiee with thP 

assignmPnt of the ehief eonsultants, extended into the SC'rvire eommands in 

the Zone of Int<'rior during tllC' mobilization and training period and OVCI'S<'as 

with thr C'stahlishmcnt of tlwntC'rs of operntions. Finall.\·, its repi"<'sentntives 

were utilized toward the C'nd of thP wnr hy armiPs, eorps, and divisions in 

combat. In this history. it would he innppropi·iatC' and unrrnlistie to disrC'gnrd the difficulties thnt nrose through the consultants' lack of cxperieru·p 

with thr military nnd the militnry's failurr to und('rstand clrarly what the 

eonsultants had to ofl'er. On the one sidr, the speeial problems of military 

mpdicinr and, on the other side, the value of specialized medi<·nl services in 

hospitals and in the field had to he lParned before there could evolve the system 

of mPdieal, surgical, and psyehiatrir supervision that existed at home and 

in the tlwatPI"S of opPrations at tlw end of the fighting in 1945. 

In the pngrs that follow, the author breaks many times with the convrntions of militar_,. rPporting. This is inevitable, since hr and his immediate 

assoeiatrs and praetically all of the medical consultants throughout the Arm.\· 

'verr produets of eh·ilinn medicine. It is thought that the value of this volume 

will he enhaneed if it refleets aecuratrly both failures and achievements, both 

helps and hindranees, at the ineeption and during the developmrnt and operation of tlw medical eonsultant system in the Surgeon General's Office and 

in the Army FiPld Establishnwnt. 

1 

M49Til'- 61--3 
2 ACTI\'ITIEI' OF :\II·:Pit'.\1. I'O~!'l'J.T.\~Tl!5 

Finl'RE I.-Brig. (;l'll. Chari(',.; C. Hillman, Chit•f, Proft>.""iomtl St•rvicl' J)j,·j,.:ion, Offit•t• 

of tlw Surgt•on G~nt•ral, 1:~ April 1\14:!. 

BEGINNING OF THE CO~SrL TAI\T SYSTE~l 

Chief Consultant in :\ledicine 

On 1 .January Hl4:!, Dr·. II Ul!h .T. ~lmwm l'l'<'l'i\ t>d n <'ommunil'ation from 

('ol. (lut<•r Br·ig'. G<'IJ.) ('Junlt>s ('. llillmun. ~It' (fig'. 1), t'hit>f, Pmfpssionnl 

St>ni<'l' Division, OTSG, im·iting' him to h<•<·onw a nwmh<>r of th<' Prof<>ssionnl 

St>rvi('<' Division with th<' title of ( 'hipf C'onsultant in ~IPdieirw to The Surg'<'On 

Gt>n<>rnl in till' l!rnd<• of l'Olonel. The lt>tter outlined th<> duti<•s of this assig'nnwnt as follows: "With till' incr·ens<•d tempo of military matters, expansion 

of the Profpssionnl S<•r·vi<·e Division to provid<• for separn t e subdivisions of 

nwdicine, SHr!!<'l',\', nnd IH'UI'opsy<"hiatry npp<'nrs dPsiruhl<•. It is conh•rnplat<>d thnt th<· ('hid of <>nch suh<livision will he till• ChiP£ ( 'onsultant and t 'onnlinutor in mntt<·t·s J>l'rtuininl! to his fjphJ of nwdicin<• tili'OIIg'hout th(' Arm~·." 

On 11 Fl'lmull'y 194:!, Colotwl (Ia tl•t• Br·ig'ndi<•r G<•npt·nl) ~ lor~an and his pt>r 

sonnlly sd<•<'l<•d assistnnt, t'npt. (lnt<•r Col.) llnrrison ,J. Shull, ~It', reportPd 

fot· duty to ~lnj. G<•n .• Jnnws C. ~In!!<'<', The Suri!<'Oil General, and wl're nssig'twd to t h<' Profpssionul S<'t'vi<'<' Division. 

Althoul!h Jw wns strong'ly support<'d by his inHHPdiate sup<'rior, Getwrul 

llillnmn, it wus lll'<'<'ssur,\· for ( 'olotwl ~lot'l!llll to mnk<• his wny in til<' Suri!<'On 
I I•· l.i I' \\ II 

:""·. \ 

! . 

·! 

•I 

' j ' \ ' ' r ' . I ~-- 0 

o' I 1'. 

,, . I . . 

I "'111'1':11', I llli,·,·. 11,. 1•:11'11• 1p:11t'd 111 ,·,·rl:llll pr~tlol,·tll, irttlllt'.!J:tl•·h. ,,,,,,,;,,:~ 

Ill tl:~· 1111'111111:•1111!1 ,.; joll\,lt';l\ 'l:lllll:l!tl, 1111' i:lolllt'lillll 111111 1!11' .\1'111\ :1l1tl Ill 

I ill' '''lt·•·l i111! 11! lit'\\ dill'..> :til.! 'fl'''·i:t\ ito•lti' 11!' 11\t'dio·;t\ 'llj'jlh. II•· 'illt•lt•kd 

'"'···lirt .. .> "' ,.,.:,,:,1111•·•·, "' till' \:lli<lil:t! !\,.,,.,,,.,.,, I ·,.lll1•·rl t'lllll't'l'll•·d 111111 

lliit'lr::,l lll•··li.·irll'. l11 11,,.,,. ,.,,rl\ ,j,,\,, ''""1'\1'1'. 1111' 1"'"11·,-i,.,,,ll ,.,.I,,,Jil:llll' 

\\1·r·· 1'\l"'' 1··~1 '" ,·,r!lirll' ri,,·11· diJIII'' 1':1tlll'l' 11:11'1'11\\h 111 ,·li1t1•·:1l pr .. l,j,.,,,,, 

T I, I I' I . " ; I ' ' II I\\ ; I I ., ., 'jtl ; I I II . I • I tl I I " . I ., I I /1' I 'Jtl I II ; I I I ,,, . ·' ' ,,, ' II I. I I' I 'I 'I II I I I I i I . I /I I I ,,, . I ,,, I \ 

:1"1..:1111/l'ill' nl \l,·•lro·;t\ I.,,.,,, 'l'•·•·t:l\j,l, 111' ,j,.,llld l:lkt· il!lll:tll\•' ir1 lll:!ll•·r·, 

drit·o·tl\ :.II'····Jir,:..: l~:o·dro:t! ,.,,,,., ,,,,·!: :1' /lll',jl,.;l\ '"l'jd\ :1111! l."'flil:tli!.:llltoll 

i'"!io'\ '1'1111•' :tltd •·li't~l'l ! :1d Ito 1 ... t'\jtt·•.d,·d Ill :1 !'"'"·,·,, 11 1 J!,ill•l:tl o·:tli·..: 1:1o·r, 

/l!o'lll j,,.f\\t'•'ll lf11' Itt'\\'\ l'llillll:/,,1111/l',j t'llli'IJII:!Iil' :lll,j lilt' -o·:t,llllt',j \(,.,jl,·:\1 

·,,1'\'' tdl':.t'l'' Ill lfll' ..._lll'..:o·lll/ 111'1/t'l':tl', ()jjj,., .. Till' !:Jilt•!'. :llll:llli:_:l! t'\Jlo•jj. 

t·!:o·o·.\ Ill !I,.· 1\:t\' 11! If,, .. \1'111\ \\o'Jt' 1111! :1!11:1\' o·ll:_:lil/;1111 11! !l!t' \\:1\' ill 1\j,j,.j, 

I""'''''"''''' ,.,..,,!Jil:tlr"!l ,.,.11 1.! j,.,, 1 .. · IJ,,.,I. ··rll/1'1' 111 :tdltilltl'll':tll\•' lllo·dl•·l!l•' 

Ill' :1! ll:o· l~o·ol-'1.\t·. 

Tl"· 1'''''''11'1:•' \1'11:\ 11l 1!11' li:ll'li•·, j,,,.,,.,., ... :_:r,j;,·.! 1111 l:o·o·d 111 If, llll',jj,·;tl 

11111 I':JI i1111- It•!' :t l'tll,-1111.11•1 '1'1\lo't'. :t lilllllt'..:ll '!It'll :t '1'1'\ j,.,. l,:t,j ! ltlt•"llttl!t',j Ill 

\\.,rid \\:1!' I. (\,·\1\:tl 11! 1"•-1111111 :i"l:..:lllllo'lil' j,, (;,.llt'l:ll \l:,_:o·o· 11/1'1 \\Ill• 

Jill' llllilli'o·r·,.:,..,·, 11•·•·:1-lll!l:tlil Iii" ll:tlok "1'1""1:11111. 11l 111:111\ t~liio·o·l, Ill 11/llll:tl 

jtt~-1111111' 11111-l,j, II o· ..._lll':..:o·ll!l ( ll'lll I :t!', ( llilo'o· :tll,j 11! '"lilt' j,,,,,[,. II. Tl~o•l't' 

\\t·r·,. llloi·,l,j,. 1'\o·o·l•llt~lt-. :tllli !11 II,,·,,· t':tl'l\ 'lljtjlltl'lo·r·- t!/1' fll'ttlo·-,11111;11 t'llli'lll1:1111 -\,lt'lll. :1- 11 li11:t!h ,.,,.JI,·.\. 11\\t'd 11111•·\t. ( ·~~1 ..._:lil\111'.! \\'. 1-"l't'lll'\1. \It· . 

. -..111':..:•·1111. (.'lllli'lil ( "IJ" .\Jo·:t l:tto·l' !-'.•1111!1 "'•'1'\lt't' ( .lllillll:tllll. :111.! ( 'u!. l:tto·l' 
.H'Tl\Tl'H:~ OF :\IEDH'.\L ('0:_\;::->l'LT.:\:_\;TS 

Bri~. G<'n.) \Y. L<'<' Htu·t, ~[C (fig. 2), Surgron, Eighth Corps Ar<'H (lnt<'t' 

Eighth St•t·vi<'P ( 'ommand), spt an <'Xnmpl<' fm· othPt' surgPons of major comnuuuls. TIH' pt·ompt and <•nthusiHstie ('OOJWmtion of tlws<' two offieN·s hash•twtl 

th<' <•nd of inl't·tin. 

('prtainly no otH' in t lw Surgt'on G<•nPml's Ofiie<' in 1'\•hmnr.'· 1942 envisagt•d tlw mHgnitudt• nnd impor·ttuH'<' of tlw eonsultunt s,,·stt•m us it P\'t•nttwlly 

furwtiont•d ut tht• limP of vil'tory in J1:uropP und in tlw Pncifi<'. ( 'olmwl ~lorgun's initial stuff eonsist<•d of two ~lt•dit·ltl ( 'orps oflit•t•rs nntl oru• l'ivilinn clt>rk, 

houst•d in om• small room and having no r<'pn•st•ntntion in nny major· t·ommnntl 

<'itht•r in tlw Zone of lntt•r·ior· or oversens. In Pn<'h of tlw major eomnumds, 

tht•rt• npp<•un•d in tinw 11s consultnnts in llH'tlicinP Ill! informnlly orgnBizt•d 

gmu p of <'X<'<' PI ionnlly <1 mtlified officers. Th<'S<' IIH'n hud h<•Pn curd ully ehosl'n, 

most of t lwm by Tlw Sur~l'on G<'n<'ral with t lw n<h·it•t• of his chiPf consultant 

in nwdieirw. In u prnetienl scnsP, tlwy Wl'n' usuully n•<·ognizt•d hy th<' ~h·dicnl 

Dt•pnrtnwn t us I'<'JH'PSPII tnt i V<'S of t lw Surgpon Gt>rwrnl 's Otfict•. a It hough t lw~· 

\Wre, in fnd, dirPetl~· rt•sponsihl<' to tlw sm·gt•on of tlw eommntul m· tlwnter 

ot· army nnd wt>r<' st>pnrutt>d from Tlw Sm·gt•on G<•twral and his ehit>f consultant 

in nwdieirw hy Z<'nlously ~uanlPd t•otnmand •·lutmwls. 

Tlw mission of tlw ~h·dical Ot•pnrtnwnt of tlw Arm,\· in tinw of wnr is to 

prPn•nt dist•nse und injury und to pmvidt• optimum tr·t•ntnwnt, to tlw <'nd of 

muintnining the lowt•st possihlt> notwffpetin mh•. \\.it h this us his primar.v 

ohjt•etiv<'· to l'<'thu·<' tinw lost frotn duty- -( 'olotwl ~lorgun attPmptPd to 

PIH·ourng<', in <'Yl'I'~- wu.\· possible, prompt, :u·t·m·utl' dingnosis und optimum 

thernpy; to t•x:pt•ditl' udministrutiw pr·o<·Pdlll'l:'; and to hPlp :H'<'Plt•mt<' tlw 

eonvnlt•s<'<'IH'<' und rPtum of t lw soldit•r to his milit:u·,,· nssignmPnt ph,,·sically 

unci l:'lllotionnll~· fit. It soon uppP:m•d thut this broad <'OIW<'pt of his funetions 

l'l'<Juirt•d t h<' t'stublishmPnt of ht·oud pr·in<"iplt•s gon•rning tlw pmcti<'<' of nwdicirw in th<' Army nnd tlw eonti'Ol of sppeiulizt>d pt•rsomwl rPsponsihlP fot· rl'lntin~ 

thPs<• pritwiph•s to th<' <':li'P of puti<•nts. 

In t lw r orma t i \'(' duys. }!'I'(' at assist allC(' \\"US l'l'IHI<'I'Pd Tlw Sm·gpon Gl'twrnl 

and his pi'OfPssional eonsultnnts hy tlw various committt•t•s of th<• .\'ntionul 

H<'scnrch ( 'oun<"il. Tht•sp <·ommittt•Ps pro,·idt'd fuels and Px:pt•rt opinion which 

could s<•rv<' us tlw husis for fomuttion of policy r<'gnrding eliniculurulndministmtivc prndie<•s. Lut<'r, Colonel l\lorgnn <'Stnhlislwd, in his own oqrnnizntion. 

hmnelws r<•pr<'S<'nting importnnt suhsp<'einlti<•s in militnr,\· IIH'dicitH' urul ussigrwd I:'Xpt•rts us tlwir ehi<'fs. Civilian consultants in nwdi<"im• to til(' SPerPtary 

of \Vur und to Th<• Surgt•on Gt'rwml Wl'l'<' nlso hl'lpful. 

Much of tlw ti11w of tlw ehil'f consultants wus O<'<'UPi<'d hy llltlll,\' lllltttt•r·s 

which W<'rc not, stri<·tly spPnking, irwludPd in tlwir funetions. For· t•xumplt•, 

tlwir <'arly efforts to <'ll<'Ourng<' an nggrt>ssive nttaek hy hospital staffs upon the 

problem of <'X<'<•ssi Hly prolong<'d hospi t nlizn t ion aft t'l' n•t·owry fr·om <lisPHS<' 

und injur~· eontrihutt'd gr<'ntly to tlw offieinl I'Peognition of tlw importnncP of 

this mattt'r nrul to t lw <'vt•nt unl t'Stahlishnwnt of n compt•p}u•nsiw, wcll-orgnnizl'd progrnm f ot· t lw numugt'lll<'n t of eon vah•se<•ne<' nnd r<•hn hili tnt ion. 
OFFICE 01•' TilE :-IUHf:EOX GEXEH.\L 

Service Command, Theater, and Army Consultants 

It wns <'YidPnt from tlw lw~innin~ that <h•lt-~ation of n•sponsihility by tht• 

rhiPf consultant in nu•tlicitw in tht• Stu·~t·on Gt•twrul's Officp wns tH'<'t•ssnry, if 

t lw mission assi~nPd him was in any n•al S<'llS<' to ht> t>Xl'<'Ut<'<l. This h<•ratll<' 

obvious to nil wlwn hospitalir.ation plans I'm· tlw futm·<' W<'I'P dis<'lost>d. Tlwrc 

Wl'l'l' in netual OJH'I'Iltion in th<' Army approximatdy 20!l station hospitals, 

with i' 1,4;)!) lwtls, Plans eall<•d for an additional 145 station hospitals, with 

Sli.S4:3 lwds. Tiw L) ~<·twral hospitnls, with 14,!ll2 h<'ds, tht>n in op<•mtion 

wt•n• to h<• au~nu•nt<>d hy L) additional installations with 20,H88 ht•ds. Thus, 

in t•arly 1!142, firm plans for hospitals in tlw enitt•d Stat<'S pmvid<>d for 11 totld 

of :384 station nnd ~<·n<>rul hospitals, with 1!)4,202 fix<>d lwds. The futility of 

an.'· ntt<•mpt on t iw part of t lw ehi<•f eonsultant in nwdiein<' to affect si~nilicantl.\· the pml'ti<'P of nwdicitu• in so man.\· hospitals sentt<'l'<•d so widdy thmu~hout the country nwr<>ly hy issuin~ dirPctin•s and hull<•tins from tiw Smw·on 

GenPrnl 's Offic<' was a ppnr<>nt. :\ lor<>m·<·r·, t ht•n• was no proYision for d<•t niletl 

control of ussi~nnwnts to k<>y positions in tlwst• hospitals. Finally, tiw di,·ision of tiw {'nitPd Stall's into corps lll'<•as (lat<•r S<'rYir<' comntands), <•ach a 

st>par·nt<' military c·onHllaJui, nuui<' dl'<>ctin• cpntml administration of nwdicnl 

uetivitit>s fl'Om tlw Smw•on Geneml's Oflic<' impossihll•, sinee authority for el•nt ralir.t•d con I 1'01 did not Pxist. 

Acconlin~.d.'·· on th<' rpconllll<'tlllation of tiw consultants of tiw Pmfpssionnl 

St·n·i<'<', OT~G. Tlw Surg<•on Gt•Jwrnln•t•omnwtHh•d t\w nssignnwnt of eonsu\tants to thP surgPons of cmps nr·pas. 1 It wns JH'Opos<>d that th<>st> ofli<'<'l'S "shall 

act in 1111 insp<•l'lionaland consultatin• capacity, and that t lwir· duti<•s shall inelude t iw PYalua I ion of t lw profpssionul cpralificu t ions of nwdical pt>rsomwl. 

uppmisul of tww tiwnlJWUiic m<>thods and a~Pnts, and tlw coonlination of prof<•ssional pnll'l i<'<' hy local dis!'ussion with hospital staffs of such spt>cilll pmhl<•ms 

ns may pt'<'Sl'll t t iwms<·h·Ps. It is coni<• Ill pla l<'d t Ita t t iw con::mlt ants scll'ct<>d 

!'oitnll lw out~tunding nnd nationally I'<'<'ogniz<'d in tlwir r<>sp<•<·tin• fit•lds." 

IIPaclqunrt <'t':'l, SPrvi<'<'S of Su ppl,,· (lu t<•r Army Spn·ie<' Forc<•s), a pproncl 

in prineipiP this r·pc•onlltH'tHlntion hut rpfus<•d tiw IH'<'otllpun.\·in~ n•qu<•st th:tl 

corps 1\l'l'll~ lw nuthorizP<i nn inc·r<>nsPd nwdienl offH'<'l' nllotntPnt in tlH' ~mel<' of 

colonel fcH' this pmpos<'. Shor·tly th<>r·c•nft<·r·, tlw following s<•n·ie<' eommund 

consultnnts in IIIPdieitH' W<'l'<' ns~i~twd: Lt. ( 'ol. (lnt<'r ( 'ol.) HPnry :\L Thomus. 

Jr., :\I<', to t iw Fourth Spn·i<'<' ( 'omnuuul; Lt. Col. (lut<•r· Col.) \\~nlt<'r Blllwr. 

:\IC, to t!JP Eighth S<·r·viel' ('oniiiiHJHl; Lt. Col. (lnt<•r Col.) YPrn<' n. ~lnson. 

:\IC, to the Xinth Spn·ic·<• t'ommnnd; und Lt. Col. (lat<'r Col.) Edgnr vun Kuys 

I (I) L<'ll•·r. TlrP f:un!I'Oil fll'tWralto f'omm·uulinJ! (lpJJI'ral. 8PrVIN·~ or f:uppl~·. 2S :\fay 1912. suhjf'ct: f'oorrlinatioll 

or "··dir':ll :'r·n·iN· lf'rnfp<<ionall in f'nrns Arr·a ln~l:tll:tlinn, witlr lsi lnrlnrsr•nu·nt tlrr·rl'ln. (21 T....ttr·r. Ttr .. l'IIJ'I!I'Oll 

r;,.ru•ral to Cnrnrn:lltdin>! l;prwral, Sr•rvier•s or :'upply, Z! JunP l!H2, suhjr•f't: Coordination and :'UJlN\'ision or MNlical 

:'r•rvir.· in :'tal inn IIMpil:rk r:l) Lf'ltr•r, Tlr•• :'nr!!r•nn Clr•twral to Cornrnanrlin!! !lr•twr:rls, :'pn·i<·r• ('nrmnanrl~, 28 July 

1!112. <uhj•·r·t: Cnnrdill:ttinn and :'urwr\'i,inn of l'rof••"innal :\f,.dil':tl ~··n·i<•• l'nrlr•r :O:r•n'i<•' Cnrnrnanols. (4) Lf'ttf'r, Tiro• 

:'ur!!r·on !lr·ru•ral lo Cmnma.ldin!! !lr•nr•ral, First :o;,·ni<'' Connnand, :!.'i Jan. 1\113, suhjt•ct: .\s>h:nnwnt of l'rort'S.~ional 

l'rm:<ullanls. 
6 ACTIYITIES 01<' :\IEDIC.\L CO.XSCLT.AXTS 

Allt>n, MC, to the Sevt>nth Service Command. In due time, as hospital beds 

incrensed in number, consultnnts W('re nssigrwd to tlw remnining service communds. 1\fnnning tablt>s contained no position VtH.'tlll<'ies for consultnnts, and 

some service commnnd surgeons wert> lonth to nccept new colonels and lieutenant colonels who would hnve to be nbsorbed in the rigidly fixed stuff allotted 

to the surgeon's office. ~foreover, the concept of n consultant in medicine, 

wlwth<>r from n militnry or n professional viewpoint wns new und unnttrnctive 

to some service commtmd surgeons. 

Gr<>nt patience and forbearunce were required of some of the eminent 

physicinns chosen to serve as consultants. Tlwir response uttests to their tolerance nnd d<>votion to duty. In rure instnnces, it wns nctunlly necessnry to 

prove to the surgeon of a service commnnd thnt the consultnnt was not n busybody, troublemaker, or imprnrticul refornwr but n physician nble to help the 

surg<>on provid<> optimum medicnl cure nnd medieul ndministrution for the patients under his jurisdiction. To tlwir cr('(lit, tlwse consultants mndE' tlwmselvt>s so vnlunhle in tlwir connnnnds that their subsequent plucpment in ov<>rsen tlwuters and with the nrmies nwt with little or no obstruction nnd in some 

insttlllC<'S wns insisted upon by the surgeons concertwd. 

Sprviee <·ommund, thenter, and urmy eonsultunts \n'rt> usunlly recommt>nd<>d for tht>ir ussignm<>nts by The Surgt>on Gt>n('rnl on t lw ndviee of his 

ehi<>f eonsultunt in medieim•. Tlwy W('f(' judged to h(• ('lllint•ntly qunlifiPd to orgunizt• and administer tlw mission entrust<'<! to them. A loos(•, informnl, unoffieinl n•lutionship betwPen the <·hit>f eonsultnnt und his ussocintes in the fi<•ld wus 

tlw onlv typl' possible, beenuse of <'ommtuHI bounduri<'s. In sueh u lurgt• 

un ·, r·t :~.king, d(•t·('ntrnlizution wns, in fu<"t, d<'siruhle. It wus the duty of the 

''OTt~ultunt in the field so to relute hims('lf to his t·ommurHI surg(•on us to insurt• 

i,llpl<'ln<'ntution of the polieies of Tlw Surgeon G<'Ill'rnl nnd his ehief consultant 

in nwdieine for the cure of medienl pntil'nls. Once nssigm•d, lw wns in <·ompl<'te 

c·ontrol of tlw dewlopnwnt of his mission nnd of pro('t•durPs hy whic·h to l'nrry 

it out under tlw nuthority of the surg(•on of the eomnumd. Inevitably, tlw 

<·onsultnnts' aetivities in the various eommunds vnried according to loeul 

cireumstnncPs. 

Tlw rt•<·ord uttests to the effieieney und effectiveness with which the consultunts r('lnh•d themselv<>s to tlwir missions. By preeept and exnmpl<>, formul 

und informnl tulks und demonstrutions, lnborious and pninstnking indo<"trinntion of militnry sup<>riors nnd subordinnt<'s, umnzing industry, tuet, pntiPnce, 

forbeurunce, und ing<'nuity, tlwy curri<'d out tlwir missions. In som<' instunees, 

rpgionul- nnd subordinute-commnnd consultnnts wPre nppoint('(l on the re<"omnwndntion of the consultnnt in medi<·irw to tlw <'Omtntmd surgt•on. An outstnnding exnmple of this type of orgnnizntion in tlw fidd t•xistt•d in ETOUSA 

(Europeun Thenter of Operntions, U.S. Army), undt•r tlw dirt•<·tion of Col. 

Willinm S. :\liddleton, :\lC, Chi<>f Consultant in :\Iedieine, ETOt:SA, and :\Iuj. 

Gen. Puul R. Hawley, Chief Surg<'on, ETOUSA. 

From time to time, renssignments were made to carry the experience 

guined in one <·ommnnd over into another. Examples arc to be found in th(• 
OFFICE OF THE SURGEOX GEXER.U~ 7 

assignnwnts of the following medicnl consultnnts: Colonel Thomas who was the 

first service comnuuul eonsultnnt nppointed nnd who served in the Fourth 

S<'rvice Commnnd and Inter in the Soutlnwst Pneific Art>a; Lt. Col. (later Col.) 

Herrmnn I... Blumgnrt, :\IC, who sern•d in the Seeond Serviee Command and 

Inter in the India-Burnm tlwater; Colorwl :\lnson who served in the Ninth 

Serviee Commnnd nnd Inter in the Pneific Ocenn Aren; Lt. Col. (later Col.) 

Roy H. Turner, :\IC, who served in the Third Service Command, in the Surg<'on 

Gt•rH•rnl's Office, nnd finnlly in the Southwest Pacific. Tlwre were similu.r 

changps in the assignments of Lt. Col. (Inter Col.) \Valtt'r B. :\lnrtin, :\[C; 

Lt. ( 'ol. (latt'r Col.) Irving S. \Vright, :\lC; Lt. Col. (later Col.) F. Dennett<' 

Adams, :\IC; Lt. Col. (lnt<'r Col.) Alt•xtmdt•r :\Iarble, :\lC; Lt. Col. (later Col.) 

Eug<'nt' C. Eppingt•r, :\[('; Lt. Col. (later Col.) Garfield G. Duncnn, .MC; Lt. 

Col. (lnt<'r Col.) BPnjumin :\[. Bnkt>r, :\[C; Colonel Shull; and Lt. Col. :\lyles 

P. Bnk<'r, :\lC. 

In nddition to chnng<'s of assignments us pnrt of a long-term program, 

devict's us('(l to disspminatt' proft'ssionul information and to mt'et specific locnl 

problt'ms ns tlwy urosp ineludPd nssignnwnt of eonsultnnt from one command 

to tt•mpornry duty in nnotlwr, nnd sonwtinws <'X<'hnngt's between theatPrs 

Wt'rt' nrmngPd. T<'mpornry-duty nssignnwnts to thP Surgt'on Gent'rnl's Office 

\Vt'rt' oftNl rPqtwstt•d. For t'Xnmplt•, ( 'olont'l :\larblc und Colonel Duncnn 

wer<• assigm•d to OTSG to assist in prPparing TB :\lED (\Vnr Depnrtment 

TPchnical :\lt'dical Bullt'tin) 168, Junt' 1945, t'ntitled "Dinbett's :\Iellitus," 

nnd T:\l C"~nr Departnwnt T<'chnieul :\Innual) 8-500, :\larch 1945, entitled 

"Hospital DiPts," rPsp('(·tiw•ly. Similarly, Col. :\[aurice C. Pincoffs, :\IC, 

nnd Col. BN1jamin :\L Buker from the Pncific urt'a, and Lt. Col. (later Col.) 

P<'rrin H. Long, :\[C, from the :\l('(lit<'rranean tlwnter, wt>re nssigned to thP 

Surgpon GNwrnl's Office to giw information nnd exchunge views with staff 

mPmlwrs on partieulnr prohlt'ms in tlwir c·ommtmds. An unusunl tempornryduty nssignnwnt wns thnt of Colonel Butwr, who wns st'nt to Sweden when tlw 

Swt'dish Gowrnnwnt rPqUt'StNl the l!.S. Gowrnnwnt to St'nd nn Army intt'rnist to diseuss with tlw Swedish medical proft•ssion udvunces made in medieine 

during SwPd<•n's rPlatin• isolation because of th<' wur. 

:\l<'dicnl Corps offic·ers who st'rVt'd as consultnnts in mt'dieine in various 

commands are list('(! in appendix A (p. 829). K ot nll Wt're nssigned on n fulltime bnsis. In certain of the srnall<'r communds, an exceptionully well trnirwd 

ehit'f of mt'dical sprvic<' in a hospital might nlso st'rVt' ns consultant in mt'dicint' 

for the commund. This dunl role wns not nlwnys n sntisfnetory substitut(' 

for the full-tim<' st'rvict' of n profl'ssionnl consultnnt. The following eommunds 

were servt'd by pnrt -time consultunts: Bt'rmudn Bnse Commnnd, Pt'rsinn 

Gulf St'rVi<"e Command, :\Iiddle East Servic·e Commnnd (fornwrly Delta 

Serviee Command), nnd r.S. Army Foret's in tlw South Atlunti<" (fig. :n. 

\Ylwn tlw <"onsultunts Wt'rt' appointt'd, it was anti<"iputt'd thnt tlwy would 

use difft'rt'nt apprmwlws nnd tt'ehniqut's in their assignments. Tht'rt'fort', 

tht'y W<'re st'lN'tt'd with the greatest care possible. The fact that tlw consultnnts })('ld important posts in civilian nwdical C'ducntion and pruetict' uddt'd 
·11 ti I _,.1: I\ 

'11".1( '111!.1-•lj·'.L '(>1il111.17'i-•.I••J Ill '.1·•1.11!11"1'"·''1 (•111!1111111•,) Jill!) 111:1'.1·•,( .1•• ,:;;lllj•jiii<J ljll\\ 

'(II:<JI:.IIIII\' <IIIII!.) '\( ·::I til 1'11:;;11\' 'l!('lilll.l·'\1 '.\.lllljl•,l '1'!11.11( ('jll-.11!-•\'-oo:: ·iljllll jl:)id'"lj 

\111.1\' ·:-:·.JII.I·'("'(\ '\' ·,IIII:IJII'II!I,l l"·'ll'"lll ·•11111-l.ll!d .\'1 ('·1\J.I' ,1:.1.1\· ! : :111 I' II .1 

! 

k t ' 

....... ~- ~- .......... .. . --. . -

-. "-"· .... . . . - -- --- ...... -. ~~ .. ·--··~ ..... a.i 

- .:. 

------ -:- -s .:2:? .liP' .... -- -:- ,$._ ~s-

--~--- . - .-.-<? ... 

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. 

____ ..,..._.-..--- I .. ,, -

__ ..... _ ...,....;u • - 5 -

·' , , , , 

, , , , ' , , , , , ' , , , , ' ' -.. 

, ' , ' , , ' ' , ' •• , ! -:. -:~. ~ . . .. . -. 

:'.1.\:\'.l.'i.l:'\:tl,l '1\ .. l(tt:l(\ .·(II ~O::JJ.I.J \J.J..t\ ~ 
!I 

FI•:I·Iu: ·•· ( ·.,111 i11110·d. (', llo·adq11:1rt•·r,.:, l>t·lt:l :-'t·n·il'l' Ct~llllll:llld, llo·lit~pt~li:.:, 1·:!!,\"Jll. 

Fd•rll:•r.\· 1~11:>. 

\n \ \\,. ohliga\ inn and ]'(•.spon:-;ibility or Th(• :-:.urg,·on n,.n,•ral and hi-; n•j)J'('..;('nta1 i,·,·..; in :-;,•\,.,., ing I !wit· n..;..;ignnl<'nh. Th,. :->llt'l'l':->..; of t h1• a..;..;igtlnH·nt..; \\·as d,,_ 

JH•nd,·nt in largP llii'Hslll'l' 11pon llllllllal lllld,•t·..;tanding and trust lwt \\'1'1'11 t lu• 

I'On:->ultant..; and th1• :--;,ll·g~·on (;l'nPral's ()lfil'l'. TIH· l'tl\·iabJ,. l'l'l'ord attaitwd 

by tiJ, .. \lt'di1·:tl l>l'parttlll'lll in tiJ,. fiPid of inll·nwlnH·dil'itw d11ring th1• war 

and th1• \a..;ting apprt•(·iation of thl' nH'Il witl1 \Yhonl thPy workl'd in tiH• li,•ld 

an• l'onYitwing and 1•nduring 11·slitt10nial..; to th1· llll•di,·al I'Oihllltants. 

E\'OLLTIO~ OF .\1 EDIC\L CO~SLLT.\~TS Dl \'ISlON 

( )r~an iza I ion 

Till' 1'\·olut ion of t h1• ~I,·di,·:d ( 'on..;u\t:lllls f)i,·i:-;ion. ()'[':--;(;, was slow. 

HPorganizations of till' of!il'l', wholly ot· in part, Wl'l'l' fn•qw•nt. 2 .\..; :1 n•sult, 

til1• :ll'lllal di'YPioptlwnt of tiH· organization of til1• ,.hj,.f l'onsultant in llll'dil·in,, 

in th" :-:.lll'g(•on (;,.n,·ral's Olli1·1• into a group adPqll:tt1• in nunthl·t· and with 

..;utfil'il'lll ..;upport to funl'lion prop1•rly did not tak1• pl:tl'l' untillatl' in th1• w:tt·. 

Th,. ~ll'di,·inl' :--i1thdivision. l'rof,•s:-;ional :--;,.,.,.i,.,. Di,·ision, OT:--i(i-, was 

l'l'l•aiPd on :!I F,·brunry 1!1-l:.!. TilP unit, ltt•ad,•d hy tht• l'hid l'llllsttlt:t.tl in 

~ ·rt,•· n·nr:: 11ri1 dinrt' .jj ... ,.,J ...... •·d in tl:j .. '•Tiinn an· h1 ... ,.d on (} l Ollie•• Ord.·r...:, OT . ..:f ;, {' .:' •. \rrrtY. ,o, ~7. I..., .\pr. 

)'Ill, -..:o.:no.:n \l,l.l!ll~; '\o.lll.l~.ITI)~ l'•n: :'\n.l,l.l·.ll.l'lll::rnol '\o.l7.' •. ~.' •. \ll~.l!lll: !~1 \lallll.dnfOr""niz:llion 

11\'' ~1 111d 1rd l'r H'1J•·•· .... t )T . ...:.1 i, .\ r rrr~ ~,., \ j,.,. For,., .... 1:, \l.1r. J~q I. :111d 1 :~ t f tr~ rrrit:rt ion C'l!:trr:-;, OT~f f, l" .~ .. \ nny, 

~I Fo·l•. I'll~.~··" II'.,~.,~. '!I-'""· )!II:!, )II'"'' 1~11-1, :; F ·lo. 1'111, "lllol :!I .\11". 1:111, 
10 At'Tl\"ITIE~ OF :\IEIHC.\L COX~l"J.T.\XTS 

nwdiein<', had to fun<·tion undPr th<• Profpssionul SN·vic<' Division. This 

urmngNrwnt wus not sntisfnctory. ProblPms Pxelusiwly profpssionul in 

na tur<', sueh ns poli<·ies con<'Prrwd with diagnosis and t rPn t nwn t, arose constantly as the tPinpo of the war irwn•nsNl and tlw Army pxpund<'d. All eommunications and nwmornndums to or from th£> :\[Pdicirw Subdivision r<'lntiw 

to thPst' mntt<'r'S hud to pnss through tlw ndministrntiw ehnnnPls of thP Profpssionnl Sprvi<'<' Division bPfon• rPlt<·hing <'itlwr Tlw Surg<•on GPnPral or 

ot lu•r divisions of tlw office. Although the officprs of Profpssionul Sprvit·<• 

Division \VPrl' coopemtive and sympathetic, the mechanics of this arrungt'lllt'llt 

n•tnrdPd dP<'isions and ndrninistmtive actions. 

On 26 :\lar<'h 1942, in a g<•npml r<•orgnnization of the Surgpon GPnPrnl's 

Office, tlw Profpssionnl SN\·icP Division lw<'nme thP Prof{'ssional S<•rvi<·<•, 

and tlw :\ledi<'in£> Subdivision h<'ennw tlw :\[pdi<'ill<' Division with un orgnnizn tionul chart providing for hmrwlws in t ropi<·nl dispas<'s, t u hPr<·ulosis, g<•rwml 

nwdicirw, and specializ<•d nwdi<'inP. ThPS<' hranelws wprp not uduully put 

into op<•rntion, with qualifi<•d personnt'l assignP<l to tlwm, until much lntt•r. 

Anot hPr gPnPrnl rcorgnnizntion took place on 24 August 1942. Five 

main S<'l'Vi<'<'S were crcntPd, including onP dPsignntcd Profpssionnl ScrviePs. 

TIJ{' :\lPdi<"irw Division wns rNI<•signatNI :\h•dirinp Branch of the :\[pdieal 

Pmetiee Division, which in turn funetioned as one of the divisions of Profpssional Servic<'s. :\ledicine Brandi retained as seetions its formt'r brnnclws, 

and Colonel :\lorgnn rcmninPd its ehicf, while continuing his duti<'s us chid 

consultant in nwdicine in the Surgeon General's Office. On 4 Xov<'mber 1942, 

( 'ol. Arden Freer, :\lC, who had been Chief, :\IPdicnl Service, "~alter Reed 

Geneml Hospital, 'Vnshington, D.C., was appointed Direetor, :\ledicnl Pntetiee Division, OTSG. In spite of Colonel Frppr's eonsid<'mtion nnd undl•rstanding, this addition of still another administrative echelon was n furthPr 

complication. ( 'olonel :\forgan repeatedly sought to obtain for the :\Iedicirw 

Bmnch a position of greater independence, orw having more direct nppronch 

to The Surg<'on Generul nnd thus being better nhle to meet promptly the pr<'ssing needs of the growing Army. 

On 12 .July 194:~, Lt. Col. (Inter Col.) Esmond R. Long, :\IC, who hnd 

become Chief, Tuberculosis Section, :\1edicine Brunch, und ( 'hief Consultunt 

in Tuberculosis to The SurgPon G<'n<'ral, was uppointPd ( 'hief, :\h•dicine 

Brunch. This ehnnge wns designed to give the chief consultant in mPdicine 

in the Surgeon GPn<'rnl's Offic(' gr·ent<'r fr<'eclorn from routinP ndministmtion 

nnd <'nsipr· nc<·ess on professional matters to tlw chi<'f of Pr·of<'ssionnl Service 

nnd to Tlw Surgeon GcnPml. G<'rwrul :\lorgan continued to initiat<' and 

direct the OV<'rull policies of the :\l<>diein<' Brnnch. On 1 ,January 1944, ns 

pnrt of unoth<'r gNwral r<'orgnnizntion, thP :\IPdicirw Br·anch wns designated 

the :\ledicine Division, with Gen<'ml :\lorgnn ns dirP<'tor. 

Finally, on 25 August 1944, the Profl'ssional ~<·rvie<' wns dissolv<'d, nnd 

the :\l<'dicin<' Division was renlllned :\ledienl ( 'onsultunts Division nnd plnc<'d 

in an independPnt stnt us functioning dirw·tl~· undl'I' ThP Surgl'Oil G<'rwml. 

At this timP, tlu• division was eornposed of four bmnches: Gl'neml :\Iedicine 
OI,'FICE OF THE ~UUGEOX GEXER.\L 11 

Bmnch, Tub<'reulosis Bmnch, Tropicul Dis<'HS<' Tr<'ntm<'nt Branch, and Communieuhl<' Disease Trcatnwnt Bmnch, the last nampd lun·ing h('en <'stnblislwd 

in li<'ll of the SpeeinlizPd ~I Nlieine Bmnch. A final add it ion to t h(' orgnnizationul S('tup wus the position for a eonsultnnt in dt'nnntology, which was fill<'d 

in ~lan·h 1945. 'Yith this structure and direct reltttionship to The Surgeon 

G<'nPrnl, tlw division <·ontinued its nctiviti<'s through V-E and Y-J Days. 

Thus, in ordt>r to carry out the mission of the chief consultant in nwdicine 

in th<' Surg<'on G<'neml's Office, with the muny routine ndministmtin' rt>sponsihiliti<'s which had hN'n made a part of his mission, tl stuff whieh in tlu~ h<'ginning had consist('(l of two nwdieal offieprs had been gradually enlarged to six. 

It was eh'nr at the outset thnt tlw aetiviti<'s for which the chid eonsultnnt wus 

h<'ld rrsponsihl<' could he performed only by men specially t mined in such 

aetivities. As n<'t'd heeame urg<'nt, trained men were usually found but not 

without ddny or, oeeasionnlly, out-and-out obstruction. 

Obstruetions can he explain<'d to some extent by the fact thnt Services 

of Supply, under which the ~h,dicnl Departnwnt oprrnted, controlled medical 

personnel with an iron hand. The Surgeon Generul's Office WitS handicapped 

on many occasions by ediets defining the exnct personnel-allotment e<'iling 

undt>r which its opemtion lwd to be earriNl out und by the fnet that th<'St' 

edids originnted from un authority which, one is forced to conelude, was often 

poorly infornwd if not completely ignornnt of the needs of the Offiee. 

Th<' ~h,dical Consultants Division had more tlum its shnrc of difficulties. 

For <'Xampl<', there wns deltty in excess of 6 months in obtaining un officer 

thoroughly familiar with tropical mediein<', although the need for expert guidnnc<' in this fi('ld had been long foreseen and repentedly urged. Another delay, 

in obtaining u position vacancy for un officer to net ns chief of n communicnhlc 

disease tr('atnwnt hmnch, at one time thrcntcn<'d the very existence of the 

~h,dieal Consultunts Division as it was nt that time constituted. In nddition, 

one may eite the extmordinary wny in which the management of venereal 

diseuse trentmrnt wus hundl<'d. 

In the ficld, the tr<'ntment of venereal discuses, with their hi~h noneffective 

rnte, was nn enormous problem and, becnuse of the mpid developments in 

thernpy, urgently required proper direction. The Venereal Disease Subcommittee of the Xationnl RcsN1.rch Council was one of the most nctive, effective, 

and important organizations in contact with The Surgeon General. It became 

mandatory that the Surgeon Geneml's Office place the responsibility for the 

cure of verH'r<'al diseus<'s in the hands of those prof<'ssionnl men l><'st equippNl 

to muster tlw new mcthods nnd techniqu<'s recornnwnded to the Army by 

t lw V <'nereal Dis<'asc Subcommittce nnd guide these men in tlwir application 

of the newl'r knowledge us it became nvuilnble. Colonel ~lorgun took th<' 

position thnt the trentment of verwreu1 diseuses wns, in fnct, n problem of 

internal medieine; that the local treatment commonly employed nt the tim<' 

wns harmful; aml, tlwr<'fOr<', that the responsibility for treatment should h(' 

~iv<'n to nwdicul rntlwr than to surgicnl (urological) cxp<'rts. This position 

was r<'udily u~rr<'d to by Col. (lnt<'r Brig. Gen.) Fr<'d "·· Rnnkin, Chief 
12 Al'TIYITU.:~ OF ~IEilH'.\L l'OXSCLTAXT8 

( 'onsultnnt in Surger~· to Tlw Surgeon G('neml, nrul irt dtw tim<' The Surgeon 

Gt>rwrnl eiiUH<'ilttt'd this ns oflieinl policy. Xt•n-rtheless, it was impossible 

to ohtnin appmntl for the assi~nnH'IIt of an otrieer who was n sp<•eialist iu 

this field. Sinct> the Pn•n'ntive ~[edieine ServieP, Offict• of tlw Surg<•on General, on the other hn nd. had the personnel available, Tlw SurgPon GPrwral, 

on the n•eomnwndation of Colonel ~[organ, in Xon•mlwr 1942 cr·<•nted n verwn'nl disenst' trPatnwnt s<•t•tion in tht> YPnt•rt>al Disease Contml Brnnel1 of 

the Prcn•n t i n• ~ [('dieine s('1Ti<'t',3 Ill HI throughout the l't'lllaindt'r of the Wlll" 

this clinical activity was adminiRtPrecl in thnt St'l'Yiee. 

Forturuth·l~·. Lt. Col. (latPr ( 'ol.) Thomas B. Tunwr, ~IC, DirPctor, 

Y('tlt'n't1.l DisPase Control Bmrwh, OTSG, l'l'<'Ogniz<'d that it would hP impossible for his field I'('prPs<•ntntiws actually to supt'rvisP trPntm<•nt. ::\lost of 

tlw Hlll'rt>al dist'ast> control ofiicPrs had had public lwalth trnining and little 

or no elinical PXJWI'it•tH't'. Tlwrdor<', th<' consultants i11 nwdicirw in service 

l'Oilllllnrl<ls, thPn t Prs, nnd nrrniPs sprved as ag<'n ts for im plenwn tat ion of n•-

IH'l'PILI disease trPatrnent polic.\· cnuncinted h.v Colonel Tumer and Colorwl 

~[organ. Tlw ~IPdical Consultants Division participated in nll rPlenmt 

activities, such as publicntion of officinl policy in 'Ynr Department circulnrs 

and TB ~lED's; establishment of tren tnH•nt cent<•rs for nPmosyphilis; clinic1tl 

trials of various methods of munngement of gonorrhea, including dut~·-status 

tt·<•a tment; nnd treatna•n t of syphilis nnd gonorrlwn with penicillin. In t lw 

field, the medical consultants, in their rcgulur visits to Army hospitals and 

other l\ledical Department instnllntions, consulted on the clinical manngement of venerenl disense. Excellent Armywide liaison in the important 

functions of control and treatment existed between venereal disease control 

officers nnd medicnl consultants, nlld the low<•red noneffective rute from vener<'nl disease achi('ved during 'Yorld "·m· II n•prescnted n triumph in military 

nwdicinc. Nevertheless, The Surgeon Genernl's organization for tlu.• supervision of venereal diseuse treatment was a glaring exnmple of administrative 

inconsistency and improvisatio11 (p. 24). 

These references to some of the orgunizntionnl difficulties which Genernl 

~lorgnn encount<'l'<'ll in the Surgeon Genernl's Office are not cited in n spirit 

of criticism of the .::\[edicnl Depnrtment. Tlwy arose usually beenuse of the 

position of the ~Iedicnl Depnrtment in relation to the Army ns n whole. They 

were the result of restrictions nnd controls imposed upon The Surgt'on General 

b~· higher nuthority, which, often enough, wus uninformed und unsymputhetic. Thut The Surgeon Geneml wus held responsible for preventio11 nnd 

optimum trentment of diseuse and injury in the Army but was not provided the authority with which to cnrry out this mission is nn incontrovertible 

fuct. It will be nttested to by experienced medical offieprs throughout 

Army. As a partial explanation of this situation, suffice it to sa~· thut 

the physician and surgeon, conditiorwd to prof<•ssionnl nnd socinl relntion3 (1) M<'morandum, Brh!. 01'n. Chnrl<'s C. H!llmnn for Thl' SU11!t'On Ot>nl'ral. 3 :\"ov. 19~2. suhjo•et: Additional Fun<>-

tfon for Venl'rl'ol Di!ll•asl' Control Branch. (2) Of!ico.• Or<fo•r :\"o. 4tl6, OTSO, U.S. Army,12 :\"ov. l!l42, suhjl•et: \'t>nrn:•:ll 

I >isf':ISf' Trt'ntment Transfl'f FunrtlOol~. 
Olfli'ICE OF THE ~UIWEOX GEXER.U.~ 

ships us thry rxist for thr doctor in ci,·ilinn lifr, oftrn found the military setting 

a trying one in whieh to prnetier t hrir profPssion. In fact, it ctm be said t hut 

the l\lPd ienl DPpnrt lll<'n t us n who I<' rXJWril'JH'Pd similar difficulties in its relntionship to tlw Army whieh it spJ·nd. 

Personnel 

Thr prohlPm of prrsonJH'l as purt of thP owmll prohlrm of or~nnizution 

hns h<'<'n indieutrd in h.-oad outlinP us it Pxish'd in tlw SurgPon G<'JI<'ml's Office 

nnd as it was g-rndually rPsoln•d. It had bN'n el<'ar at tlw h<'ginning- that 

the ~ l<'dieinr Suhdi vision, to fund ion fully, rrq uin•d ex}wrts in srv<'rn l nwdien 1 

sp<'cialtiPs to eol!Pet and collntr information, outline polieiPs in diag-nosis nnd 

trPntmPnt, initiatr nnd suprrvisr rrsPnreh, and nid in dissPmination of reepntly 

nequir<'d knowl<•dg<'. As Pnrly us ~larch 1942, n nH•nwrandum had hrrn 

srnt to tlw Exrcuti\·p OfficPr, OTSG, stating thr minimum IWfUiJ·<'IIH'IIt to 

hr fin' ofHcprs. X<'wrthPlrss, <'Xpnnsion of tlw staff und aetiviti<>s of tlw ~IrdiciJH' Subdivision nrwr kPpt pace with the rxpanding IIN'ds of the huge nrmy 

in truinin~. 

Tuberculosis Branch.-It was rrcognizcd Pad.'- hy Genrral Hillman that 

tuberculosis was an rxtrrmdy important prohlrm for thr Army despitr earrful 

screrning at induction eenters. Thrrrfon>, Dr. Esmond R. Long, Dirrctor. 

Hrnry Phipps Institute for the Study, Trratnwnt and Prt'\·rntion of Tuberculosis, Professor of Pathology, t:niwrsity of Pennsylvania, Philadrlphia, Pa., 

nnd Chairman, Subcommittrc for Tuhrrculosis, Division of ~[edieal Sciences, 

X at ional Resrareh Couneil, was asked to accept a commission in the Arn1.'·, 

nnd on 1 .July 1942, was assigned to the Professional Sen·iee Division, OTSG, 

ns ehief of the Tulwrculosis Brnneh, l\Icdicinc Subdivision, with the rank of 

lieutenant eolonel. The Tuhereulosis Branch wns concrrned with all problems 

rrlatrd to thr dingnosis, trratmrnt, and disposition of military personnel with 

tubrrculosis. In a memorandum to Thr Surgeon General dated 13 July 1942, 

the urg<•nt nr<'<l for un assistant to Colonel Long was outlined. Konr was 

nssignrd. Finally, in 0<"tohrr 1942, through an informal nrrangemrnt with 

the Arn1.'· ~Iedienl Center, \Yaltrr Heed General Hospitnl, onr of its nw<lienl 

officers, Cnpt. (Inter Lt. Col.) Willinm II. Stearns, ~fC, was placed on specinl 

duty in the Tuhrrculosis Branch, OTSG, whilr he was still nssig-ned to the Crntrr. 

It was not until 17 ~larch 1943 that Cnptnin Steams was offieiall.'· nssigned to 

the Surgeon GPIWI'Ul's Office. Sueh rxpedirnts were nrcrssnry brcause The 

Surgeon G<'rwrnl lackPd full control in thr manngrmrnt of medical personnd 

and wns thus ohlig-P<I to oprratr und<•r fixrd crilings ns to numbers and rank. 

Tropical Disease Treatment Branch. -In the Paeific nreas, man.'· E.S. 

troops wrrr <'Prtain to hr <'Xposrd to various tropicnl disrasrs. Althoug-h 

malnria was tlw outstanding problem, other diseasrs common in the Tropics 

were rxpPetr<l to affret signifieant numbers. On 21 July 1942, in a memorandum to the Ex<'<·utiw Officpr, Profrssional Srrviee Division, OTSG, Colonel 

:\lorgnn nskrd that a sp<>cinlist in the dinieal asprets of tropical medicine be 

nssi~ned to thr ~lrdieine Suhdi,·ision. No adion was takrn. On 2 November 

L-------------------------------------------···-········ 
.\t'TIYITII::-: Ill-' .\ll:lllt'.\1. t'll\:-:l"J.T.\:\'(':-: 

1-'1'"1 HI I. I ·.,,,,1111:1111- i11 11wdit·i1w. Offit·•· .. r ''"' :-:,,rt:''"ll 1 ;,.,,..r:d. 

1 l.dl. '"" < ·,.1. llarri'"" .J. ~lr111l. \1< ·. 

('!rid. \lo·dit·illl' Hr:llll'lr. I llli•··· .,f t lw :-'ill'-

!.!''"" I ;,.,,..r:d: a11d < "u11-11ltarrt 111 .\lt-dit·irw. t rflj,.,. uf till' ~,ll.t:<'""' :-'i\t h 1· .:-' . 

. \I'll 1\. 

Jl...fl. t'<'lll<'l'' ( ·.,1. Fr:~rwi- 1:. I lio·Jt:lido•. 

\(1". ('hi..t'. Tr••pio·:d (li-•·:t-•' Tr•·:tllll•·llt 

Hr:ll"'''· t lllic··· .. r ''"' :-'11rt:<'"" 1 ;,.,,..r:tl. 

cl...ft. ''"""'"' l.t. ('.,1. ('l;iro·llc'o' :-'. 

l.i\ ill'~"'"!. \1< ·. ( 'lli..f. (),·l'fll:tlllllll!\ :tllol 

:-'.' phil"l"t:\ :-;,.,., i1111. :!Ill h t ;,.,,..r:d IJ.,,pit:tl. 1':-'.\ Fl 1\T: :llod. l:lt•·r. ( ·.,11-11ll:tlll ill 

I lt·l'lll:lt"l"t:\' 111 Tlw :-'111'!.!<'"11 I ;,.ll<'l':d. 

ll:it:lill ('ul. 1:-111"11d 1:. l.lllll!, \1(', 

( 'lii..f < · .. ,,,1111:1111 i11 TltiH·rrulu~i" to The 

~lll't:<'"" t ;,.,,..r:d. 
OI<'l<'ICE OF THE ~UIWEOX GEXERAI.~ 1ft 

1942, Colorwl Freer, at Colonel ~[organ's request, sent a memorandum to 

General Hillman requesting the assignment and outlining the rensons for urgency. On 18 Xon•rnher·, GPrwral Hillmnn r·ep<•ated the requPst in a memorandum to The Surgeon Gerwral. Ko netion was takt'n. Efforts to ohtain 

appointnwnt of a suitahl<• officer W<'re rrrww<'d on 5 Ft•hrunry 1943, wh<'n wnr 

in th<' Pncific was Y<'r.'· active and malaria had become an enormous problem 

in Xt•w Guirwa. erg<•d by G<'n<'rnl ~forgan, Colon<'l Fr<'<'r again wrot<' n 

nwmorarulum r<'qlu•sting the assignm<'nt of n S(W<'iulist and sugg<'sting Dr. 

Fmncis R. Die11uid<•, then Clinical Proft•ssor of ~h·dicirw, Han·ard ~[edical 

School, Boston, ~lnss., and fornwrly Professor of ~IPdi<'irw, Peking Union 

~h·di<'al ( 'oll<'g<', Peking, China. The rrq1wst was grante1l R months after its 

initiation, and, on 22 ~lurch 1943, r .. DiPuaicle was fin.1lly commission<'d 

lieut<'nant colorwl and was assigned to th<' ~h·dical Pmctice Division, OTSG, 

as chi<'f of tlw Tropical Dis<'nse S<'ction. ~[edicine Bran<·h. 

Th<'r<' \Wr<' now five offic<'rs assign<'d to the ~~ edicine Branch of the l\f£'dical Practic<' Division. Tlwse \H'l'<' Gerwrnl ~forgan, director; Colonel Long, 

Tul)('rculosis S<'ction chief; Cnptain St<'nrns, assigned to tlw Tuberculosis 

SPetion; Colorwl Shull, G<'rwral ~h·dicin<' S<'etion chief; and Colonel Dieuaide, 

Tmpi<'ul Dis<•ast> Treatnwnt S<'ction chit>f (fig. 4). On 1 Januar.'· 1944, the 

~h·di<'ine Brn nch was redt>signa t<'d t hr ~ ledicine Division of Professional 

Sprvict>s. \Yht>n Colorwl Long lH'cnnw chief consultant in tuberculosis functioning dirPetly undPr th<• <'hiPf of Profpssional St>rvices, Captain Stt•arns becanw 

chi<'f of tht• Tul><'rculosis Brunch. The otht>r st>dions, now called branches, 

n•ma irwd uncha ng<'<l. 

Communicable Disease Treatment Branch.-\Yhen Colonel Long left the 

l\f<•dicinP Di,·ision, a numPri<'nl vacaru·y was O(Wned. To fill this vacan<'y 

G<•nPral ~forgan pmpos<•d appointnwnt of n chi<•f of a communicable discus<' 

tn•ntnwnt brunch. On 2 .Fehruar·y 1944, in a memorandum to The Surgeon 

GPnernl, General ~forgan outlined the functions of such a brnnel1 and indicated 

the llt'('(l for it, mentioning the pmhl<•ms in rt>lution to infPetious lwpatitis, 

rlwumati_c fen•r, gonococeul inf<•ctions, nnd otlwr cormnunienhl<• diseast>s. II<• 

nlilnwd Col. Hoy H. TurrH'l' thPn ( 'onsultant in ~[('(licine, Third SPrviee Commnnd, and formPrly Assoeintt> Profpssor of ~l<'dicirw, Tulnne Vniversity ~fedienl School, Xew Orleans, La., us his choice to fill the position. No action was 

tnkPn, and on 28 February 1944, the r·peommenclation was made again but was 

cl isu pprond hy The Surgeon General. On };) April 1944, another memornndum to 'l'h<' Surgeon Gt>rwral sought to have ( 'olonel Turner assigned to the 

~I<•di<'ine Division. The request, at first refust'd, wns finally approved on 19 

Apr·il 1944, and Colonel Turner wns nssigned us Chief, Communicable Disease 

TrPatment Bmnch, ~Tedicine Division, OTSG, on 4 ~[ny 1944.4 

Consultant in Dermatology.-Diseases of the skin were common throughout 

the Army, espt•cinlly in the Tropics. In n memornndum dated 29 Novembt•r 

1944, Geneml ~lorgnn requested that n consultant in dermatology be nssigned 

• OffiCf' Orfi•·r :\o. !II, OTS<I, LS. Army, t :\f:ly 1!114, suhJ••rt: Chi..C, Comrnunicahlc Disease Treatment Branch, 

Mcdicin•• llivi~lon. 
Hi .\('Tl\TI'IE:o; OF ~n:PIC'.\1. c 'OX:O:I"J.T.\XT~ 

to tiH' Surgt'on Gt•rwr·nl's Offit•t>. This rPqtwst wns appr·owd, and ~lnj. (lutc•r· 

Lt. C'ol.) Clnr'PIH't' S. Li\·ingoocl. ~IC, (fig. 4) thl'n nssigllt•d to tlw 20th (ic•rH•r·ul 

llospitnl, loentt•d ill Lc•do, Burmn, n•portt•d for duty ill t hl' ~lt•dienl ( 'onsultnnts 

Division, OTS<i, on :w ~lurc-h ln4;). 

Tht• nppoilltllH'Ilt of ~lnjor LiYill~ood hmught to six thl' nurnht•r· of offic·t•rs 

nssigru•d to tlw ~lt>dienl ( 'onsultnnts Di,·isioll. Tlw nurnht>l' l'l'lllllitu•d tht• 

snnw Ulllil dt'mohilizntioll lwl!llll nit hough St'\"l'l'lll l'lumgt's Wt'l't' llt't't•ssiuttt•d 

hy t ht> polic·y of mn kin I! nffit•t•rs of t lu• tli \·is ion n Yn iln hlP for· on•t-st'n nssil!lllllt'll Is. 

:\lnjor Stt'nrns wns r·c•lt•nst•d on 2 .Jununr·y Hl4•i. to ht•t·onu• ehil'f of thl' mt•dic·nl 

sprviet' of u mmtht•r·pd l!t'twntl hospitnl. nntl ( 'npt. JohnS. llullt. ~I<'. rPpltu·ptf 

him ns Tuhc·r·eulosis Brnneh ehit'f. ( 'olorwl Shull wns r·c•lt•nsc•tl Oil 22 ~In_,. I !14•). 

to hPc·onu• ( 'onsultnnt in ~h·tlieirw. Sixth t·.s . .Ar·m_,-. t hl'll in t hl' Pnc·ifil'. nlltl 

wns rt'plnct•d hy ~lnj. (lnh•r Lt. ( 'ol.) Fr·c•clt•r·ick T. Billilli!S, .Tr .. ~[( '. ns (it'llt•r·nl 

~ lt>tl icirw Bmrwh ehic•f. ( 'olnrwl Tm·nt•r· wns n•lt•nsc•d on 12 .July Hl4;), to ht•-

t•onu• ( 'ollsnltnnt ill ~lt•tlieirw to the• StliW'Oil. Army Fon·c•s. \Yc•stc•r·n Pnt·ific, 

nrul. httt•r·. ( 'hiPf ( 'ollsnltnnt in ~lt>dicint' to t ht' Sm·l!t'Oil, t·.s . ..:\r'my For·t·ps, 

Pncifil'. liP wns r·Ppltwt•d hy ( 'olnrwl Eppilll!t'l' ns ( 'onununienhlP Dist•nst' 

'l'rt•ntmPnl Bmru·h chiPf. ( 'olnrwl DiPtlltitiP n•mnirwd in tht' \lt'dicnl ('onsultnnts DiYision nntl lwcnmt' its tlt•puty tlit't'l'ttll'. lit• t'Oiltillllt'd to sc•r·n• 

ns ehit>f oft lw Tmpil'nl I>ist•nsP Bmrwh. 

CL:\SSIFIC:\TION Al\D ASSH;l\\IEl\T OF PEHSO~l\EL 

Approprintt• nllot'ntious of pt•r-somwl with spt•l'ittl qunlifientions. t'Sst•ntinl in 

rnnintniuiug hil!h stnntlnnls of nwtlienl eali'P, I'Ptprin•d fnmiliurity with tlw rt>-

quir·t•mc•uts of tlw positioll nu·nrwit's to hP fillc•d nntlau·t·m·ntP krwwlt•di!P of tht> 

fptnlifientions of the• nwn nvnilnhlt•. Enrly ill tiH• JH'OI!l'lllll. diflieulty wns t•nt•ountt•n•d in nssigning spt•l'inlizPd JWt-sonllt'l in Zoru• of Intt•r·im·l!l'IH't'nl hospitnk 

whieh Wt'l't' mulc•r· thl' dirt'f'l t'Oillml of Tlw Sm·l!t'Oil Gt•m•r·nl. It wns nlso 

tliflic·ult to nssil!n SJH'einl ist s to t lw st•r·vic·c• f'ommn ruls for r·pnssil!llllH'nt I o 

slution hospitnls nnd otht'r spr·,·ieP c·omnullltl instnllntions.5 This diffieult_,. 

rpsultt•d from thl' npnthy of somP oflict•r-s in tlw Pc•r-sonnt>l Spr·vict•, OTSO, in 

l'PI!Urd to SJWeinlizntion in thl' prawtict• of nwdic·illt'. Tlu• Pt•r·solltlt'l St•n·it·t• 

wus t'lll!lll!l'tl i11 t ht• t'llor·mous jnh of nssil!nilll! l!t'llt'l'lll nu•tlienl oflit•t•r-s for· t ht• 

mpidly t•:xpnlldin!! ..:\rmy. ~lorl'OVl'l', 110 stnlltlurdizt•tl ..:\l'lnywitlt• dussificution 

of nwdil'ul oflic·pr-s ns to S(Wt•inltit•s t•:xistt•d ill Purl~· 1{)4:.?, n11d nn ust• wns ht'illl! 

rnutlt• of u dnssificution of ci\·iliun intt•r·nists ful'llislrl•d hy eiviliun mPdicul 

nrgnnizn t in11s. ti 

'A~ ~onn :~< ,;,•rvh,• '''"mmn•l Nlll~nlt:ml~ wo·n• appninh·•l, lht• Ct'llt•r:tl hn~pitab Jll(":llt'<l In tlwlr ('(llllm:uul rt'<'O'i\"o~l 

frnmtllt'm a~ nnl<'h allt•ntlt>n :nul ,,,n~ultatlnn :III•IJM'r~nllllt'lmauac•·mt·nt a~ tht· ~tatinn hn:<pital~. Erfnrl< w•·n· maol•· 

In ••<lahli>h ,.,.,,.. liabnn IH·IWN·ntlw "n i<•· N>llllll:lll<l ,,,n~ult:mt in nlt·didnt• anti tht• ;\lt'<llml Cnu~ultant~ llivi>ion, 

OT~n. to maintain roor•iirmtion an•linh•!!ration In :llllllall••r" iududiuc tht• '"''il!nmt•ut nf "l"'t"i:lli7t•d tM·rstmnt•l. 

• !ll'fnrt• lht• outhn•:1k of Worl<l War II an•i a~ part nf prt•pamtiou lor th•• t'lllt•rct•u•·r. th•• Commitr.-• nu :'>lt••llrlnr of 

lht• '\atinrml H<'"<':Jr<•h Cnun<'il. iu NNlJM'r:ltinn with tho• .\nwri<'an ('nllo•!!t' nf l'h\'<id:m~. pro\·idt"l Tht• :O:nr)!t'tlll llt•tll'ml 

of tlw .\rmr wllh a ran·fullr pn•t•m••lli"t nf tho· inh•rnbl>' in till' t ·uito•d :O:t:lh'>'. Thi< da"'ilkatinu furni,.lwd a prnfo·>'.'ion:tl 

o•\'alu:tllnn of t•arh JM•r,;,m :1~ In '* poh•nti·Jiitio·~ fur a"<icnnwnl ""· war• I nlli.-·r, ,.,.,.,inn d•id. :l"i<tant !"11id, nr rhlt•C of 

sc·n·iN'. ou hi< arrival in lilt' Ofli.-· nf t ho• :O:urc•·nn 1 ;,•no·r ,J. ! 'nlnul'l :'>lnrc:lll pn,.·un·•i t hi>' li"r frumt h•· lilo·< nf tilt' l'o·rscmrwl ~·n·i.,•. Tht• :'\lo••ll'"'' Cnn"nltanl~ IJh·binn arui tlw l'•·r,.mno•l :O:t·n·j.,. "'"'' m:ulo• o•\h'n>'i\"1• usc· nf II oiurilll! tho•<•arly 

month" of lht• war. 
Ol<'l!'lt:E OF THI·~ ~UHm·:o:-.; GE:-\ElU.L 17 

Colon('l Rankin and Colom'l ~[organ, in 1942, participat('d activ£'ly in 

The SurgPon Gl'nl'rnl's offi('Pr-procurPnwnt program. ThPy ,·isitNl eivilian 

ffi('(lical soei<'t~· lllt'('t in~rs and insistt•d upon t h<• c·nn•ful. cousidPrPd nssignnwnt, 

by The Surg<'oll G('rwrnl. of th<• SJ><'<'ializ<•tl p('rsomwl proc·m·<•cl. Thes(' p<•rson11('1 functions W<'l'(' irwhul('d in tlw dutil's of thP <'hit•f consultnnts in tlw official 

dt'finition of th(' fmwtions of tlw :\[Pdiein<' and Surgt•ry Suhdi,·isions, as statl'd 

in Offi<·(' OrdPt' ~o. S7, OTSG, U.S. Army, 18 April 194:!. This order r<'ad in 

part as follows: "* * * approval, h~· liaison with tlw :\lilitnry P('rsomwl 

Division, of sdt•etion of pt•rsomwl for k('y proft•ssionnl positious." Gradually, 

t hPst' p<'rsomwl funet ions gnirwd the support of t hl' Pl'rsonnPI S('rvice. Th<' 

fnct lwcanw t·peognizt'd in tht• Sm-gt.'on G<'nPml's Offic·<' urul. suhs<•qtwntly, in 

S<'ITicl' <·ommnnds and t lwa t Prs that only through control of ~rwciuliz£'d pN-soutwl could th<• cousultnuts pprform pff('etiwly tlw duti<•s ussigrwd tlwm. Wlwr<• 

this priueiplt• hnd tlw wholPlwurt<•d support of t II(_• surg('Oil of t h<• conunancl 

nnd of his p('rsomwl officPI', it yi('ldPd tlw gr('at<•st rPturns in imprond lll('Uicul 

('fil'{'. 

Tlw finul IH'<'<'ptune<' by The Surg<•on G('tH't'ul of the proposition thnt the 

:\h•dical und Surgicul Consultunts Divisions should eoopt•m t t' with the P<•r·sonnel St·n·ic<' in tlw ussignment of ull individuuls with sJwciul quulifientions in 

tlwir n•spt>ctin• fiPlds wns busic to tlwir su<'<'<'ss in tlw Surgpon (i<•nerul's Oflice 

und throughout tlw Army. Finully, th<' l'<'rsorHJel SPrvi<'<' in,·itl'd the ~[edi<'ul 

und Suqdc·ul Consultunts Divisions to <'OOJWI'Ilt(' in Pstuhlishing lt elussificntion 

hm·wd on <'VIlhlll t ion of profpssionnl qunlificut ions. Out of the deliberntions 

whi<'h PnsuPd, tlwn• dt•vPlop<'d, nlhPit belnt<•<lly, tlw nwthod of plucing ullnwdi<'ul offi<'('l's initiully into 1 of 4 entPgoriPs---..:\, B, C, und D--neeording to urhit mrily <IPfirwcl st andnrds of profpssiorllll t ruining und t•xp<•rience. Su hseqtwntl~·, at appropriate int<'rvals, th<• elassiflcntion of l'nch offieer wns to he 

r('Vi<'W('d on tlw husis of dt•monstrutPd uhility in the .\rmy.' Beeuuse of udminist I'll tin diflieult iPs, 111 uch time wus lost in inst it ut ing this lll<'t hod of prof('ssionul l'Vuluut ion. N everthelcss, tlw adopt ion und Us<' of tlw dassiflcat ion 

l<•d to gt'<'H t im provpmen t in persomwl lllllllllg<'IIWn t during t h<' la tt <'r part of 

tlw war. The eonsultants in servieP eommnnds nnd in OV<'l'S<'U tlwat<'I'S \H'f<' 

in an idPnl position to ussume r('sponsihility for the eontinuing t•vuluution and 

tw•vuluution of nwdieul officers to ke<'p the dussifications eurrent. 

The l'<'sponsihiliti<'s of the chief eonsultant in nwdieine with r<'gnrd to 

nppropriut<' nssignnwnts to position vneancics were d<'fined nnd neeorded official reeognit ion in Offiee Ord<'r No. 175, OTSG, U.S. Army, dat<•d 25 August 1944, 

whieh stut('(l: ''As..~ignnwnts of k<'y p<'rsonrwl will b£' mndl' only with the eoncurrene<' of tlw nppropriute SPrviee or Division purtieularly eone<'rn<'d with or 

poss<•ssing speeiul knowl<'dg<' as to the q uulitieutions of t hl' offiepr·s and t h<' r<'-

quirPnwnts of speeiulty ussignnwnts." Th<' SurgPon (Jprwml PiwourngPd the 

sum<' uttitude r('gurding tlw responsibilitit's of eonsultants in medieirw in sPnicc 

7 T:\1 12-400,30 Oct. 1943, Offi<'l'r Classlflcntion; Commlsslom•rl an<l Warrant, ApfK'IIflh n, Classlflcntlon of 1\fcdlcnl 

Corps Oflit'l·rs. 

iifl4!17fl"-fl1--4 
ACTIVIT1VS MVIC LCI\ IIT -I V1

AW/

Ii I -I?;.I lt;II
OFF1~IC E "F' TH'E VSURI1GE" N GEN ERAL 1 19

F ;uia (. o t imie C. ( IIt (ti II8thtii~ (tlr NeW1f-1 Sm ithI W ales, .\n'-
I~~~~~~~~~~~~~~~~~~~ 411 14 44~41:14 4i4l\ 111II: A\ VI":-;X~\l'f4III~l'1 

Illlc IIIll 1i1IMII ll41114 i 4 114:l114 I44II/'4'i.4 1l'IIl 41l :11

)TS( 44 I i I 141 l2 I lB 444:11 111:1lt 111 14 l-d -4'IlI'- ill I(, lilt' \;Ii4'41 l\Jt'll til14,

itl, \I ll1 -)] 4' \ It- r II " p- 14:1 '11 :11 Ill11 14':1144 II;II 441,~ I144 :144l.411' 41 l4 1 4

l l.-fl 44 \4:14 \:4 l1: 41 1)41 1 444 1114-41j414.-' 14 14''1 14

III Ii 14'l \\ III \4'1 i4- I'.4 J4IlI- 'Ill\ Iii .4I4Io 14-.11- Ill 14' e ,' 14Il 41

\\A, 14444 Hill41 111(1 ill it4 4Illl :4 i4l 11j411- I11444 1-' 141 - 1 1'1:iI 11 Hil41 1.jlll- I 1 I\ 1114' ()~41, 4 41:l,
OFFICE OF THE SURIEON GENERAL 21

Interior and in Iiobile units in theaters of operations. The Me(dical Consultants Division held that the most important contribut ion of internal medicine,

ill terms of iiaintaining tile effective strength of tile Army, was tile successful

treatment andii l)ro11pt rettrinii to active (liuty of tile acutely ill patient. In

theaiters of operations, these patients noriiial1y received their initial definitive

treatinent in station, field, and evacuation lios)itals. This fact was not giveii

prol)er econsideration in tie staffiig of these lhosl)itals. Station hiospitals in

the Zone of Interior antid mobile and tixed hospitals overseas that cared for actually ill patients should have received a larger numlber of well-trained internists (fig. 5). In timne, this mistake was corrected in large measure in tile station

hospitals of the Zone of Interior. However, overseas, particularly in the Pacific areas, tile tables of organization were adhered to. Late in tile war, tile

resulting (deficiencies were in 1process of being correcte(d by local arrangemient ill

soiiie evacuation and field hospitals.

CLINICA L SERVICES IN ARMY HOSPITALS

Organization of the Medical Service

At the beginning of the emergency, it was generally believed that the

organization of professional services convention0ally employed in civilian hospitals would function effectively in Army hospitals. The major services of

mnedicine and surgery were outlined in TM 8-260, Fixed Hospitals of the Medical Department (General and Station Hospitals), dated 16 July 1941. The

inedical service of large hospitals contained sections for general medicine,

communicable diseases, gastrointestinal diseases, car(liovascular diseases (fig. 6)

and neuropsychiatry. Later, the section for venereal diseases was assigned to

the medical service. These sections were commonly housed in separate wards

and headed by medical officers, who were designated chiefs, serving under the

direction of the chief of the medical service. In addition, separate sections

had to be maintained for officers and for enlisted men, in accordance with Army

customs, and for women. Experience indicated the desirability of a section

for dermatology, although one was not provided for in the organizational chart

in TrM 8-260. The Medical Consultants Division, OTSG, attempted to provide

for the selection and assignment of personnel qualified to function in hospital

staffs so organized.

As a rule, neuropsychiatry was organized as a section of the medical service in Army hospitals in the early part of the war (fig. 7). As the Army grew

and neuropsychiatric conditions increasingly contributed to the noneffective

rate, the Neuropsychiatry Consultants Division, OTSG, felt that the establishiient of separate neuropsychiatric services in Army hospitals, indentical in

status with medical and surgical services, should be considered. This separation was effected in some of the large general hospitals in the Zone of Interior,

and these hospitals became sl)ecially designated for the care of neuropsychiatric

patients. However, for the most part, neuropsychiatry sections remained a
22t ATIV\ITIES> bil' MEDIC AL. ti NSII.T.\NTS

F~; .hi, f.Criamo GtrlI;1n .AtIw.(nJ

2

7. Pafivnt oil nvur ps~ychiolr v \\:ir. Pec m cs( ll-d Iopt l

4:11,Cck ih
OFFICE OF THE SURGEON GENERAL 23

FwnURE 8.-Scene on ward at neurology center,

Ashburn General Hospital, MeKinney, Tex.

part of the medical service in Army hospitals. The Medical and the Neuropsychiatry Consultant Divisions, OTSG, and the consultants in the field were

in complete agreement that the care of patients with somatic and psychic

disturbances was the common responsibility of internist and psychiatrist and

that the closest cooperation was indicated. Neurologic diseases were officially

designated the responsibility of the neuropsychiatrists, and, in a few hospitals

designated as neurology centers, separate and independent services were established (fig. 8). In general, however, cooperation between the internist and

the neurologist was considered so essential to proper treatment as to discourage

organizational trends to separate them.

Management of Diseases

The treatment of diseases in Army hospitals was under continuous scrutiny

by the Medical Consultants Division, OTSG. Publications based on the best

available knowledge concerning the management of various diseases were

prepared in the division for publication and prompt distribution. Their effect

upon practice wias immediate and Army wide. Only two examples will be cited.
24 ACTIVI1TIE1% OF MEDICIAL CONSU'LTANTS

The timfe-hlonoredl andl oft en coIIlipil-te~d schiedules of fiherap~v for mlalaria

were replaced wit Ii miore simpijle reg-imies, after carefuil evalialtion of thle result.,

of controlled experimenits.8 III tile mana12gremlent of tgonorrhIea, evidenice of tilie

existenlce of sulflona Iiiide-resist aiit goniococc-i ledl, ill July 1942, to the emiplov--

Iiienlt of artificially illdluced fever coli11illedl wit il sillfllna III ies., This treat -

Iitielt , hlowever, t hiotiglIi sat isfactory inl man1iy instanices, was accom ipanliel I v

app1reciab~le (agranld was aband~onied in February 1944 inl favor of peniciillin ~l

whichl had been11 'showii to b~e Iiig~ldv effective. 'Illese radhical chan11ges InII Ile

t rca I llenlt of two imlpor-tanlt (diseases were lbrollghit about prompt ly ilirou~ghout

tlie entire hiospital systemli of tilie Armyi. Policy governing t hieseI anld lianny

othler i herapelt it' procedulres was formulat ed inl tile d ca (osuilt l ants,

Division. Tile mnedIical conisult ants t hroughiout thle. Armny sup~ervised iniplemlenitat ionl of tlie policy.

Diphtheria.---Ini tile Pacific, it. was ob~servedl Otat a (listuirbance involving,,

the periphieral nierves frequently occurired inl tile presence of certain persistenit

ulcerat ions of tile skin. Diplit hieria bacilli wvere suspected, and careful baicteriological studi~ies proved thiemi to h~e hiliialbitants of these ulclerationls. These

and simiilar observationis fromt the bindia-Bitirlita theater sliedl new light upoii

hie diagnlostic Criteria, clinlical course, anld thlerapeuitic m1anlagremlent of elutaneous diphitheria. The Medical Consultants Division, OTSG, p~repared a1

comprehiensive (discussion of this subject for (distrib~ution to officers throuighout

the Mledicad Corps."1

Hepatitis.- -Clinical and laboratory studies, carried out in the Armyi

11id11(1 aiOlig civiliauis, mlade it possible, in November 1945, to publishi TB MIED

206, Infect ious H epat itis, which con taineti an evailuattion of tilie clin-ical criteriat

anid laboratory procedures used in the dhiagnosis and management of thlis

(disease.

Tropical diseases.-Descriptionis of thle, clinical feat ures, laboratory*

findings, andl tlierapeut ic managementi of many cliniical disorders enicoun iteredl

in the Army, particularly inl the field of tropical disease, resulted fromi ob~servations which were correlated under the guidance of tile Medical Consultantts

Division.

Venereal diseases.-General I\Iorgan's opinion regarding the mnanagementi

of veniereal diseases in the Army led to an important and difficult policy (hecisioli

on the part of The Surgeon Gleneral. In the peacetime Ariy, its inl civilianl

practice, the care of veniereal diseases, especially goniorrhea, was assigniei to

tie urologist. In goniorrhiea, the conventional procedures were urethirail

ICircuilar Letter No. 153. 0TSQ, U.S. Army, 19 An,-. 1943, subject: The Drug Treatment of Malaria, Suppressive and

Clinlil-1.

9(1) Circular Letter No. 74, OT5(1, U.S. Army, 2.9 July 1942. subject: D~iagnosis and Treatment of the V~enereal Dils- eases. (2) Circular Letter No. 861, OTs(1, U.S. Army, 1S Auz. 1942, subject: F'ever Therapy in the Treatment of Gonorrhea. (P) Cicuruiar Letter No. 97, OT5(i, U.S. Army, 12 May 1943, suhject: The Use of Combined F'ever arld( Ch('MOtherapy in Sulfonami Ic Resistan t I ionorrhea and I eneral Consitlerat ion on the Therapeutic U se of Physicalily Induced

Fever.

"10(1) TB MED 9, 12 Feb. 1944, subject Penicillin. (2) TR3 MEl) 16, 6 Mar. 1944. subject: Penicillin Treatment of

Resistant (ionorrhevj.

[I I'll MEl) 143, February 191.5, subject: Cutaneous D~iphtheriat.
OFFICE OF THlE SURGEON GENERAL 2

rriatinsthle frequent Ilse of prostatic massarge, ueha ons n lde

wr-ligations. Genlitourinlary wards equipped Nvith bat teries of specially designled

irrigat ion Commiiodes' were providled ats standard equipment for hospitals.

All of this was Outmoded when it was found that suilfonamides by mnouthi

promptly curedl gonorrhea inl thle vast majority of cases and that local irrigations

and manipulations caused the complications whinch plagued therapists anmd

enorim10Iosv uincreasedl tile nonlefl'ective rate inl the Arumv by increasing the

duration of the (disease. These revolutionary dlevelop~ments imadle it quite

clear that goniorrhlea, ats well ats t 1e othier venereal infect ions, shiouldl becoim e

the resl)onsibdlitv of phYsicians rather than of Surgeons. Reconmmendat ions

to t his enid by thle chief Consultant inl medicinle were receivedi without cutihuisiam mimay quarters. It, app~eared to be especially dlifficult for Regutlar

Arnmy officers, whose experience with gonorrhlea and its complications had

b~een long and dlismial, to accept the new doctrine. It. wats promptly accepted

In thle Suirgical Consultants Division. The official announcement of policy

by Time Surgeon General camne only after thle loss of munch timle.' 2 Thle reinar11kable eflectiveness of the sul fonamnides inl treatment of acuite gonorrhea

wind tile disappearance of complications when local treatuments were abandoned

SOOn) becam iie apparent to aill. He re, indeed, was anl ext raordhinary episode inl

the huistory' of minlitarY mnedicine. No Other decvelopmenclt duiring tile war

contributed so significantly toward lowering the noneffective rate.

Drugs

The Selection and distribution of new drugs and of new preparations of

01(1 drugs for Ilse by the Medical Departument. wats an imp~ortanmt function of

tie M edhical Consultants Division. Thle drug list inl the Mcedical Departiment

SuipplyI Catalog, U.S. Army, wats reviewed frequently. The (division activel *y

participatedl ill planning and observing, clinical trials of many drugs, notably

Jpeuicilliul, the p~rodumction and clinical use of which were inl thle experimental

stage."3 lII thle select ion of at thierapeutic agent for Ilse in iMedical Departmnent

inlstallationls, thle fuille-st consideration wits given iiot. only to its efficacy but

also to thle (dangers involved inl its use. Treatmient wvith proprietariy lprel.aratioums which were not onl tile Medical Department Supply List wats discouragred.

The Surgeonl General, upon recomnimenudation of the iýledical Consult ants

D)ivision, est ablishied policyN prohiblitinig tlie Ilse of drugs not includedI inl tile

Arm v1 Service F~orces M edical Stippl- ('at alog, the Unitedl States PhmarmlacoJ)oei, or ( lie Nat ional1 FormuularY, Or accepted by tilie Council oil Pharilnacv*v

and~ ('heni istr v of tilie Amnericaim MIedical Association Or tilie Councnil onl D~ent al

Thlerapeu tics of' t ile American D~ental Association, unless prior approval of

The Surgeon General or thle applropriate theater surgeon was obtained.',

12 (1 ) ('iretar Letter No. 195. OTS(L. U.S. Army, I D ec. 1945. subject: Treattnent of Veuierval D isease in Army

Hospiitalsi. (2) 'IM M- 262, 1 J1uly 11915, cih. 1, sve. 21, Mel .icjat Service.

03 (1) Se f1oo lnotv 10, 1. 24. (2) ' I'l M ET )'s 106. 11 Ocft . 19414: 1)4;, 2M Aug,. 194-5: 110S. 20 Autz. 19445: and 172. 11111t19W11.

14 (1) War Deparrrtmensit Circular No. 321, August 1911. s*ec. 11, I st of Mudicjoai Auun~t . (2) Wiar De)partmn Cuit jrcular No. 261, 1 S;vpt. 1945, sec. N 11, U*se or 'Med icinalI Aaeuu s.
26 ACTIVITIES OF MEDICAL CONSULTANTS

Chest Examinations

Roentgenographic examination of the chest of every inductee was essential

during mobilization, for the protection both of the individual and the military

service. Examinations with the conventional 14- by 17-inch X-ray filn were

culnbersonme, time consuming, and expensive. Civilian equipment and personnel were frequently employed, sometimes at great expense. The Medical

Consultants Division, through Colonel Long, Chief, Tuberculosis Branch,

was instrumental in establishing photoroentgen units using 4- by 5-inch film

in all induction stations. It thus became possible to make routine chest

X-ray examinations without burdening local civilian X-ray facilities and with

great financial saving to the Government.

Clinical Laboratories

The Medical Consultants Division, OTSG, had only an indirect part in

the establishment and organization of clinical laboratories in Army hospitals.

The Preventive Medicine Service, OTSG, was charged with this responsibility. Although in the Surgeon General's Office the relationship with the

Laboratories Division of the Preventive Medicine Service was always one of

cooperation, difficulties resulted here and in the field because of administrative

separation. Tile experience of World War II leads to the conclusion that

a more direct participation in the planning and supervision of laboratory

work by the Medical Consultants Division and by the clinicians assigned to

the medical service of hospitals would be helpful to the actual operation of

clinical laboratories in the field. The evaluation of routine and special laboratory procedures in Army hospitals or in special laboratories in support of

Army hospitals is believed to be, to a large extent, although not exclusively,

the function of the clinician for whose assistance the laboratory, in large part,

exists. In the service commands and in oversea theaters, consultants in

medicine interested themselves directly in the maintenance of high standards

in tile clinical laboratories (fig. 9). This was beneficial both to the laboratory

and to the medical service.

The appropriate use of laboratory procedures by medical officers was

the subject of special interest both to the .Medical Consultants Division and

to the medical consultants in the field.' 5

Convalescence and Reconditioning

The Medical Consultants Division, OTSG, took an early and continuing

interest in measures designed to shorten the hospital stay for the sick and

at the same time to return the soldier to duty in the best possible condition.

The great number of patients who were hospitalized with minor illnesses

and the length of time they spent in hospitals contributed heavily to the nonis Circular Letter No. 193, OTSG, U.S. Army, 30 Nov. 1943, subject: Elimination of Unnecessary Laboratory Work.
OFFICE OF THE SURGEON GENERAL 27

effective rate. SoIliers had to remain in hospitals until they were fit for

full duty. In 1942, there was no organized effort in hospitals to utilize time

available in the convalescence phase of illness to improve the soldiers' physical

status and morale prior to his return to duty. The Medicine Division took

the initiative in this matter. Through visits to the field and informal correspondence, an effort was made to develop a program to shorten the time

spent. in convalescence and to make better use of this time (fig. 10). As a

result, War Department Memorandum W40-6-43 of 11 February 1943, entitled "Convalescence and Reconditioning in Hospitals," was published;

this memorandum marked the official initiation of a definite program for the

rapid and complete rehabilitation of the disabled soldier. Although the program was far from satisfactory, it terminated the attitude of indifference

toward the matter. The service command consultants in medicine encouraged

and, in many instances, helped initiate reconditioning programs in hospitals

under their professional supervision. In late 1942, General .Morgan and Brig.

Gen. (later Maj. Gen.) David N. W. Grant, the Air Surgeon, conferred informally with Maj. (later Col.) Howard A. Rusk, MC, Chief of the Medical Service, Army Air Force Station Hospital, Jefferson Barracks, Mo., on the subject

of convalescence and rehabilitation. Major Rusk promptly organized a

reconditioning program at the Jefferson Barracks Station Hospital and put

it into operation. This marked the beginning of the extraordinarily effective

program developed by Major Rusk for all Air Force medical units. Subsequently, greatly stimulated by this successful program in Air Force hospitals,

The Surgeon General established a reconditioning division to administer such

programs.

ADMINISTRATIVE AND CLINICAL ADVANCES

DURING WORLD WAR II

At the close of the war in 1945, the Director, Historical Division, OTSG,

U.S. Army, requested the Medical Consultants Division to provide in outline

a statement of general advances in medical treatment during World War It.

The following comments are taken from the reply to this request. They

are presented without editing and represent attitude and opinion as of 24

September 1945.

1. Effective utilization and supervision of specially qualified medical personnel.-Largely

through the services of a small group of expert consultants in The Surgeon General's Office,

Service Command Headquarters, and Theater Headquarters, the varied specialized skills

of medical officers have been effectively used and supervised hoth in the United States and

overseas. A system of hospitals has been createtd with selected staff and equipment, for

the treatment of special military medical problehms. In general, professional care hIas been

standlardized at a high level. The results are reflected in shortened periods of hospitalization and rediuced fatality rates. D)avs lost because of diseasse averaged 13 for 1942-44,

against 18 days for 1917-19. Deaths from (disease were 0.6 per 1,0W0 cases in 1942-44,

against 15.6 per 1,000 cases in 1917-19.
A
II ILMIA

F*ictr: 'j. ( onthmd C. 2:1~711 Si ,jjj lt~ o piT~;t~.11 Finu.uchhi:d, New~ (iuinca:,

Ise I~h il 1, 1 ). I.-Ol NMcdj(-:l I.:ihornuto %-, It:i IY, 19t 15.
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,J
OFFICE OF THE SURGEON GENERAL 31

2. Effective development of sulfonamides and penicillin as chemotherapeutic agents.-The

application of penicillin was developed in a small fraction of the time that would have been

required in peacetime. The success of the use of sulfonamides and penicillin is reflected in

periods of hospitalization and low fatality rates for many infections, specific examples of

which are given below:

a. Alen ingococcus infections, including meningitis and sept ice mia.--Sulfadiazine

was proved to be an extremely effective treatment, far superior to any previous method,

even in extremely severe cases which occurred in large numbers at various times during the

war. Later, penicillin was shown to be almost equally effective. The case fatality rate in

World War II was approximately 4 per cent (to be compared %%ith 38 per cent in World

War I).

b. Bacillary dysentery.--Sulfaguanidine, the drug of choice at the start of the war,

was replaced by sulfadiazine which was found to be the most effective treatment available.

Although a great many cases occurred, the case fatality rate in World War II was about 0.05

per cent, whereas in World War I it was 1.6 per cent.

c. Pneumonia.-The types of pneumonia which occurred in the two World Wars

differed to a considerable extent. Nevertheless, it is noteworthy that the case fatality rate

in World War II was 0.7 per cent, as against 28 per cent in World War I.

d. Acute upper respiratory infection.-It was shown that in the presence of an epidemic of this disease the daily administration of small doses of sulfadiazine decreases imaterially the incidence of complications which are commonly associated with colds and which

are usually due to streptococcus invasions. As a corollary, it was found that certain types

of streptococci become resistant to sulfadiazine.

e. Venereal diseases.-The use of penicillin has revolutionized the treatment of

gonorrhea and syphilis. Days lost by soldier patients because of gonorrhea in 1944 averaged 7, whereas the average in 1939 was 42.

f. Skin diseases due to bacterial agents.-Medica) Department studies have shown

that various methods of using penicillin greatly improved the treatment of many of these

infections, especially impetigo, furunculosis, and ecthymatous ulceration.

3. Streptomycin.-This recently discovered drug is still under study. It has already

been shown, however, to be effective in certain diseases that are resistant to treatment with

other agents, notably certain otherwise intractable infections of the urinary bladder.

4. Effective treatment of malarial attacks.- Largely through the application of improved

methods of using Atabrine (quinacrine hydrochloride) and by the prompt institution

of treatment, malarial attacks have not caused chronic physical disability and deaths from

malaria in 1943 and 1944 amounted to only 180, although there were recorded about 320,000

attacks (0.06 deaths per 100 admissions). In 1917-19 there were 36 deaths due to malaria

among 15,600 admissions for malaria (0.02 deaths per 100 admissions).

5. Higher fatty acids in the treatment of certain superficial fungus infections.-It has been

shown that preparations of undecylenic acid and propionic acid are both effective drugs in

the treatment of troublesome superficial fungus infections, including "athlete's foot." In

addition, these agents cause many fewer sensitivity reactions than drugs formerly in use.

6. Podophyllum.-Just before World War II began civilian physicians found that podophyllum was effective in the treatment of verrucae of the genitalia. D)uring the war medical

officers confirmed this finding, obtaining spectacular results in the treatment of this

condition.

7. Advances in knowledge of the course and general management of important diseases.-

In a number of instances important advances were made in the knowledge of the course of

serious but poorly known diseases and at the same time the general management of patients

with these diseases was greatly improved, although in these instances effective specific

chemotherapeutic agents are not now available. The following instances deserve special

mention.

a. Infectious hepatitis.-Important advances were made in the diagnosis and

prognosis. Much new information was obtained concerning the significance of numerous
:12ACTIVITIES OFi MED)ICAL CONSULTANTS

tests of liver function. Early and prolonged rest in bed and dietary mianagenient, especially

tlie utse of high protein feedings, were shown to be the miore imiportant available miet hud~s of

treatmnent.

b. Filariasis.-Experience to date has shown that infection of soldiers wAhen limiited in diuration by promipt evacuiation to nonendeinic areas is rarely, if ever, followed by.

permianent dlisabilityv or significant lasting bodily changes. Psychological mianagemnent

and recondit ioniing are inllportant aspects of treatmient.

c. Schistosomi.xjs.-141te in the war, a number of soldiers contracted this little

know]) disease inl thle Philippines. Much has beeni learned about the cournse of the infection.

The drug treatmient is still a miatter of research.

d. Cocridioidomiycosis.-As a result of the infection with this diseasie of miany soldiers

in t he western part of the United States, a great deal has been learned about its course and

mianagemlent.

e. Skint diseases associated with the tropics.-Soldiers in various parts of the tropics

have acqiuiredl cuttaneous diphitheria, cuitaneouis leishmaniasis, atypical lichen planlus, and

greneralized hvperhidrosis. Suich conditions were p~reviously little understood, especially

inl the( United States.

8. Convatesrence.-The imiportance of systemnatic mianagemient of convalescence wvas

stressed early in the war and miethods of proper mnanagemient wvere dieveloped.

SPECIALIZATION IN ZONE OF INTERIOR HOSPITALS

In the Un tited States, tile trendl toward Specialization 16itl mledical p~ractice

wats very st rotng, long before W~orldl War 11. It, wits carriedl over into the

A1.t1: by The Surgeon General with the assignment of inedlical anl(I surgical

sp~ecialists to supervise the care of thle seriously ill and itnjured soldiers and to

assist progranis of prevention.

Thle frainework for thle assignment of indIividulals in the various specialties

and~ subIspecialties of internal tilelicine wats, for the most part, already establishied in the organization of the miedlical services of Army hospitals at tilie

otitlbreak of World War 11. Of course, nothinig of the sort wits feasible or desirable inl tile assignmlent of mledIical oflicers to troop~s in the field, where general

p~ract ice wats tile ordler of tile daiy.

Itt additionl to the policy of assigninig specialists, whenever possible, where

I hey could work in their respective fields, there (developedl, duritng the wnitl,

lhe use of hospitals eslpecially manned attd eqtiipped to (heal with certaimi

16 D~ocuments which imtementedl the 'Medlical D~epairtment's policy of smwclalization ;luring World War II, as ftiseu.iýs-4i in this section, are (i) WVar D~epartment Army Remulalions 40405). 6 Oct. 1U42, pakrs, 7h and 13: (2) War De)partment Memnorandum W40-i14-4;3, 24 May 1913, subject: (Wienrail Hospital., I esisniated for Sp1eiAu survicual Trevatment:

(3) Ietter, Hteadquarters. Army service Forces to Commyanding Glenerals. All Service ('ornmatifis and Conumnmnijug

Cienerals military District of Washington, 17 D ec. 1943, subject: 0eneral ltoso~tals i lesignated for semx'inaiet Trreatment: (4) L~etter, 'Medicine Division, OTSti. to Surgeons. All Service Conmnands, 7 Auz. l944. subject: New Overall

Hfospitalization Plan ats It Aiteets; the Mfedical Services of Hiospitals; (5) Memoramndlun. Brig. Glen. Hurh J. Morgan

for thei Surgeon (lonerdil 11 Nov. i!943, subject: The Tre-atment ofXMalarta; (6) Memorandiur, Mledicine Division for Chief,

Op~er-ations St-rvice, 19 Miar. lit-41, stubject: Oeneral itospttals Designated for Sweiailized Treatment; (7) Memorandum,

BriL. (Gen. Hfugh J. Mforgan for ('hlif, Operations ServIce. 29 Mlay 1944, subject: Recommendation for tho Designation

of a Gleneral Hlospital for Specialized Treatment of Tropical Iliseases; (X) Memorandum, Maj. Clarence 5. Livingood,

NtC. for Brig. (len. Hugh J. Mforgan. 23 Junelg1945 subject: Htosp~italizaition of Ilermatolo-zic Patients; (9) Memorandum,

Di re-ctor, Resources Analysis Dilvlsioti for Medicaul Regulating Offticer, 26 July 1945, sub,. -t: Revision in Authorized

l':itieiit Capacities: (10) War tDepartment Circular No. 347, 25 Aug. 1944, subject: General Hospital-lDesignated for

SN-Vi~ili7tei Treatment; and (11) Army Service Forces Ctrcular No. 4.561. pt. 11, 29 Ihec. 11115, subject: Hospital Establishtnetit of Six-cialized Center for Tuberculosis at Moore Gleneral Hospital.
OFFICE OF THE SURGEON GENERAL 33

diseases or groups of diseases. The concentration of large numl)ers of patients

with siuiliar disorders I in these hospitals---.designated "centers" for special

tirea ittelit-- favored optimum care for the sick soldier, while it assured more

economical use of highly specialized Iiedical officers and gave them an opporttinity for intensive clinical experience. Carefully planned clinical studies,

includIing the trial of approved therapeutic measures, were possible in a few

selected medical installations.

The M iedical Consultants Division, OTSG, recolunlended the designation

of certain hospitals as centers for tuberculosis, arthritis, vascular diseases,

neurosyphilis, tropical diseases, rheuni attic fever, antd dermiatological diseases,

and for the care of general medical problelils in patients evacuated from overseas late in the war under the special designation of "'medicine." The developnments leading to this designation are discussed in the following paragraph.

General medicine.-- -In all theaters, during 1944, there was increasing

need for Medi'.al Corps officers qualified in internal medicine. At this time,

it was difficult to provide full staffs for the medical services in 59 general

hospitals operating in the Zone of Interior. Htowever, a survey indicated that

provision had been made in these hospitals for a larger number of medical

patients than were being sent to theni either from station hospitals in the Zone

of Interior or from overseas. On the other hand, beds for surgical patients

were in short supply. It, wits proposed that. the numbter of general hospitals

receiving mIiedical patients in the Zone of Interior be reduced. A full staff of

internists would be provided each hospital designated to receive medical

patients. A smaller but aidequate number of qualified internists would be

assigned to each of the remaining hospitals, in which the surgical services would

expand as the mnedical service contracted. The purpose and details of this

pjlan were explained by General Morgan in letters to each service command

surgeon on 7 August 1944. The official designation of certain hospitals simply

as specialt.y cent ers for medicine was announced in August 1944 (fig. 11). Objections were voiced from timiie to time tecause of the liniited number of

specialists in internal medicine allotted to hospitals not so designated. flowever, it is believed that this redistribution of patients and specialists met the

overall probleni by providiing superior care in internal mnedicine in general

hospitals at ihomiie, while it made available specialists to the oversea theaters

where they were badly needed.

Tuberculosis.--The peacetine Army had for many years mnaintainedi a

center for the care of tuberculous patients ati Fitzsiumions General Hospital,

D)enver, Colo. (fig. 12). This designation was continued throughout the war.

The niumierical increase in patients from the greatly enlarged Army and the

proloniged period of hospitalization required for treatmnent miiiade additional

beds necessarv. In August 1944, Brinis General Ilospital, Santa Fe, N. Mex.,

was designatedi a tuberculosis (ee|ter, and its miedical staff was supplemented

wit h1 officers specially qualified in this field. In Deceml her 1945, Moore General

I lospit al, Swinammaoa, N. C. (fig. 1:3), was similarly designated and manned.

564974 11 61 5
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KEKEEKE I so EI Smo o I MINES IUa

twe I.. I I a**I ln*** I ****BEEN IJI

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ther-i.!1apy1*,I :ili l1(- ()I*1'- 44'll ,v ; 1 41Na I)44'11144'l 1 , I4\ (4'4l spIl gs Ark..1 l Ie / m4l

tilw u (i' 4 ) :I, 11- \Nl4' li 'i l J4'i:Ii.4l ll2S II 'l I '4 l111 \\.444l 4IS I)4Iiv4441'

I :41 z: m. 11 tvlis.I4 . ct414 'l4 J4 ill1 D -c l1w 41:4 :141~ ill 144 I4'' ll' the iiiii'

14) 4'X:l111:l1o 11141114441- (fl, 11411111c111 :11141 4li'.JwI)4 im (41.: I 4'444lid :11ijlilis ri lit411'l, \\.*Is

4"-I:I4bl4' tl A,411411111 G-4114.1-:11 II4~i:I \ 14IKi1114v. leX.

Vascular diseases. Timhe iiilI d~esigzimi ot ()f lonpii :i! ill thle 1Uiited

II4 I 'm I4 the1 li'-. 44lI iIl (I* vwl4'' ln' d('l llels I'44; 11441 111441(ic ill11 11 a ~u.r'i

fil'-l, II:II li'4l 4'l~oioll' 4)14 14111111, 14 '4)1111'41 Ini Iý Dki -ý.t l OTS'111 i- 4 I III Ii\ er.

441414y 'lIc~lits ntIi4 441 il11 1 411-c4 Ivpi'lt'11441 Il I~dIf-:411 1%i 4441. h l14 11-grl

.41:1ll 'Iii i I4\c 4'IL4' ill~ii, 44 \6 \1 4142 14 4I':11d :4 41 \-.illi

44441'I1'4 444-4'\ \ihI II'2441-ch 4 -iium 14 l ii I:Iilloiri~.2 :114 114 I4'l,(0 :1!4 IL' 1 -t

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lt lvx -I i o ra i iai )f im itm. 1.1. ~Artt hii ivp: lien int 1)() N%~h ~orkiatg uppetir *WIllsNN hvill at 

-
ACTIVITIES ()F MEl )l(AI. CONSU'LT'ANTS

ini( in( Ili ll t clv to tinly of' thle Airmiy general hIospi talls. 'I'iieref'ore, in 1ii III

19)44, se veni gelnerail I lospi taits localIted c ~on venlien t lvY iiiioligholiit the Zone of'

lit ei'ioi' Werie Spjeciallyl St nflt(l 111(1 (lesigunat ed for en re ol' lIetii iosp-)I ilis 1).ti ients.

Rheumatic fever.--TNo nieedfs- one f'iiifor lii*-1 nillnligelliei) t of p~atients

NNith Iiiielii i t ic f'ever inl a I'l vora hie liniiiate, the ot lier 1,0 I inc'reased kniowledge

RI'egr(Iing. nil asp~ects of tihe (lisetsc-SUtiggsted th le tst allislilileit of' specially

stinfl'ed('1 ceter'Is. H owever', air t ranlsp~ortat ion of' acutely ill rheuiniat ic f'ever

paitienlts5 cr'eated' speciali pr.oblenis. Againi, p)lanfs to coordlinate (clinical s1tidies

withI simiiilar stti~lies car'riedl on in hospitals tlndei' thle (direct supervision of' the

Air Si'Sugeonl Were dhifficullt to amnliiiist er. Discussions, begtin in thle enrlv

spigof' 1944 did not produce thle act tiil designa1t ion ol' hiospitalis tinit i Auigutst

1944, when the establishmnent of* t hree d'ieuiunitic fever ('enters w~as annouinced.

These were Foster General Hospital, Jackson, M\ iss., Birmninghani General

H ospi tal, Van N uys, Calif., and Torney General Hlospit al,, Palm Springs,

Calif'.

Tropical diseases.- -Cliniiical problenis in tropical diseases were difficuilt

all(d numierouis. In 1)articlilar, reliab~le hinfornint ion regarding prognosis aind

olpt inimiil t reatmnent was lacking for mialaria, filarinsis, and schistosoniiasis.

TIme Medical C onsult ants Division, OTSG, recommnendled early in 1943 thle

estab~lishmlent of' centers, both in the U~nitedl States andl overseas, for the

observation, SttUldy, aind special treatmbent of* patients with trop~ical (diseases.

Since' at thlit tinle mialaria was thle only t ropic'al disease occ(ur'ring with troublesonie Irequen('y and sinc~e higher authiority in the Suirgeon General's Offic(e was

uinsyiipathietic to the project, no act ion was taken. On 11 November 194:3,

the ('St alisliiiient of' a numuber of' malaria treatmiient studi~y uinits, both in thle

United Stalte (and11( overseais, wvas again recoimn ded(nl((. The Suirgeon General

resp~onded'( to t his i'eqiiest b~y establlishiing, onl 15 November 194:3, the Board f'or

.Stntd v of' thle C linical Treatmnent of' M\Ialaria (p. 50). This hoard tisedl foujr

gene'ral hosp1 it als in thle Unitedl St ate (and11( st iiei'( thle relative value of eight

dhiffere'nt plans of* treatment. One (lef'inite ('onl(ltisiOll ar'rivedl at was that

IP1asiiiocein nnlplit hoate (palnaquiine inlplithioate) did not cuire mnalaria caused

by infect ions f'romn IPia~nodiwn~ rirax.r

Believing (flint spec'ial st Iidy and1( special t rent ment facilit ies for tropical

(hise'lis(s NNei'e, in falct , inandatIoryv, tb Mi' edIical ( onstilt a it s Division aganii

re'ommiiend~edI, onl 29 i\ lay 1944, that lit least one( ('(enter be( estabhlishied and in

h~is 'oninect ion c'ited it simiiple adminiist rativye problem. At albot thtlit tline,

it had becomne n('(e~slli' to iinak( proi'ls~io liOne olioslpitail f'or a latrge mniiber

of filariaisis pat ienmts ret iirn ing fI'oiii overseas. The admiiinistrla t i ve r(qliieii ei(nei

caririiedl wVcigli t, anmd, onl 2.5 Auguist 1944, Nloore General H ospita~l was fimiiill

designa ted' a t rofii('d (lisease ('('lter. II igli Iv qiinli tied (cIinicail and lii loI'ttr 0'V

st airls we're assS('lii lde. Eveiintiidlv, sI idi( ei of' filan iaisis, iinaln i'm, triopical skilli

of' MaI~j. Iicv * M ost, \ I (, c'hief, of' tie triopical tlist :tse sec'tion ; IA. ( 'ol. (lnater'

('oh..) .Josephi M. 1INi-1munn,1 ,Jr., Nl( , chlief o" (lie inedicitl sei-Niue, and Lt. Col.

(later' C ol.) Franmk IV. Wilson, M( '. 'oinimiii lit g, officer.
OFFI.'CE OP TiHE, SURGEFON GENER:IAL 39

11,11-1110on General Hospital, Lolig-view, Tex., had Ibeenl selected by The

Sul.vl r ge i( eneral 's board oniii mala a inl 19!43 to t rv I of its 8 plaiis foi' treatmviiiet.

After The surlgeonl Getieral" WsIjard filed its fiuial report of) thle treatimen t of

mialaria onl 26 M\Iarchl 1944, 4 mou11thus andI 11 (lays after its Organli zationl, tile

Malaria st ildies wvere ta lwil over, co~l t iiiied , aud( eNjpalded l) ,v thle st aff in 111edliciiie at Ilarmoi~i ( ieiei'il Hiospitail. FinallY, iii April 1945, 11-101 lo%'t

designated at troplical dlisease ('emter. The contrilbutiollS of thIis hospital exteil(ed over it periodl of 2/11 years a111( were of great value Hil colmiectioll withi

malaria, tilariiisis, sellist oso i i iasis, andl tropical skiln disordlers. Tilose chliefly%

responsible for this work were M~aj. (later Lt.. Col.) Hlarry 11. Gordon, MIC,

chlief of tile tropical dlisease sectijonl; Colonel Marb~le aind Lt. Col. (later Col.)

Worth B. D~aniels, MNC, sticcessively chliefs of' the niedical service; and Col.

Gouverneur V. Emersoni, MIC, coimllandliil officer.

Dermatologic conditions.~- -In the spring of 1945, after ai careful survey of

the problem in general hospitals in this country, Mlajor Livitigood of the le(Iical Consultants Division recommliendedl thait, tile mianlagemienlt of patienlts wvithi

dlermlatological conditions lbe conicenitrated tin seven genle rd hosp1itails, where

thle smiall numb er of specialists then ava ilalble couldl miore adequately* care for

thlemi. In it mlemiorandumn of 23 June 1945, this p)1an1 wits described by M\2Ijor

Livitigood, and( it wits officially adopted onl 26 July 1945.

The results which accruedl fromt tile use, of hlospitals designated its special

celiters for tile care of certain dliseases or grolljps of dilseases were imlpressive.

Tile centers provided good patient catre, efficient use of limited personnel with

slpecialt :v qualifications, opport unfit ies for cflnical ilivestigat ionl, sp~ecialized pl'0-

gr'amis for convalescent care and rehiabilitation, an~d 01)1)0 11 fllit ies to p)1an1 tilie

ultimiate disp~osition of certainl large group~s of' pattients. It is (clear in r'etr'osp~ect

thait tile estali)Iislullieilt. of these ceniter's ear'lier' iii the emler'gency would have

been wise admn mist rat ion.

EXCHANGE OF PROFESSIONAL INFORMATION

A ma12jor iitei'est of thle Mledical Conisultanits Division, OTSG, was tile

collect ionl 2111( disselmiliat ion of professionial ilifornat ionl thrl'oigiotit tile M edical

Depai'tmIelmt, pai't i('lai'IV iiifor'iiit iol ('oticei'1edl with recenlt adlvalces in iliedical kilowledge ilild te('h1ifliqes aud( wvith thle (levelopmluet of liew~ approa('hes

based u11)01 obsei'valtioiis and study' ii tile fieldl. Tile Mledical Consultants

Division, iii thle highiest echelon1 of' tile M\edical Depirti'ment , wvas strategically

situa~ted( to eli('ollrage( 2111(1 (fii'ect t ins ac-tivit v.

Early1: ill tile developlmeml of the MIedlical C'onsultants, Division, at great

deal of t imie was dlevotedI to tile st tidy 2111(1 u iilipuiatii oll of' chIann~els of ('01m11111(ll icaioli thrli'~ghi whichi illpol'talnt lldical iii forri1.1ia Oll c'0111( flow fr'omi fieldl

to hleii(pl~a't el's. With titlie ('St ablishlileillt of 'ollsill~tailt 5 ill tile serviceI colli11121 11(15 s o111vef'sei thlea ter's, tile jit erci Iii Jie of profession iil niews and1( Op~illionl

becam lit e c(011pel lii i iie('essi t . The di fficul ties resuill t u from rii 'iid ad~hlelellce

to ('0111111,111(l'1 chlalllls (Ill I'111g tilie evlrljv d2Ys of' thle will- were of'suc('1 laiigiit tldi
40 ACTIVITIES 0F MED)ICAL CONSULTANTS

2a11d importance that they should be mniltionedl. Those difficulties were not

conifined solelyN to prohibit ions iSSuled by officers of tilie linle algalinst tile trinllsmlission of iledical inltell igýen ce. Certffaml service coiiiiiianld and t heater StirIgeOiis, either of their own volition or b~ecaulse of orders from higher authority,

forbade the forwardinig Of technical iniformation by the service commiiandl or

theater i~edlicalt consultant to tilie chief consultant inl thle Surgeonl Genlerall's

Office. The conclusion is inescaipalble that much of the dhifficulty regarding int erchang-e of technical in fo'miat ion which chiaralct erize(l the earIlyl perio(l of tilie

war couldl have b~een avoidledl had line and mnedical officers alike mdopted a sane

com Io01nSenls(, at titutde towardl tile interpretat ion of directives dealinig with coinmianti channels anid miullit arv securit V.

Reports, correspondence, and meetings.-M-Te ETMD (Essential Technical 'Medlical Data) reports iniitiated l) 'v the Medical Department inl 194:3

hielpedl greatly to facilitate tile interchange of professionial news and ophin~io.

These reports, gathered in the imajor oversea hmeadquaiuters, comntained (lmata

concerning the incidlence andl Iniaagenlienlt of dhisease in tilie various sublordinate

unlits; tilie satisfacetoriness of treatment agents, equipment, andl supplies; and

the avatilability of qualified professional personnel. Though fair from adecilite for the needs of thle Medical Consultants Division, these ET.MI reports

furnishiedl one medium at least t hrough which professional infornimition could

be exchiangedl between personnel in oversea theaters and tilie Zone of Interior.

Service commnand l nedical consultants in the Zone of Interior usually forwarded to tim M\edical Consultants Division carefully' prepared rep~orts of

visits which they made to each medical installation within their commani'ld.

These formal reports were frequently suipplementedl by personall corresponidenmce. The service commliandl consultaiits were encouiragedl to 'onmmlunlicate

freely when they\ felt, that the Division could give assistance or that tile Stirgeon General's Office or thme medical installationls in Other coniniaunds should be

informed concerning professional mat ters. These lpersomil letters p~ermit tedi

raipid1 transmission of news and ideas and free expressiomis of opinion.

Annual meetings of inedhical consultaints in tile Zone of Initerior were

held, withI programis dlividhed between clinical andl adhmiiniist rat le topics (appenidiX B p. 8:31). In1 194:3, the mieeting was IlieI( in thie Surgeon General's

Office (fig. 13); in 1944, at Ashil'ord G~enerail Hospital, White Sulphur Springs,

WV. N-1. (fig. 16); aind in 1945, at Thomias 'M. England GetineralHospitail, Atlant ic

City, N.J. At thle first of' t hese mieet ings, iii 194:3, thle neuropsychmiat mists

were in at tendhanmce. Sub~sequent ly, in 1944 amid 1945, attIend~ance was ('olifinled

to te linedmical consult ants from tilie service ('011illidisl and tilie civilian (conlsutitats in medicine to 'Ilme Surgeon General. Thie Surgeon General or his

deputy aind the chiefs of lpersomiflel and hiospitalization services also ait tended.

At the meetings in 1944 and 1945, it was possib~le to have representatives,

teimiporarily inl this countr rv, froiln some of thle oversea thelieu rs.

In auddition to encoura12gim gr exchange of' inrormiatiomi on professional

imia1tte (i'sI t mmoighmou t tilie Arm.y, te lM('iedical ( onisult ants Division, OTSG,

imiammlit miied limiisonl with ter tIi imldividhumils aictivye ili tilie field Of clinlicall inivesti-
V . . . ,tT 1,1

i ''
POO
OFFICE OF THE SURGEON GENERAL 43

the I1.S. Army 3fedical Department. In this bllletin, there appl)eareld regularlv

through the remainder of' the war both 'articies and news it ems relating to

current problems in the field of medicine. Tie estawishiment of the bulletin

was announced in Circular Letter No. 165, OTSG, U.S. Army, 15 September

1943, and the first issue appeared the following month. T he chief consultants

in surgery and medicine became mtemnbers of the editorial staff. Unfortunately,

(listribution of this bulletin, even in the Zone of Interior, constituted a major

problem. Copies were never received by many medical officers in oversea

installations, although direct mailing to officers at their APO's improved

distribution to some extent.

Another medium for dissemination of official communications concerning

diagnosis, treatment, and disposition of patients in Army hospitals was the

circular letters of the Surgeon General's Office. These were discontinued on

31 December 1943. They were replaced by TB MED's and to a less extent,

by War Department circuhlars, Army regulations, FMI's (War Department

Field Manuals) and TM's.

FIc.URE 16.-Conference of military and civilian consultants in medicine, Ashford General

Hospital, White Sulphur Springs, W. Va., 30-31 October 1944.

Left to right, first row, seated: Col. 1). M. Pillsl)ury (Consultant, l)ermatology,

ETOUSA), Col. F. P. Strome (Surgeon, Third Service Command), Col. E.. A. Noyes (Stirgeon, Fifth Service Command), Brig. Gen. H. J. Morgan (Chief Consultant in Medicine to

The Surgeon General), Col. C. M. Beck (Commanding Officer, Ashford General Ilospital), Col. A. Freer (Chief, Professional Administrative Service, OTSG), and Col. W. P.

Holbrook (Chief, Professional Division, Army Air Forces).

Second row: Lt. Col. T. H. Sternberg (Director, Venereal Disease Control Division,

OTSG), Col. E. V. Allen (Consultant, Seventh Service Command), Col. T. Fitz-Ilugh, Jr.

(Consultant, Third Service Command), Col. W. Bauer (Consultant, Eighth Service Command),

Dr. J. H. Stokes (Consultant, I)ermatology), l)r. W. L. Palner (Consultant, (;astroenterology), l)r. J. E. Moore (Consultant, Venereal Diseases), Col. I. S. Wright (Consultant,

Sixth Service Command), l)r. M. F. Boyd (Consultant, Tropical l)iseases), l)r. I. B.

Watson (Consultant, Tropical D)iseases), Lt. Col. H. .1. Shull (Chief, General Medicine

Branch, OTSG), and 1)r. P. 1). White (Consultant, Cardiovascular D)iseases).

Third row: Col. V. R. Mason (Consultant, Ninth Service Command), Col. F. D. Adams

(Consultant, Fourth Service Command), l)r. R. L. Levy (Consultant, Cardiovascular

Diseases), Dr. C. B. Thomas (Consultant, Infectious Diseases), and 1)r. R. A. Cooke (Consultant, Allergy).

Fourth row: Lt. Col. F. R. I)ieuaide (Chief, Tropical Disease Treatment Branch,

OTSG), l)r. C. M. Jones (Consultant, Gastroenterology), Lt. Col. H. L. Blumgart (Consultant, Second Service Command), and l)r. C. M. MacLeod (Consultant, Infectious Discases).

Fifth row: Dr. W. B. Wood, Jr. (Consultant, Infectious l)iseases), Lt. Col. M. J.

Farrell (l)eputy Director, Neuropsychiatry Consultants D)ivision, OTSG), and Maj. A. C.

VanI Ravenswaay (Chief, Medicine Branch, Army Air Forces).

Sixth row: Col. B. M. Baker (Consultant, South Pacific Base Command), Lt. Col. J.

Mc('uire (Consultant, Fifth Service Command), and I)r. It. W. Brown (Consultant, Tropical I 'nsewses).

Seventh row: I)r. F. M. Rackemnann (Consultant, Allergy), and Lt. Col. G. P. Denny

(Consoltant, First Service Command).
44 AcTIN'ITIES% OF MEI)ICAL CONSULTANTS

Circular letters of thle Surgeon Getteral's Office and TB MIED's were thle

Usull vehicles for conveyl ng useful clinical information and outlining professional procedlures. Eacht of these publ)icattions, when written by the Medical

Consultants Division, wats the editorial responsilbility of one member of the

staiff. Its contents expressed, in general, at summation of tile best available

iniformiation ilo the Sulbject under discussion. Thrhoumghout. the emergency, the

IDivision's staff devoted miuch time and effort to the preparation of these pubIicattions. Trhe circular letters, TB MIED's and other publications which

were prepared wholly or in considerable lpart lby the Division are listed in

table 1.

TABLE I -Pn blicat ions pre pared wholly or in part by, the Medical Consultants Dir ision

Puhilut t a Sbject Datoe

(Mlice of the Stirge'oi Genierail circular letters:

55 ------------------ N otes oil t he Treat ment of .Jaun~dice May 1942.

74 ----------------- D iagnosis and Treat ment of Venrereal I is- July 1942.

eaSeS.

86 ------------------ Fever Thierapy in the Treatment of Gonor- August 1942.

rhea.

105 ----------------- The Treatment of Syphlifs, b~y Unit. 'Medical August 1942.

O fficers.

13 --------- The Treat ment and Clinical Prophiylaxis of August 1942.

Malaria.

158 ----------------- Medical Books---------------Novembler 19142.

27------------------ Staff Rounds and Meetings in Hospitals of January 1914:3.

the 'Medical D epartment of thie Inited

States Army.

.3:------------------ Treat ment anid Control of Certain Tropical F~ebruary 1943.1

D iseases.

126----------------- --Medical Books and Jouirnals Incluiding Aui- July 194:3.

hoirization for Limited P~rocuremnit.

1:13;-----------------Treatment of Hevat Stroke, Ifeat Exhlas- July 1943.

fl011, and~ Heat C'ramps.

153 1-----------------Thei D rugs Treat ment of 'Malaria, Sup- August 1943.

pressive and~ C linical.

175 ---- --------------\anagenieiit of P'oliomyvelit is ------------ ( )ctober 1943.

197 ----------------- Maniagemeiit l of Conivalesenice from Ma- I ecember 1943.

lar ia.

Ti \EIs:

------- Peniicillini-------------------------------.anuary 1944.

9, chaiign. I-----. Peicillin Septembe-r 1945.

72__ ----- - Treatmuenit of ( litijeal Malairia and Mla- July 1944.

I aria Pa rasi lend a.

I :6------------Avoidance of Relapses of Viva x 'Malaria by January t945.

U se of Suippressive Medicateion.

138- - Cholera---------------------------------January 1945.
OFFICEl OF THlE GUUON(ENERAL 45

TABLE I.- Publications prepared wholly or in part by the M1ediral Consultants Division '-Con.

Publication Subject D~ate

TB MED's-C~ontinried

142 ---- --------- --- Filariasis (Wuichereria) with special refer- February 1945.

ence to early stages.

14:3---- ------------- Cutaneous Diphtheria- February 1945.

149)------------------ Descriptive List of D)rugs and Chemticals inl March 1945.

Far East CAD Units.

159)------------------mebiasis ------------------------------- May 1945.

167 ----------------- Schistosomiasis Japonica ------------------ June 1945.

168 ---- -------------- Diabetes Mlellitus---- June 1945.

172 ---- ------------- Treatment of Infectious D iseases ANith Sul1- Junte 1945.

fonamide D)rugs.

175 ---- ------------- Prevention and Treatment of Adverse IEr- .June 1945.

fects of Heat.

183 ---- ------------- Visceral Leýishn,,~iiizisis-KatIi-Azir ----------- July 1945.

193 ----------------- Poliorrvelit is----------------- igust 1945.

202 ---------------- Allergy ------ ------------------------- October 1945.

205 ---- ------------- Leprosy ------------------------ - -- November 1945.

206 ----------------- lHepat~itis- November 1945.

210---------------- Professional Rounds anid Meetings in flos- D)ecembher 1945.

lpitals.

War D epart ment circulars:

189----------Section III. Malaria (Information concern- January 1945.

ing effect of attacks onl health.)

321------------Section 11. Use of 'Medicinal Agents- Auigust 1944.

264 ---- --------- --- Section VII. Use of Medicinal Agents- September 1945.

Warl D epart menit Supply

Bullet ins:

8-3 ---------------- Medical D)epartment~ Professionatl Books- March 1944.

8-4 ---------------- Medical D)epartment Professional .Joiir-nals Mlarch 1944.

8-20 ---------------- Medical D)epartment P~rofessional Books -- May 1945.

FM 21-11- -------------- First Aid for Soldiers -------------------- April 194:3.

TM 8-5001--------------Hospital D~iets ------------ March 1945.

1 In addition to these numhered publientions, the Me~lical Consultants D~ivision assisted in the preparaItion of thep

"Booklet of Instructions for the use of D~rugs Contained in the iO-NMai (*fitl of the Medical List for Allied Prisoners of

War In the Far Fast," published hy the American Red Cross.

It should be repeated that the dlistribuition of professional pubIlicationis

was neither so prompt nor so colipJlete ats it should have been, especially in

oversea theaters. Jou~rnals and lbooks received at oversea (depots hand low

priority ratings for dlist ribu tion, and~ (delivery to hospitals wats often (delayed

or failed completely. Individual miedical officers in forward units who mlight

have profited miost frolin the mnedical technical bulletins frequently did not

receive theni at aill or receivedl them only after great delay. Often, careless

handling at miedical installations (lelayed or defeated proper distribution.

Educational mnedia.- -General M~organ believed that the assignments

of mlost physicians in tile Medical Departmlient [wovidled t101 hem1 anpportunlity
II; ~~ACTrIVITIESc, tiIF MEIIII'AI. t,4)NS4II.%'rs~N,

for J)I'tfi-ssional3i III piJ vl') ie~lt lie 11ll,') Ilt'ive~td I113111 (ihe \vletIczl Iepairtmil'ill

ill h4'it Mrt'ort, s I im tprove dwhil.IISit k timed-A.. Collstylt-utit v, po

lil rlol andW ox0141 t)Vts . Ie'll'ilt Ii ivoIa :i rol I'~t)Ill I~ Il tis IllStideI4'i lkilig. ( Citeiar11

L~efler No. 27. O)TSG , Umilel States' Arm *iy. 22 .Jtimar * 194:3. wid 'I'll MEl)

210, )t4eeznilwr H1-5 ¶I.sI trest't iliJwortZanev of stair romiids ZII114 S lall! liieet lltg)

ilhospitals1,. Ililt' N it'(iclt*1 ( olsiliaill111s Di)tvisioni wn Wflevei~tssl Ill itiis tlrort s

toii Ilodit-l- 4)1' andVt't (f Ispitk5 31114.1-e I~'l)Iltli,*()JS Itllt'0I1to inernl Iei-Ivi3141

seet'4tfionis of lpr4)ft'ssitol3l. I eXIS 3111d1 jtil-IMIiiS 111V~lil3lkidt' 10) t'3-14]ll itdIcan inistilllatiol l~l '~i for pl lv)11'ilMs (1. 49'). I'3Iilitit's of lthe Armii Nl- edivil Nltset'iii

we're opt'ilt't to 4)111 liO'4jil 11. To slwet't 11 t het pro)curement('l of special in forcii it ie, for t1w14' r ot'Jlr)41 io' .41 111d1 (list luauII 1(111 of iiiicroiiliii for lilt X-Ilt'lv ivai

officer olr 111sf 113lhtoll req'(f iitlttu it. Visit s of t'ivilialti coulsil Ialits to IIosJpit 3115

Wtt'1i llt' "t' 4)1 11V IIVd44111), II 1141 t g Ai wlt' livid'1 1 Itlv lle e ausice ofl1gthe1.All ieOotr- 11

wit Ii thle silirgolis Ge'nerali o' (hlet Arili andit Navy. Mltdical C orps ofJict'rs

t'114011zg'11 (111111-ig-dt ft lifY t'ul insc-tO's for1 cer'It ificato 14)11 lit(114 Ameicui'tan

of boll)1I ArItit v1111d ci iliail 11Ill] %Si4'tiI 11,.

ArN t'tIvrleca I111 ti'S were.~543 lilt'd b c04iv'tit'lia orAllzol ' i'143 I(lit'g lsel o thtslivriva i

lit' .\ il'l A43 ilt oiit(g lol ofSiii't'ocieies, ' t1h1 e Amer1r iiticanl groile11 tI'll of, vRock llt'

ot'hie Awr1' iclt'oll I(4i43 of ('411,11-1313,4 i 1d ) tii,4iE' II(ldCk )T(;, 54'I'1315) 31 401411 ok-'ie

;kgr'114.'\t bet wee'n the Army medii t31ofi4't'rS cal aluld t i~ltS ('itliatiI o'galtlizat 1011,4.

I NTIIAOFFICE, AND I NTEIROFFICE, REILATIONSI!! I'S

In flit- I l'gt' co14 mp4)1letx orga1iziltZol lo of tlit' Suirlgeout ( 'eiierail's O ffitce,

thit 4)enl)'3Iitolis of cert'1'l servi5tices i and' 3 d1ivision WI4~l ere of sl)4ciall ilil poI't 3111(1'

Personnel Service. It is ol iotius 11111 at'tii raleI classi fielk itOll 3a1nd pruoper

1SiZi s Illt'IIt(I tof profess5ional per'50111'Id irtt i fft'tts tlit' uilt of unethicall

W4l iv clY ililiO' pcl~l'04114ivitlil olf iiieldi4'ail o)fficers'. \N lit ny tiviliatl itit ernIists,

first conflicatt wit 1 lt'e ArIlilv ill 111111 D ivision. Ilirtotugl such ('liltile4t 5, Getli-
OFFICE O1F TIlE SURGEIt •N GENERAL 47

cral ilori'gan assisted tlie Personnel Service, OTSG, 1)y acquainting himself

wit h tile avaial)ilitv of individuals with1 special quialifications in internal] eedicine. Through ipersonal knowledge of civilian phlysicianis, lie was able to

select and procure for the Aryiiv, I)- informal ineaiis, individuals best suited

to fill certain key positions. Generals Mlorgan and Rankin made frequent

visits to civilian medical meetings in the interest of Medical Corps officer

procurement during the early days of the war.

A close, effective relationshiij) between the Mfedical Consultants Division

and the Personnel Service was clearly essential to the proper utilization of internists by the Arniy. When this relationshiip finally received official approval,

the Medical Consultants Division assumed one of its most important dutiesthat of determining, by recommendation, the classification and assignment, of

mlnedical specialists in Arny installations. This activity involved constant exchange of information between the Personnel and Mledical Consultants Divisions regarding the need for and availability of mnedical specialists, the continning evaluation and classification of individual medical officers with experience in internal medicine, and recommendations as to where these individuals

could best be used.

The information used by the MIedical Consultants Division in personnel

evaluation covered many aspects of an officer's qualifications but chiefly had

to do witli his participation in postgraduate education and training programs

and his record of professional performance. The service command consultants

regularly reviewed the classification of the internists assigned to their coniInands, evaluating their on-the-job performance.

The Civilian Personnel Division, OTSG, was important to the Medical

Consultants Division because it provided not only secretarial and clerical

personnel but also civilian consultants to The Surgeon General. The role of

the latter is described elsewhere in this chapter (pp. 66-67). As to the former,

the Medical Consultants Division was fortunate in having capable, industrious,

and loyal office employees, whose work was essential to the success of the

division.

Operations Service.-The Medical Consultants Division cooperated with

the Operations Service, OTSG, and the Personnel Service, OTSG, in studying

the need for medical officers qualified in internal niedicine in tile various types

of Army inedical installations. These studies formed the basis for the tables of

organization for numbered oversea units and for the manning guides for the

fixed installations in the Zone of Interior. Unfortunately, these tables and

guides proved to be unsatisfactory in the light of actual field experience. Even

when hostilities ceased, they had not been revised insofar as professional personnel was concerned.

The Hospital Division of the Operations Service designated hospitals to

receive certain types of patients, recommended establishment of centers for the

care of special (disorders, and evolved and administered plans for the transfer

of patients from one hospital to another. Under the leadership of the Htospital

Division, group visits to selected hospitals throughout the Zone of Interior
48 ACTIVITIES OF MEI)ICAL (ONSILTANTS

were made by representatives from the NMedical Consultants Division, the Surgical Consultants Division, and certain other divisions within the Surgeon

General's Office. The Hospital Division frequently requested the Medical

Consultants Division to recommend administrative changes which would result

in more efficient management of medical patients. The relationship between

the Medical Consultants Division and the Operations Service was extremely

cordial, to the greater effectiveness of both divisions in relation to the care of

the sick. This was the state of affairs during the last 18 months of the war.

It is unfortunately true that, during 1942 and 1943, opportunity for cooperative endeavor of this sort was very limited.

Supply Service.-In the earliest days of his assignment, Colonel Morgan

was asked his opinion concerning medicinal agents for use in the .Medical Department of the Army. To a somewhat lesser extent, he and his staff became

concerned also with the distribution of medicines and items of equipment to

the various medical installations in the Army. As the war continued, the Supply Service, OTSG, requested the Medical Consultants Division's cooperation

in the review of tables of equipment with a view toward adding new items, including medicinal agents, and deleting old ones no longer in demand. The

Medical Consultants Division was often asked for an opinion on the use of nonstandard medical items. From time to time, it provided background information and assistance in developing therapeutic agents and in expanding production. The development of production facilities for penicillin, streptomycin,

and blood plasma was obviouslyv a matter of great concern to the Division.

Other services and divisions.-The NMedical Consultants Division and the

divisions representing preventive medicine, surgery, and neuropsychiatry

cooperated closely in the formulation of professional policies. This cooperation was essential to the planning of a balanced professional program. The

Medical Consultants Division regularly gave assistance also to the Physical

Standards Division, OTSG, in refereeing questions pertaining to borderline

physical findings in military personnel. It cooperated actively with the editor

of the Bulletin of the U.S. Army Mledical Departmeid in the preparation, approval, and e(diting of professional material for dissemination to the field and

with the Technical Information Division, OTSG, in reviewing professional

articles submitted for publication and also material to be released to pul)lic

information mediums. In addition, the Medical Consultants Division was

called upon from time to time to advise and assist other divisions of the Surgeon General's Office in the preparation of bulletins and manuals for dissemnination to the Armed Forces. Such a publication was F.MI 21-11, First Aid for

Soldiers, 7 April 1943. The Medical Consultants Division cooperated with

the Surgical Consultants Division, OTSG, in preparing the manuscript and

supervising the collection of data. A large part of TM 8-500, Hospital Diets,

published in March 1945, was prepared under the NMedical Consultants Division's d(irection.
OFFICE OF THlE SURGEON GENERAL 49

Special boards.-The Medical Consultants Division, OTSG, provided

members for at number of special boards, five of which were of special interest

to the Division.

1. Board to prepare, develop, and implement the medical portion. of the War

Departimen t's program for aid to citilia n populdations in liberated coan trie.s.-This

b~oard wats established onl 28 June 1943, by Office Order No. 419, OTSG, U.S.

Arriiv. Colonel Dieuaide of the Medical Consultants Division, servedl on this

b~oardl until after the end of the wvar. In many meetings, supplemented by

indlividlual interimi studly, comprehensive plans were dlevelopedl for furnishing

Inedlical supp~lies to civilian populations in the countries to be lib~eratedl by*

Allied forces. Itemis to lbe included in various supply assemblies were carefully

select ed, andl instruction sheets wvere prepared by Colonel Dieuaide outlining

the purposesC and recomm~lendled miethod of using these supplies, particularly

drugs.'5

2. Board fo eiu f Books and Periodicals. --Thie Medical Consultants

Division wats representedl oil t his b~oardl by General Morgan and C olonel Slhull,

chairman an(1 secretary reslpect ivel *.01Thie board Provided reviews by appropriate Professional authorities of all medical textbooks and periodlicals submitted

by 'VPublishers to The Surgeon General for purchase. It. recommlendled to '[ie

S rurgeon General medical text books and journals for the libraries of Medlical

Department inst allat ions of' all t 'vpes andl, at. regular intervals, revised thle.

recommllendled list. The board i~so provided thle Supply Service, oTrSG, with

aut horitative opinion whlel requisitions were receivedl for nonlstandlard books

.,nd jounll.11 s.21 ' '['lle con~sultan ts in mnedicine throughout the Army stimulated

conmmanding officers to providle libraries in Army hospitals wvith adlequate

p~hi*ysical facilities and personnel and to supplement the supply of books where

local kindIs were available for thlit p~urpose,.

"Thle act tial delivery of journals to oversell installations remained a prob~lemn

throughout. thle war (p. 45). T1hie Board for thme Review of Books and P~eriodicals finaI v arranged for thle direct mailing of journals by thle, publishers to the

individual units. This wats found to be anl imnprovemlent in the theaters where

it. wats tried, hut nlogenluinely sat isf'actorv' niet 110(1 for tile. continuing and promp~t

(list ribult ion of' culrrenit journals and books to Army libraries wats dlevelopedI

duiring World War It.

Thle Board for the Review of Books and Periodicals also took a lively

interest inl a mlet 110(, dlevelopedl by thle Armiy Medical Library, for the rapid

tranismiissioni of professional data onl microfilmn to niedical installations in the

Zone of lilte('for and overseas. This very Viportant u aidl to prIofessional educationl 11(d trainling wats onle of nianiv successful efforts of the Armyv Medical

iT M1N1E i) 149, 17 Mfar. 1945, suhjvet: I )escri ptivi, List or i )ru'zs m'lI Ciernica Is in Far Fast CAD VUnits.

190111(4c Order No. 3.1,. OTS(I. V.9. Army, 4 June, 1943, subjvet: Board for the Rieview of Books and Peiriodicals.

21 (1) Circular fLet~ter No. 1.59, OTSOl, U.S. Army, 27 Nov. 1942, subject: Medical Books. (2) Circuiar 1A~tter No. 1261,

OTIS(O, U.S. Artný, i41, July 1943, subjeet: Medicali Books ann! Journals, Inciudlnp Autihori7vitjo: for Limited LclPro-

* ureinent. (3) War D~epartment Supply Bu~liein 8-3, 21 IMar. 1944, suibject: 'Medical iDepartnient, Professional Blooks.

(4) War iDepartmient Supply Buiietin 9-4, 21 Mar. 1944, subject: Me'iolle iDepartmnent Professional Journals. (5) War

D epartwmn t Supply Btullet in 8-20, May 1945, subject: M ed Ilal Dveipart nient P rofi-ssional Books.

i5649701 6 t1 -. -6
50 A(TIVITII. OF MEDICI'AL CONSVITANTS

lbilbrary to project its influence into tihe oversea theaters an(I, in rare instau'ces.

even to individual medical officers assigned to combat units. Facilities were

enlarged at the Armny MXledical librar 'or photoduplicatiou, and pr'ojectors

for reading the niicrofilns were niade available to all Army installat ions. 2 1

3. Board for Study of the Clin ical Treatmeit of .lfalaria.--The initiation

of clinical studies of malalaria treatnent wis ilnipedcd bv the opinion of a few

medical officers in high position that sufficient knowlehdge was alreadyl at hand,

based on prewar experience of the Army in the Tropics. Early atteml)ts to

niodify this sentiment were unsuccessful. Finally, on 15 Novemniber 1943 in

Office Order No. 890, The Surgeon General appointed a special board to supervise studies in the field of mnalaria. Colonel Dieuaideserved on this l)oard.

Trials of eight plans of treatment for malaria were conducted at Bushnell

General Hospital, Brigham City, Utah, Kennedy General Hospital, Memnphis,

Tenn., Percy Jones General Hospital, Battle Creek, Mich., and Hariion General Hospital. Plasinochlin naphthoate was one of the drugs especially studied

in the hope of curing malaria caused by infection from Plasmodium vi'ax. The

Plasmochin naphthoate method was unsuccessful, as indicated in the final report of the board, dated 26 'March 1944.22

4. Board for the Coordination of Malarial Studie.R.-Early in November

1943, an interservice Board for the Coordination of Malarial Studies was

created by joint action of the Director, Office of Scientific Research and Development ; the Director, National Research Council; and the Surgeons General

of the Army, Navy, and U.S. Public Health Service. This board continued

the functions of the Subcommittee on Malaria of the National Research Council

and established means for direct collaboration with the services. It was

brought into existence because the usual consultative arrangement with committees of the National Research Council was found inadequate in the face of

the complexities and size of the malaria problem then confronting the armed

services. Colonel Dieuaide, on the recommendation of General Morgan, was

appointed by The Surgeon General of the Army as a memnber of this board and

served until after the end of the war. The Malaria Board, as it was called, was

a clearinghouse for all available inforlnation about malaria, as well as a forunm

for the discussion of plans and a directing body for the supervision of research

in the field (fig. 17). Through the Malaria Board, most of the planned studies

of malaria treatment in the Army in the United States, and to at less extent

overseas, were coordinated with research carried on outside the Army. The

Board for Coordination of Malarial Studies published several volumnes of malaria

reports from 1943 to 1946. Of 600 numbered reports approximately 90 were

contributed by various Army sources. Although the efforts of the board failed

to disclose any new curative drug, several powerful and important new drugs

21 (1) Monocular Microfilm %iewer. The Army Merlical Library Microfilm Service. Bull. U.S. Army M. Dept.

74: 119-11Q, March 1944. (2) Journals Availahlv on Microfilm. Bull. U.S. Army M. Dept. 75: 12 Apr. 19 4 1. (3) Microfilming 11, arch Material. Bull. U.S. Army M. l)ept. 79: 29 Aug. 1944. (4) Microfilm Projector for Army Hospitals.

Bull. U.S. Army M. Dept. 8,: 612-63, May 1945.

22 Memorandum. Board for Study of the Clinical Tre:,.tment of Malaria for The Surgeon General, 26 Mar. 1945, subject: Final Report on the Treatment of Malaria.
OFFICE O1F TH'E SURtGEO N GENERtAL 5

bictI(.1 l 14.-( oll ting.. mosquit ~rvaeo a10 in the field for stuzdy,

8thi Medical Laboratory, Auszt ralzia, 194:..

wvere sitlidied(in ud g SIX-76i18 antd S-N-8s7 13), and~ thle rout inle trleatmiient of'

mialaria with th le drugs t henl available was vastlyx imiiproved. Iminport anlt cointrilutit ios inl(udled a dlefinlit ive comliparisonI 01' Iu~iilil a111( Atabrinle, winich

dlemionst rat ed conluelsive 1 Y thi e suiperiorit V of' th l altterI and~ the djelerinijat ionl

of' tilie opt iIIItiI iniiietliod, fo it ie.23

5. Board to sarrey and eraluate the medic( al probleinx of rep~atri'ated AmeriCanl J)riSoflcr of 1war. AVithI thle cessat ion of' hostiliities inl thle Pacific, a large

numb11 er of' American prisoners, of' wart were relvase~d from .Jalpatese prison

camiips. The leiigthI or ca1)1i vitY rtanigedl troii a few da vs; to 31'., years. The

viivirolilieiit al coiilhit iols had1( Variedl coiisidlerali lv bt1) 1. tohIle iiiost part had1(

Ibeenl ext reiiielY poor (figr. 1,S). Tlzotsa iids died as a1 restilt of' disease and~

st arva tijon (fig. 1N). Thle M edical ( ozisulta tits D)ivision believed that at caref ll

healithi shirvev of' thle surixiv-or., woil](l b~e Of va1lue ill plannlingll thleir f'tittre iized1-

ical vare. Ill p)reven tilig thle sprvid bY t heml of (om Iillilhlilcablv tlis'eise's to faiiii1-

ties anid commulnuities, and ill providling at bet ter' understanding of' the chaniges

thati take p)lace inl mene durinig exposuire to suich hardships (fig. 20). Accord21 (1) 'rhe Boa~rd for the 'oordhiaut inn of Nh~ri~il Sttiviies. Wart ime tRescarch int NfaIlria. Sciencee 103:: -S-, I Jan.

19l46. (2 The Sm~wsiiiW.ve Treatmnenit of T;,ihtria with MTeplerinte (0tiiiiacrin~e)...A.M.....A. 126i: I)9N. 23ý D~ec. 1914.

(:;ý rmtim-Hripi ilvdrochrloride fritnariviel for Malaria. .. A. NT. A. 12.1: 977, 5 A1t.19. IN . (1) Sitarino, .. A., Earrle, 1). 1'..

Jr., tirolie. It. It., Tlamirlr . I. V.. and Blerlinter. It. W.: The I'Kitrmatcoiogitcti Ba:sis for the Rar onal I se of A latrine in,

the Treat eriten of Mfalriai .1.1 ltamurtlttO. A, E.\per. ITherap. Si: 3047-330). Augrist 1911.
T I V I' I' I I.:,, V N I E I I A I N SI LT A N 11

, .0

dim

;Ar

Fiq.(fo IS. I ("Indiii,111- f4w AIli(,d - Idicr- :11

, V 

14 1. :111-1 f:11*14w , v. IIIIvIlifk:1 PW B. K ill-lo-11 \O wn- 1111) pri-4111"l- Im il f4m)(1.

P\k C:11111) C. Y.,1Iw-,:m;I MI"r." lai-flor, wwlo.d, Ichi"k:I PNN (*;Imp.
OFFICE OF THE, SURIUEON (.ENE-'RIA 53

F'(. URE 18. (Thit iired. 1). Qutarters, Niihatna PNV Cap I Excellent quarters by

Ja panese -itandards Zenstuj i PNN Camnp.
54 AqI4I1:-IVMDCLC)S .AT

C: ',

%OLA "V-1

Fifl C o.IS itllll~. . 111.1m (f P :11)
OFFIC'IE OF TilE SUIRGE(ON GENERAL 55

/ (

/ Iq

FIGURE 19.-Typical picture of malnutrition in ani American

prisoner of war recovered in Japain.

ingly, in Office Order 218, dated 30 August 1945, The Surgeon General established at board to survey and evaluate the medical problems of repatriated

American prisoners of war returning from the Far East. General Morgan

served as president of this board, Colonel Wright as coordinator, and Captain

Hunt as recorder. The work of the survey teams that made the study and

the results of the undertaking are described in a published report."4

Army Air Forces.-Contact between the offices of The Surgeon General,

the Air Surgeon, and, to a lesser extent, the Surgeon, Army Ground Forces,

was not close. This was a reflection of the separation by command boundaries and the compartmentation of responsibilities in the various fields of

Army medicine which existed at the beginning of World War II. In spite

of the inherent difficulties, the Medical 2onsultants Division attempted to

serve the Air Surgeon and the Ground Surgeon, as well as The Surgeon General

of the Army. The organizational and physical separation of the offices rendered the efforts difficult and, on the whole, unrewarding.

24 Morgan. IL.I.., Wright, I. S., and Van Ravenswaay, A.: IHealth of Repatriated Prisoners of War from the Far East.

I.A.M.A. 1:41: 99.Uý1 , 13 Apr. 1946,.
56 ACTIVITIES OF MEDI)I(AL CO)NSULTANTS

404

- IF'imf;u. 20. I Iob((sý-i1g rcc(vi-rt( A~Ilivd pri~.onrsr of war at -12dI (wiieral Hos~pital.

I'okvI, .Japan. A. Pi.-40rs arriving. 11. Stiperficial s.kin examiniiaIion.
.4P

Fnu;2. oomd.( jjjf-~j)I I + a ~~g
58 ACTIVITIES O1F" MI.IICAL CONSULTANTS

In tie fall of 1942 and spring of 1943, servi(ce co(101111111111d I Iedical consultants in the Zone of Interior regularly visited Air Force hospitals. However,

autoiiomy of Air Force operations, coupled with I isunierstaiding which

occasionally grew out of tile consulta uts' suggestio ns desiglied to improve

tile quality of niedical care or to change medical officer assigminiits, often

resulted in friction. When friction occurred, it almost invariably involved

administrative or command personnel rather than the professional personnel

in hospitals. Because of such friction, medical consultants in certain service

commands ceased visiting Air Force medical installations.

Fortunately, the value of these visits by professional consultants was

apparent to Air Force clinicians. Therefore, the Air Surgeon established a

system of consultation within the Air Forces, with visits by the senior clinicians

in Air Force regional hospitals to the smaller hospitals in their areas. 25 The

Air Surgeon also appointed consultants who functioned in his office much as

(lid medical consultants in the Surgeon General's Office. The relationship

between the consultants in the Air Surgeon's Office and those in the Surgeon

General's Office was good, and many professional problems which would have

been difficult to consider through regular channels were handled well on an

informal basis. Examples of cooperative undertakings carried on in spite of

administrative difficulities are clinical observations on atypical lichen planus,

clinical trials of penicillin in certain infections, notably gonorrhea, and observations on the management of rheumatic fever and other diseases related to

streptococcal infection. There was little cooperation between the two offices

with regard to the assignment of specialists. During World War II, The

Surgeon General of the Army had virtually no control over the professional

personnel of the Army Air Forces.

Army Ground Forces.--In the Army Ground Forces, the importance

of the quality of professional medical services was overshadowed in the early

months of Army expansion by more pressing quantitative needs and the necessity for field training of medical officers. It is unfortunate that no professional

consultants regularly visited Ground Force units in training in the United

States. It was not until tile early months of 1944 that the consultants divisions of the Surgeon General's Office participated in personnel selection and

assignimment to the professional staffs of numbered hospital units destined for

oversea service with the Ground Forces. The training program for medical

ofhiýers in these units emphasized physical conditioning and( practice in triage

an(d transportation and evacuation of patients, especially the wounded, but

little emphasis was placed upon tihe curative treatment of disease and injury

with prompt return of the soldier to duty (fig. 21). Thus, the primary mission

of tile M1edical Department in timmue of Wl.. the maintenance of tihe lowest

tio||efrective rate possible was often neglected. The emilphasis upon surgery

2 This system was als:o In r llmration in certain Army Service Forces hospitals • s a supplemrent to the consultation

providedi by the servi(e colnand consultants.
it -. - . '' I , iI -hh I I tt I --(1 sI ()I i . .' I '';i I10-r X .,IIII

N1tona Amria 1Red ;I('rossI. I - ) I IIII) II -I r n' Ii Ihdia ~tI 'tl ( ol-
;I~)';I'I14 )'41121)2.liuliio wll h I)~ Iliert'k (iopeiiilflh Jti('5 l. iii(

1,11 o v of. (.\.l Iovr l Na ~lt fI doii -(,('it I efor tsiul wlioh olt Nat jonah

:111oat riid)1lim tli4 h.11aul HNct~ia) i tI4'4 ill~~i 111c' o A i. T'ilt'fi (11 i(.l iovt' 11iin it,

aptiwarei tos a be diml 14) .iiz4 1 aiitb l o L4;Ii(-I(t aI- i&, There I tt (111 011 f 1)ui totvt 

111,1 1 he Ic.' me ic. of tI uied rapdi e I.v ,\,IT) Tt1!IT A iT , andi -Illh ll
OtFFICE OF TIIE S[IMIEON (ENEIRAL 61

As the war progressed, the need for answers to medical problems, both new

and old, became increasingly urgeit. The facilities of the National Researclh

Council were used widely. It may be said that without this help the Medical

Consultants Division, in relation to many problems, would have functioned

ofteti in a vacuum and almost always would have been less effective. The

Committee on Chemotherapeutics and Other Agents, together with its special

subconimnit tees, gave invaluab)le assistance, especially in regard to the sulfomami(les, penicillin, and(1 strel)tonivcin. Also, the Committee on Medicine and

each of its Subcommittees on Tuberculosis, Infectious Diseases, Clinical Investigation, Cardiovascular Diseases, and .Medical Nutrition assisted the Medical C(onsultants Division in solving problems in these specific fields. The

Subcommittee on Tropical Diseases initiated and coordinated investigations in

its field. Upon official request of The Surgeon General, the following topics of

special importance to the Medical Consultants Division were made the subject

of study and reports by the appropriate committees: Amebiasis, schistosomiasis, leishmnaniasis, filariasis, malaria, polioniyelitis, and tuberculosis; the

treatment of ill effects of heat upon troops; the treatment of venereal diseases;

the use of sulfonamide drugs; the use of penicillin and of streptomycin; and the

management of fungus infections of the skin.

The facilities available to the National Research Council for its study of

Army medical problems were confined, in large measure, to civilian institutions.

As the Army was organized and administered in World War II, it was not

practicable for the National Research Council systematically to carry on studies in military installations. Nevertheless, many of the problemis facing The

Surgeon General had special military aspects that could be studied only in

Army installations.

The need for such clinical studies, initiated and directed by the Medical

Consultants Division, was evident when War Department. technical bulletins

were in preparation. These official publications were intended to guide medical officers throughout the Army in diagnosis, treatment, prognosis, and disposition of soldiers with certain medical disorders. In many instances, informnation was not available for specific statements and directions regarding the

particular professional problems seen by the Army. The choice of the Medical

Consultants Division was either to depend upon impressioins, guesses, and conclusions arrived at on hypothetical grounds or to imake studies designed to provide the answers. It was extremely difficult to do the latter at any time

during World War II.

The criteria for the early diagnosis of infectious hepatitis constitute a case

in point. There was little imnformatiomi ill tile medical literature, and that little

was not certainly applicable to tile disease its it was experienced Iy the Army.

It was sooni apparent that tihe patient withi hepatitis slioul(l have l)i'Otmil)t and

prolonged hospital care, but there were many umincertaiities concertimig diagnostic laboratory procedures. Eveti tile p)iecemeal imnforum ation available on

thiese points reaclied tile N.ledical C'onsultit:,ts Divisiomm by imeanms So imidirect

and slow that tile probleIn was never Coipl)letely amid satisfactorily solved,
62 A("1'IlT1ES OF MEDICIAL CONSULTANTS

al1thlough useful informnat ion wits oIbtainied thlrouigh ciViliani consult ants and

Anti x personinel inl selectedl hiospitals. Patients with niiatuirally acquired inltect ions hiepa tit is were ntot seenl ill stiflicieuit liinumbers inl Zon e ol Interior in stillhat ions, ntor Were enough qutalifiedl invest igat ors eVer concenitrated ill onle or

mtore of' thle oversell comininaids, to permiit thlorought stu *dy of' tilie p~roblemi.

Suchi research as was undt~ertakeni inl ArmY inst allat ioins inl tilie n111anagemleit.

of' disease wats often fragmnentary and poorlyN coordlinated. There wits no e-still)-

lished admintist rative 1i1iaci hiwry for catritYi ig on t t hese stutdies. Thle iniitia tion

of catch p)roject requiiredl sp~ecial a1)1V')vidl, speciall airrang1(emlents for equi jpileit

11i1d personntel, special intstruictionls to thle commilandlers of the installat ions -onlcerned, andl~ the approval of several organizations wit hin the Surgeon General's

Office. It wats difficult to get in formation abotut clinical research inl overseat

Commanda(s because early' ill the war there wvere nto dlirect channilels of conimunicaltion lbetweeli tilie field installations anrd thle Medical C onsultants Divisionl.

It is true that clinical investigation carriedl otit bothI inl thle Zone of' Intterior lu11(

inl oversea t heaters wats excellent, b~ut inv~estigaitors Were often lallitperedl and

their accomiplishinents rendered less Valualble to the Army 'ais at whole because

tieanis of communinication and~ coordhinat ion wvere tenuous or nonexistent. The

Medical Consult ants Division wats especially sensitive to t his serious hatndicap

inl relation to its problems with mintidria, filariaisis, schist osomiasis, hepa tit is,

and penicillin.

The followving tire examuples of clinical research withI which the Medical

C onsultants Division wras actively concerned:

1. JHepatitis.----It thle spring of 1942, numerous cases of infectious hepatitis

occurred inl soldhiers who haid been vaccinatedl for yellow fever. Thle Mledicall

C onsultants Division succeedled inl obtaining the assignmtent of' four medical

officers to four separate Army hospitals to ob~serve the clinical course and1( the

effe~cts of various formns of treatment. These stud~ies providled early clinical

experience in at prob~lemn that, wats to develop into one of great magnitude and

Simpo rt ance.

The Division enicouragedl as b~est~ it cotuld the extensive field studies onl

hepatitis which were carriedI out, under difficult circumstances inl the Zone of

Inmt erior.

2. Tropical di.,:eaxse.-.Extensive and valtuable clinical observations andl

therapeut ic trials w~ere ma11de inl thle field of' trolpical medicinle, eslpeciallv at

Mobore and~ Ii11ani11on General Ilospitamls and ill tilie Pacific. Stuchi stutdies illCreaISP(I 1,nlowledgec of filarma~s-is an1d of' schjist osolmilaSis anid ga.,Ve, informnation of,

thle g"reateýst practical Value onl thle use of At abrinie inl imalaria. F'rom i t heSout itwest Pacific inl 1944 and 19)45, lar1ge 1 tii iher,; of p:ticimts w~ere ret uruiedl to thlis

colnitt ,~ VWith anl 11 nuSUall skini disordler, Which camne to he calledl a IvpIcal lichenl

Jplaittnus. A c'oncise, (lea r-cutm cl('inical (lescri pt ion evelitut Imally resuilted from iicarefully organiizedI st udies of related groups of cases inl hospitals inl this countr it s

well as overselas.

:1. jrtenckfoot.- Seect ed hospi t als, nuiiaied andi~ equlippedl for the purpose,

made it'spec'ial stutd~ies of' at great inam v t retcli foot patients retutrnedi froini tilie
OFFICE O F TiHE SURGEO)N GENERIAL 63

European theater. TI eSe st tidcies vieldC1 Ilsefill in fortIIll t10on11 Up)liczble t hiroug"IIout the Arity.

4. Pen id/inl and 84repilomycin.-The M~edica! ( onsultants Division wvas

active ill p)lanning and (developing withinn thle Army oppIort unities f*or st udyit

tilie use of' Penicillin. 'St udies Oil tilie absl-)Srt iou, excret ion, and~ methlodls of

p)rolonging the act ion of' penicillin were carriedl fl-rwardl at two spcal designatedl Army hospitals, WXalter Reed General Hospital, and Fort Bragg Regional

Hospital, Fort Bragg N. C. As the war closed, extensive ob)servations on the

use of at newer antibiotic, streptomycin, were under way.

By the sp~rinig of 1945, there wvits fairly wid(eslpreadI acceptance of the con-

(sept that it is the province and (luty of the M\edical Department of the Arnmv to

pursue actively, Iy whatever ineans aivailab~le, clinical research in Army hospitauls and laboratories. There wits increasing (but never 'ompiJlete) agreement

in the Surgeon General's Office that it wats soundl and1( proper p~olicy to establish

facilities andl assign mnedical personnel for this purpose. Earlier efforts made

in this (direction front time to time had met with resistance or failure. MNemlbers of the Medical Consultants Division and others contendled that establislimient, of it special b~oardl, within thle framnework of fihe Surgeon General's

Office, composed of Medlical Corps officers wvith research interest andl training,

would facilitate research undertakings. Establishment of such at boardl, to be

(designated thle Army Board for Clinical Research, wats formally proposed lby

the Medical and Surgical Consultants Division in March 1945, with tile belief

that its creation would, strengthen and, extend adlministrative, provisions then

existing for the initiation, supervision, and coordination of research by Thle

Surgeon General. The proposal was not approved during the wvar.

VISITS TO SERVICE AND OVERSEA COMMANDS

From the beginning, it wats apparent that firsthand knowledge of tile prol)-

lems of medicine ats encountered in the field wats essential if at bureaucratic,

theoretical approach wats to iie avoidled. Experience strengthened this opinion

(fig. 2:3). Accordingly, General M\orgaIn, during his tour of duty in the Armty,

spent approximately one-half of thle tinme in thle field, including more than 8

niuonths in oversell theaters. As thle Medical C onsultants Division, OTSG,

grrew, thle ('Iliefs of' branlches also muade frequent field trips. Thus, personal

contaci(t wats maiantained with titlie mledical consult ants assigned to service

couiimmandIs, theaters, andi~ iirmiuus.

In 1942, General M organu atitended Army maneuvers in the ( California

(desert (fig. 24). During this Year anud subsequently, he aind iuleiuibers of hlis

division muade frequent visits to t he ninime service coimmiand Iliea dq tillrt er's andl

tlie muedlical unlits (general anid station liosf)itauls) inl thfese comm iands, (fig. 25.

In 194:3, General i\ orga ii visit ed tilie North Africani thlea ter ; the M\Iiddle East

theater, iniclud~ing- Egypjt , Erit rea, Palestine, and thle Persian Gulf Service

C omumand; tlie ( hinal-Bumrnia-l udia theater; tilie Sout hwest Pacific Area (Auistralia , New Guinea) ; and tlie( H awaiian Islands. C olonel Dieuiaide visited thle
ii 14'11~~~~~~~~~~~ .1 1' CT V11 IT I'I I:('41414 I I" NI 1: 1) 1~411n1i4 CAx C~14i N 144 s V'(

m: .2I44' Brci414 Gen4i~4. i41(1 J. Mm44' : I',CI4 Vr1X1 W. W41141 144, 14wi4'4 Ni~ \'l

Pncillr 111 i 9.4'1 I I 14 to 4\\ld lvv III(. I s as r h rlý Iigv ln 11d i l'l

4lv ll B -1141441 I vit \ ie I JIl 144- iv M dio I 14:11111II I1114 i 4l lo t i 1to1 '1L.11d44 (v 41 ifcio -l('14 '4'.is

III I1411w 41 1 9n 15.'4 iv 4411 ic- i \nI. xx1 v hI is~ited Ill 1144'.~ole11

th 'lI.;1(,nll JIJ444 Dn.)4;1 '.1 acco 4ip'll11ied h CoIl mi; l DWII44'Ilt ho i.4*

I414 III 441l inx 4 u: 44411111 III114 k ArI".vP Illc1.S r .

Ti'' l l,11141t' \ I 1 411 d 414 l ' - III4(.. f~iel 114 d II2'41 414111141 his 1114141111 he'

24. I14x 1'44gI 11141'1111.; w 111-1-cl1 441 1114 411 411111,410 4I11L 441 li'e i. 44 ' 11c , 111 411
OFFICEI~ OF THEii GUtFO ENERAL

FiGURE- 24.-MzNatwu%-vr.- in Cailiforniia desert . Armore*d halftracks approaich Blytihe,

Calif., 7 O ctober 1942.

andl subIsi(Iiarxv commndiih(s t he funict ions of Thle Surgeon General and his office

ill relation to the Army as a whole.

6. lucy encouragIed, b% examplle, a cont inuing andl lively interest inl clinical

prob~lemls. Tinie anid tunle againl, imedical officers exJpresse(I appreciation for

visits made by individluals from thle Surgeon General's Office to the bedside of

sick or injured patients. lInspect ions lby nien inl high positioii in the Army oftein

comipletely ignored tilie actunal care of the sick or injuredl soldier andl the clinical

problems incident thereto. This c.are wats tilie chief activity of thle majority

of medical officers, anid I hey rightly viewedI it as their primary mission. T1 liev

miorale andl performanalce of thlese officers were impijrovedl when The Suirgeon

General or his representatives took a simiilar view.

7. They bridged thme cliasimi which inievitably dlevelop~s ibetweeii tile iiieii ill

field assignm11ents and thle hieadquI art ers group.

8. TIhey broughlt to thle Surge,(oni General's Office thle Prob~lemis of thle field

for such comntribut iomns to t heir solut ion as could be provided.

It should be stated t hat adminiiist rativye dIuties inl thle Surgeon General's

Office did not permiit enough visit at ion by tilie st aff to field 1units, Whet her ill thle

Zone of Interior or overseas. Ill addit ion, visits to oversell inst alla tions were

often discouraged b~y thle War Depart umenit amid, at tinmes, by the over.ea,

theaters.

5649i70'-61 -7
L N OS AC TIVITIS INl MEDICILNE.11"AA-11

(IN(~l~r liU~elV \ U li ~ti~' I (elerd 1 lriliriiio le \eAMa

Ii'iediclelca tol: esearch r5- in 111(1ion JNia icervi ivilt- lifed lowevtil, weore 50gimi

I~~~~~~~) haIliUlv(li iei pcfiait Trhiii Cie~ltli er weref. refi9r~ 1o:iiu ii3.hi

(i vevlal effort. iloever, i iaiv sul-voo wereaiixii to servel into thle Miivedicall

Desearch ( 11vi 1(1o teoriiiii t i('(5 bvi srieso ioto to heoesJeifront s erel

l11ita -I~ a.\ va h Ide lla 1 The a-sii~ei"1 vil to r vei l. Iimi lie, ill t1v yerf ied o wIle elar. 1111(

I2OOvdical'li' Anucitiilv wriscacco"Ili lplisliec v ill foriiiall clitact alulVVI1 WjTesoigrat on

rEh.11 111,vee1 deic * Spcalitt li chief colivllt l Ie ic ii \ i(Iliciliuie ad ho 1-is 'lafl ati ithes

(.Zr-ll -1)1 1)li1'il5 Moeo er 111,111lav wh w)4e(re lierl Irx*irciiieidd l~

R'l'lie Siiroii( rlcierl coJlmi' lev, the Services ofl1l)oiil;ult of, ciilia Spciaisiits Nits

iliie iiiediciie to Thle Slrireol Gelleral. Ill the (oislaris ak of the i'e(rZimuch

0 for 1v.li silh-selweas m11011 plus, as e seiall tilesaoelddt:la ols~tlt

~ iicds~~ee ~ectl f);otltel. s ollws lii Novlfciibe and44 a ((lsolultl c

reach lldvlieatc dieasesl 111v( civI tronl~ica1tl liledicilie;ii .aindIlls 11145.1 and adiThelia colisllt ntii ( latpoloved 111v a forml March llIt of4, c()liallta cltIiivsciilir

(hiseases. Ill14b'vliltenlsts Illohi()scne as spciaIvilia c1oasiil alditisonalTh consultants

( reiienal 41111iiu1g W~orld~ War 11 are list ed Ill zaplellhi.\ ,; 1). 8:3).
iwFwic: (w rw:it SURG~EON (;ENICRt, 6 7

General N [organ, hiis st aff inl the Surgeon General's Office. and~ tble miiijt arv

Medical coli1stilt alits inl tilie field Were ii itled greatv lvIi tile civilia il coistilt alit s.

Th'lrolugh t liese conlsult ants, hot il Iiiedical societies and individuils, hail direct

access. tilirou~ii offlciAi liai ie to Til Icsiir-von Generall and( tilie cilijef conlstlut alit ill tiiediciiie, anti dltvt'lopiniitiits ill Viviluizii miedicinie were iiiiiiiediat el *

available to thle Army. Frequeiit lv, adtvic-e onI ujr~reIit matter, wasi. asked Ibv

lettelr or telepilojie. Tile ('iviliali coiisi~iltlits prepalred iiia1teraial to lbe ilicorpoirated inl 11ar1 D epar1tment iit cli inca I ullet iiis for Arml ywu he (list ribu t ionlhelY aittended coniferetices with tilte N ledicall ( 'onsiilt an fts D)ivisioni atiltitlie

seric ccii1111 idconisult at lits. an tlthey offeredl suiggest iols, anid reconimndiia1111-

110115 regalzrd iIQ NI edicall Departmiuent Ildiniiiist rat ive pi'ocediire andh pr'oft'5slouill1

1) ra vt ice s. lin shiort, t hey providled at close aiil effective lialisoii bet weenl civilianl

Mewdical priict ice allid research11 andt Ariiiv Iii('(icail lplact ice 1au1ti researlch,. to tilie

-.rriat henletit of hotIil. Occalsiona'llyv, tilie civilian consult ants, were ordre o

aIctive (lilt v 215 Col)IfI nissioiie(,l offictrs withliedi Ariuiv forif few (lays, followino.

wihich tilitv 51ihliiit ted 'ommuienit., and 1'e('onititentat ions regardinig tile problem

ait bianid. 'IlcY Visitedt Arniv boptl. l t lie Zone ofIneit r ill (companyv

wit ii tilit niilit aln' consultilant of tilie co01mmand1(. Suchl visits, maide joinitly hby

civihia ii an i~niitiit 11 colisuilt aints, were found to be stimulating to the Ilioraile

an pilfroft'ssional performnanlce of mied ical ofic'rs Onl dthty inl hospitalls. It shiould

bereoredt ateah f les cvila (onula gave ;t freely and willingly of

timne anud knowledge. ITbvir ext raortl mary 'oni iet lice, 1and lvieu a vaihlabilityv

llia1le thieiii a valtitlde source of ad vice anid pr'ofessional assist anice for' thle

Siii'gt'oi Gvello'l's Office andl for miedi(cal officer's ill the field. Their appointmen'its, wer'e terminated as of 31 Decevnier 19435.

PLANS FOR THlE POSTWAR AR'MY

Planning for the Medical Department.-Gevneral IMorgan and hIls colleaguries inl suirgery :11(i psychliatry devoted a1 great deal of tlioull~it and( enlergy%

to planls for retaining an adequate number of prop~erly trainled generall miedicall

officers and1( sjieciallists ill tilie piost war A'nnY lin ordter' to prleserive thle exce(llenit

wart iuiie standards of proft'ssionail care. 'Fie p~rob~lem was tilie prIoculremen'lt

of specialized per'sonnel for tilie Akrmy N Ldi Corps. Su~ggest ions a111id recoiiiliiendla t ilols W(ere( suhtibi ittd 21(I as arly a is 1942 and were reslibmillittedl periodallnissionl of intere'(sted'( officers of abhility~ who were eit hem' cert ifiedl spec'ialists

01' Caiiditlates for' cer't ificat ion. lDuriiig. tilie wari, thiese sugg"est iois w~er'e coii5ide(rel imipr'act ica ble beca use tilier' wer(e few, If a l1Y, VACa u1cies it) app~roprIiate

gV1'a1l(s a11n( it requiiredl ait ac(t of Conigress to iiiereztse thle size of thle Arnivy

N led ical Corps. Followinrg cessat ion of hiostiliities, tihere was af shiarp dirop

lit liiitei'est oil tilie pairt of' hot i thle I ed icil Departmeneit and( th lib etrs0l1iel

1i1hider conisid er'a tion.

liveomm.rwitti:tons for the N1,41ci~u I h-.pirt im-lit in a F'Ituri- Enwtrsevlny.
(;S ACTIVITIES OF MEDICAL CONSULTANTS

Plan to continue the consultants system.-Tlhe professional constultants

systei i, as em1iplo lOyed during World War 11, hal1d gained general acceptianice

liarollgholat the Armiy. Tie following (lirective, War Department Circular

No. 101, was pubhlished 4 April 1946, monthis after cessationi of hostilities

a d lit a time Nweln demiobilization of tile Army was well 1 under way.

Indirectly, it is a ppraisal of the consultant systeii in tile foruu of a statelent of Nwhat tile Arilly hlald come to expect of it and how tile Army planned

for continued operation of the system in tlihe -postwar period.

III. PROFESSIONAL CONSULTANTS. 1. During World War II, The Surgeon

General developed a system of utilizing professional consultants from which great benefit

was derived (reference is made to p)aragraph 2d, section II, WI) Circuhlar 12, 1946). In

order to insure the maintenance of the highest professional standards and to provide close

liaison with leaders in the medical profession at large, this system will he continued :lnd

extended in the future. Professional consultants who are recognized experts in the imedical

and allied specialties, including internal medicine, surgery, neuropsychiatry, preventivv medicine, dentistry, veterinary medicine, and other special medical fields, will be designated

by The Surgeon General. Recommendations for ap)pointments in connection with special

subjects, such as dentistry and veterinary niediciae., will be made by the senior officer in

these fields. They may be either appropriate officers commissioned in the military service

(Regular Army, Army of the United States, Officers' Reserve Corps, or National Guard of

the United States) or qualified civilians selected to render consultant service (see par. 4).

Although the provisions of this circular apply particularly to the United States, oversea

commanders will utilize appropriate medical officers in their commands for similar duties

or may procure professional advice from locally available civilian medical experts.

2. As representatives of The Surgeon General, the professional consultants are concerned essentially with the maintenance of the highest standards of medical p)ractice. It

is their function to evaluate, promote, and improve further the quality of medical care and

sanitation by every possible means, and to advise in the formulation of the professional

policies of The Surgeon General and to aid in their implementation. The proper performance of these functions necessarily involves an appraisal of all factors concerned with the

prevention of disease and the professional care of patients, including particularly the organization and program of professional services in medical installations, the quality, numbers,

distribution and assignment of specially qualified professional personnel, the diagnostic

facilities including roentgenologic and laboratory procedures, the availability and suitability of equipment and supplies for professional needs, and the nursing care, dietary

provisions, recreational and reconditioning facilities, and other ancillary services which are

essential to the welfare and morale of patients. The professional consultants exercise

their functions by assisting and advising The Surgeon General, the surgeons of major forces

and commands, and the commanding officers of hospitals and other medical installations

on all matters pertaining to professional practice and preventive medicine, by providing

advice on professional subjects in general and on newer developments in prophylaxis, diagnosis, treatment, and technical procedures, by stimulating interest in professional problems

and aiding in their investigation, and by encouraging and participating in educational

programs such as conferences, ward rounds, and journal clubs, and by giving advice oni

matters pertaining to research and development. The execution of these functions involves

periodic visits to medical installations and other types of units concerned with the medical

care of military personnel. The functions of professional consultants vary somewhat

according to their assignments.

a. Office of The Surgeon General. In addition to medical officers permanently assigned

as professional consultants, other specially qualified individuals will he placed on temporar.y

duty from time to time, for the l)url)ose of rendering advice and assistance to The Suriceon
OFFICE OF TIlE SURGEON GENERAL 69

General on broad problems connected with policy and practice in the prevention of disease.

the care of p:',ients, evaluation and m'axinuurn utilization of specialized personnel, medical

researc.h, postgraduate meoical education. and other important professional matters

throughout the Army b)oth in the United States and overseas.

1). Lower echelon headquarters. Designated professional consultants will be placed on

temporary duty from time to time in service commands, Military District of Washington.

and air force command headquarters for the purpose of rendering expert advice to surgeons

of these headquarters. It is desirable that such consultants he individuals with military

exl)erience. Their services will be utilized regularly in connection with problems within

the command which relate to the care of patients and other professional matters as indicated above.

e. Artny ho.spitals and other medical installations in United States. Professional consultants will be placed on duty from time to time in Army hospitals and other medical

installations in the United States which are designated by The Surgeon General to provide

graduate education for medical officers in certain medical specialties. Such consultants

will have the l)particular duties in hospitals of furthering in every possible way the eduicational program for the advncenent of medical officers in the specialties and of maintaining

the highest standards on the professional services of the installations. They may, however,

be called upon by the commanding officer for any professional advice or appropriate professional assistance he may desire of them. Their services will be utilized regularly. For

further information regarding the educational program of the Medical Department in the

medical specialties. see AR 350-1010. Professional consultan~ts in the various medical and

allied specialties will also be used in other types of medical installations, including especially

those devoted to research and development.

3. At the completion of a special mission and at such other times as may be required,

each professional consultant who has been on duty shall direct a communication to The

Surgeon (eneral dealing with the functions set forth in paragraph 2, including recommendations (if any). These commmuications, with appropriate indorsements including those

of hospital commanders and surgeons of commands concerned, will be promptly forwarded

through technical channels to The Surgeon General. Indorsements will show what action

has been taken on consuilta'its recommendations and will give an evaluation in terms of the

consultants services.

4. Qualified individuals designated by The Surgeon General will be utilized as medical

consultants in one of two capacities-that is, either by being ordered to active duty as officers commissioned in the Officers' Reserve Corps or the National Guard of the United States

inl accordance with WVar Department policy, or by being employed as consultants holding

(,Xepted civilian appointments under the authority of the Secretary of War. The consent

of the individual concerned will he obtained prior to placing him on duty. The Surgeon

General will maintain up-to-date lists and from time to time inform all concerned of the

ianies, addresses, and qualifications of medical experts selected and approved for consultant

duty. lie will also furnish details regarding the procedures for placing consultants on duty.

5. The above instructions are equally applicable to dental and veterinary consultants.

6. Thes, instructions do riot relate to the provision of civilian medical care, specialized

or otherwise, for individual military patients at public expense, as outlined in paragraphs

3 and 4, AlH 40-505.

ROLE OF THE INTERNIST IN WORLD WAR II

Among many miscellaneous topics claiming General Morgan's interest

was the relative importance of the internist in the Medical Department of the

Army. The topic was forced into the foreground of attention by the tendency

on the part of some to emphasize the Medical Department's surgical activities

in such a way as to belittle the contribution of those who cared for the sick.
70 AC'TIVITIES OF MEDIC(AL CONSULTANTS

This aSttitudite oil t it', part of lavnieii is not surp)rising, for, when t heir alttentiion

is dIirecte to( tile M edicall Depart ment of thle Arnn (luring wartime1, it nat -

Iurall1v focuses upon the( wound(edl inn ii anid his care. Ajcttlaliy, tilie nonlef'rective r'ateI and~ tite factors thlit aiffect it atlvers-elv are equally thle concern of thle

Army Medical IDepart ment; they aire, inldeed1, its, chief 'oncern'i iii respect to

its niission to help win wars. Viewed inl this light, thle wounded mlan, aside

front thle great ('11101 ionail react ion experienced by all regarding his plight, of

liec(s'sity assum nes a posit ion of secOndlarv imiportanice, for hie is oftenl non1-

effective for a veryv long timue. if not permianiently. Preventive andI curative

med'(icinle aire niore ininiiediatelv efftect ive iii retliciiig mtetdical noneff'ect ivente's5, which forti unat ely (oist itlutes thle bulk of thle problemi of t he' Medical

Departmeneit as a whole. InI tlie It alian camipaigns of W~orld War II, 80 pe'rcent of iiom'effect ive soldlier's ret urn('( to dulty by thle Mledical D~epart mentI

were mnedical patients; only 20 percent were' surgical. The int ernist , thbanks

to thle (developmlents, in miedical t herapetit ics since th li'earl.% 1920's, has become

t ie( miost eff(ect ive therapist extant., ait1 this fact is reflected in Armiy records.

Neve'rthleless, thle traditional tendlency in military miedical planning and

admiinist rat ion is to t ie( greatest St ress Uiioui the 'surgical aspects of mlilitaryw

iiiedicinle, oft en to tilie (letri-intnt or neglect of thlie medical aspects. Ge'neral

N Iorguiii considlered it onle of, his import anlt dut ies ats chief consult ant in inedicinle

Ito rep~re'sent tilit profe'ssional initerest s and to emipjhasize t he praict ical iunporta211cc of tilie nite('riist with Ii the Army in lt'e field in order to claimi for hiimiself, in the( councils of the Surgeon ticiie-al's Office, his prop~er place 2111(1 to

ur1ge that Ilit be prope'rly r'ecognuizted and ad(equa~te(ly supp~lortedl. Ini t his posttion. Gienteral Mn Itrglui wats, sI roglv Supp~ortetd by nianny iiedical officers withI

field experience inl th Ga (rountd Forces, not ably C ol. (later M aj . Gen.) .Joseph 1.

Ma urtini, NI( ' Stirgeoni, F'ifthI U.S. Armiy. Nevtert heless, til lt naxniiuini exJploi tat ion or wini t in ternal iiicthicinle liatl to ofel't' inl retduci ng th li'nonieffectivye

ritt' of, trioops iniilie fieltd was not un1dt'rt akenl dulring. World Warl III. To tdo

thi s, 21 rt'vis-ioii of t ie( 122blets of or-ganiiza t io an eiqu'121lipmet'l for Giroundit Fortes

iiied ical inist ll~ationis would have' been ne('es-2Irv. lIn tilit field of l)Syvcliiat cv,

ii ucli \%-.s accomnplished't in this tdirect ion tlur1iiigr t lit war, wit hi nottable rtun

ill reduclti on of psychiitrit ncioiu'ffect iveiless. The Ground Forcets aiitiiiiiist ration of' problemis in tilit field oif intternal intdicine duirinig Worltd War 11 differted

litIt'e froini tilie p~ract ices of 191 7-18, tlie , 111 ;ei ii t'nt of lie( venerteal tIiseast's

being almost tlie( sole e'xcept ion. Betcause Army Mledical lDepartmient Inls1ti11inions were plainned an1d( adm1iniistetrted primalulrily for 11 surgical mission,

inefficiency andt imiprovisait ion ch2i1t't eriz'd theitir perform~illict withI regarid

to illedical problems. Intlit'e thteate(rs or op~erait ions1. tlie( lack of spteciallized

personniel in internal m'ldmcili ntd21( the pai11(11v of beds for the cart' of the sick

inl installat11ions unde~1tr Arnmv j in-isditt im restil ted iii miiuchi 11n ecessar 'v t'vacu 21-

tioul to tilit coiiii In iicat ions zonies, prolonged hospit alizat ion, antd increasetd

iuoiiefl'ect iveniess. The aissignmlient of illediCad coiisultialits to field armly hieildC(IhIiI't ers ill t his War wits all) ext reilelvi Importa21nt initiatl step in the direction

of correction. 'Miuchi still remnainedl to he tdonte when' host ilities ceased.
CHAPTER 11

Service Commands

Hugh J. Morgan, AL..

There cou1ld hardly have been foundl any group of' Army officers of the

samile ageT and graide With) more1 original and~ independent alt tittudes and patterns

of behiavior than thle group selected to be service commland1 consultants in)

medicine (figs. 26i and 27) b)y The Suzrgeon General onl thle reconmmendation of

h1is chlief mledicall conisultanit. However, the group had certain at trib)utes inl

commnon. Each wats (list inguishied inl civilian lnedlical practice andl inleical

edlucat ion; each wats at loy ail patriotic American, ealger to serve his country; and

each b~ecamne at dledicatedl officer inl the Medical Department of the Army.

A prerequisite to their selection wats t hat thle consultants be suifficiently

imnaginat ive and resourceful to graisp inl broad out line at concept of thle role at

prIofessionial conisultanlt ilnight play inl thle Armny. After comnmission, however.

hie consultants were provided With little more thain officer gradle and a very

vague Jl), jobefinitioni for support to establish themselves and make their wily

in1 a soiletimles hostile and frequientlty indlifferent headquart ers.

Tile role of thle p~rofessional conisulti ant inl civilian internal mnleticinle wats

afnhroetteeme.The knowledlge, resourcefulness, tact, andl perseveranlce Which t hey required inl civiliani practice were essential also for their

role as consultanits inl the Army. They went into their new assignmients eniCtouiragetl bv Tite Surgeon General and his representatives to (10 for sick s01ldier-s

an1d the medical officers who cared for these soldiers what these consultants

knew well how to (10 for pat ients and1( practitioners inl civilian life. This atssignmient required inot only professional ability but also ability to evalialte

and mm111iamiiplt e lprOfessionl pes Iie to create anl environment fin Armyv

hiospitauls conducive to high professional standairds, to encourage cont inuing~

iiiedical edhucat ion ill t(le Army, to st imulat e p)romplt. admninist rative thisposit ion of convalescent patients, and, inl every other waly, to keep the Army

nonleflective ratte h'omii dlisease at thle lowest pos5sib)le level.

The effectiveness of the medical consultants inl thle earliest assignments to

servic'e comimiands encouriragti surgeons of other commianids to experiment, with

this new kinid of officer.' Trhe assignments were not mandatory. The Surgeon

General h1ad 110 such anti horitY over service comiimmand stirgeons. Following thle

prompilt 1111(d conspicuous success of tlie( consult ants who were assigned to tile

Fourthi, Seventh, Eighth, and Ninth Service Commiands inl August 1942, other

ICol. Heinry NI. Thomas. Jr.. NIC. was assiened to the Fourth Service' Command on I Aug. 1942: Col. Waiter Bauer,

MIC, was assivnei- to the Elahth Service ('oninianti oi 1N Aug. 1942. Coln. Verne R. Ma~son, MC, was assigned to the

Niinth Service Commflandt and~ Col. Edear van Nuys Alien, AMC, to thle Seventh Service Command somewhat later in

the samie month. Tue First andI Third Service Command surgeons mere (lie List io request consulitants ini medieine.

Officers were assigned to these service coniniands in January 1944.

71
4~d I ~ M I C.i "'111: I 111 il N Id cic. Ih
"SIll Vwi', [ lull It ut1iul l''ft If i.'r j ( '1 )11111:1 ill,'

',-ill r Nirlllrd '~i .Sl11-'l lur' M ( ill' M '4Cil (M c

il i..t7II N ilw.( M '.(ITIi1'u ii 1j:m lit'. I'M od cl l. I fi v (fIll
74 ACTIVITIES OF MEDICAL CONSU LTANTS

commands requested consultants, despite the fact that early in the war no

position vacancy existed for then in the allotment of medical officers for service

coinniand headquarters. Consequently, the presence of a consultant used a

position vacancy vdesigned for other purposes and blocked promotions.

It should be pointe(l out that the success of the consultant system in

the Zone of Interior during the early training phase of the war paved the way

to a large extent for its adoption later within the communications zones and

finally by the armies within the various theaters of operations. A conspicuous

exception was the consultant system adopted quite early in ETOUSA (European Theater of Operations, U.S. Army). Under the guidance of Maj.

Gen. Paul R. Hawley, Chief Surgeon, ETOUSA, and ('ol. William S. Middleton,

MC, and Col. (later Brig. Gen.) Elliott C. Cutler, MIC, Chtief Consultants in

Medicine and Surgery, ETOUSA, respectively, there developed consultant

coverage that was ready for and kept pace with the rapidly expanding European

Air and Ground Forces in World War II. The professional consultant system

reached its fullest development and maximmn efficiency in the European

theater.

The names of the medical consultants in the Zone of Interior and the

service commands in which they served are listed in appendix A (p. 829).

In the preparation of this chapter, full use has been made of the service

command consultants' final reports wiicih were prepared at the request of

the Medlical ('onsultants Division, OTSG (Office of the Surgeon General),

at the termination of the fighting and just prior to the separation of the consultants from military service. All of the reports have been helpful, but special

mention sh0ouhl be made of the report, Activities of the .Medical Consultants

in the United States, prepared by Col. Walter Bauer, MC, Consultant in

Medicine, Eighth Service ('omnmand, from August 1942 to August 1945.

DUTIES OF MEDICAL CONSULTANTS

The service commands varied greatly in size, from the relatively small

First Service (Command of the northeastern seaboard to the huge western Ninth

Service Command (map 1). Because of the geographic area included in the

more extensive commands, consultants found it. almost impossible to visit

even the larger hospitals with any frequency. Problems encountered in cornmani(s with large areas and populations and the means used for meeting these

prol)lems were discussed in the final report, of Colonel Bauer. lie summarized the scope of the activities of the service command consultants as the

consultant pro,,ram evolved in the different commands. Also, lie comnmente(d

oil tile jurisdlictional conflict regarding medical administrative aut hority,

which plagued The Surgeon General and the Air Surgeon and their offices

(hiring the war and winch was brought into sharp focus by the medical consultanits, whose chief concern was the improvement of the quality of medical
SERVICE COMMANDS 75

MAP 1.-Service Commands, Zone of Interior, during World War II.

care received in military hospitals.' The following paragraphs summarize

his observations and recommendations.

The magnitude of the task to be performed by a service command consultant in a given service command depen(led on the wishes of the service

command surgeon, the size of the area, the available transportation facilities,

the number and type of installations, and the total troop strength. In one

of the larger service commands, the surgeon desired that the consultant be

responsible for the supervision of internal medicine, including all subspecialties

except neuropsychiatry. He was to serve all fixed Medical Department

installations within the geographic limits of the service command, including

Army Air Force installations, induction stations, reception centers, replacement centers, internment camps, and, when necessary, Army-owned or Armyoperated industrial plants. Even thiough the consultant worked rapidly,

it was impossible for him to visit approximately 150 installations in a year's

time. Experience soon demonstrated that, unless he could visit each installation at least every 2 months, he could not achieve maximum professional

effectiveness. This assignment was in marked contrast to those of the smaller

service commands, where it was possible to maintain the desired schedule

with relative ease.

In the event of another national emergency, every effort should be made

to correct such gross discrepancies. One or more additional consultants

should I- provided in the table of organization (manning tables) of at

least the larger service coninmands. Designation of an assistant by the

2 In fairness to Air Force hospital commanders and hospital staffs, it should he said that proximity to patients diminished the intensity of feeling which characterized higher echelons. If left to themselves at the operational level in

the field, the service command medical consultants and the Air Force hospital commanders and staffs functioned together well with benefit to the patterts and everyone else concerned.
76 ~ACTIVITIES 4)F MEDIC'AL CONSIULTANTIS

consuilt anit, withl the aipproval of tile service coniniuad sulrgeVon. wouild assure

harmiony. 'This airrangrement wouldl increaise thle frequency of hosp)it a! visits

and provide for the continuious presence of at qualified Jprofessionail consuiltaint

at headquarters.

Since no provision wais made for additional service comimand consultants,

at substitute plain was developed by the Eighth Service C ommiiand in 1944.

Each of the regional andl~ generail hiospit als, wNithI thle approval of thle Suirgeon,

Eighth Service Command, (lesignalted a comipletent internist. ulsually the chief

of the mnedical service, to serve ats consultant to its satellite stat ions. B3Y

having these regional consult ants visit the smaller hospitals every 8 weeks,

it was possible to provide better sup)ervision of clinical activities, miore intimiate

,association with the parent institution, and more frequent constidtattions.

Once this p~lain was in effect, thle service commiiand~ 'onisult ant wais table to maintam the desire(I contact w~ithi those inst allat ions (g-enleal2, regionall, aInd Ilarg-e

st at ion hosp)it als) responsilble for the care of most of' the service commiiandl

pattients. His association withI the mnedical officers- of tile satellite hiospit als

cont inuedl t hrouigli the medium of edlucatijonal exercises itehi at thle t iine of' his,

visits to thle parent inst itutiion. At at hat er (late, thle iiiore comipet ent service

coimmlandI speciaili-sts in railiology, dermatolog~y, neuropsvchia try. Ophlmlthlmologv, aind otology were also dhirectedl to visit tilie hlarer hospitals. Thetse

augmIlentations of tilie consultation service prloved very efrective and were

adopted'( by several ot her service comimiands. The chief adlvaiit ages, were more

frequent visits to all hospit als, greater exc'hange of' professional exp~eriences,

and1(, mlost impilortant of aill, higher quality of niedical service for every sick

soldier regardlless of his locat ion.

The consuiltants, having hbeen instructed to visit all medical installaitions

in their service commands, rightfully aissumled that their rehit ions with tie

Ariii Air Force hospitals were to be tile same as with inst allat ions of thie Army

erice Forces. They were at the outset. However, in Mairch 1944, tile

C'oimmiandling General. Army Air Forces, specifically request ed that thle service

commiiandl consultants visit the Army Air Force installations only upon request

andl then for the sole purpose of teaching andl holdling clinics. This action

marked the terniinat ion of the initial plain except in the Eighth -Service Coniiiiandl, where the surgeon of that conmmanid insistedl thalt tilie consultant continue ats before or discontinue aill contact with the Armyv Air Force installations.

In at few of the other service comimand(s, tile visits were conitinuedl on] a himited

scale but only lbecauise muedical officers, assignedl to tihe Army Air Force hospitals

u11rgently requested that this profitable iiiedical experience be continued. In

rerospect, this action by the Armii Air Force apek--vr nwise, sinice 11o

substitute for the service conimuida~ consultaint was p~rovided until tilie closing

moiiths of tilie war ii. nd then only on at restrict ed scaile. This and similair exp~eriences at thle p~orts of emb~larkat ion indlicate thle need for definitlive st atemnents

of policy regarding the function of thle consult ant in lie ot her inlstalilations

under separate coniniiiia(s, (fig. 28). lThe nieedIed mnt erat ion of aill tilie miedicall

ser'vices located in at service comimiiaid cainnot be achieved od ierwise.
S-c Uvntwi-cj-( Pon1' o4f iwi. C''vkO l('fj.. V'4 t2.

(14''444'( 4Iui1l)14' 144 Ow4( I14'4'4,~ (4 Ili., ()\\-I service44 command;41. I l4'ip)h4 i4~ '-'

til441 wvrv4 14(4'vc i('41 i II'4)41 114;444 4I4444,4. fi 14ll, ost impo1)4I'a441 bin4j4r 1114' sc4'iV44'

fellm ow 4 1sli4l;4114l 1141 fllt, c'441414a44d4'l1.r of 1iccr.,' and1 stalk. of' mall 4v (41 1144' flsjpit'4l4. v\4-ýilv. 1The \4';4irV 4410Il4'4('Ilce otes ( 1114', (0111 onu a 11441414'4 fforde e14414x4l1(111 oppo)44't111111 441ily'' dal!,. 1()11 problems'44.

The4 scope)4 oI* tilt- cmisl1 nlltart ati vilk 4 n5 s fiinull*v v''(01 i1'I4(44 W W4 wiT

vi.,il4lr Owll Jpl44I4'5i4)4n'll civiliv (45 tf e med 41'(ical svi'vl'' Cs4' 1111d t~le ;41Ii4'1 5J)4'4i:Ili('5 prl4'io44s1\ 4414'l~l 14)144' 4(li''ising144 the s 4(' ('41444a4( It ()l~~44 i)4ll pro

ill t114' Sil44'l-gcol Geller4's;1 Office'4; :45s41g.l4 1igl Im1'd4c1i4; offIicer' pv.Sll4';I'5411141 l4)r14llg-

('4414 'h1414 llilg L I4(p144'1ti %\il v it 11'(It 144'~l di~isi44is o)f' Ow lle'd44hie1Il Ibl111ch'l

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v'114ia mi4114 dillies nid illg- ill 114''414v contro (4) ep1i 14'144i al 1141 14' aval52l ;4': 1: Il'41

reques44',t by fill' c'41414:444 i lding 4)licc('4 o's 4 Jlospill :s a., ('(Plsll 1:4141o. of)1 1411 411slIa oi.

NI:4ry 41' 1114' 4'44l,1411:4 Ills' fivlls. (di' .:4uiv i ,'Iv over'I':Iel4'( O11w t 444'41''01'

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ý iA('r~vI'rIs m)., MEDIC&AL CO~NSULTANTS

c'oncernledl primarily w~ith tilie professional needs of* the miediicail services in the

service commandiii(s. III t hose service (oliinjifl~lds eet i ~igieie c I stl

tat ion svst eii wvas jint roducedI, t hese pl-0lessioiiaI (luties required only 75 percent

of' their time; the remiaindher wvas spent ait hieadquarters.

Anot her appraisal of' muedical consultants' dulties its t hey evolved1 wit Ii tilep~assage of timle is providedl Iy C'ol. F~. Dennet Ic Adams, M( ', (1 onstidtant inl

Medicine, FourthI Seivice C ommiand, from September 194:3 to December 1945.

C olonlel Adamlis ob)servedl in his final report t hat (diring thle earlier mnontlis

followANing tlie( tinitiat ion of' conisultanits' service iii his commliandI, thle conusilt 1 itl's

act ivitijes were limiited1 almiost exclusively to mlatter's Pertainiling dlirectly to thle

(.tre of tilie pat11ient. Ilie wais chiargedI with ti t(l following dhuties:

1. To adlvise the 'Surgeon, Fourth Service C omimand, concerning till mlatters relating to thle diagnosis and uinediciil treatmienit of (disease and thle p~rofessional operation of' miedicail and hlaboraitory services in aill service (oniniaild

hospitals.

2. To maintain liatison with thle cliief consultant in mnedicine in tihe Surgeon

General's, Office on matters of' a professional nature and those pertaining to

key p~ersonntel.

:3. To visit aill ser-vice command hiospitals, survey the medical and laboratory services and make recommliendlationis to the chiefs of services and the corn1111iiiii(Iii officer in each installation as well ats to tilie ser-vice comimiand surgeon,

11i1d prepare at report of' each survey for chiaiinelinig to Thle ýSurgeon General.

4. To hjold teallciing roun(Is anild clinics ait instazllaitions visit ed.

5~. To serve ats consultant f'or chiiefs of medical service wit~hin the hospitals

of tilie service command and1( adlvise them regarding professional prob~lemis.

6. T1o evaluiate professionial qualifications of mnedical officers serving ait

eatch insta[llation.

7.To be available to act, onl the rcequest of the coimmanding officer of a1

hospital, ats a1 consultant Oi a 1 ,N, iny tiusuall or compiIlicated case und~er his jurisdiction. (In1 SOllii instances, I his inivolvedl a p~ersonal visit to tilie hospital; in

others, the chief of medhical service or oilier qualified officer front at nearb *y

genleral1, regional, or stattion hospital was dlesignatedl to act for thle consultant.

As timie elapsed, the consuiltant's (hut ies were broadened to include the

following:

1. To survey professional (hlalificat ions of officers assignedl to the medical

a11)(I hi horatIorv services ill ordher to recointiieml~ proper professional classificattion

aild( ('odiuig.

2. To assist the personnel branch of the service conllanlll su-rgeonI's offic

iii the proper assigunient of miedhical officers.

3. To review aill cases of' (heutli occurrhig in the service comimnand t~o detect

p~ossible errors inl (Iiagnlosis or treat ment and1( to iiiake recoinmmendat ions ainied

ait prevent ing~ siimilhar miistakes iii the fmitutre.

4. To reviewv, edit, and a pprov'e or reject, prior to dIispa t ch to The Surgeon

General 1',r final review muid1 action, art icles wvrit teni 1)*v medical officers in tilie

co0111i11im 1(d anmd iii tetided for p)11bhica tionl ill hpro r~eH)Iin Ia journalIs.
SE'RVICE CO~MMAND)S 79

5. To prepare articles of' t imely professional interest for publication in the

mionthlyl Hfedica1i Bulletin of' tite Surgeoan, Fourth Service C'ommnnid.

6. Tro enicouirage oilier officers lin the coinimandl also to conitrib~ute approIpriatte articles to this b)ulletin.

The service comimandl consultants were not buLreaucrats. Not miore. than

one-tliirdl of their I inle, and usually less, wa-s sp~ent in headlquarters. A sumimiary of C'olonel Adlams' ob)servations onl miedical consultant activities in the

Fourth 'Service C ommiand gives at detailed, intimate viewv of hlow oine- medical

consult ant carried out his mission.

InI general, tilie consultant spent 75 percent, of his timie in the field and the

remaining 25 percent ait headquarters. Days ait headquarters were devoted to

administrative wvork, suich ats wriit ing ireports of his visits, familiarizing himself

w~ithi eurrelit Wair Department directives, discussing policies with the service

commnandl surgeon so ats to be qualified to initerp~ret them prolperlY to officers in

the field, reviewing papers submnittedl for publicattion, anl(l discussing with thle

M\ edicalI Personnel Branch, Headquart ers, Fourth Service Command, changes

of assignments to bring, about b~etter (list ribu t ion of the more proficient officers

andl so encourage at higher level of' medical care.

The consultant usually spent front 10 to 20 days on each trip to the field,

visiting front 3 to 6 installations, depending Onl thieir size. Such trips were

alternatedl with periodls of fromt at week to 10 days ait headquarters. Until

March 1944, Army- Air Force hospitals were included in the( itinerary. Subsequent to this time, because of changes in War Department policy, an Army

medical consultant visited anl Air Force hospital only tit the conminanding offi-

(cer's specific request that tile consultaint, come for thle. express puripose of consuilting Onl anl individual case Or of participatting in at clinic or in waird rounids.

These requests were not common.

It. requiredl front 4 to 6 (lay' s to accomplish at mission in at hospital with at

large number of' medical beds andl from 1 to :3 (lays in at snialler hospital. Usually, rounds wvere held omi everY ward onl the miedhical seirvice or onl at least, one

waird of eachl officeir assignedl to tile service. The chief om' assistant, chief of

service together with tile Section chief and waird officer concer'ned weire expected

to acecompany * vtlie consultant. Otlier officers were always inivitedl but. never ordered to at tend and, in most installations, rairely did so despite the fact that

roundhs were modeled afIter simnilair r'oundls hield In civilian tea('hling hospitals.

However, in at few installations, notalbhv those iii which the ward officers were

yo ung and a ppeared eager to learn, at tendlance wats gr'atifying. Once init

wai'(l, the consultant made it at point to see eachi p)atient. Wordh spread rapidlyv

01hroughi evei'*v hiospital that a1 consultaint fromt headquar'ter's wa-s making wvardl

visits. Patients who wer'e not given some attemntion felt neglected, p~erhaps

r~esenlt ful. Tiime p~ermiittedl detailedl consider'at ion of onlyi time mnore dhifficult omr

serious prolblemis, lbut. each record wits read and thle soldier b~riefly questioned,

often en('ourag-ed.

lIn surveying at case, the consultant reviewed the history with great calre,

miot img especially thle lengthi of thle pat iemnt's stay in hiospit al, thle adequatcy of'
SO ACTIVITIE'S OF MEI)I('AL CONSULTANTS

the history, progress notes, and details of treatment. Where inicated, a phys- ical exaimnation was perforned. In a f riendly way, the ward officer or section

chief was questioned concerning his diagnosis and treatment, in an effort to

contriu)ute constructive teaching as well as to gauge tile oflicer's al)ility. ('are

was taken neither to emlarrass any officer I)v a thoughtless remark nor to

weaken the confidence of the patient in his physician. Free discussion without

regard to rank of the medical officers participating was eiDOuraged.

An estimate of each officer's abiility, industrv, and judgmnent was always

recorded in the official report and becaame tihe basis of a recolmnnen(lation pertaining to MOS (military occupational speciality) number and letter designating proficiency in tile specialty.

A profitable opportunity for gauging the quality of' professional work and

judgment was afforded by attendance at meetings of the officers' (lisl)ositioll

board, certificate of disability for discharge board, and other boards concerned

with tile final evaluation 11ati disposition of patients. Here, in addition to

estimating judgment and proficiency, the consultant often was able to help

with decisions and interpret War Department disposition policies.

It was planned to give at least one talk or clinic to the medical staff or

the entire professional staff at each installation visited. In certain hospitals,

the consultant was always requested to do so; in others, it was necessary for

him to ask the commanding officer or chief of medical service to arrange a

meeting. Interesting or problem cases discovered on the wards were presented

and discussed, a talk on some timely subject was given, or a clinicopathologic

exercise was conducted. In many instances, the officers appeared alert, interested, and anxious to learn; in others, apathy was the keynote; in still others,

the staff seemed to regard attendance as just another chore. As would be

expected, those medical officers most in need of instruction were the least likely

to attend.

The following deficiencies were f'requently encountered during surveys of

the medical services:

1. Failure of the chief and assistant chief to make proper ward rounds sufficiently often to maintain familiarity with their cases. Sometimes this could

be attributed to either lack of drive or lack of self-assurance. More often,

however, especially in the larger installations, it was the direct result of the

heavy load of administrative work. Where the hospital commanding officer

was sympathetically interested in the actual care of the sick soldier and clearly

recognized the need for careful clinical supervision by his chief of service, he

made every effort to reduce this administrative load. If sufficient personnel

were available, he provided the chief of service with one or more able Medical

Administrative Corps assistants and capable enlisted personnel. Where the

hospital commander placed primary emphasis upon administrative details,

the chief of service was overburdened with a10noying and time-consuming nonclinical tasks. In fact, it was not uncommon to encon Ater a commanding officer

who habitually, several times a day, called his chief of service to his office to

discuss minutiae that cou( 1 have been covered in a routine daily conference.
SER\VICE COMMANDS

In so doing, lie interrupted rounds or otherwXVise Iiuipercd professional wvork.

Tile consultant alwavs imade the effort to have Mehdical Administrative ('orlps

assistants assigned to the chiefs of service and to dissuade commanding officers

front calling upon tihe chiefs for such duties as Saturday inspections, investigations, and nienibership oil administrative boards and councils. Shortage of

personnel was the reason most often given by hospital commanders for failure

to caIrry out su(ch recollinlendat ions.

2. Failure of ward officers and section chiefs to take adequate histories.

When this was encountered, it somietimnes reflected lack of interest but more

often was due to lack of fundanental medical training and knowledge of symptouIatologv in relation to disease entities. Often, tile history was a record

muerely of what the patient said; it showed no indication of an attempt to run

down symnlptonis, to follow leads, or to unearth facts that iiiight point toward

the correct diagnosis. In urging for better histories, the consultant emphasized

not only these points but especially the need for an account of the patient's

perforaince and adjustmiients in civil and military life. ('arefully taken, such

performance histories often brought out emotional limitations responsible for

the symptoms a(d were valuable in estimating the patient's suitability for

future military v duty.

A social history was rarely taken on the inedical service. Here was the

cause of the backlog of neuropsychiatric consultations encount ered in many

hospitals. The neuropsychiatric specialist was forced to spend one or more

hours taking the emotional and social history on each patient sent for consultation front other services.

3. An excessive number of intersection consultations and the thoroughly

established precedent of regarding each specialist's opinion as infallible. Once

a so-called clearance had been obtained for any section, the decision was reg(arded as final. Personal consultations and discussion of cases ati the bedside

were infrequent. Too much emphasis was placed on written reports.

4. Thoughtless requisitioning of unnecessary laboratory and X-ray studies.

A complete blood count was ordered when white count, hemoglobin, and differential count would have been sufficient. Sedimentation rates often were a

inatter of routine, ordered without consideration of their diagnostic value.

Gastric analyses were performed when )y no stretch of imagination could they

have been helpful. The unnecessary load on the laboratory resulted in hurried work. The same can be said of X-ray examinations, electrocardiograms,

and other special procedures.

5. Lack of attention to detail in prescril)ing treatment and failure to ascertain that treatment was given properly. This applied particularly to feeding

l)roblems and to administration of fluids, especially in patients treated with

sulfonainides. Often, orders were written sketchily or only given verbally to

the nurse. A sense of obligation to follow up and confirii was lacking.

6. Too free use of sulfonainides. Particularly true in the earlier stages of

the war, this beicame less noticeable as education an(1 experience was accumulated. ('oryza, mild sore throat, and fever of undetermined cause were treated

with sulfonamides without due consideration of the potential dangers and

:5 649701--- 61•--8
S2 ACTIVITIEIS OF MEI)I('CAL ('C)NSI'LTANTS

limitations of these drugs. This was avoided in tile case of penicillin by

proper instruction prior to its release for general use.

7. Tendency to label as a psychoneurotic any patient in whonm routine

examination failed to establish the existence of structural disease.

8. Prolonged hospitalization of patients with minor ailnents, especially

neurocirculatory asthenia, functional gastric disorders, chronic headache of

emotional origin, and other like (listurbances. Psychoneurotics not only were

made worse but many were actually created in hospitals. If promptly and

properly handled at the start, a good share of them could have been saved for

some useful military purpose.

9. Failure to perform rectal examinations.

10. Failure of the ward officer or his superiors to establish proper rapport

with the patient, to encourage a close physician-patient relationship and to

exhibit evidence of genuine interest. The most common complaint hear(d from

soldiers was, "They ain't done nothing for me. They ain't told me nothing."

The consultant continually emphasized these deficiencies on his rounds.

They became somewhat less noticeable in the later months of his tour of duty.

PERSONNEL MANAGEMENT

In World War II, after medical officers were commissioned, they were assigned to The Surgeon General's pool for redistribution to Army Ground and

Service Forces and to tile Air Forces as well until tile independent procurement

program of medical officers for the Air Forces came into being early in tile war.

The Surgeon General assigned officers (1) to the Army Ground Forces, where

they were reassigned by the surgeon of the Ground Forces to mobile medical

units and to combat units, or (2) to the Army Service Forces. Personnel were

provided directly to those installations under the control of The Surgeon General, such as general hospitals in the Zone of Interior (excluding Walter Reed

General Hospital, Washington, D.C., until after April 1943), the Army Medical

Museum, the Army Medical Research Laboratories, the Army Medical Service

School, andi oither C'lass II installations. The service commands were provided

personnel for reassignment by tile service command to station hospitals and

other service comimand installations such as induction stations, reception centers, redistribution stations, and dispensaries.

The extent to which service comnman(l consultants influenced or controlled

the management of personnel responsible for the (care of the sick was usually a

measure of the consultants' effectiveness. The service command surgeons

and personnel officers learned quickly that the medical consultants, constantly

moving about the command visiting and working with hospital staffs, often

for several days at a time, were the best informed officers in the co!a.mnand regarding professional personnel. In most instances, after the assignment of a

consultant to a service command, there was no great delay before his ('ounsel

and advice were sought in personnel evaluations and assignments. Exceptions

were few, conspic(uous, and not tolerated in the later mont hs of the war.
NERVICE COMMANDS 83

A discussion of a service eonlniand consultant's view on personnel problems

h)tsed upon extensive experience and Miany conferences wit h fellow consu1ltaants

was provided by Colonel Baner. The following paragraphs summarize his

observations.

The most difficult prol)lem confrontinqg the consultants upon their arrival

in the service conmmands was that of personnel, so basically important to good

medical practice. rle personnel needs were never adequately filled, either

numerically or professionally. The situation became more acute as the need

for well-qualified officers in the various theaters of war increased. Many of the

difficulties that did arise could have been avoided had the service command

surgeons delegated their authority for personnel assignment to the consultants,

once the latter were thoroughly acquainted with the me(lical officers and the

needs of the individual installations. This method of proceduire or some modification thereof was finally adopted by most of the service conmmands. The

consultants then sought the most equitable distribution of medical officers on

the basis of their qualifications, the total needs of the service commands, and

the individual requirements of each hospital. An attempt was made to have

the appropriate consultant interview every new medical officer before assignment in the service command, but this was not possible when the consultants

were in the field. The consultant's appraisal of the intrinsic qualifications

of a medical officer and decision as to the officer's correct MOS number was

postponed until after personal contact on ward rounds. Proceeding otherwise

resulted in too many injustices.

The reassignment of medical officers, particularly chiefs of service, within

the service command was always difficult because of the obstructive tactics

emploved by many of the commanding officers. Sometimes they opposed the

transfer of favorite incompetent officers as much as the transfer of competent

specialists. In such instances, it was the duty of the service command surgeon

to intercede. Without such support, the consultants were unable to utilize

the available personnel properly.

The conception prevailed in some quarters in 1942 that every medical

officer was capable of performing any type of professional service. Accordingly, newly assigned consultants often found highly trained specialists serving

in assignments for whiich they were not qualified and men with inadequate

training in positions of responsibility. Once correction of such malassignmuents had been achieved, the transfer of key personnel thereafter was not

l)ermitte(l--or should not have been-without the consent of the consultants.

Serious disruptions of medical service would have resulted without this agreement, particularly when the transfer of strong chiefs of service was involved.

It is also important that the consultants be permitted to maintain close

liaison with the chief medical consultant in the Surgeon General's Office regarding needs for qualified specialists, whether undersupplied or, possibly, oversupplied. Tile help received from this source, thoughi necessarily limited, was

extremely valuable.

Thie tinequal (list ribution of medical personnel between Army Service
84ACTIVITIE~S OF ME'I~~CAL C'ONSUL.TANTS

Fobrcest'5 111 Ari'iiv Air Foirce hlospitals. wnas unifort illialte 21nd, while impossible to

corrvet all ti( tlie Iie shouldh I ot b~e 11llowed toI occur agi. To g'o froml one

liospit iii with -5 ii'leicall oflficers caring for 1,200 miedical pat itiet to itilot her

ill tilie sliin( larval with I .5 ph ,ysicianls aliid a1 totill liospitial ceilills .21eYxceediing

100 "was- (list Iir-bini". It wats e4qually1 regrevt talble thait 50om 111 well-t riine(I

sjieciailists 5Weie cotleiclt ratt('( iii thle smaill Army- Air Force hiosjit als, where

there wats lit tie neced for suchl tilleuit becaulse wepll-st aiffed re-zionidialta1(] gzezerail

hosp1 it als were withli eal.,y reachl. Thie service colllmmnld mledivail services

Nvoiild ll hve been st renglt henled ma 1teriallv bv- these officers, couild tilie officers, halve

been t raliisferred to thlese services. These slpeciailist s could halve beenl replace(I

wvithI well-t ial inied g-enerail pratc(Iit ioners. M\ore' regmila r alssigInmient of officers

froml numbered mledicall unlits, inl trainling but without paitienlts, to nevarlby

seIrvice ('Oilliliiliid hospitalls wouldI hatve brought simillar, I hougli relatitivel y

teiiilorarvleielits.

The tvpe of miedicall personntel alssignedl to a1 hiospit all governied its pro'-

fessionail success, 1iiiless it wats liain1pei'ed too greatlY bY thle commaitnding oflicer.

Tl'le presence of til aide ('hillicitan possessing t eachiing ai t11idimiiinist ra e aibilities ais chief of miedicinle matiteriaillY influencedl ti he frofessioniil dlevelop~ment of

tie officers as"signedl to tilt h ledmicall service. I nit iallvN, manily of tilie chiefs, of

service, not being of t his cailiber, luid~ to be replaced.

IProfessionail development wats en ha ncedl onl those medical services orga inizedl along( tilie lilies suggest ed bY thle Surgeon Generails Office; nanielv, chief

oif service. aslsistant chuief, chief of sect ion, ainf wardl surgeon. This airrmngeilielit permii ts thle (lelegat ion of responsibility to a group of individluials each of

whomis 1(hirectl *y responsible to hiis iminiedia tte superior, and it allows for promotion onl t he balsis of merit . If well orgaiiized, th lie rralilngeent a iso a~flords

thlt chief of service sufficient t ime to supervisweclosely, the clinicali activities of

his- service. H owever, mitiivy chiefs of service did iiot function inl t his mann111er

becaulse of at lieavil.N imp osed or self-tassumied administrative load. This wats

remedied inl mlost inlstanlces bv aissigning \ Iedicaid Administraitive C orps officers

land Medicall lepfirtmlent enlisted mien traiined inl aidministrative maitterss.

U.S. Arinmiv niedicid officers representedl a (cross sect ion of thle Naition's

mnedical professioni. Theyv vii riedl greatly iii their lprofessioniii comipetenice.

Some of t hem laicked thle quallities befitting trite lphYsicia uis, inicludli ng in teres't

ill patients Its l11111i21an being-s. Ini tlie( Zone of Int erior, nia invmedicail olhieriswere reluictia t to work more t han 8 or 1) hours at diiv and dlesiredl to be free onl

sumnd' v. This lack of sense of (llt * wats aill too frequently reflected inl thevir

wvork. It wats (difficuilt to uiidersti and tlie( Willinlgness of man11y officers to enItrust their miore seriously ill paitieiits to the( officer of tilie da1Y. H owvever,

5oflie ('0111 m111ini ilig officer"sa 11(1 chliefs of service were successful inl impressing

upon01 t heir inedicaul officers thait in ('lire foi-sriul ill patients there (-tlt be no

suich thliing ats (lit y hou rs.

These land~ ot her obser'vedl deficiencies indlicatte thle ineed for at short course

of baisic trainiing lit I lie Armyl * vledical] Service -School followed bY at periodl of

froml 3~ to 6 ilomithils Withi troops in tratining before iissigniemit to at hospital.
SERVICE C'OMMANDS .-

W~ithi(lit suici experiences, miedlical officers have little conception of the 1)ll:ysiCail

ahi~l men tal requirements of it soldier. With hi properl 'y condulct ed periodl of

inldoct rilat ion, miedlical officers wvould colieW to applreciate t hat t heir Illost

limiportanit dutity ill thle Armii is to keep tilie nioneffective rate as low as possib~le.

rhe -y wvould also gain at better uinderst anding of the impijortanice of lprevent ive

J)S~ciajt iv and t i e p)s 'cviology of leadlershiip inl Army inedicinle.

It is 0)1 far ooint out t hat iiiaiv miedlical officers onl (ltvt inl hospitailswere uniable to dlevote Its tituich ini e to proressioniil work mis t heY dlesiredl

becaullse of as-signmilenits to ibivotiac areas, tiiie spent accoinpalliyng trPoop

trains 1111(1 pat ienits, overseeing- ward propertyN, and Simiilar activities" withi

ill add~it ion, iiiaiiy adminiiist rat ive duties. These difficuilt ies wvere gradhliall 'y

overComle inl sonie of thle installatilonls bY Assigning well-qualified Medical D~ePart iniiet enliistedI enl 1,or tilie (I titis iieitit oned . bYmy akiiig MIedical Adlillilist rat ive Corps officers responisibile for property.Y aiid[ by providling messenger

service, aidequat e secr'etar'ial aidI. aid1 1wt aphlolies.

The nutmber of hlighlyV t raiuiedl speciailists was dlecidedlly limiited ats wats the

numiber of generalinit erniists qtialifiedl as chiefs of service or sect ion. As mnight

bie expected, thle personmnel records of eclucat iouial t ratiniimg and post gradua t e

neiiic(hal experienice wvere niot. sure guiides to medical proficiency' . For inst ance,

cert ainii edical officers withI at wide range of miedical knowvledge, somue of \N-ioumi

liad been qunalified 1w till Ameriecani specialty board, lacked conservative. sound

clinical judgmienit or tilie niecessary qualities of leadership. Conversely. ot her

medical officers withI lit tie lpost'gradliate traininig, wh-[o had mlainitainedh an acivi e

inite(rest inl Scien tific miat ters (huriig years of general p~ract ice, were fully quialified

to be chiefs of at iiedical service at at 250- or 500-bed station hospital. The

better internists and specialists, when present. wvere tilie backbone of tilie

medical organization andi con trmibuted ats well to thle training of phy.%sicianlls.

H-1iNvSicianls of average tl-raiiiing aiid ability formied the largest single group of

miedlical officers. The niajorit 'y of t hien made every effort to coiipeiisate for

t heir lack inl skill and training b)'y (diligence and willingness to learni. Much

credhit is dule t hese officers who carried laIrge cliniical loadls. There were ot hers

who, because of lack of trainiiig mind abihit v. could not tbe trulstedl withI thle care

of tilie sick withlout supvrvisiomi. A simall number of officers emiteredl upon

active dut 'vwith more rank, or shortly acquired it, than wats contsistent withI

their professionial ability. They were at constanit source of dissat isfact ion to

tlie consult atilts becaulse thlese officers could iiot be it ilized ill posit-ioiis coiiimuensurate withI their rank. Though reclassification of such officers wats

frequently' suggest ed, rarely wats it effected.

A short age of' officers wits commiuoni, particularly inl late 1944 and 1945.

This short age could( have beeni alleviated to somie extemit b~y greater exp~edition

and efficienc 'y iii allocat ion of thle large number of nmedical officers inl Medical

D~epartmeniit replhacemienit pools. Soime of these officers reniained uniassigiied

for mionithis.

Somie phscascame inito teAm wit great enthusiasm and at deep

desire to Serve, even at at sacrifice. MNy~tt ot hers caiile iii under stress of
S6 ACT"IVITIES OF' MEDICAL CONSULTANTS,

various kinds and were subsequentl *y poorly p~repare'd for (t(-enct irely new

life. As time passed, many of them lbecaie, (discouragedi or disgruntled becamse or their inability to adljust saifcoiyt nry life, failure to resolve

other personal problems, mlalassignnu'nt, injustices inl promotion, t he ri~vitit y

anld lack or uiiters-taininig or certain hospital commiuandters, dissatisfaction

w~ithI efficiencY reports, t ime wastedl ill orientation courses that Were not Pert inent to professional activit y, cont inued (trilling and physical training after

assignment to at hospital, 1111(1 unnecessarily poor living quarters anld mless

facilit ies. Thle consultants were pairticuilairlyN impressed with tilte fact t hat,

(it-spite all1 these dhifficult ies, group~s of heterogeneous doctors gathleredi froin

hie four corners of thle Unitedh States were assimilated so readilyv that t hese

doctors could funct ion ats coordhinatedl statffs inl i remarkaibly short Periodl of

ofasimlain t'ell

This process oasiltonwats most redlyaccomiplishedl inl the Air

Force station hiospit als because tilie staffs were smallder anud coimplosedl of younigrer

meni wvho were approxiiiately the sanme age and muore nearly comparaible to0

one anot her inl their muedhical education, traininig, and thliinkinig. The Air

Force stat ion hiospit als had an additional advanitage. The conmmaniding

Officers Were Nyouliger,* an11i niore recently remiovedl from professional work,

with thle result thalt mlost of them were ats interested inl the professional actiyit ies of their hospitals ats inl admninistrative muat ters. A coimmiandting officer

with these (dual interests frequently imadle possible a more iintegrated and

efficient institution.

Medical officers aissigned to airfield dispensaries and similair posts suiffered

from the effects of isolation. Ani active rotattion sYstemi wouild have correctedl

this.

The followving p)aragraphis tire at summnarY of commninits onl personnel by

C ol. .Johnson McGuire, M( ', Consultant inl Medicine, F'ift h Service Command,

from 7 .July 1944 to D)ecember 1945.

The assignment of' medical officer personnel within thlie Fifthl Service

Conmmand wats madi(e by thle service commnand surgeon thiroughi thle service coinmuanid personnel division. Inl practice, t his antlihority wats dele'(gatedt to tilit

assist anlt sumrgeon anld constf ituted a1 large part of his dhuties. Until thle mledical

consultaiit hald beenl onl duty* for several iiionii s, t here wats relatively lit tie

olplort uiity to discuss assignmenclts to specific hiospit als whetn officers were offered

to time FifthI Service (Commnand by tilit SurgeVon Gt'iieral s Office. This- lack of

dhiscuission wvas duet ili part to t lie frequent visits of tf lit ne'tical consultant to thlet

fieldi and ili part. to thlit re'muarkable knowledge of thle assist ant stirg('oll of pe(rsoruid problemis ill each hiospitali. Thme assist anmt surgeon thiere'fore thought it

unnecessary,' to discuss assign mients w~ithI te li'eutdical consultanit.

After aipproximuatecly 4 mionthis, thlit assistaunt sumrg('on consultedl withI

lhe muedical consult ant before itnatkinmg assignmenit s of medical officers- to kt'y

p~osit ions, authd by -v his milne, th lt mitdical consultant wats sufficie'ntly famiiiliar

withi thit problemis inl each hospital to umake spec'ific recomnmetndat ions, Which

wert' uisually accep~ted(.
SERVICE CO IMMANDS 87

With the permission of the Surgeon, Fifth Service Command, the medical

consultant kept the Chief Consultant in Medicine, OTSG, constantly informed

of the needs for replacement of key personnel within the Fifth Service Command.

Such information was transmitted informally by personal letter. The cooperattion of tile chief consultant's office was outstanding, and, within relatively

short periods of tinie, replacements were made available.

The chiefs of service of the general hospitals of the Fifth Service (Command

had an MOS of A- or B-3139 without exception, and, during the period covered

by this history, these officers were uniformly capable and efficient. Outstan(ding assistant chiefs of service were disappointingly few in nu1iiier and

difficult to obtain. Section chiefs, as woul l)e anticipated, varied front superior

to mediocre clinicians. The latter were replaced when better officers were

nmade available.

Ward officers were, in many instances, mediocre. Nlost of the young

an(l healthiy officerss had b)een assigned overseas, leaving only middle-aged

general practitioners with relatively little postgraduate training in internal

medicine for assignment as warrd officers in the Zone of Interior.

Thie effect of the size of the service command and of the attitlude of the

surgeon toward his own role and toward that of his consultant on the type

of personnel program which could be successful in a service coniiiand, as

well as certain points of view of the consultant, were discussed in the report

of (ol. Alexander .Marble, M( , who, after long service in the Pacific, was

assigned as ('onsultant in Medicine, Sixthi Service Command, froni March

1945 to September 1945 andl as ('onsultant in Medicine, Eighth Service Comnand, from September 1945 to December 1945. Colonel Marble reported,

in essence, as follows:

Thie matter of personnel was handled differently in the Sixth and in the

Eighth Service (Commandls. In tlie Sixthi Service Command, ratiher than

having a group of officers whose sole (luty was attending to matters of personnel, the service command surgeon acte(d largely as his own personnel officer,

seeking the suggestions and advice of the consultants when indicated. His

decisions were carried out through an officer of the general staff personnel

division of headquarters. The latter had his office on anotlher floor of the

building and so was not an intimate part, of the office force of the surgeon.

"The Surgeon, Sixth Service Command, had requested that, when medical

officers were assigned to the Sixth Service Command, they not be sent directly to specific hospitals but that they first rel)ort to service command headquarters. Tlus, the service comnman( surgeon together with the ap)propriate

consultant had( an opportunity to see and talk with the 1ian, thereby niaking

possible a better decision as to an al)propriate assignment. It is possible

that in a large service comiuand this p)lan would not be feasible, but, it worked

very well in the snialler Sixth. Of course, those few officers who were sent

by the Surgeon General's Office for definite assignments were given them,

but, even in the case of these men, it was an alvantage to have an opportunity

to meet and talk with thiem before they reporte(d to t heir duty stations.
f ''

t n-~to m:lt 29.ti i~irdint-f il W tt Chiiai ic. () M.,t Welt (d f hew m)1ajo llt edttltit)!)-

Shift it~ of ii intlt'al 4 itt' if] 111 he t 11l lltillt Son 11(14t1t allot t(e Was11: 

S I 'ltiIt '-miullV Ip c otIt s id . llh if's eotlviilev a i ll WaIl jSix t't1 t' 111.1 l idt o

Iti Ion. I N is I)0 oitv orls oi te stl I deith at 1 aolt mosi t ett' l - insta1101lla 'tionfore'i ~Itlo

hci-ofiuil o v. At i ~ i-. (ie lo 9vv' Thv hicka of nluesille peroii~ lietl \\Iatll 1lieu*

kel"N Il ~~LI ml )1 I(v'I XI.111il. . PHOBLIthre'A -Is Il d pat IIIIIv

k is n. hard t t' lat thei tr a e ile l tlt- l 1ssh 1Y o1 1 lie e hillad a vt'e no.-
SERVICE COMMANDS 189

Colonel Adams provides a broaid view of the trends of disease as he observed them in the Fourth Service Command during the training period and,

later, when patients invalided home from overseas began to arrive. Colonel

Adams reported generally as follows.

During 1942, 1943, and the early part of 1944, when training activities

were at their height, hospital adinissions for disease were largely due to (1)

upper respiratory infections; (2) pneumonia, especially atypical pneumonia;

(3) meningococcic infection; (4) diarrheal diseases occurring in epidemics; (5)

dermatologic disorders, especially d(erinatopihyt osis and other eruptions on the

feet; (6) venereal disease; (7) asthma and other allergic disturbances; and

(8) ill-defined symptoms for which no organic causes could be found and which

were usually thought to be psychoneurotic. The last group included a large

number of individuals designated "inadequate."

Acute upper respiratory diseases and the run of contagious diseases posed

no particular problem, except for loss of time from training. The sulfonamides

were prescribed much too freely in the upper respiratory cases, but, as medical

officers became increasingly aware of the indications for and against their

use, this practice diminished.

Meningococcic infection first appeared in this command in epidemic

form in December 1942 and for several months created a serious situation.

The first epidemic began at Camp Sibert, Ala., in late December 1942; at about

the same time, cases began to be reported from other camps. Immediately,

a letter was sent by the service command surgeon to all post surgeons, inviting their attention to the need for watching closely for outbreaks of the

disease, describing the signs and symptoms (especially the earliest), and outlining a plan of treatment. The medical consultant on his visits to each camp

gave talks on this disease. This educational program is believed to have led to

early diagnosis and more prompt and vigorous treatment, which may have

contributed to a lower mortality rate. The following figures for this command

were compiled: For December 1942 and January 1943, 317 cases with a mortality rate of 8.8 percent; and for February and March 1943, 761 cases with

a mortality rate of 2.1 percent.3

Cases of atypical pneumonia also appeared in large numbers. Here

again, an educational campaign was waged. Little was un(lerstood about this

disease. Most medical officers were not familiar with its manifestations.

T[he officers were instructed regarding the clinical picture. Especially emphasized was the fact that the disease could exist in a severe form without

physical signs, the diagnosis depending chiefly upon chest roentgenograms.

As experience was gained, officers on the respiratory wards, especially in

large station hospitals, l)ecame extremely proficient in recognizing this disease.

At first, sulfonamides were too freely administered; time educational campaign

red mined their unwise use.

3 Thomas, II. M.. Jr.: Meningococcle Meningitis and Septicemia; Report of Outbreak in Fourth Service Command

i)uring Winter and Spring of 1942-1943. J.A.M.A. 123: 264-272, 2 Oct. 1943.
90 ACTIVITIES OF 'MEIICAL ('ONSULTAXTS,

ExplIosive out1breaks of (liarrhlca occurred ill severall orga nwzat bus. iusuially

thos-e oil bvl~inOeS, especially (hiring thle early periods of train jugp. fInvest igra -

tionl reveailed t hat t hese epidemics most oftent were (lhie to lack of recogniit ion

IW line comnmandiers of t11w neceýssit v for rigidl fieldI sainuitatioli. As office~rs and

troops lwcanlet more experieniced , imiiportanut outblreaks ceased.

Ani allergy p)rogramln, sponsored by C ol. Sanford AV. F'renchi, M C, Surgeonl,

F~ourt h Service C'ommanad , was Wvell conlceivedl andi(lnaiallg-e( (fig. m0). ]'atients ill thle comlinand l suffering front anyv allergric (dist urbanices received the b est

p~ossib~le diagnostic and therapeut ic care. H owever, if a soldier was t ranisferred

to another command or overseas, uniformuity of therapy could not he guaran1 lteVed.

1I e11ce, thle limpract icab~ilit y of Arin vwide ap~plicationl of the procedlures stainda rd lized in this commnniud litiu it ed tilie overall valuie of t ie( lprogramn. Few soldiers;

wit It allergic (list urlbances were restoredl to full (general service) military duity,

but manyv were enabled to render useful (limlited) service wvhen assigned to fixed

installat lolls.

Admuissions to gellerall Iloslpit uils durinig the first 2 years, in large part conSitdof difficult diagnostic problems and cssrequiring long-term ar o

serious op~erat ive procedlures. Ini June 1944, thle large stat ion liospit als were

(lesiguiat ed regional hospitals and wvere charge(ld, in adldit ion to previous assignimnent s, wvithI the care of such Zone of Interior patients as formerly would have

lbeell t ransferred to general hospitals. (This w\as (lone Iin ordIer to free beds for

tlie( reception inl the nlamuedl general hiospIitals of patients fromn overseas.) Tfhius,

.it b~ecalne niecessary to st rengthien prompt l~y thie staff~s or regional hosp1 it als.

IThis augnIentaft ion was rar('ly szat isfactorilY accompllishedl because of the shiortag(e Of sp~ecialists.

Alt hiotwgh deskignated for Zone of hi terior patients, thle regional hospitals

also received a. fairly large quota of pat11ients wvith d(iseases thlat had been acquiredl

Oveu'seals. These soldhiers Nvere ili thle Un ited Staitvs as at resullt of rot at ion or,

having been returnied as patients, had beeni dischlargedl from general hospitals

to duty inl t his counit uv. M\ alaria., aunieliasis, allergic staltes, pep~t ic ulcer,

residuals of hepatitis, intract aide (lerniat ologic diseases, and( p~sychosoma~t ic (listurbanices were most commutonly encounut eredl in this group.

As the load of p~atiments frontl OV-rseas inicreased, tilie following- catego0ries

of illnesses were predomniiant in thle general hospital miedical wards: (11) Recurrent malaria ; (2) acuite or chronic h epatitis; (3) peptic ulcer; (4) allergic dlisorders, especially bronchial ast hmma; (5) 1 relmclifoot ; (6) amielbiasis ; (7) rhieumua tic

fever, rlieuinititoid arthlintis, a~nd ot her fornis of inuscumloskelet ail (disease: (8)

psychiosomnatic comiplainits inl soldiers Who had beenl screenledl imiprop~erly anli

seuit to mledical services of hospitauls inl the Zone of Inmt erior inst ead of toieup~sychiaitric cent ers or (oivalli'c('iit hiospit als; (9) skin diseases., especially

lit * )Ical lichen phlanums and1( (lerl'uatitls ill patients from the Pacific areas; and1(

(10) various tropicald disease, especiallY filariasis andl schistosominisis (Moore

G'eneral H ospit al, Swannanott, N .C ., oldihy).

The peptic ul1cer cases we.re oft en d ifficuilt . M any soldiers were encouinI ern-d ili whomi timis d1

iagniosis had been es-tablisliedh inl theat ers of op~era t 1015.
F'ICURE 30.-Aflergv )rograIJt. Iiiit Ii Ervic4' ( ufuruaJI(I rgv cliiiic, Siat jot,

(Ii:1t.itO,is :1:01 rlts:ttiti,:ti bit. Fotirt ii Srvivt' ( nininajol Medjeal laboratory Fort Mcl'Ior-

.oii. ( :i., ( )ctobr 1912.
Oil tilie soldiiers-, ret tirii to thlisco (1tlltr iV , perhaps h1 'a uise of relief fromi comin ht

tensii~on and~ treatmnent ill ON- -sea hlospitalls, t hey e'xlhibte ('( 10 chiilical or

roenitgenologic evidence of ulcer. Mlost of them had mildd gastric comiplainits,

but, it was imipossible to determine hlow mlanly of these coimplaints were tilie

result of anl tmicofls( tis (desire j be relievedl from ililitary (in tv and~ hlow m11ny1

the result of persistence of the (disease. Chiefs of gastroinltestinal sections lia1(l

(lifictilty ill (lecidhimg whet her the pahtienits actually ever lhad peptic uilcers

anld inl evaluating their patients' currenit condition. Early inl the war, manly

of thiese patients were sent to lumited (Iuity, bllit it soonl was learned t hat t hev

would hiot (10 we'(ll.

The proper (disposition of general hospital patients returnedl to the Zonle

of Interior from overseas presented at liffictilt prob~lemn. In the early stages,

lie emplhiasis was placed upon returning these patients to (i~ty. However,

it is doublt fuil if many were able to contribute effective service except w~hen a

real desire to remain inl the Army existedl. Later, there app~eared a. growing

tendeiicy- to d isehiarge oversea patients froin thle service.

The following is a partial list of cases of unusual interest reportedl from the

stations notedl:

Cases Slationi

Sarcoidlosi ------------------------ Batt(% General Hlosp~ital, Honie, G;a.; Regional IlosJpitad, Fort lionning, Ga.; Regional Hospital, F'ort

McClellan, Ala.; and others.

Ifistoplasmosis ------------------- Foster General Hospital, Jackson, 'Miss.; Regionial

Hospital, Fort Benning, Ga.; Regional Hospital,

Fort JIackson, S.C.

Spontaneous rupture of spleen ------ Foster General Hospital, Jackson, 'Miss. (during malaria therapy for iieu rosy philis) ; and Regional Ilospital, Fort Benning, Ga. (during attack of mononuicleosis).

Leprosyv------------------------ Stark General Hos-pital, C'harleston, S.C.; and Regional Hlospital, Camp Blanding, Fla.

Act inoniveosis -- ------------------ Several hospitals.

( occidioidornlcosis ------------------- 1o.

Amehic absces~s of liver ---------------- 1o.

E'ndemnic tvjphIs fever -------------- Several hospitals, chiefly inl Southiern Georgia andi~

Alabama.

Tiflarviiiia - ------------ 50 cases at Station Ilomnital, Camp Forrest, Temn.,

(lrimig Tennessee maneuvers in 1 942-43 (fig. 31;

from hospitals in Mfississippi and elsewhere.

Thi~eridr~ u nuliormisinfect ion --- Regional H1osp~ital, Fort Benning, G;a.

('narcini ion (if aorta ------------------ Do.

Ifeait stroke ----------- SeveralI hospitals, especially in) southern training

Camps.

.1nrijlos.omn bra Zilense (creeping

erupt ion) - -- - ------------- Regional Hospital, Camp lBlanding, Fla.; St at ion I losjpit al, Camp Rucker, AXla. ; and soot heri camps.

l'olionlVe'liti is ---- Sharp (outbreak of 17 cases with 3i: deathls. in 'March

and April 1945, Regional Hospital, Fort -McClellan,

Ala.
'o o. 11vI Ienrv N1\. Thomias, .Jr., N I( oilsilltl [it Ini N I dicitie, Folur Ii (Ific

o'lilmald rut.l'oiii Auvjirst 1942 to Amnist 1194:,. reporte e(l i cljinicalI problemi,-

IIi fiillti I r hsital,. i In I 942. Il i-,je~ are of' sp~ecia1l in1 teest Iii reltalion to

later devehopiiients, ill deleiiiatohogV. veileimul (liseases. andi~ ineiroJsychiinitry.

I 14 ciiil' i ll( -cm-ndii~~4. I,, follows:

Ih.,,41 bdnqq. I)t'i iiaI llaologv Shiouldt be( .1 Separate Serv~ice(4 sepa'lj e thI(. at

I-:, h10111 veii ereal diseases, witIh which It was so ofteii colibiihrid. 'I'fiere was a

siiijpiisiiii, deaIith oIf well-1-ai lled 4ter-iiat()lo,(ists. Ill ret rosp~ect , it seemls it

W011il(l ha~ve beet or iVhi( to collect n e siipl-eruw de(rmiatologist, alld Send

fielli .;iioiiiIl 1 to Ilie vari-ols hospitals as' Ilnstri'ictors. l~raS.chools, of deiIiiatolo-~v could( hav e l)(e est'ilblislied, but Aiiiiv (eleriiiiohoirv is, rathter stere,(otvjped aiid doves inot cover. a very wide fild. .A basic deleriiatoto~Zic t raiiiii

grivell to all ofnci (iii iiicl(al Services, wolild 1)4 valliablve par-ticuilarl *v Illn ropical arevas. 11(4le Illedi'Al conlsultanlt alasvstd dvn' -merIialoqIoi(* eaIses:

liowev('r. Ilie (')11 illnbit ed rio(tlijiil.,r JIIt iourieiitartinrs.

2 11crII(/(l 1. flS~(b*.((,".- Ini 501114 liosl)i I a I, 5VI[)Ilii ti anid (len iialtology we(re'

t reate I 'Ioi th 1('iiiedical ('el-i((' nil(I "oiioi'liva onitle siirjv service: ill others:.

syphiilis, andI goiiol-rrfien wd'i'4 both Iitieat('( of)1 t he( siiirical 5('-ievic';ii Ill still

(It her l1si0)i a'lIs. SYjph Ilis ar ill goilorriled~(i' Ivawrbli ti-rdatv((Ilo t 1(4'iild'(ical 5('P'icd'.

It is a iiilutter of sollia impllortanlce' I hat the i'esJpoiisililit ,v for I Iiei;(pY shouild be

1irjfoii -I. Ill I his consultant's opinion. syphuilis 1 is lt ireyaiid ldsae
94 AU'rVITIES O F MEDJICAL CONSULTANTS

and1( g"onorr-heal is it inedical (lisease withI a verY rare siurigical compIl1ication It

is trute thlit a1 certain iiuniher or geiiitotiiiiary Surgreon s specialize inl tile t reat -

Iiieiit ol' g-oiorrlima, while Rt is (lMNI:(il to find1( antiv oflicrm on t lie liedcli servies

who Wae had experience withI t real tient of' gonorrhea. Furt hermore, chiers of'

linedical services take very, little int erest ill gonlorr-hea cases. Thiese officer,

have learned abhouit tilie (disease iii this war, 2111(, frontiio 010WO, gonloirrhea will

becoiiie ait Ied Wal d I~Ciseas.

:3. Neartip.sychin try.-- One of the linost generally negldected phIases of therapent ics ill tile leadhing, miedicail schools of tile count ry is so-called psycliosoimat ic

Iinedicilie. '[rie osleriati school t reatedl t hese cases with hi (ract cal erist ic wave

of, tile hand and pat Oil tilie back, went to tilie niext patient withI a heart iniiuriiiur.,

and froml there went to tile pathology laboratory. The usual teacher of clinical

liiedlicline finds, it (difficult to crowdl iiito thle small numbher of hours t he aniouni

of' lea rning~ essentKit to the fundamenitals of' diagnosis. Whien it conies to the

tin~e-coisumininga and soitiewhiat subtle exposition of tilie patient its a wNhole 1111(

the part thle p~sychie plays ini symuptolna tology, the clinical teacher ortenl feels

himiiself ait at (isadlvantage and~ avoi~s undertaking at coniplicated role. It uvss

tlie Inedlical consultant 's experience that, by and large, the wvard officers iii thle

stat ion hiosp~itals iii the Fourthi Service ("oninmnand had very lilttle concept ion

of' tilie patijent s' worries, 1111 tilie psycliologic asp~ects of tile paltients' treatmient.

This coiisultan t, eairly iii his Arny- experence, became interestedl in the( functional aspects of (luodmenl ulcer cases and1 referrd to t his subject iii discussions

of wde le fildof psy cliosomiatic sylltohi, atologv.4 Ths -oever, cannot

be taught 1y Armiy coiisultants alone and iste tcual responsibility of thle

imilekhca school curriculumll. In tlie( Army, thle conisidlerat ion of the patient ats

a whole involves ti( lie orale of tilie pat ient as at soldier.

The greate'st help was Ohbtainedl froni It. C'ol. (later Brig. Gen.) Williami

C. N\Ienniing~eu, M( ', Consult anit in Netiropsvcliiat rv, Fourthi Service ( oniniiahidl

who frequently minaide rouinds Onl the linedical ward andl discussedl tile mnany

borderline psychiiatric cases that abounded in all vwads. A large percentage of

inedhical patients have such prob~lenms, 2111( thle responsibility rests clearly onl

tilie chief and( other meimbers of tilie invedical service. The iieuropsychiizrit c

Consultanit canniot see every patient, hblt lie (-aii function through te lie edica I

officers. During t his war, thle M~ edical Departmient, wvent, at long way in (-oil)-

billing activities of tilie neuiNopsychintii c aind iinedical services. The inedlica I

consultant was ext rnielv iiitprest ed ini occupational therapy, bothi omi the wa id

and in the workshop (fig 32). Since thiere was no occupatioiial therapy inl

niost of t he station hospitals, it became necessary to try to get thle Americani

RePd C'ross to p~rovidhe t his valuable service (figr. :33). Later, onl visits withI the

mleirojpsychlin I c coiisultanit , it becan miit con test ats to wvhiich consuiltan mt would

get the mnost ('oopeatiomi from thle Red (Cross dlepaurtmlenit. Actually, thle mieliropsvchiamtrnc consultant could have kept two Redl Cross dlepartmients busy at

each hospital.

I iliormi, "I. r!, In lept e IMlee ini W Amly AM.JU .t TO ML~ AMH Xpi ~3. M9 
SER:VICE* COMMANDS 95

Fim~im~ 3~2.---)ecuipat ioala th~erapy) at MI:(igaii ( vetEral IIo$Ipit.11I

'Iavoina, WVas.h, A. lit waUrds. It. W~orkshop 'sene.
1N i1 ACTI Vta rIII Fs IF4: MIA 'it 'At 1, 4I '1i I.T\N'

Fl : IIt II I I I I t I) Iio I \I r I ' I . ýf:1iIl

Co(lontel Milleri. ifin r eport oil thv Nvenktivi'. (11the ti(hict iminia ;iridI l fiticettiilitg thle proper and1( prIompit (llsposiI loll of pa I euuts3⁄4 iiialle thle f~olho\\iii1z

a11ltltcii1l n I*(\\ of I lii' coitlhiitts1111. hiV'nvol- It- bvl)4ii-a si'p.i i"I es~'IelC'Vc. E

pel)4iv(ei( dlt'itoIt-;I i:Ielv I1, al ici('her scliviiie 11)(4(,SS:6ri*v prov~ided' siicit-.-fuii

bv4c;IlI~e 411, their n:ill ittel's kli~lk andi ioutalIhlespt for 4)114 ;utollt ltes dlISviIplilie'3⁄4 are cajpalbe of'I'l Ict itil'4)ill,- .1, Inv(itllber, of a coopiV4~)1'nitiv Ii 14' tl

('OOrlI iiI.I ecl tea iii. I itfort iuita Itlv. t here werP~4Iv few Stichl (iaS.!ilot)'1 .*a11(14

tlii'i wii c grolIpsC 11'iI)4. I t hey 1011 Iteril itiort' liuuiuter()ti'. Own.'r woliidlinv live 1141

le- dl~i,ýiUViVViii'iit (oliceiiilin- th l ocation lollo patieuits, thle phlic~ji-m rveýpotisilde for1 thi'apW * v iian the vintoll 41 of livi('i-oj)s~cint IV to Illehicifite.

Never Imi, ( he ;ieed for ptvii os 14) eo-nitie zni i 11)0 1ii0gZ psychuliltteuI'l ir

It 1i0'fl1-cIs tile grreIt4't fl4'ficietie ill AlXivictI''4i iiielic.1l educa~tionii ll 1444' i-i

\e~i- 01(1a1so f~~~i-14slie evils of specejaMlzl ou. Elviuherilv , the' i'fforI

II) p llvsic~i(ný1:ii 4I) I4'4 Lniiz4' andh t ''ptliv5i4)logZ4 ili and ioiii 411 54)14l1'nivi
SERVICE COMMANDS 97

has resulted in failure to stress tile importance of personality functioning and

psychopat hology.

The (lefects of such medical training were readily apparent in tile service

comnlanld hospitals. Too many patients were admitted; too inch was done

to tlieum; they stayed too long; they were subjected to much indecision and

receivedl little or no psychotherapy, and their disabilities were either prolonged or increased. Under such conditions, the number of individuals salva(red for soldiering was disappointingly small. In many cases, treatment,

at the dispensary or outpatient level would have been more successful.

These patients were essentially the same as their brotlhers in civilian life.

The approach to them should have varied little. Carefully taken histories

usually revealed the basic nature of the disorders. Well-trained medical

officers who could handle their own anxiety and demonstrate friendliness, syvnpathy, and warmth to the soldiers as well as sincere desire to help had little

difficulty in determining the patient's personality makeup, past performance,

and relation to symptom formation. The failure of medical officers to function in this manner led to such labeling as "gold-brick," which resulted in

increasing, unrelieved emotional tension and the precipitation of neuroticismns

and psychosomatic complaints.

A prolonged period of observation and study of neurotic patients is not

only wasteful of time and money but is also harmful to the patient, since the

persistent effort of the physician to find an organic cause and failure to do so

tends to aggravate the patient's belief that he has an obscure malady. Furthermore, the inexperienced physician, overimnpressed by a minor deviation

from normal in some physical finding or laboratory test, adds to the patient's

anxiety. Reliance on this method of procedure-diagnosis on the basis of

exclusion-should be discouraged if not prohibited.

Some of the difficulties that arose were attributable to administrative

uncertainty and indecision as to the proper disposition of these patients.

Under the pressure of an increasing manpower shortage, the administrative

position changed from one of excluding them from the Army to one of retaining

all but the most severe cases. With this change, however, there was no adequate system for assigning patients to suitable types of duties. During 1943,

thousands of useful soldiers were discharged from the Army to their own detriment as well as to that of the service. As the regulations governing these

discharges were tightened, the hospitals faced other difficulties. When these

men were returned to duty, they found scant welcome in their organizations.

The unit connmanders found it easier to return the men to the hospitals than

to find a place for them in the original unit or to follow the procedure necessary

to have the men properly assigned elsewhere. Consequently, they were returned to the hospitals again and again by their commanders in an effort to

get rid of these soldiers. This practice not only added greatly to the burden of

the hospitals but also confused the medical officers and reacted disastrously

on the soldiers. In no other instace in the Medical Department of tlie Army

was there greater need for formulation and execution of a policy that) in the

564.q7 f --- a
98 ACTIVITIES O.iF NlED ll.AL CO' )NSUL.TANTS

iianiagement and disposition of soldiers with psychoneurotic and psychoso- ma11tic' complaints.

LABORATORiY ACTIVITIES

The laboratory Division, Preventive M hedicinie Servive, OTSG. exercised supervisioii over Medical lahoratories in the Aruty. In tile United

-tates, elalortite service command laboratories Supported those of the general

and station1 hospitals, and the dispeliaI'ies. l,1boritor\Y petrsonnel. equipien+t, and supply were administered separately from tlihe clinical services of

hospitals ill spite of tilie fact that tie laloratories operated ill hospitals almost

exclusively in support of tile clinical services. Of course, important laborntory work was done for preventive inedicine and public health, especially

in tile service command laboratories.

Ill tile best hospitals, there was tile closest liaison between tile medical

service, the laboratory service, and tile conisultanits in mledieine. Wise clinicianis and wise clinical pathologists saw to this. The interest and support

of tile professional consultants was important to the proper functioning of

tile hospital laboratories, since otherwise, in the opinion of man*y observers,

they had limited supervision adl advice from other sources. In ni1yV, if

not most instances, the clinical laboratories would have functioned ii professiona l vaicuuliis had it not been for the consultants ill medicine and the

chiefs of medical services and sections.

A critical appl1r1iisal of tile it ilization and operation of the hlboratory

facilities in a large service coimmand was provided in Colonel Bauer's report.

H is views ar'e suimmarized in thtle following paragraphs.

A satisfactory laboratory service reqyires a director capable of coordinating its activities withi those of tile clinical services. It also requires properlv trained person nel, suitable space, adequate equlipmelnt, andl at workload

adjusted to tihie size and ability of tle laboratoroy stafif. D)irectors who were

comletent paltliologists and int(rested ill clinical pathology and t eaching

contrilmted greatly to the intellectual atmosphere of hospitals. When such

men wer'e flanked by compeleil Sanitary ('OrpS officers trained inl Iiochemis ryv.

imimunology, and bacteriology, t ihe clinicians were assured thit t he labomratory

work would be carefully supervised and well executed. Unfortunately, sutch

laboratory services were all too rare.

The hospital laboratories were sufficieiitly well equippedl eventually to

perform practically all the exai i ina I ions which are done in the betier civilian

hospitals. The |nainiteniance of adequate technical staffs, however, was always

diflicilt becaurse tiet, enlisted iien were poorly trained and rapidly transferred.

The resulting vacancies were of necessity filled by civilian technicians who

were inadequately trained. Getierally speaking, the bacteriology and iaiiiimunology sections were tihe weiakest.

The ahbuses of hlabratory services alttril)utable to tlihe clinicians were many

and resulted ili counttless numile|s of umn necessar1Wy determinations, which flirlher impaire~d tile eflicienc'y of tlibe work. This misuse of laboratories, common
SERVICE, COMMANDS 99

in civilian as well as military hospitals, was undoubtedly accent uateid in tlhe

Army by the absence of the cost factor. (linicians without firsthand knowledge of laboratory procedures were most frequently responsible for excessive

requisitioning of laboratory studies. In some hospitals, tile additive effect

of all these factors was great enough almost to nullify the laboratory's contribution to diagnosis and treatment.

The consultants continuously impressed upon the inedical officers the

rational use of laboratory procedures as diagnostic aids and therapeutic guides.

Tile consultants also urged the chief of the laboratory to ineet with the chiefs

of medicine and surgery immediately following the completion of each monthly

report, in order to promote full discussion of matters pertaining to the efficient

functioning of the laboratory. Supervision of the laboratories by the medical

consultants wits reasonably satisfactory when they had experience in such

matters and could allot the necessary time. The assignment of an additional

consultant in medicine, with suitable training, would have strengthened this

objective of the consultant system, particularly in the larger service command(s.

In some hospitals, tile laboratory was established as a separate service.

This had the a(lvantage of placing the director on an equal footing with the

other chiefs of service and enabling him to perform his duties more easily

and satisfactorily.

The service command histopathology service, the Army Medical Center,

and the Army M\ledical Museuin discharged their responsibilities extremely

well, considering the many duties these installations were calh'ld upon to

perform. The work done by some of the service command laboratories did

not justify their large staffs1 and annual expenses. Many of the directors

failed in the particularly important duty of maintaining helpful contact with

the staffs of the hospital laboratories. The function of the service command

laboratories should be reexamined and redefined. They should be required

to submit test specimens periodically to all service command hospitals. This

arrangement would provide an additional check on the quality of laboratory

work.

(Colonel Thomas, the first service command medical consultant to go

on duty, reported on observations in the Fourth Service Command. The

following paragraphs summarize his comments.

There should be a laboratory consultant in each service command and

theater. He would be one of those rarest of all medical officers, an excellent

clinical laboratory man. By and large, the laboratory service was the worst

in the hospital. There were riot enough good, general, clinical laboratory

men to go around nor nearly enough technicians. Later, this shortage was

partially filled by Army schools for technicians (fig. 34), but this deficiency

still reached into the theaters of operations, where it was even more noticeable.

When the medical consultant, to the Fourth Service Command found

a laboratory problem, lie, with the chief of the miedical service and the ward

officer involved, would go (directly to the laiboratory service. Tlenr 21
dliscuissioni woiii be 1) tiilti' 144' ;keiio O h w inictlitoit i 14 'fir.. altor t~v exaiiiliatl ions.5

flitv resultls, tOe techlifii~jiis. alid other j'li lvilel iiil'oruiiat ion. It was a1 ver x

rare thiliii- to find If ine(Iical w.r1)-1 litt'rl whot wv't tliret'ttv to thev lalboratlorv

with Illhs probilemis. ()If thle ot her hand. fie- labora10to aliiilost aiwa vs Senti

a ralit her fl)oodv tralulwletitt'hiiilif1,1 to th li'ardi to hianidle specillielns. 'I'll'

reutwas thatl iiiaii1V tests wvervt'illirt'ial)It'.l spet'iuiit'ii werte iliislianidletl and

lthere wa, fit) close' cooJpera IliOl b)41weeil lilt, clinicual laborat or v aind I lie ward.

This prolem)t'i was takenl 111 regulal.-y ill eathi of thle hiospitals With Ow tlie del

of, tOit iiielvi(al serv~ice, thit t'liel, of thet hlaolloaor\ service, atitd witll) thle tw()

It wais tjscovt'retl t'al'l ill visits to hiospit als t hat a1 !Zrtat dt'al of' useless

r-out it'e labora torv work was blivil- oitlt'itd for anid pt'rftwliiutd by Ia bora torie's

111iat wert' tdttiiilrtaled v over-loaded. F~or Inifistlie. at Fort JIacksoui, S.C.,

it was f'iiiitl 111,1 Soilit' 8)00 coiiip'ew blood t'ollilts weret bl~eligr rt't''111stt't o~l

lpt'ak tlays. Whieui t is was brouilrlit to t lit a t'1vlutiol of' flit' siillt'oii of' ili'

sevlt'VC t'oiiiiii:iiit, uil oitdter was iriiiuietliattlv t'r'zae 'ortl-1Illtlir routine'

laiIoi'attllv wtwrk 'iit t it4iui th attl",111 'athi tt'st \\ouilt be' otlt't'tld .ittotldiiig to)

its ttwii iii]'rlt . Surpiijlilig-lyvit'lighii, this st't'iirullv '.iliuple tIlirettiv' t'alist't

toliftijoli iilvwa' ilitt''jrt'tt't 1)y somiit liiedital tofficers to Iliitali tlit:I no t'akSt'

'l'lt'le tuuirt I Svivilt' ( tuulialill Liboraitor~v. Fotrt Nhtltit'r'oli. ( ;a.,ws

S plendiidi S1.rv ivct' o 11: iiluilt l:1itwattor'v (flitr. :;5). It \\i ts lit' 11i1ilu of* t lit'
fi q)[I:a js lit II.iti Visi I l o4 t h~Ile ('4111liiaildid g offlicer' of thiis Ia lab ' t oi'v. Thiis

~'lVl'4 U~11~il( abrl)(loat4Wv Senit test sJ~e4'llllells to thle vali.olls. hlosfpilaf

1.abI rnorl'a 0 4s foii' a 111.1v is. 1i ii v aV Y le 1'l(Il11 Ic i t 'll and1( .1ccu(lllac. of, a1 IaIb1aI0 1% to *v (I ofI tl's loll . coul ~ I'(l' chaked 'I fa'tl- oi'y In I(IW('V4'i , iii II adit s ecllieto

Ii 'teY '; I t isil ait ~e lito be it 4 alvc e ill lit t'd e it rIi Inbli ti' oll f li In ( 'I (' Hill.a I)-i

kb rl't ol' v \t l'k. rs i T I14 hi 'lt \*s 'V 'tl CI Sllitt Isfaiorilt f'iI'lowvvill Ilil Idillof l toa

A[ TOPSY PR~OTOCO oSL 

lo eVl' .lit ops plwot o ols Ill IlI 14'4 11' Iti~' ll'lat I ll Ile~ ''i''(01 alt

~Ii as11 w follows.
102 ACI'TV ITIES OF' .1lEI)W(A1. CQ~swi'rANTS

( oliliiialiid , sooti issuied it dIir'ect ive reqtiest i hg t liii tiall at itps OJ prIIot ocols be

rlorwa r( ed to servi('e (10111 IIU11(11 Ii adq niart ers for' review ) theitl- apropriate

coiistil t it ti t. () tile ad vice of Brig. ('len. Iiughl J. Morganl,che olttli

ill M~IedlicIine to 'Ifie Suirgeon Genlerall, t his prIocedurie was later adopted by

tilie otilier ser'vice .oinllallllllls.

Elicht of, tiliese auttopsy, protocols inlcluded at comiiplete abstracet of thle clinlical fi Iiilin gs, cliii ical comi se, ti ii.t1 ('IIllicadit( agniosis, gi'oss an m11 icrios'op~ic

1)11 t I ilog.i(' (les(ripft 10115, fi iiil paitliologic (l iitgiioSis, atnid it piit'Igra'it l Siiiiitmiarizilg th eIllc lee itst iat were t liougilt to halve ledl to (leatt l. Thlree

lill ilneogra1).1 pi ed coplies we''frwa rol-wl-e( to tilie sei'viCV (10111i111 and I ieaqitl~l nt els,

two for. fil illh alhI olie for. review 1) v tilie conlsulta lit. ( )t herIs were (list rilmt ed

to t he miiedficalI officers ofr I' Iv iospi tal , preferal-A'y at a1 cliniical coiilereiielce rollowngi" recei pt of' tilie coiistilIanlt5('011 co iienits. Thie q~uality of tlie( protocols, whlichl varied greatly. furniishied iifrit o egard,(ing tIlie ablility eln'd,11(

ilitegritv' ofr ho ii pat fologist anld ('lillic(iaii. It wats tIlie coiisiilt au t 's dii ty to

forwarid writ t el (commiienit s pert aitiling to er-rors of omi ssioni11( (a01d coinlissil~l

its well ats to ('ommilenid eXcellene * of' performiance. Tfiis prio'eduriie priovedl

ext reiiel ,v vatlua ide to tilie coiisiil talit its well ats to tilie fiospitial Stally and served

ats at f'ultlier ('heck onl tlie qialit~y of care beinig r'enideredl. It also lia1d afllti(ipaltorv 'alule ill tiha t it waIs geiierally, uiildelst ood tfilat tilie clinical re'ord( of tiny,

serioulslY ill patient iiiigfi t eveli tiitlllY lbe scruiitiniizedl ill tIlie slilgeoli I office.

Tile iiost seri~ols and)( frequeli t dliagniost ic and tilieralpeult i( errors disclosed

by thet pr'otoc'ols, weire oftenl discussedl by tie consultants ait subsequent visits.

POSTGRADUATE EDUCATIONAL AND

TRAINING PROGRAMS

From thle otltset , those r'esponsilble for tile initiation anld developmient

of tilie ('onsultallit system b~elievedl thfat, tin active prIofessionial edlucattionial pro'-

gl'aln1 wouild be tfile best. st i uitlanlt. to high stanldalrds of niedicall prac(t ice inl

the Army. The following is at genieral (descr'ipt ion of tlie( Iiiedicidl educ(at ion

programis p~rovidIed d ie Sixthf and Nint Ii Service Comimaindi~s under thle dir'ect ion

of Co0l. Irving S. Wrigit , NMC, liiedli(al Coiisult ant to ea(fil of thlese C'ommandt~s

tit (lifleel'et. tiiiies.

It. appealred earily to tilie nmedical Consult ant t halt cont inilledl medicall

educai'it ion Il(Id trainling were vit itl to tilie nliiainteniance of sup Jerioir miedlical

crespecially* if tilie will. wits to lbe a lIlig one. TI iere were mian *i viiet liod~s,

mlost or' wilieili wer'e t ried bY tilie ('olistilt alit ill eit liel' tilie Sixt i or. N ili t i Ser'vice

C'ommainds. Tiley vwere ntot equallyN succes'sfiul anld somie that were succ-essitil

inl onle Ilospita 2d itile(l ill allot hiel. The followinig tecim('Il i q Is were lit iiized:

Ward rounds by the consultant. Visits to wards b),y tile ciisiltalit

aJ)reied to lbe it vel'v y sefiul t'ol'Ili of mledlical eduic t o ti Ialii. I

wits tilie ('olisliltit lit s )ol ic , ili Ilospit a I visits to spela I bet weenl 8t) wid 90

p~ercenit of hIls tuiie of) tIlie Wiirils e.xitiiiiliilig patielits withil miemibers of tilie stitll'.
SERVICE COMMANDS 103

The objective usually was not only the solution of the problem of a particular

patient but, also the use of that patient's prol)lemi as a stimulus for consideration

of both scientific and administrative principles.

Field trips.-Visits to the field installations, made with civilian consultants

in meledicinle who were outstanding teaichers, were also beneficial to all concerned.

These visits problal)lv constittuted the highest form oft medicd teaching and

were pol)ilar with anid greatly al)preciated by tile hosl)ital stiafls.

Unfortunmtely, the numiber of medical officers benefited during any one

trip with a civilian consultant was small. Neverthieless, tile employmnen t of

tle civilian consultants in this fashion was important, for it introduced new

alttitu(Ies and fresh points of view from medical schools 2li(1 civilian hiospit Ils.

Wartime graduate medical meetings.---The princil)le of wiartiime graduate

medical imicetinigs was sound. There existed factors that militated against

success in sonie of tile service colimainds. Cert ain requisites were essential,

as follows:

1. A consultant who believed in the program and was willing to work for it.

2. One or more civilians who believed in the program and who were

dynamic and self-sacrificing enough to activate it on the civilian side.

3. A sufficient number of medical schools or outstanding hospitals to

provide men of high professiodal caliber to act as speakers for tile programs.

For example, the small Sixth Service Command with its many medical schools

wid hospitals was an ideal command for this type of teatching, whereas the

Pacific Northwest in the Ninth Service Command never achieved a satisfactory

pr,'rain.

After some experimentation in areas where the program was feasible, one

meeting every 2 to 4 weeks was arranged. The speakers arrived in adequate

time to permit bedside teaching through ward rounds and consultations.

Papers for the formal program were usually brief, and an opportunity was

provided for discussion and questions front the floor. The wartime graduate

miedical meetings in the Sixth Service Command were available to all of the

personnel in the service command hospitals once or twice each month.

Conferences of chiefs of services.-It was helpful for the chiefs of the medicall services of service command hospitals to come together at regular intervals

for the exchange of ideas and experiences and for the consideration of recent

a2dvances in thie fields of mnedicine that were of practical importance. This type

of meetiing was not sufficiently used. Some service coimmands managed to

aIchieve one conference (luring tile entire war. Such a conference should be

heldi at least once a ye*lr. The program of a conference iii the Ninth Service

Command is included in t his volinme as appenidix D (p. 841).

Clinicopathologic conferences.- M\ I at cri 1 for olin icop)a t hologic conferences

was made available through time courtesy of the M\lassachiisetts General Hospil~d at Boston, 'Maiss., and the New York lPostgra(hiate AMedical School of

olhiiiibiai Uiiiversit y, New York City. Arrailgeimeits wvere imide in tile Sixth

1mld Niiith Shrvic Coinii mialds for the protocols to arrive at regular iitervals

at elacih large hmospitill.
104 AcTIVITIEs OF MEDICIAL CONSULTANTS

Th(' suiccess of such cotift'rvilies de(pendi~s upon0 ce'rtainl factors. 'liwt chief

of tw lt' l)ii l kor ivr 5 ('iVý Ini ist bet it colilpet ('11t pat hologist whlo ('1ij0V5 ('lichi i h

anid tiiill'i'st iliiis thec techliiijie for fpl'tseit ill- t~t lie iiterial. Sinlce it wats

noticevaide ti lint ill lhospit als where I lhe staff win' predoili nl in t Ilv siurgicall lthe

conferences were lot verY ipouniar, it wo~ji(l seemn ti hu ienoiiiis of toli nwiedica

ser1vices appreciaite t i is tyV p or tenclijiing to at greaiter (legree

iProbl~ii, v thle iliost inijiort aint t ,pIe otil patliologic 'oiifereiice is iilie 3ititlopsv.

I'llifort tifilatlv t , aitteiiluIIIt', Wvas no0t re(-Iliii'e( ill sollie hoplisll as, althlouigh t is

(10lishitalint toiisisteiitY I'vretoiiilivield('t thalt it be 1iiatle iiiniitlatorvY.

Temporary duty assignments for training.- A very *viniportalit in'alis of

CMoin11latrig experielices 2ii1d gzi thleriiig iiifor-iikiiit wals t-he tietnil ilig, of, cerlla ii

officers to tt'Iillporir ,v (lilt -VN ill (other hiospitalis where the l o ul(d11 leatrl ceri am11

iecliiiiqIies or- observe spec.ild lrocedilires. For exaiiiple, whl ilei 14 conisult anti

14)1111( t hlt Il lie se of thle classificuit loll of r-lvieuiint ic fever was qulile tlifirt'iii

lie 1nrni-iigt-d for 11wt chief of thev Iiedicni service ait Birili ing-liaIii to V:isitl0Ile

211141 later for tlit chiief ofthlIle iiit'(icial s('rvice ait Tloriiev to visit Biriii iiiglalaiii.

Theyv sni iithit'I atijelts ,iitl weiit ovt'r tdiarts togetheri and1( were aible to n-solve

ifr(t''IIct's III t~t liese, of, thle classilici t ioul

Editorial duties.-Tlie coiisni taitn r('viewt'l113 inay pa pi'sl)vN re'i)irt'( bY

Inletical officers. This wats at plealsant talsk, which seeiiiet wvorIliwliilt antid t'51)tcia liv he(.lpful to Yvounlg, i li(xptri('lcetl itOtithors. Nintierotts papers, severel v

crititizetd ill their originail foriii either halve reaippearied llater. 1iiuicii bei k'r

becaluse tofCr fli-ther t liouglit anid revisioni or- lii vt' bteii iiitl udtet ili thle 31111 hors'

.sOulvellirs of wair t'xlptrielices where t hy right fully belong".

lit S~ii1113 1 v1 v . lienl althIoughi t here wouild probalblY l]t s01iv( obstlacles to

conii illetd Iliethit'3i ed lcat ionl lnia i111anv noiir1et'tpt i e iiiedit'al officers. such

t'tluicit ionl is liliquitst ioiliui *vl)IVd Iiiitiuiit itill to th l11it' Iiiilteivect of' propter neiiielta

tioughit 311141d praictitce In all ,v hospital sv* steli thuiriiig t iiiits of pet'ive or. wial..

'lThe progril inls tdescribedtt inllis pa(I( P111ragra lis, were not t'lt i r'ly suiccessful ill

(VVVl'V (etl(' l ill thit t wo ser-vice coiiiiiiaiitl(s toiisidert'tlii t his rep~ort , blut th *itv

tid tl ippa l toil It)lii e lawn i'l he)1111 to tw lit'uiiujorit V of officers oil t~ lit' ivitlcl services of liospit alls ill theitste t-oiiiiiuiuiits.

FlT'e postgraduaillte edlicaltioinld progrinii developed inl t li Eighth IiSrvict'(1

Co0111ilmmln Was Illost c.11efull1Y plainn1 findt v10 xetii et. A so 11111iarv of' C oloniel

Ba uitw'rs rep~ort follows.

It is g'eiierailiv conictdtet t hut t lie st l'eligt II of till\. iist it utiioll for)I t lit'ci

of t it'. sick is thi rett lv relait et to t' Iuciat ionail facilitites which 'xist thlert'ihi. I I owct'ioit p(131Josshlbhlithes of' Ariii*v hiospi)tail.; ie' ivet prol'wti. ('Ii ipliiisi.

rit' c'tuiisit iii ts sooii r('tOghii'/.' ti liit fostert' "itih strioing etduiatit onali priogritliwast lit' be(st ii qjoit' o or im iprovinig tw lit' iivt'lia st'rvictes. They fu rtit'er

ligrvett thlit biringinhg to t it'- hiospi tal a1 syst ('li of' post gnidtitlitt e ('thicuit ioh wVouild

behit'fit tw ltargtest numiiber' of iiiedicnl officers.
SERIVICE C03MMANDS 105

The consultants' wardl rouinds and clinics served ats edlucational exercises

and stimulated lbetter prof'essional performance. However, ats visits were too

infreqluent to have tile desired continuing effect, the chijefs of service were urgred

to establish strong edlucational programis. These usually: included weekly tile([-

ical staff metig, (dillicopat hologic conferences, clinical X-ra.v conferences,

alld(iwel hospital staff mneetings. In add~ition, somne of' thle medical services

est ablishedl Journal club~s for reviewing thle current nmeical literaltire. The

smaizller station hospitals conducted edIucational prograins onl a smaller scale.

The staff meetings were Athen the basic educational activit ,v. Genlerally

speaking, t hey were well cond~ucted. The cases selected for p~resentaltionl were

well (hioseli and~ the available pertinent, literaltire t horoughlyl reviewed. A few

of' thle abler aind iiiore energetic (clief's of' service preferredl ward conferences

froiii 2 to :3 times at week, at tendedl bY the entire mediical staffs. These exerc'ises, if lproperlyN conducted'(, eii('olrageai free dliscuissioni, fI'lrt I ieredf prof~essional

thought, andl servedl to unify (diagnost ic ali~l t lier peutit c lroce(lirIIes.

'I' lie clinical X-ra ,v confIeren ces were veryv suiccessfutl whien well cond~luctedl,

as evidenced b),y tilie large weekly atidlienlces. Whlen thle part icipa tion by bothI

tlie cli ;icicn and tilie rad iologist wats active, suich conf'erences were extremelyinfforiiiative and conitrilbuted greatly to thle intellectual atmosphere of thle

lioslpit al.

The general hospital staff meetings vatried greatly both in quality and

puirpose. Tin many of' thle inst allations, the major services suirgery, mledicinle,

neurops.- natry, arnd radliology were responsible for one mneet ini each mon11thI.

Tliese meetings wvere usuiallY devoted to at f'orniial presentation of' some topic

of' genleral interest. In somie hospitals, thle mieetings were held Only rarely Oriiot at all b~ecauise of' the lack of cooperation b~etween the iiedical and surgical

Services. This wats niost uin fortuiinate because such meetings, if wvell organized,

aided niaterially' in unifYiig, thle puripose of' the hospital staff.

The otlher eduicatIion al op~port unities afforded mnedlical officers were the

wartinie graduate inledical mieetings sponsored b.y thle American College of'

Ph v-sicinu s, service coiiinanl(l ('011erences for chief's of' service and their staffs,

spe:cial post1gr'aduatec and refresher courses in civilian and Army hospi tals,

tell) porary (IuitvN asignmen1i1Cits, and an intern p~rogram,

The first of' tlese Wats Vecy Nsuiccessful in several of' the smaller service coimmiands hiaving~ Inianl ilmedicial schools and energetic, enthusiastic regional chairmen ; for examiple, ti he SixI hi Service Command1i11(. Lack of success in othler service

coliiliian1(ls wats at tribult able to failure to have the regional area correspondl

geographit cally withI t hat of' thle service comimnand, thle long (distan rce between

lie Army hospitanls and tlie inedlical centers, thle lack of' dyniamnic, sel f-sacrificiiig re'gionial chalirniieri, and tilie absence of suifficient mledical Schools and ouitst and(inrg hospitals to prIovidle p)roperly qualified t eachers. Effective wart i nie

gradiuiate mnedical meet ings requiredl tilie ut Iiost cooperation between thle regionial chairman and tilie service commiiandl surgeoui and his consultanit. WithOut t his cooperation, thle mleetiiigs were not suifficiently well initegrated to

nIeet tilie nieeds.
106 ACTIVITIES OF MEI)I('AL ('ONSULTANTS

A model program should furnish one or more civilian consultants to each

service coniniaind hospital at least once a nionth. The participants should reniain for at least I day, spending the greater part of their time oil the wards

with the medical officers. If talks are permitte(l, t hey should be confined to

appropriate topics anil he sufficiently b)rief to allow ample time for discussion and

questions from the floor. The aim of these wartime graduate niedical meetings was sound.

During the first 2 years of the war, many medical officers were sent to

various specialized schools operated either by the Army or for the Army in

civilian hospitals anti medical schools. The benefits derived from these courses

depended upon the individuals assigned, their ability, diligence, and interest

in tile subject. Too often, poorly *vqualified and indifferent officers were indiscriminatelv ordered to these schools in or(der to fill the required quota. Therefore, in many cases, neither the individual nor the Army profited from

the experience.

The refresher courses held at some of the service command hosl)itals

varied( greatly in their accomplishments. Many of the courses were too

ambitious considering the teaching staff that was available. Those courses

of a more limited scope were the most successful and the only type that should

be permitte(d.

Assignment of medical officers temporarily to service command hospitals

in order to acquire needled techniques and other information proved to be a

very helpful means of strengthening certain hospital staffs.

Intern teaching programs were established in order to provide additional

instruction for recently graduated p)hysicians entering tile service. These

young officers were assigned as assistants to the best qualified ward officers.

They a cconlpanied the chiefs of service on their rounds and received 1 hour

or more of didactic instruction each dlay. The majority of these young physicians were enthusiastic, energetic, receptive to instruction, and( helpful in

the operation of the wards to which they were allocated.

During this emergency, the space, fixtures, and equipment. apportioned

for libraries were often inadequate. In some hospitals, the libraries were so

dissipated bty informal loans to service and section chiefs as to be of little

value to other staff members. In the institutions where they were rea(lilv

accessible, attractively furnished, and well managed, the libraries played

important roles. The number of current, medical journals received by the

larger hospitals represented an excellent cross section of the better periodicals.

However, the quota of books originally supplied was inadequate b)oth numericallv and (1urditatively. This inadequacy was due largely to unnecessary

duplication, such as from 6 to 8 volumes of ('hristopher's rextbook of SurgeryCe(cil's Textbook of \Iedicirie, Dorland's MIedical Dictionary, Useful Drugs,

anti other books to a lesser (degree. Later, the libraries were supplemented

by a(l(lit ional books and purchases from specifically allot ted funds. In addition,

books anml periodicals were loaned by the Army Medical Library, medical
SERVICE COMMANIS 107

schools, and societies, whose generous cooperation enhanced the education

of medical officers.

The educational program in the Eighth Service Command was more comprehensive than that of other commands because the surgeon and the consultants obtained a substantial yearly grant from the Rockefeller Founda t ion.

These a(lditional funds made possible better lil)raries, the distribution of

clinicopathologic conference case material, and the active participation of

visiting professors in the teaching program.

Considerable time was devoted to the selection of the volumes needed

to provide each hospital in the Eighth Service Command with a library sufficiently complete to furnish definitive infornmation concerning, all medical

and surgical diseases. The books were then purchased and(l dist ributed.

This undertaking not only profited the hospital staff but also served to (lemonstrate that small civilian hospitals could have reasonably comprehensive

libraries without spending large sums of money.

The use of case teaching by means of clinicopathologic conferences, first,

introduced in the Eighth Service Command through the grant-in-aid from the

Rockefeller Foundation, was very well received. The numerous requests

for this material finallyv led the foundation to make it available to all service

commands. Selected case repojis of the type published in the Vew Enqland

Journal of Medicine were obtained from the Massachusetts General Hospital

for these conferences. Two such case reports were distributed to each service

command installation ea'h week. The hospital staffs were urged to conduct

these conferences in muci the same manner as is done at the Massachusetts

General Hospital. The success of the conferences (lepended in large part

on the ability of the hospital pathologist to teach and to invite discussion.

Participation in these conferences bty the staff members necessitated reading

the medical literature and keeping in touch with the newest developments

in medicine and surgery. In ad(lition, the conferences served to maintain

interest in those diseases not encountered frequently in Army hospitals.

Case records pertaining to the major psychoses, psychoneuroses, psychosomatic disorders, and neurologic diseases were (listril)uted to all hospitals.

These were used in much the same manner as the clinicopathologic caseteaching material. They were well received and stimulated interest in neuropsychiatric disorders.

Another an(d extremely important. feature of the educational program

in the Eighth Service Command was the provision for the active participation

of eminent teachers. The annual budget was sufficient to permit nationally

known internists, surgeons, neuropsychiatrists, orthopedic surgeons, and, for

a time, radiologists to visit the service command hospitals. Once such specialist

accompanied the corresponding consultant on his monthly tour of hospitals.

Each visitor spent 2 or 3 weeks in tle service conmman(, depending upon the

length of leave granted by his medical school. The foundation grant paid his

traveling expenses andi provided him with a modest honorarium. The invited
108 ACTIVITIES4 OF MEDICAL (MXULTANTS

guest joined the service command consultant in making ward rounds, holding

clinics, and in roundtal)le discussions. Formal lectures were not featured with

any regularity because of the desire to have the visiting physician demonstrate,

by actual performance, good medical practice.

Initially, the consultants and their visiting specialists visited all types of

service command installations. With the institution of the regional consultant

system, visits were confined to the regional, general, and large station hospitals.

The continued participation of the staffs of the satellite stations in such exercises was made possible by having the commanding officer of the parent or host

institution invite the staff memblers to attend. This they did with great

regularity. Not infrequently. the staff meml)ers requested aid in the solution

of some of their more recent therapeut ic and diagnostic prollems, and occasionally they presented cases. While at tile parent hospital, the consultant and

his visitor were available for consultation to the satellite installations.

Seeing tile visiting, professors intima tel" and in action had a most stimulating effect upon the inedical officers. They a pplrec.iate t )rushing shoulders

with these leadlers and eminent authorities of the profession, submitting cases

to them, and having the b)enefit of their experiences and opinions. Tie give

and take of the ensuing discussions provided the, medical officers with professional experiences of great and lasting value rarely to be had in private practice.

An unexpected result of these educational programs was their effect on the

visiting professors. The two impressions most frequently discussed by the

civilian consultants are worthy of recording. First, the consultants were of

the opinion that, concerning diagnostic facilities anl technical equipment,

military medicine was at a very commendable level. Second, they were agreed

that most of the graduates of American medical schools had not been taught

sufficient psychiatry to enable these graduates to practice comprehensive

medicine. Several of the distinguished consultants returned to their medical

schools determined to make changes in teaching methods. One wrote that

his tour of military hospitals had opened his eyes to the role of psychosomatic

medicine and convinced him of the importance of teaching the fundamental

principles of psYchiatry not only in the department of psychiatry but in every

division of the medical school.

Many, especially commanding officers of hospitals, argued that the institution of educational exercises of the type just described would interfere seriously

with the discharge of the medical officers' routine duties. Experience soon

demonstrated that the beneficial effects more than compensated for the time

required. The most important direct result of the educational programs was

better medical care for sick soldiers. In addition, tie programs furnished

needed instruction for medical officers who came directly to the service after

long periods of practice, and these programs continued instruction for the more

recent medical school graduates.

If the Army 'Medical Corps is to provide the best possible medical care,

it must fulfill certain educational obligations. In time of war, this obligation

will necessitate greater discrimination in the use of tihe affiliated hospital staff
SERVICE C()MMANI)S 109

members,8 the Army's greatest, source of clinical teachers. The assignment of

most of these officers to key hospital positions and tile establishment of systematic rotation of ward surgeons will provide excellent opportunities for the

development of physicians.

ADEQUACY OF MEDICAL CARE IN ARMY HOSPITALS

This subject is one of prime importance to the historian. The discussion

that follows represents thoughtful, thoroughly objective treatment of the

subject. It is a summary of an appraisal written by Colonel Bauer, a service

command consultant whose knowledge and experience rendered him exceptionally qualified for the task.

Tile mfedical care provided sick soldiers in Army hospitals was, in most

instances, superior to that previously received in civilian life. This care

was made possible through the organization and supervision of clinical activities, the unification of diagnostic and therapeutic procedures, better placemerit of medical officers, and continued education. Nevertheless, unnecessary

fatalities (lid occur.

In criticizing Army- meldical care, it is important to stress that many of

the deficiencies reflected more upon the undergraduate and graduate training

of physicians than upon military medicine. Physicians often did not adjust

well as members of disciplined teams, nor did they always accept unusual

assignments graciously. The majority of officerss, however. executed their

responsibilities to the best of their ability despite handicaps such as new surroundings, unaccustomed administrative procedures, and unfamiliar professional duties.

Deviations from the basic principles of good medical practice were frequentlv ol)served in the form of poor (loctor-patient relationships, unnecessary

hospitalization, inadequate histories. al)bsene of personality evaluation, incomiplete physical examination, delayed clinical evaluation, institution of therapy before establishing a diagnosis, paucity of progress notes, inadequate treatnient, and indecision in diagnosis, therapy, and disposition. These shortcomings were consciously or unconsciously co|mpensated for by superfluous

laboratory tests, radiologic exa inations, consultations, clearances, and treatmient. Such practices often bespoke either inadequate Inedical training or a

feeling of insecurit'*y on the part of inedical officers and constituted some of the

ictrogenic factors to which sol(liers were exposed. Such factors further increased an already staggering neuropsychiatric rate.

Full docunientation of other breaches and deficiencies would not justify the

tinie and space required. It is sufficient to cite a few examples regularly observed, such as limited knowledge of colninitnicable diseases; mneager tinderstanding of the principles of cheniotherapy; unwarranted reliance on laboratory

procedures; and lack of clinical judgment concerning the varied manifestiations

s Experienced teachers in inedij, units tormel by a sponsoring niedical school or hospital.
110 ACTIVITIES OF" MEI)I('AL (ONSULTANTS

of rheumatic fever, infectious hepatitis, diphtheria, infectious mononucleosis,

malaria, and diseases incurred in tropical regions.

The adequacy of medical care depended upon the professional qualifications, attitude, and performance of tile chief of service and his fellow officers

and also on their relationship to one another. It was demonstrated repeatedly

that even with personnel of average al)ilitv a capable chief of service elevated

medical care above the level of mediocrity by constantly striving for improved

diagnoses, therapy, and disposition. In order to achieve this, he had to avoid

being saddled with a heavy administrative load. Good leadership not only

promoted better performance but also invited a more critical attitude and

a free expression of opinion on all professional matters by medical officers,

irrespective of rank. This atmosphere improved rather than diminished

esprit de corps.

CLINICAL RESEARCH

At the outbreak of the war, tile policymakers of the Medical Department of the Army were not favorably disposed to clinical research in Army

installations. These administrators were preoccupied with the many and

important problems involved in planning for supplies, hospitals, personnel

procurement and management, and operations for the huge and steadily

expanding Army; and, at the same time, they were concerned with the efficient

operation of the 'Medical Department in relation to pressing current problems.

Not only did clinical research fail to receive encouragement at this time, but

attempts to carry out original studies were actively discouraged.

In time, this attitude changed. The influence of the consultants was

of the greatest importance in bringing this about. They understood the Army's

need for additional knowledge in order better to support the combat, training

program in the Zone of Interior and, later, the combat strength of troops

in the line. This responsibility made research a very practical matter for

the Medical Department. MMany questions had to be answered. What

disposition to make of patients with hepatitis? What treatment to employ

for malaria? How to prevent and treat properly cold injury? How to prevent and treat. heat exhaustion? These and innumeral)le other questions

could be answered only after study, and often the studies could be made only

with troops. As time passed, the attitude of the Medical Department in

the Zone of Interior changed from one of active resistance to clinical research

to one of passive acquiescence and, rarely, to one of wholehearted acceptance.

Only in isolated instances, however, was it possible to obtain the necessary

priorities in material, transportation, and especially personnel. If priorities

could be obtained at one echelon of comnmnand, it was conunon experience

to have them denied at another. Nevertheless, clinical research developed

in a modest way in certain p)laces. In some of the hospitals designated for

tile care of special disorders and, less frequently, elsewhere, research actually

flourished toward the end of the war.
SERVICE COMMANDS 111

The following comments regarding clinical research in three service colrnmands tllre based ol oi)servations of tlie Inedlical consult ants who served in

these conmmands anti who often initiated andi supervised studies. A suninary

of Colonel Thomas' experience in the Fourth Service (Command follows:

There were several clinical research projects in some of the hospitals.

Some officers turned out a great many papers; a few of them were quite good.

Whenever the medical consultant saw an interesting and unusual case or

at well-studiied group of cases, he encouraged the chief of medical service and

warrd officer to prepare a report for publication. The Fourth Service C(ommand

Laboratory was interested in various studies including dysentery and meningococcic infection.

The influenza commission was established at Fort Bragg, N.C., where

primary atypical pneumonia wias studied. Members of the staff of that comimission contributed to the program of a conference held in the service command

and distributed information concerning their work. The large epidemic of

meningococcic infections presented an opportunity for careful clinical and

therapy studies. At Fort Bragg, Lt. Col. (later Col.) Worth B. Daniels,

MC, studied an outbreak of at rare disease, which he called pretibial fever. On

the whole, the medical personnel in the hospitals in the Fourth Service (Comniand were not trained for clinical research. There were a number of cardiologists who collected rare forms of cardiac arrhythmia, and the gastroenterologists inade valuable contributions in the study of peptic ulcers. The work on

the use of prophylactic sulfonamides in aborting a nieningococcic epidemic was of

great value, and the studies along this line performed by the Fourth Service

Command Laboratory personnel were outstanding.

A sumniary of a report, by Colonel Adiams, also concerning the Fourth

Service Comnand, is presented in the following paragraphs.

The following studies and investigations were made in this comniiand:

Location Study

Battey General Hospital, Rome, 1. Clinical studies on acute pericarditis.

Ga.

2. Comparison of vaccine products and Brucellergen

intradernial tests in brucellosis.

Finney General Hospital, Thomas- 1. Malaria therapy in neurosyphilis.

ville, Ga. 2. Penicillin therapy in neurosyphilis.

3. Spinal-fluid Wasserman reaction during the course

of and subsequent to malaria treatment of neurosyphilis.

4. Studies on penicillin concentration in spinal fluid.

5. Value of Thio-Bismol (sodium bismuth thioglycollate) in quartan malaria.

6. Value of gastric analysis in the diagnosis of duodenal ulcer.

7. Survey of bronchial asthma in soldiers.

8. Studies in histamine-stinmlated fractional gastric

"analysis.

9. Statistical study of 200 cases of arthritis.
112 ACTIVITIES OF MEDICAL ('CONSLTANTS

Location Study

Foster General Hlospital, Jackson, 1. Clinical studies on rheumatic fever and rheumatic

Miss. heart disease.

2. Value of salicylate therapy in rheuniatic fever.

3. Effect of various adjuvants (such as sodium bicarbonate, ammoniunm chloride, and aluminum hydroxide

gel) on blood salicylate levels.

4. Penicillin therapy in chronic bronchial asthma.

5. Clinical study of asthmatics returned from overseas.

Kennedy General Hospital, Mere- I. Evaluation of certain drugs in the treatment and

phis, Tenn. control of malaria.

2. Studies on palnar sweating.

3. Clinical study of asthmatics returned from overseas.

Lawson General Hospital, Atlanta. 1. Comparative value of liver-function tests in hepGa. atitis.

2. Gastroscopic studies in acute hepatitis.

:3. Electrocardiographic studies in various forms of

heart disease.

4. Effect of amputation of the extremities on the

electrocardiogram.

5. Evaluation of penicillin in treatment of skin

disease.

Moore General Hospital, Swannanoa, 1. Comparative evaluation of different drugs in

N.C. treatment and suppression of malaria.

2. Clinical sttidies on filariasis.

:3. Comparative evaluation of different drugs in

treatment of schistosomiaisis.

4. Evaluation of certain antigens in the diagnosis of

schistosomiasis.

5. Comparative evaluation of different drugs and

dosage in the treatment of kala-azar.

6. Clinical studies on hookworm infections.

7. Clinical studies of various forms of treatmenu~nt in

atypical lichen planus and eczematoid dermatitis.

g. Ilistopathology of atypical lichen planus.

9. Relationship of Atabrine (quinacrine hydrochloride) administration to atypical lichen planus.

10. Clinical studies of dermatologic and faucial

diliht heria.

11. Study of metabolism of antimony by use of

radioactive tartar emetic (in conjunction with the

U.S. Public Health Service. l)epartment of Zoology,

National Inst it uites of Hlealth).

Oliver General Hospital, Augusta, i. Combined penicillin-hlelparin therapy in subacute

Ga. bacterial endocardit is.

2. Evaluiation of various forms of treatiment in

ati*ypical lichen plantis.

3. Retcirrence rate of malaria treated witlhoumt specific

druigs. D)iagnosis of Strongyloilcs stercoralis infestlation by duodenal drainage.

4. Statistical stiudies of I hv incidence and types of

asthma in the Army.
SERVICE COMMANDS 113

Location Sludy

Oli~ or General Ho-spital, Atigusta, 5. Evaluat ion of Ant hiomialiuue (a nt i mony sodium tibjoGa.-Continued mialate) in granuloma inguinale.

6. E'valuation of intrathoracic penicillin treat ment of

('Ifpyetfa.

Regional Hospital, Camp Blanding, 1. St udies on heat stroke.

Fla. 2. Loeffler's syndrome in cases. of .lfcyloJstomfl brazdiinse (ureeping eruption).

Regional H~osp~ital, Fort Beunning, 1. Evaluat ion of immune globulin in the prevention

GIa. of mnumpis orchit is.

2. (last roscopie st udies in infectious hepatitis

3. Evaluation of ant istreptolysin titer in differential

diagnosis -of rheumatic fever.

4. Evaluat ion of sulfonamide drugs, in the prophylaxis

of gonorrhea.

5. Studies to determine the optimum dosage of

penicillin iii acute gonorrhea.

Station Hospital, Camp McCain, 1. 1Evaluation of sulfonamide drugs in the prophyMis.laisof mieningococcic infect ion (in cooperation with

the Fourth Service Command Laboratory).

Station Hospital, Camp Wheeler. (;a 1. Evaluation of sulfadiazine prophylaxis in the control of respiratory diseases in(l rneningococci('

infection.

Thaver General Hospital, Nashville, 1. Malaria therapy in neurosyjphilis.

Tenn. 2. Penicillin therapy in neurosyphilis.

:3. Effect on propylene glycol aerosol in barracks on

the incidlence of respiratory infection.

tnited States Army General ilospi- 1. Studies on trenchfoot, including biopsy material.

tal, Camp Butner, N.C. fluorescein studie-s of circulation, and mycologic

st udies of skin complications.

2. Value in hepatitis of the coagulation band, the

Watson quantitative urobilinogen, and the quant itative methyle'ne blue tests.

Welch Convalescent Hospital, D ay- 1. Studies on antiamehic drugs in diarrheal p~atie~nts

tona Beachi, Fla. admitted b~y transfer with the diagnosis of functional

gastrointestinal disease."

Regional Hospital. Fort Bragg, N.C - 1. Clinical and laboratory stutdie-s on pretibial fever.

2. Clinical, laboratory, and epidemiologic stt u(lies on

ain out break of bacillary dysentery (in conjunct ion

with the Fourth Service Command Ljtborat orv).

3. Tnt ensive arsenot herapy of syphilis.

4. Penicillin therapy of syphilis.

5. Evaluation of Frei antigen.

6I. Therapeutic value of l~ncli-esa-entoil

mnixtutre in variolus infect ions, including gonorrhea,

early syphilis. tonsillitis, pneuimonuia, and ot hers.

7. A coinparatitive st udy of penicillin and sulfadiazine

in the treat ment of lpnelimococcic p~neumonia.

8. Stutdies to determine the optimum dosage of

penicillin in acute gonorrhea.

Regional Hosp1 itail, Fort 'McClullan. 1. Use of estrin in the p~revent ion of muimps orchiti~s.

Ala.

5649701-601-- 10
114 ACTIVITIE~S 0PF ME1I)DICAL (C)N-SLTANTS

Location Stildy

Regional HIospital, Fort Jackson. 1. Evaluiat ion of stilfuruinjde drugs in the prophylaxis

S. C. of iIIeniflgoeoccie infIi ciofl (ill cooperation withi the

FouirthI Service Coniniani Lab~orat ory).

St at ion Hospital, Canip Forrest, 1. Clinival sttidv of an epidemic of t ularetinia.

Tenn.

An extensive stu ' x- of nifetio(Is for prevention and treatmnent. of derniatophvtosis wats conducted ait Fort Ilennirtg, Ga., fromn August 1942 through

December 1945 lby the Division of War Research of C'olunmbia Universityv, under

contract with thle 'ominfit tee onl Medical Research of the Office of Scientific

Research arid Developmlent. The project wits directed b~y Dr. J. GardIner

Hopkins, Professor of' Deriniatologv, College of Ph vsicit'its and Surgeons,

Columibia University. He wats assisted by four trained mvycologists and several

technicians. Office anti laboratorY space were first providled ait thle regional

(then station) hospital; later at lbarracks b~uilding wats allocated by thre post

surgeon for at laboratory and clinic. Troops for surveys and testing of p~rophylactic measures were inadle available fromt various infantry' reginten ts an(I other

organizations onl tite post. Treatitent clinics were hield in two of thle post

dispensaries. In .July 1945, the scope of the project. wats extended to include at

st udy of Penicillin thterap~y in aill types of skin infection, including those secondiary to derniatophytosis. A special ward in thle regional hospital wats allocaited for thlese cases, and at trained Medical Corps dermnatologist wats placed

in chtarge of the clinical work.

The following problenis wvere investigated: (1) Incidence of fungus infection in infantry troops; (2) types of fungi andl bacteria concerned in these

in fect ions; (3) effectiveness of prophylactic measures, including foot bathIs,

p~owders, ointments, and special types of shoes in preventing derninatopltvtosis;

(4) evaluation of new fungicides, including a number of ant ibiotics, inl the laboratory, (5) evaluation of new fungicides in treatment of mycotic infections;

(6i) evaluation of antiseptics and the sulfonamides in treatment of secondary

infect ions; and (7) effect iveness of penicillin in pyodernias andi the frequency

of sensitization resulting front its use.6 As a result of these studlies, at new

fungicidlal ointment containing undecylenic acid wats added to tile supply

tables. Met hodis for treatinient, of (lermiatolphvtosis andl secondary' infections

were published in tlte Army Medical Bulletin. Close cooperation existed

between tite post surgeon, tite htospital staff, and Dr. Hopkins and his group.

Tile latter freely gave their services in consulting with the htospital staff onl

dlifficutlt (lermatologtc cases.

The ('ontnnission onl Acute Respiratory Diseases, I of tlte 10 coniniissions

activatedl by tite Army Service Forces Board for thle Intvestigation and Conttrol

of Influenza and Other Epidemic Diseases itt tite Army' , reported to Fort Bragg,

ott 19 October 1942. Its general objectives were: (1) To maintain continuous

* A detailed discussion of these inves lig:t tom; appears in Medical Department, United States Army. Preventive

Medicine in W~orldI War ir. Volume V. Co~mmunicable Dilseases Transmitted Through Contact Or By Unknown

Means, chapter Vii. [in press.I
SEI'IV1C ('4 OMBIAN1)S 115

observations of respiratory diseases as they occurredt at Fort Bragg and to investigate their epidenliologic, etiologic, serologic, clinical, anld prophylactic

aspects; (2) to maintain a constant watchi for the occurrence of influeniza and to

study- ayit outbreaks of this disease; (3) to carry oil studies of primary atypical

pneumlonia, with particular emphasis on its etiology; and (4) to conltuct field

investigations as (iirected by The Surgeon General.

This coinm ission had its special laI)oratory in the regional hosp)ital and had

access to all clinical material. Its invest igations were carried on withi tile full

cooperation of the hospital staff. The members of the commission were most

helpful to this hospital as well as to other installations in the (coninand in

performing special laboratory tests and in freely giving their expert clinical

advice whenever calle(l dupon.

A summary is presented of an informative statement about research in

the Fifth Service Command. The statement was included in a report by

Colonel McGuire. The experiences ati the ,Wakeman General Hospital, ( 'amp

Atterbury, Columbus, In(t., illustrate some of the not infrequent obstacles to

well-plahued investigations.

There were two major efforts to carry on well-planned investigations

within the Fifth Service Command. One was a study of physiologic alterations

in the circulation consequent to arteriovenous fistulas. This investigation

was planned by Lt. Col. (later Col.) Daniel C. Elkin, MC, Chief, Surgical Service, Ashford General Hospital, White Sulphur Springs, W. Va.; a group of

clinicians who were members of or selected by the National Research Council;

representatives of the Surgeon General's Office; and the Fifth Service Command

consultants in surgery and medicine. The study was conductedt at Ashford

General Hospital.7 A civilian clinical investigator, Dr. Eugene A. Stead, Jr.,

trained in the technique of measurements of circulatory physiology, was placed

in charge of this project. Technicians and the necessary apparatus were

l)rought to Ashford, where an extraordinarily large number of patients with

arteriovenous fistulas were being prepared for surgical treatment. In a carefill and thorough manner, alterations in blood volume and cardiac output and

other changes in cardiovascular physiology before and after operation were

investigated. Measurement of peripheral blood flow distal to fistulas was

planned t)ut abandoned following V-J Day.

The second investigation was a careful study of the nutritional status of

tile paraplegic patients at Wakeman General Hospital.8 This study was

planned by the nutritional consultant, the chief of the surgical service, and the

medical and surgical consultants of the Fifth Service Command. The project

was first formally presented to Thie Surgeon General in May 1945 but was returned with the comment that the patients to be studied were definitely surgical

7 Elkin. Daniel C.: Arterial Aneurysms and Arierlovenous Fistulas Circulatory EfTects of Arterlovenous Fistulas.

In Medical Department, United States Army. Surgery in World War 1I. Vascular Surgery. Washington: U.S.

Government Printing Office. 1955, pp. 181-2015.

6 .eIdi ai Department, UtnitvA4 States Army. Surgery in World War I1. Neurosurgery, Volume II. WIashington:

U.S. 0overintent Printing Office. 1959, p. 151.
116 ACTIVITIES OF MED)I(AL (CQNSULTANTS

and therefore tile project should be carried on under tile direction of tile surgical consultant and tile chief of surgery at Wakemian General Hospital. The

project was then resubmitted in accordance with this suggestion, and formal

approval was received unider (late of 11 July. In the interim, the conditions

under which the project had been originally conceived were markedly altered.

The cessation of hostilities in Europe (liminishc(d tie flow of p)araplegics to the

hospital, redlucing the supply of the more acutely ill patients. Personnel

shortages made it (lifficult for the hospital to organize and properly staff a

special ward for the care of the patients under observation. The construction

and equipment of a laboratory for the considerable volume of analytical work

required was deferred by the increasing emphasis on the enlargement of the

reception-station and separation-center facilities which were located at Camp

Atterlury, for it, was through the camp administ rative channels that approval

of such construction had to pass. Such wias the status of the project when

V-J Day arrived. Shortly thereafter, it was recommended that the project be

a)abndoned, and, with the concurrence of the service command headquarters,

The Surgeon General gave authority to discontinue it in October 1945.

Col. Thomas Fitz-Hugh, Jr., MC, Consultant in Medicine, Third Service

Command, from May 1944 to January 1945, provided the following comment

on clinical research.

One of the highlights of this war has been the output of excellent clinical

research pullications by many medical officers. A greatl deal of valuable material has b)een acnumulated under difficult and trying circumstances. The

medical consultant is dlutybound to encourage and aid such endeavors. By the

same token, it is his duty to be critical of poorly organized, repetitious, and noncontributing pul)lications.

RECONDITIONING

The delay in tihe development of a reconditioning program l)y the Army

Medical Department was principally due to indifference in the Surgeon General's Office to a need which had been recognized by inedical officers in the field

installations. Stimulation from the field, and especially from the splendid Air

Force program instituted by ('ol. Howard A. Rusk, MC, eventually led to reconditioming in Army installations. The need for such a program was evident

fromn the single fact that medical officers in hospitals were or(lere(d to retain

their convalescent patients in hospitals until they could be returned to their

units in full-duty statius.

The interest of the service command medical consultants in the reconditioning units which ultimately came into being varied greatly. The consultants were almost to a man extremely busy and preoccupied with important

matters for which they were directly responsible. Once a separate program

for reconditioning became estal~lished , tile medical consultants usually considered themselves relieved of resl)onsil)ility in the matter.

Col. George P. Denny, MC, Consultant in Medicine, First Service Comimnand, from January 1944 to December 1945, commented in his final report.
SERVICE COMMAN1)S 117

on the reconditioning program for that command. The following paragraphs

sumnmarize his observations.

The usual reconditioning programt at general and station hospitals for

class I, II, ill, and IX patients was in operation at the time of this consultant's

assiginient to the service command. This was set up and operatled in accordance with Circular Letter No. 168, dated 21 Septemlber 1943, OTSG, U.S.

Army. In March 1944, the nmedical consultant attended a meeting for reconditioning consultants of all service colnlnands at Schick General Hospital, Clinton, Iowa.

U.S. Army Medical Center at Camp Edwards

In April 1944, a reconditioning center was set ul) at Fort Devens, Mass.,

and patients in classes I and 1I were sent there from all hospitals in the First

Service Command. 'Ilus center was a part of Lovell General Hospital, Ayers,

Mass., and, because of the comn)lexity of the programn, the difficulty of obtaining imiachiinery anti materials, and the work necessary to adal)t the barracks

buildings available, tie program got under way slowly. About the time things

were working well, the whole activity was uprooted and moved to Camp

Edwards, Mass., where in .Jai1uary 1945, it became a part of the U.S. Army

Nledieal ('enter ati Camp Edwards. This center was ,designed to take care

of 6,000 men with the idea of freeing hospital beds for patients evacuated fromn

overseas. Beds were quickly filled to capacity by class I and II patients,

and imany more patients were carried on furlough.

The original, primary object of reconditioning was to return as many men

to duty as possible and to fit the remainder for return to civilian life. As the

programti progressed, it was found that only a small percentage could be returned

to duty of any type, and the (center became a vast waiting room of men who

knew they were on their way out of the Army and who did not take kindly

to the various moral, mental, aiid physical methods of improving their condition. This impression was (lerived from personal observation and talks

with the officers concerned. The ideal of reconditioning wias worthy and high

but so comnplex and diffused that it appeared to choke itself.

At first, there was a tendenlicy on tie part of hospitals to transfer patients

who coul(d not by any stretch of the imagination be benefited and who should

have been discharged at the hospital of origin. This procedure was gradually

corrected, but reconditioning remnained in part a dumping ground used by

hospitals needing to free beds for anticipated new patients. Many men were

sent directly to the reconditioning center from (lebarkation hospitals, sonie with

either no records or very scanty ones and requiring examinations that couhl

only be accoimiplished in tit(e general hospital or by consultations. Finally,

a consultation service and X-ray and clinical laboratories were established

within the reconditioning unit, and, although medical officers in various

specialties front the general hospital were still called upon, the hospital load was

greatly lightened.
118 ACTIVITIES OF MED)ICAL C'ONSULTANTS

There were not more thanl two comlpaniies Of miedhical paltienlts (exclusive of

neuropsychiatric patients). The usualt medical censuis was only ab)out no~

fromt a total of 6,000 in the c-enter. ( hronic skin disease represented abl)Ott

50 Percent of this group. Ot her common con(Iitiolis were the residluals of acuite

infect ious hiepat it is, recurrent malaria, and the usual gamutt of indefinite

gast roinitestinial complaints without (lefinlite Organic (lisease. Little could be

(lone for t he (lermnatoses, but. the gastrointestinal and mialaria patients usuially

were ret urnedl to limited (lutit. Rehabilitation of patients withI thle residulals

of lhepat it is had been given special at tent ion in 1942 and 1943 with little or no

SUCCess, anid thle same wvas found true at the Canip Edwardls center in 1945.

No special diets were available, thle assumpltioni being-and rightly so-that

if a iat w1111ere Wvell enough to be recond~it ionedl, hie should be able to eat, at a

genellral Iness. It lbecalne conimon practice to (dispose of these nien by providhing" t heml 90-day furloughs with the hope of sufficient improvement at hiome

to permiit their ult imlate return to (luty-a fairly slint hope, as it turned ouit.

Each comipaniy hadl a niedical officer in charge who sawv all of his patients

every day,Y if lhe could catch t heil bet-ween classes; andl medical consult ants from

lhe professional service visitedl the companies routinely and oii request of the

officer in charge. If a miian became sick, lie was sent to the (lislpemsarY ly the

company medical officer whiere one of three things wvas (lone: (1) Ilie wvas given

appropriate treatmeneit and( ret urnied to barracks, (2) hie was referred to the

U.S. Army Genera~l Hospital, C amip Edwards, Faninoum b , Mass., for stud I andl

treatment, or (3) hie was referred to the convalescent hospital professionalservice consuilting staff for their opinion and advice. Ti'l( p~rofessional eonsulting service usuially (let ermlinedl the type of (disposit ion to be nind~e.

Viewed fromt a realistic poiiit of view, the convalescent and~ recondhitioning

hospital was esscntial for the freeing of hospital beds for p~atienits evacuatedl

from overseas, but its complex and unwvieldy system of reeducation hardly

mminerit(I the vast effort andl expenlse put into it.

C olonel Batier also had exteinsive experience w~ithi prob~lemns of convalescemice

andl rehiabilitat ion in service command hospitals. A sunmmary of his comments

oin recondhitijoning follows.

lin Deceniber 1942, one of thle largest, service conmmands, withiout the (-oilsent of higher authlority, established dletachmenets at thiree posts. Th' ie ir

purpose astli phsial recondhitimoning of conivalescemit p~atientis 5nd t li

pit mysical amm(] niental rehmabilit at ion of selected soldiers wvithI neuropsy' chiiat nc

comnplaints, to thle end of saving training (lays and reducing tihe nmbmiher of

soldhiers receiving cert ificates of (isability for discharge. Thlese (let achimmemnts,

locatedl some (list ance fromni thle lhospitamls, were inde-pemidemit l operated under

time dhirect ion of thle post. commiianders amiu suirgeomis. If thlese thlree (det achmimieits achievedh their aimis, it was planned to est ablish simmilar unlits at aill

pos5ts. Althloughi their value was (lemnist rated iii applroximnatecly :3i mont lis,

hlig iger auit hority ordleredl t hat they lbe disconitimnued . So;nic mnomit s hatemr, ill

Septemiber 194:3, the previously mniit ioned Circular Let ter' No. 168 directed
SERVICE CO MMANDS~ 119

the estali)inlllii of recondlit loning11 units tit till lanrger servict omm Iand liospitalls. ,Ihese units wvere inainitainevd for tilie dur'ation of tilie wall (fig. 36).

The program heldl pronise or' contrilbut ing to thle inilit ary knowledge of'

the (-lire of convalescent patients, for tilie good 4f bothI the Ariv iandl tlie(

SoIldiers. It was ob)vious iroiii tilie outset t hat I tie progrilll II's success would

depend~ upon at sound1( p)lain, e'xecutedl withI ilitelligelit Vnct l11ilsisll by tlit( service

commIlandl suirgons, thle plost surgeons, andl tilie lversoiiulel ~in illiIllclnit e claiirge

of' vaci unit. Failure to develop a sat ishiictory progr:nii miore rapidly wn-s due

to 111iin1 caiuses. There was insufficient coordi liltt loll and( dlirect ion froni higher

commandiuii, and at lack of lunderst andling o01 the principles, and purposes of

reco(id t ioningo l)V hospJi ta iicoI~llmi'llidhers and( cdil inicians alike andl(, salve' for nlotedi

except ions, no0 real, enthlusiaistic (desire to (10 thle job). I nit ially, wvithi no extra

persnnOiel allotmient , t here Was a1 short age, part icula~rly ol' trained iniicividullls.

However, this was correct ed by~ creiiting at t able of Organiizait ion aind by aissignling, at nutcletis of trainedi men. Reconditioning units with in t elligent, wellt raliued per-sonniel accompllpishled 11 g-reilt dead. WXhen such personnlel wals liacki ng,

reconiti~ ollilig becalulle Somlethiing to b~e t oleratle(. Where units operat ed Inl

this atmIosphlere, lip) service Was usuially 5given inl thle form11 of' zunli cographied

sch~edulies issuied weekly showing exact lv whlat patienits in tilie fourl different

classes were supp)losed to lbe (loing hour by h1our1, (liy by dlay. (Close scruiny m

of' such1 unlits frequent ly reveialedl nliliny omiissions and1( deviiations from the

printedl schledulle.

Although it is not directly related to the problem undler disvius-sion, attenit ion should be directed to thle pr-ol)lenil of' collditionling or hrein I(~ trops

MX any admiissions to hospitails Were necessar'y beciause of' failure to adj ust the(

Physical trainling pr-ogri-III in thle Armiy to thle imaiteriail at llilidl. Uslliall, 110

(hifleren('e Wvas ma1.de in What Waus requlired1 physically of thle college athldet e or

farm boy ais cont rasted1 with the clerk or bank teller. Laiiie hacks-, sore feet,

alnd general ph ysical exhiaulst ion were oft en causes of' hospita iadml(ilssions aindl

thle baisis for the act ivat ion of' uinderlyinig neuroses.

DIETETICS

During t he wilr yeilrs, no0 prIobleml relative to p~rocuiremienit of' food supp)Jlies

for tilie Arniv hosp1 it als Iin thle Zone of' Interior was experienicedi, nor was, t here

rat ioninig, for U .S. soldiers in t hese htospitat11. nie only probilemis Iin the Zone

ofr hlt c'or were those liiaving to (10 wvithI thle preparation aind serving oh' tlie(

abundant rat ions which wvere alwauys availa ble (fig. 37). The li ospi tail sodai

fountan and1 11( caii(Iv counter ('5 made t heir uisual in roads upon tilie hulla wced

diets providled by hlospia di (iet it ians1. 'Illhe ilied ical consultants, withI ot her

Armiy oflicers, in simuiilar posit ions, showed the t rad~it ional conicerni abhouit thle

quality and1( quantity of' food available for thle soldliers for whoin (iey were

responsible, but act miiily thle only reail prob~leml ii thle service commii Iii (1was t0

get tilie soldhiers to vaiit thle good food providled them. Poor hiospita mi lesses

existed inl service coimiianid hospitails but not f'or long. D~iete(tics iii Arim y
ACTIVIT11:,- W., A11:01CAL ("INS[

makIIIAM I w AW-W -AW.2

!r

i w

Pic,

ill :it I m l. V(wl M ich.

I'll 1,:tli- Ill- :it I flit, 1" 'll C u -ll-r. \ li(.Ii.
SERVIC

u t~36. -( 1⁄4nitlitlirle. (. Watei r IIt'crapij N ill f)(H)I. I). ( ':irfizli.y slenr\isdl acttivit ies

ill 14V1lIII:IsIlitfl.
122AC IVI1114 "I. M i 'll
S i'MviCi: COMMANDV~IS 123

II(uRiE :37.-('ontimied. C. Serving line wvith steam tables and huige atitomaitic toaster

(center rear).

hospitals, eX(Ihlisve or tile special (liets prescribed in certain dliseases (such as

dliab~etes, gout, iiephlritis, hepatitis, and acute infections) was of little concern

to thle medical consultants.

The TMI (War Department Technical Manual) 8-500, Hospital Diets,

dlated Mlarch 1945, was prepared in large part undIer the supervision of Col.

Garfield G. Duncan, MC, who was on temporairy duty in the Medical Constiitants Division, OTISG.

MEDICAL SUPPLIES

For-t uatvlv, medical supplies in albunilant qujantity were practically

always aalalepromptliy to Army medicald inst allat ions in thle Un~ited States

fia. :38). Such1 short ages as were encount ered were uisually lbecauise of fauilt v

ilipillem~elt at ion of I lie Army system of requisit ioning, haiulty interpretation

of Ilie tmictetion of' a g"ivenl hospitall, andl, tilierefore, fauilty (list rilbutionl of tilie

'1ilpplies a1)prOp)riate and~ available to thlat hiOslpit al. Thle p)rocuremnent or

(list 1.11)111 lt)~ of mnedical slippJ a's for general anmd stat ion liospi tals ini tile U nit ed

St at es was5 never' at problemi, and1( tile (o'oti~ll tants ha.d little occasion to (lealI

wit il sliapplN I problemis, except wh-len acting as' per-sonal representative or' a

hiospi tal commiuander to tile service commiatanid stipJply officer. or Vice versal.
I'aIs'\ :I~jl4:'14hI c4 lifl ml 441 1141 , 11'41Z1:I14I" 4)! II4'4 [Il

h44! i144:11-4 \ Il411, Il( ý rls' 1114 ( 14 11 444:11)(Il~l llI \\:1ov I'1411 4:11 ; I.\\ ii) 411:114, : 111dto \ :

fi 414411 t -. m 11le l ýo l fr )111111 r

'I'll In I44IIIL Sr. r 1114'111.1 l14 1 - 1~' ;4 (411 1 1111"1111 41441' m 'I.1I~I iss
FIGURE 39.-Senior cadet nurses in training.

nursing care was usually adequate except when there was a. numerical shortage

of nurses. Experience indlicatedl that wardhuen couild be trained to discharge

mianv jitrsin, dluties in a satisfactory manner. Ini general, nurses servedi in a

-,tperioycpctecp i h ease of seriously ill patients.

Colonel Marble reported onl nursing in the Sixth Service Command. The

following paragraphs sum nimarize his comments.

The inauiguration of the system of cadet nurses put into operation a plait

which apparently worked excellently. For all practical purposes, a nurse who

had had 21,' years' training or its equivalent in anl accelerated program in a

civilian hospital was as capable as one( who had spent the full :3 years and wats

fully qualified to (10 her share of thle nursing work in anl Armyv htospital. The

fact that shte wvas obliged to stay only 6 monthis and the fact that, thle majority

of cadIet, nulrses chose not to remtaint in the Army was offset by thle fact that

whien the 6 i11tioitIs' tertit of (lutv for one group of nurses wvas uip, that of antot her

'rrOttp rbegan. Alt hotugi t his consultant (toes not claini to know much about

lhe Cadet Nurse Corps andl the actual results achieved, inl his opinion, thle idea

is fill excellent Onte, Which inl aniother eniergrency should cert aitnly lbe usedl ii

order to provide a sufficient numtber of nuriises for the Zone of Initerior (fig. 39).

Ut~iti tilie I ittte of thle establdishtmetnt of thle C adet Nurse Corps, it. was anl

almtost unliveýrsal compllaint thIat thtere were not enougit nurses in any of thle

liospit als. IThis wals titore or less true, but tilie Whole situiationt wits contfusedl

Variouts it admin iiistradt ive j)reýcedetit s. lIn soitte hosp~it als, wN-ltat sevtiel(A to 1be

all unIwarran ited Inumiinber of on jrses were kept att ad11it ninistrmitt we wor'k iii tilie office

of tilie pritcipitl chief titir-se. It Was t houight t lY soitte tiliiit thle iitt5'5('111(1 co lihave

lbeett of mtore h el p doin pr ltofessionalt work ott tilie wVard~s. A cot nstul a itSOMi r

of tigravat bit w the14 conditinual Ahift it. 4)f ttii'ses ftromi ()ti itr(l \\a o one sect toi
126 ACTIVITIE'S OF MEII(AL (CNSULTANTS

of the hospital to another. Upon inquiry, it was always stated t(hat tile shifting

of nurses was necessary because of two reasons: (1) An unbroken rule that at

regular intervals every nurse must take her turn at night duty, and (2) the

number of nurses actually available for duty from day to day was constantly

changing as the result of leave, illness, (lays or afternoons off, and transfers in

and out of the installation. Whatever tile cause, the shifting of nurses when

they had just become used to a given ward and( trained in a specialized technique

was a decided nuisance and resulted in a poorer qualit of care for patients.

One complaint mnade by nursing supervisors was that in the average Army

hospital there were not enough real nursing problems to challenge the capabilities of the nurses. As a consequence, over a period of time the nurses becaine less alert and less interested professionally. It is true that in tilie average

Army hospital there are fewer patients who are acutely ill and who need specialized nursing care than are found in the average civilian hospital. The consequence often was that the nurse in charge of the ward spent. most of her time

doing clerical and administrative work. It will be interesting to observe

what effect this practice has had upon the performance of these nurses on their

return to civilian life.

COORDINATION WITH OTHER CONSULTANTS

The medical, surgical, orthopedic, and psychiatric consultants assigned to

a service command had much in common. Their ultimate aims as medical

officers were identical. They worked in the same administrative setting,

employe(d tile same channels of communication, often occupied a(djoining offices

in service commnnd headquarters, and shared transportation on field trips.

It is not likely that any other officers of the headquarters group possessed as

much personal ki -)wle(lge of the general inedical activities of the command as

did the consultants. The relationship between the consultants themselves

and between them and tile service command surgeon was often intimate, to

the great advantage of all concerned. The following summary of comments

I% ('olonel Adams, of the Fourth Service ('ommand, provides a picture of how

tile mnedical, surgical, psychiatric, and orthiopedic consultants coordinated

activities among t hemuselves, with the officers of otiher headquarters divisions

and services, and with their chief, tile service command surgeon.

The consultants representing the four major specialties- -medicine, neuropsychiatry, surgery, and orthopedic surgery---coordinated their efforts closely

and worked in perfect harmony. Friction was nonexistent.. Whenever possible, two or more of themn ma(de trips together, reviewed their sections of tile

hospital separately, and coimipared notes in the evenings. As a general rude,

because of the inevitable interruption of work, hospital comnmanders rerarded

it as undesirable to have visits from more than three consultants at any one

time; most preferred riot more than two. By mutual agreement, whenever

one consultaint ol)served a situation that needed (correction within the sphere

of amotlher's activities, he always reported it to his confr~re. Such problems
SERVICI ('4 MMANI)DS 127

or deficiencies otherwise migh t have escaped attention b)ecause of infrequent

visits to a particular installation.

When two or more consultants visited an installation simultaneously,

they sometimes conducted joint clinics or teaching rounds or together studied

problem cases. It was hoped that such denionstrations with the free discussions that always occurred in the conferences would serve to promote similar

interservice joint consultations with free discussion and to discourage sole

reliance upon formal, written opinions.

Again, in the consultants' relationship with the officers of the other divisions and services in the surgeon's office, friendliness and close cooperation

were the rule. It was the policy of the Surgeon, Fourth Service Command,

that members of his staff returning from the field should report directly to

the appropriate officer any observed deficiencies that fell within the scope of

other divisions or branches. For example, if unsanitary conditions in a camp,

a mess, or elsewhere were encountered, the chief of preventive medicine

branch was notified. The discovery of any minor epidemics or threats of epidemics were similarly reported. Shortage of supplies or some special need. as

for an instrument, for example, was referred to tile chief of supply section.

This system of direct reporting led to the more prompt correction of unsatisfactory situations.

A close and friendly relationship existed between the consultants and the

officers in the Medical Personnel Branch, Military Personnel Division, Headquarters, Fourth Service (Command. In spite of this, the consultants were

often unable to advise the personnel officer regarding the assignment of medical officers as effectively as was desirable. The necessity for quick action

and the established policies of the Military Personnel Division made it impossible for the medical personnel officers consistently to obtain the advice of the

consultants when the latter were away from headquarters. A more generous

use of telephone would have resulted in more effective distribution of the

better trained officers within the command.

SERVICE COMMAND INSTALLATIONS OTHER THAN

STATION AND GENERAL HOSPITALS

The relationship of the medical consultant to nonhospital medical operations within his service command depended in large part upon the attitude

of the service command surgeon toward these installations and toward his

consultant and the interest (iisplayed by the consultant. Thus, in the Third

Service Command, Colonel Minor made no visits to induction centers, reception centers, replacement centers, dispensaries, or outpatient clinics, lie

pointed out in his report many weaknesses with regard to professional care

and professional personnel management that cou.d have been avoided or rectified by cooperative action of the service command surgeon, the surgeon of

the ground forces, and tile post surgeon.
12:8 AC'TIVITIES OF 'MEDICIAL COENSULTANTS

'Ihle following dletailed commtient u~pon thle subject ats it affects till service

c10i1ii11i(Is is lbasedl upon at rep)ort fronti C olonel Bauer, whose extra-lioslital

interests iiild activities were lively 1111( who sp~eaks front at fundl~ of e'xperienlce

anid knowledge of the consultant systent in the service commiands. The (liscuissioni includes tilie effects of impilroved(1 amlbulator.*v medical care of thle soldier

in trainling camps upon thle noneffective rate and1( the effect of proper professional p~ersonnel mlaniageim ent uipon tilie morale of Medlical Departmenet officers.

The service commnandI surgeons' policy affecting thle relat ionslhip of tilie

consultants to various service commnand installations governedl the consuilt.

ants' activities in tile inistaliat ions. Some service commnandl surgeonis -onlSidleredl tihe Supej~rvisioni of thle care of tilie sick thle consultants' sole function.

Others regardled tilie consultants as their professional representatives and

dlirectedl t heml to aidl in the( coordlinat ion of till medlical activities of thle service

conliiandl. Thle latter policy is at most (desirable one, lbut it caninot he realized

tint il thle requisite antitioritY is dlelegatedl to Thle Surgeon General and the service commiandl surgeons. When t his is granted, it will be possible for t hem,

with ti lie aid of their professional consultantts, to estalblish thle proper type of

integration of the Medical Department's activities ait aill Army- levels. Such

action will not only strengthen the 'Medical Department lbut also wvill really

cont rib~ute to military planning, training, and operation. If such a schemle

is ever effected, add~itional service commandl consultants will be nieeded to

suipervise and integrate properly the activities of the inistallat ions which are

considleredl in the following paragraphs.

Induction stations.-In at few of the service conimiandls, the consultanits

visited thle induct ion stat ions frequently. The deficiencies most often observedl were inadlequiate and poorly arranigedl quarters, wvorkloads too large for

thle doctors to handle efficiently, insuifficient social service investigation and

lpsycliologic examinmat ion, andl at pauicity of goodl neuropsychiat rists, comnpet en t

rad~iologists, and qualified specialists to serve as consultants. The medical

officers lacked the authority necessary for the proper execuition of their duties.

The most conmnon infringement was (dictation by line officers as to the nunmber of rejectees permiittedl in a given period. Matny certificates of dlisability

for dlischlarge, pensions, lost training days, and in uch Ihospit alizat ion were

(hirect] 'y at tribuitab~le to poor screening ait thle induction stations.

Reception centers. Many* of the induction station errors could have been

linearthled ait thle reception cenit ers if rescreening had been allowed. H owever,

se'para tion front the service or checking the work of ind~uct ion stat ionis at this

level was (eit her (hiscoilragedl or preven tedl. Neither sufficient t ine nor- persotnnel was allowed for tilie piroper classificat ion and assignment of thle mnen received. These import ant dlecisiomns were made onl the basis of quota, demnandls

and tlie iinduct ees (desire rat her than onl qunalificat ions and apt itudi(es (fig. 40).

Ill flitumre mnobilizat ions, reception ceniters shiouldl be charged withI a greater

respolisilbilitv ill thle classification ii n(l assignmiienit of mindtic(ees. Det ailed

reports pertaiining to iiiiproved select ion aii( job assignment, based onl excellent

Stumd ies, lire a vailiable.
h " 0 ti 1:1a Im I-- ilw 41 :Ii d .I 144 IS i 41441ifl 1-4-vm1 icil* - 1ia l d fo

Fw a;I 1il11c. Ihe In re1cit (dl ofvelileal' 4d1e(Ises it l,(eee lclll erste~ NN;Is i1(1l

-at iiatr. ~~ '['Il wwýe dile to ai lack()( f t he Ii&c' (!irV v failit jeS.

Replacement training centers. Thel( est a hlishliieit of psvhlial iecoisil

tat loll servIcesv! Hti tile l'ejlpeeilelltivia1115 ceilters was (0, Illilliellse vahle 'Ind

lereeJi('4'ite (' I-av;I11 ndva re III th lie 11 c1(1 preol "l.1-alIll of thle Air iv. Tie 1)1'! I c

l)5~ii~ill~s dv(i'lml~ll't ~lt( IIIoT-i illillvi( ivel *v thle role of vieallitjtiall1, preVeli-

(Ii f I iivs'1' j1), vcl Il I-I t CtlsllIT t ifill 1 cc , \\'~e IS- jillip)11 ilt(l lit tillies b clle~ se ()f hickt

Iftllita (.svtithlc-,1s '()tlllIl SeVI'ce w~orkers, lilt ei-viewers, and1( Stelmt 'Prtplit

Camp dispensary and outpatient services.-- lDir-ilg the trainili prid

lihe Sick soltl ler , va lInst, seen iiiI 111l*~ C 11"ieli)t.al, e1Z otw c.1ll1 d tispelis'ir-V

dfi-z. 4 1). Ini ret rosjnect, it is aJpparerilt Hant failu11re to organlize an1ditert

thle Iilet i w.i f"Iiil itles ;if ('IciI ('11111 ll ate It 1111 p055 lie to prlovide ' idequ at e

.1111lallk torv Illedical1 care. 'Iliere Is littlie to lbe ;iiel101 I leirt)-li exiosilion of tihe evils.,I iof htt (islpellsari-es, liilllislliiW" oilVl\ (Til1de Illeticilie i

ilost ilIStillces, epoimded liosjifial olilt I),lt iilt (leill1,rt ijilits. where thle l:Ia-ISlasei

lllt'(IicTII offhictiser, c ihi ould 4llt's hS as to it' caiul~d' o siiJtoillM ll .111(i 'Iilhhst (d, t11v

ilmsphl~il W-et' ivilirolH' O flllle iowhlri' roe'St-lt'titl wasi ho(t lperlillitet't.

. 1f I 7w #;I I1I
Will(, as .1 result too 111.1l1Y admiissionis were( allowedl andi~ 1111ilec('55;iiN hiospil1aizat loll. withi It-. at tend(Iilit evils. \\,as eliCOiii-agedl. The ilist ititioli of, all ideal

iii ip iiied ical service r-eqoj hirs 111,1t tlli- 1)0ot Sjlireoli lbe dleleg~ate col fril resipoiisilbility I fm thle IievilthI of* all soldliers oil thle post.

1,11ik first esselita i~l or. aul adlequhate callipj illedical1 plograll is a strolldi.,elst'1i5;i sei*',ICe. The( assistalnt 'hliel, of* thle sta~tioni liosplit1 aIiiieoicail ser'vice,

who( Also) serves as chief, of, thle cailiip (lisJpeisar.:v service. shiouldl t iereofore b~e aill

eielet i. e~l- i~iii ililiterl-Ist xvithI a workiii iolog fo ueeti

I),; vlc Ia. t r v. 0 11 ce te Ip )ro per 1.orn&IIIZlIiz I i ou 11s effe c ted. s Iper(kv vIs io 1 oI'f IIc (Isp1 cI II'aV 'voilol not requ iio'iire mon hat11 .5) p~ercenlt of' thle chief~s I ille. (Oi visit ing~

Ible li..;po'iislii not less I liat evv~ivY second~ daYi, l1ie shiouildh dlemonstraite bY ex\-

:1111pfle t hiat adhlerenice to t1( lieljSio' )I (wli of I' oooliidcl Jl;Ctic 1iC(Olilplislies I lie (lhsireol g-oal.

Uldi or-t ii nt eI ' te li Arm * v h'ile thol1 strless t hat the d islw'ilsa,1- rv sihieoll Is

ilie keY po'lso ii efec hutle lowest possible uiouieflect ive rate. D ispellsary,

shhgen lilutrelzeth ir llholialice to thle Arm , v, be vestedl withi I lie leceslSarI. va ut hon ilv, liii ye lrtre,1ou 1i 1st ii iiihie lpresshlile( bv comimuiand to liii m1v

"-1[ 11 sick~ calls, licceive suipport ;iuid shilli'lvisioli of t Iluii clilic.il act ivit jes. be.

uiCl iuoeo ill I lie fiiofe:-;.ioiimi a 1 n ocial act ivi ties of 1 t ielospi k t il-, ii sliaire

ill a1 just, ron at loll svSfvlill. fIl m.111 Ii'fst anrcesil M ii lari 11or 11, 1 hiesecouolit j110is
SERVICE CoMIANDS 1:1

were not met, and this explains the development of aniny bitter, disililisionled,

ineffective Inedical officers, who did more harn than good.

Because of assignment practices and notions concerning the prestige

and the relative importance of work done, there was a regrettaible and erroneousi

overevaluation of the hospital staff positions. This misinterpretation merits

special attention by responsible leaders in the Army Medical( Corps, since a

good dispensary physician is much more valuable than a hospital ward officer.

The scope of the physician 's activities is much wider and demands infinitely

more enterprise, social skill, and emotional and administrative adaptal)ility,

for lie is physician to a large group of men and the logical source of advice on

all matters pertaining to health and morale. Due to his position and special

vantage point, lie can do much to help line officers fulfill their obligations as

leaiders. There is literally nothing in the soldiers' lives which may not be of

(concern to command and hence to the ,dispensary surgeon who should be a

sensitive observer and an accurate tra nsmiitter of information to responsible

officers.

The dispensary service is the most strategic location for the management

of psychosomatic complaints. Therefore, it is important that the dispensary

surgeons appreciate that most of the soldiers seen oii sick call are suffering

either fronm relatively minor illnesses or from concern over personal health

and welfare. The majority of these patients can an1( should be treated on an

amnbulatory basis. On the one hand, if these individuals are returned from

the dispensary level without adequate examination, treatment, and reassuramnce, they will continue to worry about their health, will lose confidence in

the Medical Corps and become less effective in their assignments. On the

other hand, if they are unnecessarily referred to the consultation clinic or

needlessly hospitalized, they are very apt to assume that the dispensary surgeon is in doubt or that their symptoms indicate the presence of serious disease.

Such practices increase the neuropsvehiatric casualty rate and loss of training

days as well as make it evident to soldiers that disablilitv is an asset. Most

of them ask such questions as: "What have [ got?" "Will it get worse?"

"(''an I take a 20-mile hike?" Some semblance of an examination at this

time and an explanation as to the cause of tie symptoms, assurance, and

simple psychotherapy frequently are all that are needed. Fulfilling these

requisites keeps at a minimum the all too conimnon gripes: "He thinks I

imagine it." "He called me a 'gold-brick' ('screw-ball,' 'eight-ball')." "All

I ever get at the dispensary is the brush-off."

The dispensary surgeon's multitudinous and important duties prevent

him from personally undertaking detailed diagnostic studies. Therefore, he

must have access to a strong hospital outpatient clinic and good camp and

hospital psychiatric services. If the .onsultations are to be of maximum

benefit to the soldier, the dispensary surgeon inmst ma iniitan good liaison

with the people who provide them in the outlpatient clinic and should inform

them regarling the soldier in his Army environment. Sutch consultation

privilege must be used with discriminaition. It is extremely important that
1:12ACI TIE i l ( 1 t NtlTNr

lie l'('Spolissilbilit.% flo t lie pa1t ient rIii~laili pruuiipzilil*v Nvitl IIe t lt is-peiislnrv

SIIlrgt'Oi1 and1( t ! 21t 2111 p~ersonal31 prob~lem s be relereti-e back to I lie li~pelis-i IN

slr~'etiil I111(1 tilie st'elie or coniflict. 1isli3Iiv thle So)Ildier'1 1)131tooii COlij3 l

bait t3ilioli , or. reciileliit. III order to a1voidl Illilt-ceC553r liosjpilit izit ion. t here

lluist h~e Ildt'tptI3te fricilif les rl. ' So!hi('l'5 treated'( oil (fliil'ft'rs sf31 i s. liS)isjw531 i'is, propely(I'~ designa~ited 13 'll'3i t'ks. ori the (conlvaiIS'' t3lesen(t3111 I ie tisv IS

rot* t his purp)ose. RCcond~itioninig Shou11ld be iiiilde a1va113iabl for a1il1)1113t01'V

(Iispeliszi *.V pa t jetit ij'q ti1i ii ('is Sta31tus1 is not detsiraible tit' per~uiliitedl

wvere or greu at vaI ize to tilet d ispelisi IN sit i'geo)i IllII these clilnics, Soldi er's were

frI'l -1isliled with - odt pt'ofessit)1131 care1', 3ilid ilIIIeICVSS~IW hvlospitailizatio 101was

1 y.\en te('t . Ileele' v tss, of' tilie outat )1titIilt Serlv ice Ill Sta31on h~llospital1 s

Nv iIC oll r tilie blest iiitlexes- of' thle qi 131lit \ of' meica1l(3 car (' nere 1)t *''iIrt \I t lI I ('

hiospitalIs. Ill tilie liiitire, (t(li illiport'llit'e of' good out pat ient ('lillils Sholdoi bie

st I-e-sed~.

Tilie rullei( ollilig. or li't'ie c. i liSI)('dispensry Stervicet andt los-pital (liltpatjt'lit

1neicalhi Service. This f'it'i~taitt's th lit 'tion a otltf, 31111 ca liii Ilii'leicvl offlitctrs,

exceptjf f'oi ktey petrsoillit'l, thlroughi tilie dlsesi Wvs''nefo'31fe'o fio

miore than11 4 nilonlt is. Th'lis YI *ve of' duty , would a1t'(fi~llit thet lila1jor-it 'v o r

Iliedica31 offIicerls withI thlie iiiip l-otaill(' of' good a3libi~llaIolt-i ca3re ill I1.ii filt3illilpr

tilie lowe'st piossiblel( iititit'fttt i vt ratet . lReglihi r 1, Ot tatioln of' mied Iical of lit'trs

ret nloves t(le otitis of' discrimination1 anl d p111 l)1isllihil t, So rireylviieN. I * 1 5tis i t 't I

withI ilidlttel'Iinina~t( as3i5I&lilivltslt to tilie tlisJ)('ls'li'V St't'Vit't' elIIot'Il'3iirCS bettelr

Jpt'rfol'liiiit'e or (llltYv; a111( pvvi'iits grea:ter' jploft'55i01i31 deCve'lopment'I

Ti'le nuiiih1er. or, offiaer's asi-slged to .1 dispensary will de(pend1t uponl tilit

numiber of' Soltdiers servted. 11 two alr't retqufired't, 5t'let'tioll k11I(I ;IsSigjllelit

sh ouIld be so effecte thtat111t tilie r'3 11ki hg, Officer't is tilie Ii iore '11ittCItllyi13I.

A ('3ilii meica'lt'i 5('vI-\'t' SO Oi'glliizetl 3iflorsi't5 laiz illi 111 perfCo'liiaiict' 31i~ll

lffe t'vvle(' of ifs Ileici('lt3i rav(lit iC5, pr'ovitdes Ptproper pirevet'itvle iit'tli('ili',

and1( g"ivv 2i111 medIIical.1 offvr ii(ti' 31 gieatei' Sense5 ofre pl'SilIsibihi y withI keiener

p~ossible~ be'ttter' qilulifietl, Iiioi' eficienvit. 31( i~ldhppie'r Ilnedicail officers.

Ports of embarkation. ''lit' iiietlicvl ac(t ivitijes at( ports of' ('ii barkat 1(1

shliolld ha~ve beenll mor closely int-hlifedrI( withI t host' of t ile Serlvi(ce 'olIIi~iIid"&.

QtlVIt'Viv (coniian 111 5 u rt eonsl. Tllioungl iflit hiospi talts a11lwuys welcomeld tfnivil

uthere was1 too iii1c dl'iv(isiioni of 111 ltliiit v to ('1131 ie tile' ('o1nsultant s to lie of

113 illatilll uj) Iit to tilie por't Surtgeonis ill tile Solu tion of 111211]y I)I'tlei(his t hat

*1l'OSt'.

Separation centers.-- 'll(- process of Separaion ~ m iirrior'ed tilie inditl ltion

exam~ina11t ion Nvitl IIII31 its hand icaups (fig. 42). It was1 i'tuttilY ai~pparent tha miosIiit)
FicuRbF *12.-Separaitiori Center, Fort Dix, N.J., October 1944. A. A step in medical processin~g. B. LosI to t he Armyi, discharged soldiers on their waY home.
(I(~(4'lii ~4\ a ii i'I A ( t 'T Is V T (I I IF A I 14 :1 )fItI 1 I'-.\ (IN I I II N 1( S

I~~ehar,-ti h 1n fsital. Tf 4l i rz 114 Wallclf in Vtr lli II(. j~lI df-'I

b~II)' l4('e h-p44 11 lIaiispoile fir~el~ Ail),1 Co(V41S4'a'. 14\ V ' f114 V111( all. 1 klIml

I ~ ~I ~ ~ ill ~ 11441 n III 115 Il)lel141~( 
SERVICE COMMANI)S 1:)5

CONSULTANTS' EVALUATION OF THE CONSULTANT

SYSTEM

Sumnmaries of evaluations of the consultant system, its weaknesses and

strengths, its failures and accomplishnients, as formulated by a representative

sample of tile opinions of tile medical consultants to tile service commands

are herewith presented. Their statenients were prepared soon after V-J Day.

They were formulated in a spirit of thoughtful, constructive criticism by indivi(luals of great competence and of comnplete loyalty to the United States

Armny and its M\Iedical Department and also to the highest ideals of medicine.

First, are presented the views as generally expressed by Colonel Adaams,

mnedical consultant to the Fourth Service Command from Septeniber 1943 to

December 1945. His conmnients are sumninarized, as follows:

It is believed that tile consultant system as set up in the service commands

contributed definitely to the welfare of the patients. In anticipation of this

report, a questionnaire was sent to the chiefs of niedicine of every hospital in

this command. With one exception, the replies indicated that the consultants'

visits were helpful and stimulating but too infrequent.

The following is a sumiimnary of Colonel Adams' criticisms of the consultant

systeii as it operated (luring World War II:

1. In a large service command, such as the Fourth, one consultant in each

major branch was not enough. Each consultant should be able to visit an

installation at least once from every 3 to 4 months instead of from every 8 to 12

months. This arrangement couhil be accomplished by assigning assistant

consultants, who could be responsible for bedside visits and personiel evaluations ini a specified group of hiospitals. Then, the service conmmand consultant,

using tile information provided by his assistant, could cover the command

mnore rapidly and frequently, concentrate on trouble spots, and devote more

tine to teaching, personnel assignments, and general supervision.

2. The suggested plan of having the chief of service it, each large hospital

visit nearbv smaller stations was not practicable. The chief of service ini any

large installation usually has miore duties than lie can discharge adequately.

To send hini away for several days each month to visit other stations would

result in increasing the backlog of his own work.

3. To execute his mission properly, the consultant should have a grade

commensurate with his (duties and with his relative importance as an officer

of the Medical Department of the Army.

Next, a summary of the opinion of Colonel Denny, medical consultant to

the First Service Command from January 1944 to December 1945, is presented:

The uses and possibilities of the service command consultant can be

illustrated by a visit to the northern bases in Newfoundland, Labrador, Iceland, and Greenland made by the First Service Command consultants at the

request of the Eastern Defense Command. Most of the medical officers in

these isolated stations had been on such duty from 2 to 3 years without a
136 ACTIVITIES OF MEI)ICAL CONSULTANTS

visit from a medical officer who was primarily interested in the clinical work

being done. The hospitals were small and not active when visited in May

1945 and probably not much was accomplished professionally by the visit, but

the interest and gratitude of the medical officers was, in many instances, almost

pathetic. Phy'sical and professional isolation lowers medical interest and gemieral morale. Visits by consultants much earlier in the war would have been

of real value to these medical officers, almost all of whom were well-trained

and conscientious men who by reason of their isolation had come to feel that

no one in higher authority took any interest in their professional work. Given

sufficient authority consultants might well have been able to rotate such

officers before dry rot set in.

Colonel Fitz-Hugh, medical consultant to the Third Service Command

from May to December 1944, expressed primarily the following views in his

evaluation:

1. The medical consultant system as it operated during World War II

was fundamentally sound and necessary. Some of the difficulties and problems

inherent in it, were no doubt unavoidable; some could be corrected.

2. The autonomy of the service command and the necessity of going

through channels at times impaired the relationship of the service command

consultant to the chief consultant in the Surgeon General's Office. Higher

authority in the service command at times resented direct communication

between the service command consultant and the chief consultant in the

Surgeon General's Office. If possible, this conflict should be resolved.

3. The autonomy of the service command also made it difficult for an

overall adjustment of key personnel needs. The office of the chief consultant

in the Surgeon General's Office is the only qualified central authority possessing

the necessary knowledge of personnel qualifications and institutional needs.

Therefore, in the future, the authority and power of the central authority

shouhl he increased.

4. The service command consultants' concern with professional personnel

should be more effectively implemented. The consultants should, through the

office of the chief consultant in the Surgeon General's Office, be given more

real authority over assignment, transfer, and reassignment of professional

l)ersonnel. If this authority is considered unwise, then the consultants should

l)e instructed to keep out of personnel problems and to confine themselves to

the task of trying to improve the personnel of each installation as they find it.

5. The selection of consultants in the recent war was generally well done.

In the opinion of this consultant, the service command consultants should

always be men who are fully qualified and have proven themselves adequate

as consultants and teachers in civilian life. The outstanding qualities of

General Morgan were tio doubt responsible for much of the best that came

out of the consultant system in this war. All consultants should not only be

good enough to rank as full colonels but should have this rank. If an inflation

of grade occurs in the next war, then the consultants' grade should also be

comparably inflated.
SEIRVICE: COMMANDS 137

6. Finally, the Medical Corps of the Army, in general, was undergraded

and( promotions were too slow and too few. Improvement in this important

aspect of militarv service would result in much better morale.

Colonel Minor, medical consultant to tile Third Service Command from

December 1944 to December 1945, summarized his opinion of the consultant

system, generally, as follows:

The medical consultant service was an important addition to the NMedical

Department and served very well the functions for which it was planned.

These functions were (1) to assist in establishing and maintaining professional

staffs as well qualified and as stable as possible in hospitals an(l other installations; (2) to oversee the general picture of medical professional care in the

command me(lical installations, to keep the staffs informed of recent advances,

and to bring the practice of medicine to as high a level as possible; and (3) to

furnish consultation of professional and often personal nature for the medical

officers, develop educational programs, stimulate special study projects, and

minister in these important ways to the total professional morale of the medical

officers.

A corollary to these functions was, of course, the maintaining of close

relationship with the surgeon, by making suggestions and preparing directives

about professional matters for his signature. An additional function was the

correlation of activities withi the surgical and neuropsychiatric consultants.

The consultant functioned to a very large degree on a personal basis because duties of the position, while of evident importance, were not officially

integrated into the preexisting planning for the Medical Department. The

consultant's activity, therefore, and his ability to accomplish his objectives

depended first on his relationship to the surgeon and the amount of confidence

and respect he earned from his direct superior and, secondly, on the same

factors in tihe commanding officers and the key professional officers of the

hospitals with whom he worked. In other words, it was necessary for the

consultant to sell himselfi as a useful and competent individual with something

to offer before lie co(hl0 function effectively, there being no recognized or

official status for his job. As a result, success in accomplishing his mission

was largely dependent on developing such relationships.

It was Colonel Minor's opinion that the quality and amount of interest

taken by the service command surgeon in the professional matters that were

the prime concern of the medical consultants was a determining factor in tile

effectiveness of the consultant system. The consultant was clearly responsible

to the service command (through the surgeon) and had only an associated

relationship with the Surgeon General's Office. All administrative power was

placed in the hands of the service command headquarters; that is, in the hands

of the commanding general. It was therefore necessary to sell one's wares to

the commanding general directly, when possible, or indirectly through the

surgeon or other officers. In this command, the policy of complete control of

all installations on a post by the commanding officer of the post raised many

serious diffieulties in the allocation and shifting of medical personnel. All the
138 ACTIVITIES OF MEDICAL C'ONSULTANTS

methods that could be used by the consultants to bring about needed changes

sometimes failed to overcome the opposition or passive resistance of the comnmander of a post, who might l)e an infantry officer with no knowledge and

little interest in the real medical prol)lems at hand. Similar difficulty was

occasionally encounteredl with medical officers commanlinig hospitlls, b)ut in

large part these officers were cooperative. A point of view not infrequently

encountered was that one me(lical officer wits the same as another, and this

without regar(I to special professional training or ability. This viewpoint

might be called thc( "'doctrine of the body.'" However, as time passed, there

developed realization among even the most reactionary medical officers that

spe(ial men were required for special jobs.

The most effective portion of Colonel NMinor's work was visiting the hospitals in the service conmmn(Is. It was necessary at the start to make clear

that these visits were not inspections in the usual Army sense. When the

professional staff realized that tile consultant was intereste(I primarily in good

work, in the a(lwvalcement of competent men and their proper assignment.

and also sincerely interested in their personal problems, little opposition or

resentment was encountered. The more time spent in visiting, the more effective was the consultant. With rare exceptions, the consultant was made

welcome and was able to establish satisfactory liaison with the various officers,

administrative anId professionll, who operated the post.

The promotion of educational activities and the holding of formal and

informal discussions with members of the staffs to consider professional problems of importance furnished an opportunity for free interchange of ideas,

which was mu t ually beneficial.

Ward lounds were of great importance from three standpoints: (1) They

afforded the best opportunity for the consultant to evaluate and to know the

officers on a service; (2) they provided an overall view of the management of

patients and of diseases, as for example, diatbetes, rheumatic fever, hepatitis,

syphilis, gonorrhea, arthritis, pleurisy, and others; and (3) they made possible

a review of problem cases by the consultant, which was an interesting and

instructive exercise and often contributed directly to improved management

of the case at hand.

In the preparation of reports of visits, an effort was made to give a general

picture of the operation of the hospital from a professional angle; to evaluate

with fairness and frankness the various officers; to describe important professional problems and the methods by which they were handled; to nmke

recommendiations as to the proper classification of officers by MOS numbers;

and to reconmmend promotions when deserved.

The relationship of the medical consultant to the Surgeon General's

Office was as close as was permitted by the organization described. It was,

of necessity, largely on a personal biasis, its the Surgeon General's Office was

unable to implement its plans with regard to personnel or method without the

consent of the service commannd. In the case of the Third Service C(ommand,

nearness to the Surgeon General's Office and the warm personad relationship
SERVICI' ('COMMANDS 1:39

existing between the officers there and all the service command consultants

made possible tle solution of" many personnel probflems. Also, questions of

policy and procedure were readily ironed out by means of this direct, personal

contact.

The medical consultant service in the Third Service Command earned its

way and proved itself a most valuable addition to the organization of the

.Medical Department. In the long view and from the standpoint of promotion

of the best in medicine, it call only 1be called an essential element to the proper

functioning of the lMedical Department. In spite of frustrations, difficulties

in administration, and the reliance on personal relationships to achieve ends

that could be attained only in that way under the existing system, tile medical

Consultant plan achieved important success alnd was of great benefit to the

practice of medicine in the command and to the development and proper use

of professional personnel.

Colonel Marble, medical consultant to the Sixth Service Command from

March to September 1945 made, generally, the following ob)servations:

1. There is no doubt, that the consultant system is worthwhile. It

is imperative, particularly d(uring tinmes of expansion of the Army, that medical

officers with the necessary professional qualifications be assigned to service

command headquarters to advise the service command surgeon on professional

matters and, by visits to medical installations throughout the command and by

other contacts with medical officers, to promote and maintain high standards

of professional care.

2. It is desirable that the position of the consultant in the service command

headquarters and throughout the service command be clarified so that administrative difficulties may be avoided and the carrying out of professional policies

expedited.

3. Some plan should be worked out whereby free and informal contact

by the consultant with higher authority (Medical Consultants Division,

OTSG) and medical officers throughout the service command may be possible

on purely professional matters, without arousing concern that administrative

channels have been bypassed.

4. One of the greatest fields of usefulness of the consultant is in his advice

to the service command surgeon and the headquarters personnel officer regarding the proper placement of medical officers. By his personal professional

contacts, the consultant after a period of time comes to know the professional

qualifications of medical officers and the professional needs of various installations in the service command better than any other officer on the staff.

5. The next greatest field of service of the consultant lies in the teaching

and professional encouragement of medical officers by frequent and prolonged

visits to hospitals and other medical installations.

Colonel McGuire, medical consultant to time Fifth Service Command

from July 1944 to December 1945 summarized his endeavors, in general, as

follows:

1. To be of assistance to the service command surgeon and the chief
140 ACTIVITIES OF MEDICAL CONSULTANTS

consultant in medicine in the Surgeon General's Office by keeping b)oth constantl* infornied of professional and personnel problems on the medical services

of tihe general and station hospitals.

2. To be of assistance to the chiefs of the medical and hal)oratory services

of service command hospitals by: (1) Presenting their personnel problems

to the attention of the service coflinland surgeon; (2) conducting teaching

ward rounds and attempting to stimulate the section chiefs and ward officers

to carry on their professional duties ati the highest possible level; (3) stimulating clinical research; (4) encouraging scientific meetings of high quality;

(5) reconmmn(ling transfer of mediocre medical officers; (6) recommending

changes to improve physical location and administrative procedures of medical

libraries; and (7) obtaining clarification of confusing administrative procedures for chiefs of medical service from the service conminand surgeon and the

Surgeon General's Office.

Colonel McGuire stated further that, if the consultant system should

be needed in the future, a clearer definition of the consultant's responsibility

to the service command surgeon as compared with his responsibility to the

chief consultant in medicine in the Surgeon General's Office, would be of value.

In the Fifth Service Command, no problem arose, since there was perfect,

cooperation between the service command surgeon, the chief medical consultant, and the service command consultant. However, it may vbe difficult

to serve two masters, and, unless the consultant's fundamental responsibility

be more precisely defined, it is clear that on occasion his position will be

ambiguous.

To prevent misinterpretation of the function of a professional consultant

and to avoid being regarded as an inspector, the professional aspects of the

consultant's function should be emphasized and the administrative aspects

minimized. However, since the best available personnel are essential to the

maintenance of the highest professional standards, it was the opinion of this

medical consultant that assignment of key personnel to the medical services

of hospitals should be made only on the recommendation of the service command

consultant.

Finally, in a summary and critique prepared in 1945, Colonel Bauer,

medical consultant. to the Eighth Service Command front August 1942 to

August 1945, presented the views expressed in the following paragraphs.

Regardless of the accomplishments or shortcomings of individual consultants, there can be little (doub)t that the consultant system has favorably

influenced the medical service of the Army and therefore should be included

in its permanent organization. It has served particularly to focus attention

on the primary importance ot the professional aspect of military medicine.

The problem now [1945] is not so much the future of the consultant svstenm

its what to do about the future medical service of tile Arm*y. The high standards of professional care attained in this war must be maintaiined and advanced.

The way must b)e opened for capable and ambitious young officers to progress

in their profession. Postgraduate opportunities must be iimahde available to a
SERVICE COMMANDS 141

sufficient number of officers of the \fedical Corps to furnish the Army a group

of qualified specialists ili the various branches. These men should receive

recognition in the form of rank and pay commensurate with their eminence

in their profession and the weight of the duties that they will be required to

perform.

The benefits of the experience gained by the group of men who have acted

in the capacity of consultants in the service commands during this war should

not be lost to the Army. Through this experience, they have acquired an

insight into the practical workings of the Army Medical ('orps. This, joinied

with their professional knowledge in various special fields, fits theni for the task

of evaluating the future needs of tile niedical service of the Army.

Colonel Bauer made the following recommendat ions: '

1. That the Medical Department be represented on the Army staff at

the departmental level instead of being relegated to a subordinate position such

as was the case in the Services of Supply and Army Service Forces reorganizations during World War II. This representation of the Medical Department

at the highest level will provide better opportunity for the integration of medical activities throughout the Army and restore to the Medical Department more

prestige and autonomy. It is hoped that the changes in staff organization at

all levels implicit in this recognition of the responsibility of the Medical Departnment will permit it to make a greater contribution to all military planning,

training, and operations.

2. That the Medical Department formally recognize different career

patterns for medical officers who are primarily interested in staff and comnimand

functions from those who are primarily interested in the professional practice

of medicine or in research and provide appropriate training, assignments, and

rewards to each group.

3. That the consultant system, as evolved during the present conflict, be

retained and extended.

9 The original recommendations made by Dr. Bauer were revised in a letter from I)r. Bauer to Cot.l. B. Coates, Jr.,

MC, Director, The Historical Unit, U.S. Army Medical Service, 9 Nov. 195-1. and a letter from Col. Coates to Dr. Bauer,

19 Nov. 1956.
CHAPTER III

Mediterranean (Formerly North African)

Theater of Operations

Perrin H. Long, IL.D.

FUNCTION AND DUTIES OF A MEDICAL CONSULTANT IN

AN OVERSEA THEATER OF OPERATIONS

The advent of World War II found the M edical Department of the U.S

Army without a professional consultant group in either medicine or surgery.

From the middle of 1940 until shortly after the entry of tile United States into

the wair, an attempt was made to overcome this deficiency by the establishment.

of liaison, in strictly professional matters, between the various newly created

advisory committees of the Division of Medical Sciences, National Research

Council, and the Professional Service Division, Office of the Surgeon General.

Between the end of World War I and 1925, when the Professional -Service

Division was formally established, the activities normally carried out by such

a division had been performed by various professional offices or divisions of the

Office of the Surgeon General.

Even after the Professional Service Division was set up in 1925, its scope

had been limited and its functions poorly defined. It had been concerned

chiefly with routine administrative matters, and its influence as a positive force

in developing and guiding the professional aspects of medicine and surgery in

the Army id(1 been negligible.

As at consequence, when consulting services were established in World

War 1I in the Office of the Surgeon General an(! in the service coommands and

the theaters of operations, a certain amount of education was necessary on both

sides. ('ommand and staff officers of the Medical Corps of the Regular Army,

whose work, in the emergency, was necessarily chiefly adlministrative, had to

learn the functions and the potential value of consultants in the maintenance

of professional standards. For their part, the consultants, most of whom had

been commissioned from civilian life, had to learn the complexities of their

position in the Army and the extreme importance of what might be termed the

administ rative background of military mie(icine.

It was not until both the consultants and the Regular Army medical

officers had learned-usually by trial and error-to define and comprehend

their individual and joint responsibilities that the consultant system achieved

real efficiency. Much time and effort would have been saved in World War II

if a consultant group had been iiaintained in the Office of the Surgeon General

between the two World Wars. It would also have been helpful if, before any

consultants had been appointed, the nature of their duties had been clearly

143
144 ACTIVITIES OF MEDICAL CONSULTANTS

established in an official publication. For those who were fortunate enough to

see it-and aniny were not-tihe first official notice of the c'onsultant's fUnctions was contained in T.Ml (War Department Technical Manual) 12-406,

Officer ('lassification, Commissioned and Warrant, dated 30 October 1943.

In this manual, under MIOS (Military Ocupational Specialty) 3117, the duties

of a consultant are summedt up in the following paragraph:

Renders special professional advice to various headquarters concerning the medical

service within the command. Visits various medical installations and ladvises the staff of

their medical services as to methods of diagnosis, treatment, and operations, with special

reference to professional improvements and new developments; conducts clinical-pathological

conferences on umnsual cases; reviews professional aspects of work of medical services; develops methods for training junior me(lical officers; adIvises superior officer concerning professional policy on matters pertaining to the practice of internal medicine within the command; transmits professional information and suggestions between subordinate installations

and higher echelons.

In the North African and Mediterranean theaters, the medical section,

which was a component of AFHQ (Allied Force Headquarters) was always

maintained at the theater level. This gave the Surgeon direct access to the

theater commander, tile chief of staff, and tile chiefs of tile general and special

stalff sections; and it facilitated tile Surgeon's entrance into all subordinate coinman(1 s in the theater. Tile consultants division of the Medlical Section, AFHQ,

was enabled to coordinate the professional aspects of medicine and surgery in

the various echelons of t lie conmmand more easily than would have been possible

had the medical section been placed at ttile level of the communications zone

or the services of supply. As a result of this system, advice on all technical

subjects emanated from the highest level in the theater; the various consultants

rarely experiencedi any difficulty in entering subordinate echelons such as the

field army, tile air forces, or the communications zone; and coordination and

correlation of technical subjects between these commands were made relatively

The need for consultants in the professional fields of medicine and surgery

was amply demuonstrated during World War II. The establishment of a consultants division in the medical sections in oversea theaters of operations freed

the Surgeon and his staff officers from perplexities arising in the practice of

medicine and surgery and provided the Surgeon with expert advice concerning

tie care of the sick and wounded. It also provided him with a channel for

ascertaining, and putting to the best, use, the professional talents of non-Regular

Arniy medical officers. At their peak employment, these officers composed

approximately 98 percent of the Medical Corps of the Army.

Professional Functions

Advisory functions.--The functions and duties of a medical consultant

are many and varied and in practice are much broader than outlined in TMI

12-406. In the first place, the consultant should always remember that lie is in

an advisory capacity, and that, unless lie is directed to do so by the theater
MEDIITERRTANEAN THEATrER 14.5

Surgeonl, lie Wvill be ait, falult if lie (lescends to Operaitionail levels. HIis prime (mt , X

is to keep) thle Surgeon constantly and( accuraltelY iiiforiiied of tilie standards

of professional (-tre obtainling inl tile (-tre of the sick. Thiis service cannot be

rendleredl 1) sitting ait ai desk inl lieanl(Iuarters. The conisultanit mu tst sJpeiid ati

lealst two-t i irdls of ins t iine in) tilie field, ob)ser'ving and~ sitidying iiiedicill cai'e ait

aill levels, froiii tile aild stlutions t I-lirogl tilie generaIl liospil als. Ilie sliOil~ld be

famniliar. Willi tilie tacticall and oth~er condiitions othat affect tilie dia~gnosis andi

treat ii en t of (lisviase andl governfi lie evalcui t iou a iid d isposi Iioi i of pat ienits in ll .1

eclielotis of tilie conin Iiaiid To accoliiiplisli this mnission , tile consulti ant litlist.

hlave eatsy, access to till iI e( licall i list 111l11 t ionls, and1( lie sh~ould be regarded als at

friend anld adlvisor to tilie Surgeon iinll Iliedicuil officers of aill couilinaiids. ft.

sliould be well und~erstood t hat tilie conlsiltialit '5 ainai intecrest is imiiprovelinent

inl hie care of tlie sick, inl ordler ti hat patients may1' be ret urtied promlptl *vto (duty.

The consultant shiould niever assumne tilie funuct ions of, or be regairded ats, anl

inspector.

Administration of professional personnel.- The second~ imiiport ant function

of thle Iliedlicul conlsultamlit. is to aIlvise thle Surgeon upon lpersoiinel chianlges thalt

111iav be niecessarly to insure a highi level of professional efficiency. The Surgeon.

als at rule, hals niot had the training, nor has lie had thle timue, to evailualte mnedical

p~ersonnel. lie in uist halve conlfidenice inl thle recoiiindieilt ions mnade by* his

lliedlical consultanit an1d should (10 hlis uill nost to support theml eveni thloughl,

ait I imes, reluictanlt comiiliiaiilling officers hatve to be broughit into line. Otherwise, it w~ould be b~est for the consultant to ask to be relievedl of hlis dutties, so

essential is this funiction to his usefulness. For hiis part, thle mledicall conisultilant

muist have accurate knlowledge of the professional capabilities of aill niedical

officers dhirectly conicernedh wit Ii the care of thle sick. fie shiould halve understilidilhiig, ats well, of officers' personailities anil reactions to their enivironnment..

Anl indhividlual Iliia*v (10 lbetter work if shifted from at particulair situat ion to onie

to whichl lie is better adapted. Again, at family prob~lemiiiniav lower efficiency

and1( call somietimies be solved or amieliorated by jud~iciouis recomnivienlat ion of

leave, rotat ion, temiporary (duty, compassionate leave, and otlier (devices.

The consultant inl niedichin sliouldl interest hliiniself inl thle welfar'e of thle mnedicall

officers, gelieral duty, NIOS :3100, because thlese aire hie forgottel n enl of tilie

Medical Corps, till([ it is fromi t his group that niany of the wardl officers onl thle

mfedhical services wvill ultiniately be dlerivedl. Finally, it is the duty of the consutilt at inl niedicinle to (direct thle Surgeonl's at tent ion to nieritorious or outstianding services rendered by miedhical officers.

Professional education.--Thie consul tant in niedicine sliouild be thle leader

inl mlithit iiig anld guiding professiomial educational progranis for thle miedical

officers unider his advisory supervisioii. Thirough thle mlediumll of clearly

writ teii circular let telrs fromi lie Office of thle Surgeon, he should keep tihenli

comistalitly advised concerning iiedhicail experienice wit liim the command and

coiicernii ig new dlevelopmiien ts ill sciemi t hr lilld clinical uiicd icilie ill tilie Zoiie

of Int erior. fie shiould see tihat mnedical officers r'eceive aill tilie textbIooks allidl
146 ACTIVITIES OF MEI)I(AL CO)NSI'LTANTS

me(lical journals to which they are entitled, and if he thinks a(lditional publihat ions wouhl broaden their intellectual horizons, he should make the necessary

recommendations to the Surgeon. W1hen conditions permit, the consultant

should assist in establishing a medical periodical, in which local experiences

in the prevention, diagnosis, clinical course, treatment, and other aspects of

(disease are recorded, for circulation to all medical officers within the command.

It is his (luty to initiate staff conferences, clinicopathological and X-ray conferences, journal clubs, and other educational programs within hospital installations. He should recomnmen( and assist in tile formation of mnedical societies

in the lower echelons and should see that medical meetings are held in which

medical officers from all echelons of the command participate. The consultant

in medicine, being generally himself a teacher in civilian life, should always

revert to this capacity when making ward rounds in any medical instalhltions.

He should plan and initiate a program through which medical officers assigned

to field service or nonprofessional duties could be rotated to hospital assignmnents, in order to prevent the professional deterioration that frequently follows

too long an absence from professional duties.

Medical research.-Research, having for its aim the better understanding

of medical problems and the more efficient care of the sick within the command,

should be fostered by the medical consultant. He should not be discouraged

if his first. efforts in this direction are rebuffed by administrative or commanding

officers with tihe reminder "there is a war on" and the assertion "there is no time

for research." In reply, the consultant should outline the problem clearly and

show how, with the resources available within the command, knowledge might

be obtained that would benefit the health of the command and save manpower.

He should encourage and assist medical officers who have initiated research

problems on their own. He should critically correlate and coordinate the

various problems in order that the work may progress in an efficient manner.

When results are obtained, he should see to it that they are made available to

the command and also to the Office of the Surgeon General for wider dissemination. In promoting research within a command, the consultant in medicine

should endeavor to secure for it adequate personnel, supplies and equipment.

Finally, if the problem appears to warrant extramural aid, he should recommend

to the Surgeon that investigators selected by The Surgeon General be sent

into the command.

Care of prisoners of war.-The medical care of prisoners of war should be

carefully supervised by the consultant in medicine. It is his duty to report

to the Surgeon upon the expected needs for professional services in prisonerof-war compounds and to recommend what should be done to insure an adequate

level of medical service among prisoners of war. He should visit, such installations and should supervise and advise upon care of the enemy sick. If

tile latter are under the care of their own medical officers, he should informim

these officers of the prevailing theater policies on the treatment of disease and

should instruct, them in the use of U.S. Army medical supplies. At all times,

the consultant in medicine should be on tile lookout for violations of the Geneva
MEl ITEIRRIANEAN TrIIEATER 147

conventions in respect to protected enemy personnel, and, if such are noted.

lie shotild make strong recommendations to tile Surgeon in respect to their

correction.

Liaison and Staff Functions

Hospitalization and evacuation.- It is sometimes assumed that the

consultant inn medicine has little or nothing to contribute to the operational

side of the Medical Department. Oin the contrary, lie can offer valuable aid

in estimating bed needs, based upon his knowledge of the prevalence of and

average duration of hospitalization for current diseases. His opinion is

also of value in respect to the ability of any given medical installation to

handle overloads of patients. His advice on the triage of sick patients and their

assignment to suitable medical installations will be useful to every operations

officer. It should be the consultant's function to recommend to the Surgeon

the creation of special centers to facilitate and improve treatment. He should

also recommend to the Surgeon a plan for the evacuation and disposition of the

sick that will meet existing needs and one that will insure uniformity in procedure thoughout the command. In the course of actual tactical operations,

the consultant in medicine can frequently be of aid to the task force surgeon,

by recommending holding policies for the sick. Often through his efforts and

influence, a considerable saving in manpower can be effected.

Medical laboratories.-Although laboratory services are under the direction of the preventive medicine service, the consultant in medicine should be

cognizant of the functioning of laboratories in all of the medical installations

under his supervision. He should carefully check the diagnostic methods being

used and the accuracy of the results obtained. If lie believes a laboratory

service could be improved, lie should communicate his views to the preventive

medicine officer in the medical section of the headquarters and request the

necessary action. The consultant should also ascertain the extent to which

the ward officers on medical services rely upon laboratory tests, rather than

upon clinical ability in making a diagnosis. If lie thinks an excessive amount

of laboratory work is being requested, lie should recomnmend proper corrective

measures to the chief of the medical service.

Medical supply.-Problemns of medical supplies should rarely be the concern

of a medical consultant in the U.S. Army. To be sure, local shortages may

develop, but, these often can be corrected by dropping a friendly word to the

officers in charge of me(lical supplies. The consultant's greatest concern should

be the requests made by medical officers for nonstandard supplies, which they

have b)een accustomed to using in civilian practice. It is his duty to instruct

mledical officers in the use of those preparations found on the Armed Forces

supply table. He should constantly keep abreast of all therapeutic advances

and miiake appropriate recommendations to keep the supply table uip to date.

In addition, he should make all recoitinendations concerning tihe acquisition

of nonstandard items that are deenied necessary for the proper prosecution of

clinicual inviestiglt ions.
148 ACTlVITl1>s 01F MEDICiAL NSL X'S

Interpersonal relations with the headquarters staff.- Tile conisultatnt inl

liQlleiciiie siOilud nlot let l1imuseif becomie the liead(lq art ers st afi or generals'

d1octor'. fle Sliouil( refraini fromi givinig Iiiedcall aldvice or aitteit ionl to lIns

fellow~ staiff officers tailess requlested to (10 so bY thle Siurgeonl or by tilie chlief of

mledicinle of tile genlerall dispensary a tt Iiis lieadquariters. F~irst , if hie practices

med icine tit lieamlquitarters, lie will ft 11( it nlext to uimpossible nlot to disculss

quiestioiis inivolvinig ined ical Policy wit i, membi ers of oth~er staffs; suici (i iscussiolis siiluld b e left to tlie Siurgeon or Ii is (lesigraiat e represel t atti yes. Seconidly,

Ii is proper work will lbe ('onstaint l interrupjted, land hlis t rips alwiy frorul lieaIqulail cr5 curt ailed. ft. shlould be thle policy'N of tOlie conlsultanlt ill iiied icinle to

refer, politely anld inl it llelpfllfiilluanner, aill questions relattinig to miedlicil treaitmienlt of staff officers, to thlose, wiose (luty it is to pracetice mledicinle ait at

Staff work.-'Tlie consuiltant inl medicine sliould become versed in stalff

wvork ais rapidly ats p)ossible. Hle shiould nlever forget thalt lie fuinlctionls ill anl

adtvisor" capv*ty. He shiould learn t he p~roper channels for commiurmica ion),

should aivoi(I going out, of chianniels, anld refraini fromu anyi activities t hutt mighit

creatte tilie imilressiori lie is goinig over ti( lelhed of the Suirgeoni. Staff work is

niot, too dhifhicult if one renmemnbers thiat every' patper shlould be coordinatted

witl hiall interestedl parties wit hin 1111( wit hiou t the office of tile suirgeoni of tilie

hiend(llmtrt ers before it is paissed onl by* thle Surgeonl. It, is ailso less difficuilt if

one( remiembi ers, tfuhat ,as at principle, est alblishied chianetlsck aire the most effective.

A properly coordinalted stiff papelr is rar11ely ttiruiedl downl, if only becaulse it

fias beeni lgreedl to iW av tllcolileemiedl before it is presen ted. The consilt ant inl

uIiedlicinle shoul1d be tin constant cominunicationm wit ii the otlher contsultaints, the(

p~revenitive niedicinie officer, tilie suipply' officer, tilie personmiel officer, an1d, for

hialt maitter, witl hiall othler mnemibers of his sectioni. Close liatison withi ot her

('0115111tan ts is especiailly desiralble beca use in mattters of broad professional

policy at unlitedl fronti is genterailly irresistible. If thie consultant inl niedichie is

funictilonlI ig inl ant allied force, lie shiould coordiniate hiis professionail wvork withi

hiis opposite aillied nunihber antil shiould take every opportunity to visit thle

niedicall inlstatllation~s of thle ailly' . At. the samie timue, lie siould matke certain

hamt similair privileges tire extendedl to hiis allied colleague.

Visits in the fleld.-Whien thle conisutiunit inl iiedicine is visiting any

Iliedlicill iistalliat ionl, lie shioudd visit tmi alppropriatte cross sect ionl of thle p)a1ltetits

ol tilie miedical service iii coniftiiiv wit Ii thle chiief of thle medicail ser-vice. Dill'-

ing suichi visits, lie sliould chieck onl thle prevallencee of varliouls disealses, (fliagilost iv

iiet hiods, tlhieralpetitic measuires, tilie conidit ionl of Patienits, 1111(1 the policies inl

force regn-iirnlg dispositiont of pattients. It. is liere, too, thiat lie can (d0 [)is

b~est. teachfimig- -at thle bedside of thle paitienit.

The( (oiisiiltuant ili medicinie shiould remnemiber to observe miilittary courtesy

eachl tihme he visits at sulbordiliatto eclielomi. After reportinig to tilie office of tilie

suirgeon of (t( lie iit hie is visit ing, tilie -otisuilt a lit shiolid ('1111 uiJoni tlie( colin11111 tdi( irg officer of tile echieloii or Ii is designiiated represerlitat~i ye 1and explalinl inl

geiiendiflay13 t ermis tile lpuirpose of Ii is visit . Thiis Jproceduir'e shitotild be repenited
3EIl)ITERRANEAN TTIEATER 149

Fi(;URE 44.-Col. Perrin H. Long, MC, Chief Consultant in Medicine, Medical Section,

AFHQ, MTOUSA (formerly NATOUSA).

when the medical consultant leaves the comninand. Common courtesy demands

that lie inform the comninanding officer of the observations and conclusions

made during the tour. When medical installations are visited, the commanding

officer or his representative should be seen first and the purpose of the visit

should be explained. At the termination of his visit, the medical consultant

should discuss with the commanding officer those points, both good and bad,

that have been noted. This permits the commanding officer to take such corrective action as may be necessary. It obviates filling out long reports, since

iio furt her action need be taken, unless the commanding officer is either unwillimg or unale to act upon the recommendations of the consultant. Finally,

it is important to relnemnber that the consultant in medicine should allow

other consultants, the chiefs of medicine, and the officers working on the

medical services a considerable degree of latitude in the performance of their

duties, provided they stay within the bounds of the established prin.,iples of

the practice of inedicine. It is only by doing so that the spirit of mutual

esteeli, which is so necessary for the maintenaice of high standards of medical

service, can be preserved.

Assignment and Arrival

On 20 November 1942, the Deputy Surgeon, AFHQ, informed Lt. Col.

(kiter Col.) Perrin i1. Long, MC, who at that time was the Scientific Liaison
1.50 ACTIVITIES OF MED)ICAL CONSULTANTS

Officer, Oflice oft the Chief Surgeon, ETOUSA (Etiropean Theat er of Opera tions,

U.S .A tiyhat, hie had put inl at request to thle Chiief Stirgeoli, i'YIN)SA, for

tlie services of Colonel Long ats conisultanit iii mledlicinte (fig. 44) for thle Amiericaln lbraiichi of thle Medical Sect ion, AFH1Q. Tnis requnest wits ref isedl bY the

Chief Surgeon, ETOUSA, but onl 14 lDecemiber 1942 thle following radiogramn

Wats reeve "'C inl C (directs tblit Perrin Long Lt. Col., MC, ET()SOS be

relie vedl fromi present assignmient and dispatedied bY first availalble tranlsport ation and~ assigiied to AFHIQ.' 1His niew assignliient wits dhirectedl by it letter

ordler (littedl 17 Decemb er 1942, andI passage was- secuiredl for himti ill coiivov

K. N .S., .5, sailing fromi Glasgow, 26 Decembher 1942, and arr-1ivinlg inl Aklgiers

on :3 .Jantim*-Y 1943. Reportinig to All IQ and being assigned to thle medical

sect ion, b)*y the a i1tt ority' cont ainied inl paragraph 5, Special Orders No. 3,

AFI IQ, :3 .Januatry 194:3, lie iminiiediattely assumied his dutties its consultant ili

iiiedicilie.

ORG ANIZATION

Allied Force Headlquarters wats thle comnbined Alliedi command for all

op~erat ions inl thle Not-tit African t heat er anld 'tile later M edit erranleanl theat er

(matp 2). NAT()USA (Northi African Thieat er of Operat ions, U.S. Arnivl)

an1d MTOUSA (Mediterranean Theater of Operations, U.S. Arnmy) staiff

sections suplervisedl strictly U'.S. Arniv op~eraitions withliin tilie t heat er. Operationial and1( tactical control remiainedl w~ithI AFHIQ. Thlis control was exercisedi

hirouigh various task forces, British Armiy Groups, tite Seventh U.S. At-liy

and latter thle Fi fthI U.S. Army inl Itaily.

At, its incept ion ats at functioning unlit withinl thle theater, thle Medical

Sect ion, AFll Q, wats at compiJletely integrated1 special staff sect ion because, in tilie

early days (tint il June 1944), British andl~ Amiericatn Interests wVere interlockinig

ats r~egalr's both Ii tatics 1111(1 logistit's. Ani officer of thle Brit ishi Army Medical

Service (not tilie Royal Armty Medhical Corps) wats IDirect~or of Medical Services

and C hief Surgeon, AF'IIQ. The Depuity Surgeon, AFIIQ, wats at U.S. Army

medical officer. Wit hin thle MIedical Section, AFIlIQ, Brit ishi and Amierican

comiiponent s wvere divided into at Brit ishi branch and (1 a American branch.

Thel( American lbrandll wats allotted five officer Spaces, thiree inl I li grade of

colonel an~d two inl thle grade of lieutenant colonel. Whienl tilie consult ant inl

miedIicinie arrived atit AFI IQ, onl 3 *Januiary 194:3, t his branch consist ed of thle

Deptity Stirgeon , AFI IQ, and executit ve, (lential, an1d preventive niedicinle

officers. Th'le consutilant inl tnedhicinle made tilie fifthI officer. In addit ion,

Brig. Gen. (later Mlaj. Gen.) Albert. WV. Kenner' wats assign~ed to AFIIQ ats

tiiediciil inspect or, at posit ionl from which lie report ed (directly to General

I Wien- thre Allied' forces In vaded Northi Africm on 4 Novembe-r 19)12, tihe reL'on was. insofar as strictl UvI-.S. Mementins

we~re conrcernedu, a pairt of t he Eurzopean Itreate~r. N ATO I 5A was stablished on 4 Fh-rivirr 19143 and incirrilir northiwest errn Africa, Italiy, arid portionis of the Meniiterrar'rart Sea. Thv t Inater was renamed NITOUR5A on I Novemberi i944

and ex pandie to ineludfeall of thre Mediterranean Sca, Gireeco, and tihe Balkan nationis. On 20 Novernh-r 1944, however,

hasi sectloris ini sotith4 ni France were aIssiVnd0 to the Errropr-an theaiter. Early in 1915, M TO)US A was fulr her d Iiminnishned

In! aIssign inig iifs A fricar territory to the Africta-Midle KiiEstlirratir. 0o I October 1915i, A EliIQ wais foirmalnly separated

fromi MTO[S A arid. for all practicai purposes, ce-ise' 11o function.
w. ae 0.C

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152 ACTIVITIES OF MEDICAL CONSULTANTR

Dwight D. Eisenhower, Comliander-in-('hief, Allied Expeditionary Force,

without reference to tile Director of Medical Services (Chief Surgeon) and the

Deputy Surgeon, AFHQ.

Most of the important prob)lems facing the Medical Section, AFHQ,

were settled by conferences and committees with representatives of the British

and American branches meeting jointly and bringing in recomnen1dations to

the Director of 'Medical Services. The American consultant in medicine,

from the earliest period of his assignment to the Medical Section, AFHQ,

maintained a constant liaison with his opposite number, the consulting physician in the British branch, Brigadier Edward R. Boland, O.B.E. Throughout the war, the recommendations on professional practices that were made

to the Surgeon, NATOUSA, were the joint and coordinated effort of the

British consulting physician and the American consultant in medicine.

Later, as the participation and responsibilities of the French increased

in the war, representatives from the office of tile surgeon of tile French Army

in North Africa joined in these conferences and committee meetings. Following the invasion of Sicily, the line of demarcation in respect to tactics, logistics,

and administration between the two components of the AFHQ began to take

form, and, from that time until the war ended, the actions taken by the two

branches of the Medical Section, AFHQ, tended to become more unilateral.

Hence, with the exception of certain problems involving the control of diseases

(such as malaria), joint, action resulting from the decisions of Anglo-American

commit tees became increasingly less common.

The Medical Section, NATOUSA, came into existence in February 1943.

It was not until sometime later that, a table of organization (chart 1) for

this section was approved. The Consultants Division, Medical Section,

NATOUSA, was purposely restricted to five officers, one each for surgery, medicine, orthopedic surgery, neuropsychiatry, and chemical warfare medicine. The

reason for restricting consultant spaces to five officers was based on experience

gained in certain other theaters which tended to show that the need for consultants in other medical and surgical specialties, although definitely existent,

was not, always great enough to require the full-time services of a specialist.

.Moreover, it was known that a considerable number of affiliated general

hospital units were to arrive in the theater, and specialists from these units

could be used as consultants on a temporary duty status in the Office of the

Surgeon, NATOUSA, for such periods of time as were considered necessary.

In the North African, and later tile Mediterranean theaters, this approach

proved to be sound. Such medical specialties as dermatology, neurology,

tuberculosis, and others were adequately supervised in this way without tying

up valuable p)ersonnel during the periods of relative inactivity common to all

theaters. An added advantage was the fresh and enthusiastic outlook of the

special consult ants, unjaded by periods of inactivity and the petty annoyances of

nornmal administrative routine. No provision was made in the table of organization for a chief of professional services, because it was thought likely that the

addition of such an officer would increase administrative detail without
.MEDITERRANEAN THEATER 153

CHART 1.-Organization of Medical Section, North African Theater of Operations (American

Medical Component of AFI1O), August 1943

SURGEON

II OFF DEUYSURGEONI IEMl

CHENUS. IPASOEAn~iFOPTLZT0N 

I OF 

UL 

I 

EIA NPCOI1DENTAL,,.

IM

I. FF E , OFF & CUATIONI EI8EV LIAPISON F I ~

30FMEDN 'EM 60IISRTINCONSULTANTS CONSULTANTS

121 OFF S E 40" OEM

?v LPERSONNEL ORTHOPEDICNE O I DISEASE SURGERYC PSYCHIATRY

CONTROL PUB3LIC cHEMICAL RELATIONS WARFARE

MALARIA MEDICAL

CONTROL RECORDS

HISTORIAN

C ADAPTED FROM CKART. P. 0, ANNUAL REPO•T, MEDICAL SECTION, MATOUA, 19431

serving any useful purpose. For the best functioning of the division, it was

thought that each of the five consultants should have direct access to the

Surgeon of the theater.

Officers assigned to the medical sections of NATOUSA and later MTOUSA

also were assigned to AFHQ. These officers served in dual capacities. When

dealing solely with problems concerning the operations of U.S. Army forces in

the theater, they would act in their staff capacity as members of the medical

section of NATOUSA or MTOUSA, but when planning, operations, or policy

matters required joint action with the British, their staff actions would be

carried out as members of the Medical Section, AFHQ.

Initially, an organization entitled "the Service of Supply" existed in

NATOUSA, but this organization dealt solely with supplies and had no other

service or a(lministrative functions. Later, in February 1944 when the name

of Service of' Supply was changed to the Communications Zone, it was given

true administrative, service, and operational functions over the various base

sections, and at that time the American special staff sections at the Allied

Force, NATOUSA-MTOUSA level became, in theory, advisory and planning

sections with no operational functions. This resulted in the organization of

large general and special staff sections at Communications Zone headquarters,

which, at least insofar as the medical section at the theater headquarters level

2 The organization of such an intermediate headquarters between theater headquarters and the base sections was

necessary to coordinate activities of widely separated base sections in providing logistical support for the opening of a

new front in southern France.-). B. C., Jr.
N54 ACTIVITIES 0F MEDIICAL ('0NSULTANTS

CHART 2.-Organization of Medical Section, Mfediterranea n Theater of Operations (A merican

Medical Comnponenot (4f A ElK), April 19i3

11OFSURGEON 2E

IDEPUTY SURGEONI

SURGICAL ADMINISTRATIVE MEDICAL NS 6 OPERATOIOS PREVENTIVE MED MEDICAL SPLY CONSULTANTS SECTION CONSULTANTS SECTION SECTION SECTION ROFF 0OEM LOFF 4? EM 30OFF 0OEM 30OFF 3EM 30FF 2 Em 60FF 21 EM

ANESTHESIOLOGY tPERSONNEL NRPSCATY HOSPITALIZATION It [VENýEREAL DISEASE ADMINISTRATIVE 46

a RESFUSCIT=ATION SUSCTION EVACUATIONCOTO SIPIGOTRl

ORTHOPEDIC MEDICAL REC:ORD:S SUBSCTIO SUBECTI

SURGERY SUBSECTION ERTLOY ADMINISTRATION, BIOMETRIC STOCKCONTROL

GNERAL SURGERY ADMINISTRATIVERCODaRERT SUBSECTION SUBSECTION RPI

ROE ~~~HISTORICAL MITNNE

ROETGENOLOG SUBSECTION IREOT& AIS

MEDICAL MACHINE TC RU

IOPHTHALMOLOGY RECORDS UNIT

SUBSECTION I

MEDICAL DENTAL VETERINARY IDIRECTOR OF

INSPECTOR SECTION, MI1SECTION 'N NURSES SECTION [OFF OM OFF 40F1 M OFF E

(ADAPTED FROM CHART. PP§53-55. ADMIN OF THE MED. DEPT. IN THE MTO, BY WI , MURDER. OFF OF SUMS. MTOUSA. 10Pd0451

was conicernied, calused a collsi(leralble anioun t of almtiinistriative andl openttiotmal confusion in problenis involving the ground and1 air forces, and tile

C omnmunications Zone. NATOUSA was renanmedl, effective 1 November 1944,

NIM'1'UA, and within the mionth I its medIical section assumed the functions

of the formier medical section of the Communications Zone in adidition to its

theater functions. This reorganization restoredl to tilie thieater surgeon aill the

resp~onsiibilities lie had( previousl *y, before February 1944, and added ain innlportant new function inl tile form of at comiplex supplyv activity (chart 2). The

mledical sect ion acting ait theater and allied headlquarters wats now responsible

for all medlical funIctions of thjeaterwidle scope.

In laite 1944, all the officer's tihen assigned to the Miedical Section, MITOUSA

Were realssigned to AF11Q.

CONSULTANT ACTIVITIES IN VARIOUS TYPES OF MEDICAL

INSTALLATIONS

lin tinme of war, and1( especially in a newly established, active, oversell

thIeaiter of operations, ai miedical officer is likely to have many taisks in addition

to hlis assigned dluties) and1( the UT.S. Consultant in Mledicine, AFIIQ, wais no

1'111, Itls I CommIunI icationIs 70714. organir joit 1) ini -outhern France, consisting of SIlithlernl I .111 of Comnl~lllica1.

hulls. (')111ifill Ill Ad vaitcv. -ud1)(1 )l! limse SectOilns, wwl p014'1Iart of F'I' 01 SA. With theI loss of thlis arva am[4 the

:lrev cooil :lfds, thll .1I el icl Seet oll. I l.'oI'IImrters. \11'01' I) ýA. aga!:in :1551 fll 1 IIirvet 01Rrlm~ki )1:1 a co l trol ovu lit141 itcal

IllatteIrs ill thle orjigial ha~we Sections that had (011sfitttl 1N A 'I'0T'SA before lprel aral 101 Ilwsl I for th invIl asionl of southlcr11 Franmc.-J. It. ('..Jr.
3\1 !D:I T IE 1 I\NEI.AN' THE IATEIR 155

exception to this rule. Initially, he was the representative of the Deputy

Surgeon in all conferences and committees having to (to with professional

services of all types, and, because of the illness and the subsequent transfer

of the preventive medicine officer to the Service of Supply headquarters, lie

assumed the functions of tihe officer in charge of veiiereall disease control for 2

months, those of the preventive medicine officer for 7 monthis, and those of

the theater nutrition officer for 18 months. Summaries of the problenis with

which he dealt in these other capacities can be found in other volumes of this

history.

In the North African and Mediterranean theaters, the function of the

consultant in medicine was purely that of an advisor to the Surgeon, except inl

those rare instances ini which, by command, he was placed on an operational

or at a commanl level. His prime duty was to keel) the Surgeon constantly

and correctly informed of the standards of professional care that were being

exercised in tile treatment of the sick. Ini addition, the consultant represented

the Surgeon in matters pertaining to the care of tihe sick, he advised the surgeons of lower echelons in respect to medical problems within their jurisdiction;

lie prepared circular letters upon the diagniosis, treatment, and disposition of

medical patients and prepared other educationad matter for medical officers;

lie supervised the activities of the consultants in neuropsychiatry and cliemical warfare medicine; lie advised the Surgeon on problems of professional

personnel in the Nledical Corps; lie attempted to stimulate clinical research;

lie interpreted tihe policies of thlie Surgeon to members of the medical staff of

tle various hospitals in tile theater; lie considered himself tile guardian of all

medical officers, general duty, MOS 3100; and lie prepared that section of the

monthlily ETMID (Essential Technical Medical Data) report that dealt with

medicine. These duties were accomplished by constantly observing professional work ini medical installations and by trying to maintain a continuous

contact with medical officers thiroughout the theater. Because of the shifting

nature of operations iii the North African and .Mediterranean theaters, withi

the resultant rapid buildups and as rapid deflations of tactical units ail base

sections, it was not considered expedient to have subsidiary consultants in

mediciie, except for the Fifth U.S. Army. A consultant was recommended,

but not accepted by the surgeon of that command until the closing days of the

war ini Italy. As a result of this general policy, the theater consultant in

medicine was away from his headquarters on tours of visits during 67 percent

of the time in 1943, 74 percent in 1944, and 69 percent in the first half of 1945.

It was only by being in the field that it was possible for him to fulfill his duties

to the Surgeon.

Initially, the activities of Colonel Long, ('onsultant. in Medicine, AFtlQ,

were limited by tile uncertainties surrounding the actual position and powers

of t lie American branch of the Medical Section, AFHIQ. This section hadl been

established primarily ias at planning and advisory section; the operations of the

Medical l)epart'ment in the theater were to be carried out at the level of tle

hmse sections, task forces, and air force. By December 1942, however, it had
156 ACTIVITIES' OF MED)ICAL CONSUL~TANTS

00

T UU

400

0 in In 

2z I..

uJ V) w

o c

CCO

w g

0

-Jz 0-

to -i

It0 U

~- w

0 0k

0 IA' t)

*Z 4 0U

4i 0)

400:

.W 4 2 uW

C- C.., 1 
imEI)rEIIIANEAN THEATER IS7

lKwoile clear t hat tilie M\ edical Sect ion, AFI'IQ. b~ecauise or its p)osit ion lit tlie(

th eater level, WotiIld have to 315511iiie tilie addl~it ional fuilu-idoll of coordi int( ing t it(-

Ieii vial act ivit jes of its Sub)ordlinaite echielons. As this nat urallv mevant that

tlie Ail e'rica it branicli 11( t0 (enter' tilie fieldl of operatioins, wI iici tilie original phlan

1131( not en visaigedl certaini adm11 in iist rat ive (lificult ies aii 'se bewtweeii ta I tsectioln

-111(1 tile miedlical sections of thle lower echelons of coinnmand.

Th'lis situta t ion created(, ill t urn, cert ai difi (hl'illt tes for tilie Consult ant ini

meicinei~l. surgeons or somie lbase setions (map 3) acceptedl hint at once C onsid erabile edul ioca %%oi ws Inecessilr * Wierot, thle surgeons of ot her secttions fully

accepted 11iii1 or- miade real use of himii. Generally sp~eaking, at period of abouit

6 mion thls elapsed I I ror thle 511 l('Ols ini thle thelea ti ulilderst00( th Ii ' ltis or'

tie coisuilltant il n i edicille Well enlough to perlilt him i to ruiiet ioul propherly ill

his a"I"sigied miso.It ias only lail- ito add, th'at it also took thle consult ant

ill Iiiedtiviie at certain p~eriodh or thuh' to learin 1ow to rIul(*tioli efrect ivelv within

lie framiiework of Ilt'e Armyi in lin active theater or op~eratitolls.

The activities of tilie onsuiltat aidii nedicuie in the Nort it Arric-an andl

Med('(it erraniea n thlea ter's were practically always ljimit ed to t hose of al ad311visory

nniiitmil 1 )aueii( opera tionlal and1( tm(ciii tcal comnmiand (ltites' were' sharply liiiiit ed,

with li tIile Iiied ical brantchi to tilie -"In rgeol andl his 'xeemit i e officer. Thie constit a nt vse t ieSugeon. N AT( USA, and1( thle suirge'ons of st hordI 1in t(

niflinlali 11(1 collcernihg, thle proldeiis (liscussedl un der tilie Vairiouis headings t hat

follow.

P~ERSONNEL M xNA(;E1I IINT

One of thle mlost iminportan11t (lit ies of Iboth Iiniedical ansuii11rgical consultants,

Wats evalluialt ionl of iiiediciil personinel. Ilospit 3d st affs Were freq nelitly found

priofes'sioilallV unbilalanced . Soi ie of t I ei ii, 1)1rt icuila iv tlie( affiliated units,

had1( 31 soi)l uphs of talent . Ot hers had1( 60 meicolisttite t((1withiouit dIume regard for

their special funwtions lit, thle abilit y of their professional stit~s to vitiry themi

ouit.

It was5 th pl'lract ice of tilie conlsultaniit ill iiiedicinle to i'eView tihle lpiofesSional attIaninments of mledlicaLl officers assigined to tilit iiiedicul, se'ivices of 31111

I a i tais dsp usm a0s1 uSmssiiile after thlei r airrival in thle t hneat ('IxThis was (lolle

W) b)*y stnd11 ilig tlie( questionnal~ires whlichi all iiiedical officers were required to fill

out and1( (2' lby iiiterv tewing thent indiIvidlually aS soon, asopp))011unity pernmitted.

A ssignmu~en t and Rleassignmeniit of Med'(Iical Officers

If glaring errorsi' ohf assignime(nt 1131( been imiiide inl at unimt recolimmendaitionis

for relasýigii ii en t or t ransfer Were ii alde to thle coinlillandin ig officerl immii edniate(ly.

Otherwise, recolil 11Ii(ildlt tons were withIihhel uinitil t I emcouiilt ant ini IledIici iie had~

I)een able to review the( p)rofessionaul work of thIn oficer hin question afer the

unlit Wits ill operat ion. Then, if (Iefic-ieiici('5 were noted'(, app~jropriate reeCoiiIivi('ldat ions Were Made.
158 ACTIVITIES OF MEDICAL CONSULTANTS

It was sometimes difficult to convince commanding officers of the need for

these changes, particularly if tile changes involved transferring officers of sup)erior al)ility to build up weaker units. In the North African theater, the general

hospitals were all affiliated units and were tiherefore rich sources of mliedical and

surgical talent. Officers with such qualifications were sehloii relinquislied

willingly, even when the new assigunients iiight mean promotions and 1)ositions

of great er responsibility for i hem.

At the other extrenie. although the functions of the consultant in medicine

included the making of reconinmmendations for transfers, these changes were sonietimes initiated without reference to his opinions and reconinend(lations.

One difficulty which arose in the first days of action in the North African

theater was not entirely settled until April 1944. Because of certain comnimand

policies in effect wit hlin the theater at this time, it was not possible for represent -

atives of tile theater Surgeon to interview replacemnients andi unassigned personnel until their completed questionnaires had been received at headquarters.

h'llis policy meant. that medical officers somnet imes remnained in replacement

pools for a month or more before assign muent, a waste of mnedical manpower

which the circumstances of tihe theater did not warrant.

In a numnber of instances in 1943, Medical Corps personnel entered the

theater and were assigned by G-1, NATOUSA, without reference to the Office

of the Theater Surgeon. This difficulty, like the one just, described, was not

satisfactorily settled until April 1944.

Replacements

In 'March 1944, a further complication was added when the Comimunications Zone connimand took over the personnel services in the base sections in

addition to its already existing supply function. Thus, an interniediate echelon

was created b)etween AFIIQ and base section levels, and, although the Surgeon, Coniniunications Zone was always cooperative in respect, to time recoinmenldations of the consultant in medicine, this imieant that every contemnplated

change in Medical Corps personnel that affected base section units had to lbe

coordinated with still another echelon of comimnand. Then too, at this time,

becauise of a shortage of replacements for medical officers in combat units, it

was decided that all medical officers in base section units who were under 35

years of age and physically fit were to be made available to the Fifth and

Seventh U.S. Armies as needed. The responsibilit v for imaking these officers

available was given to the Personnel Division, .Medical Section, Comimnunications Zone, which was presided over by a nonmedical officer of the Medical

Departnient, who again had had little or no training in personnel prollenis.

This really niade things difficult. and this officer had to be watclied constantly,

beca use to Ihim, a captain in tle M'h ledical Corps was a captain, and hence, regardless of whetlher he had had sp)ecialized training or not, was material of

which battalion stirgeons were mnade. When chiefs of services or assistant

chiefs of services (0ianY of whom were (lil)loniates of American Specialty
MEI)ITERIANEAN THEATER 159

Boards) were recommended for transfer to combat units by the personnel section in the Office of the Surgeon, Headqiwarters, Communications Zone, it, was

only tile vigilance of the consultants that, prevented serious dislocation on certain services in general and station hospitals.

In the Fifth U.S. Army, the chief of the personnel section in the Surgeon's

Office was a nonnedical officer until after the surrender in Italy, and the philosophy of that office dictated that Medical Corps replacements, no inatter how

highly qualified they mighti be professionally, should serve 6 months with coinbat troops before they could l)e assigned to hospital units within the Fifth U.S.

Army. The extreme example of this type of thinking occurred in the winter

of 1944-45, when an officer who was a member of the American Board of Ophthalmology was assigned to a general service comni)at engineer tinit at a tine

when there was a real need for well-trained ophlthalinologists in tie evacuation

hospitals within Fifth U.S. Army.

In July 1944, Maj. Gen. Morrison C. Stayer, Surgeon, NATOUSA, having

surveyed the situation, took the steps necessary to establish central control in

his office of the initial assignment of -Medical Corps personnel within the base

sections and, to a certain degree, within the Fifth U.S. Army. To make this

plan effective, he first arranged that all replacements and unassigned medical

officers should be concentrated in a replacement, depot close to theater headquarters and that his office should! be notified 1) telephone on the day any

inedical officers arrived at that depot. Then, through tile l)ersonnel section of

his office, arrangements were inmnediately miade for interviews with the newly

arrived medical officers. When tihe professional attainmiments of these officers

had been ascertained, they were pronmptly assigned by NATOUSA, and later

by MTOUSA orders, to existing vacancies in Me(dical installations in the base

sections, or they were sent. to the Fifth U.S. Army with recommendations respecting the ty.pe of duty they could best perform. In effect, witil this system

placimig the initial assignment of these officers in the hands of the consultant

staff, there was miore chance of their being properly placed on the basis of their

professional abilities, and the time they had to remain in the replacentent depot

was cut from weeks to a imatter of a very few days. It, night also be added that,

following the institution of this system of personnel placement, complaints

arising from alleged improper assignments were practically eliminated.

Redeployment

After V-E Day, the Commanding General, MTOUSA, directed that redeployment to the Zone of Interior and the Asiatic-Pacific areas of Medical

Corps personnel assigned to hospital units be the responsibility of tie Surgeon,

MTOUSA. The Surgeon, in turn, delegated it to the consultant staff in his

office.

These officers laid down the policy that the seventeen 500-bed station

hospitals, time three 400-bed evacuation hospitals, tile three field hospitals, and

the two general dispensaries that hadl to be re(ieployed by MTOUSA would be
160 ACTIVITIES OF MEI)ICAL CONSULTANTS

staffed with medical officers (1) who possessed the proper MOS; (2) who had

dlemonstrated their ability to fill their new assignments; (3) whose adjusted

service ratings were below 85 points; and (4) whose ages. whenever possible,

were below 40 years. It wits also decided that every opportunity would be

given for promotion; this meant that assignments were not nmade in grade but.

in one grade below that, which was called for in the tables of organization.

Although the theater was short of medical officers--in May 1945, it was

operating on a basis of 4.6 medical officers per 1,000 men-it was possible to

complete redeployment upon the basis of the criteria just outlined.

Classification and Promotion

One of the outstanding advances in the proper management of Medical

Corps officers resulted from War Department Circular No. 232, dated 10 June

1944. which created the graded lMOS numbers. As the resudt of his long

service in the North African and Mediterranean theaters, Colonel Long was

well aware of the professional qualifications of the majority of medical officers

who belonged to field army or base section units. In anticipation of the

responsibility for grading medical officers, he had, late in 1944 and early in 1945,

interviewed chiefs of medical services of hospitals in the base sections and in

the Fifth U.S. Army, as well as the majority of battalion medical officers in the

Fifth U.S. Arimy, for the purpose of reviewing once again the professional

attainments of medical officers in MTOUSA. In the actual grading, the status

of each medical officer in the theater was reviewed before an MOS was assigned.

The consultant in medicine was assisted in this task by Col. Donald S. King,

MC, and Col. Marion H. Barker, MC, each of whom had a wide acquaintance

with medical officers in the theater. It is a pleasure to be able to state that

the Office of the Surgeon received only one request for a change in MOS. In

this instance, the purported error had resulted from an improperly filled out

questionnaire. There can be little doubt that the possession of an accurate

'MOS contributed more than any other factor to the proper assignment of individuals during the redeployment period.

In the Mediterranean theater, as in other theaters, the promotion of

medical officers was always a problem. The number of vacancies was limited,

and the number of medical officers who( deserved promotion on the basis of

their qualifications and performance was many times the spaces available. It

is to the credit of the officers who entered the service from civilian life that, in

spite of disappointments and actual injustices in this regard, they did not let

them affect the excellence of their work, particularly when, as inevitably

happened, less qualified officers sometimes received the promotions which they

felt belonged to them or for which they had been recommended. The question

of promotions was a problem which the consultant in medicine was never able

to solve.
IIIl IiTEII HHA N' EA N' 11' 11 EAT R 161

At I

UI( iit 1.. -15.- A iptiýt Otnr:Oig Of invIi-: I sij p i it-,Naples, It aIv.

N1 111)1( It. I ML PITIA ES

thlea ters wn 11110 uc 111 to i flomlal Omitu fnoli I ls Nif4i i llen~e hnejati ra rely

htad to lbe eotievtitd \\t[Ill Jpro~de1vil of iiedhical SltJpplies .Aside frltti (Prthliti

mml W~~i ~e loeal sliotta:(rvs. ii eilial stllplies, (fit,. 45i) Nvere 1ilwU ~as lbttilalt.t

atnd( t lie sup ply~ If lievits ill 111 'IlieatIer ti , ee ( iperatIive ill (lit -. 1111( u M lllost attlat dI illI t ms tht were dvlt'tietl desira lde lor ( lhe t I-va ttiivtit of pa Itietits. or fomr

thle pulr-tti I ()f rvsearh

1)1S[ \SF1 O 01) \1 JKI)I(.\ 1ATERlE:1STl

'I'li le p ii i4)Ietttl 11a ti ]itt t11i Nortth Afrtican and t~ Med it erranvale thea teaI(rs

ill reI-Tvcee ii)tli 1114, ttala-eliviit of vai riols (Ii-:-wases will Ilie litsviis'el itlidl

Niietrops'.~eliarinc ( asital ties

E'A d I it i lehtawii- 1943.. Oie pr1 )to ~ldt oh' tOet --Iteiti Iliti lilt(] d1ispositioni of

ltitt'if~V('iii r 'Iht tt e anid tmbiotlttle ('atstialt elie. ail prtessitigo. SitIIc(

De'eviitha'r 19-12. datate 11ftli-7; tvpe had bveleti(tieritipg Brt'iishi llne(i('a Ill-

-ll t iti. from the 181 h R"Ime-1iniet1 a'(milbill Team CUS) ofiiiitantdo II tid
D1 2 A\t 'T I IT I :s M., .\l:1h1'.\J". 44N1 j'TAN.`ý\

IL I

illfll 44 W hei iI ll itI 1 .%Ip \lin I4li 144It1 44 lit4l '1' 14' 4'l'4 11t4'41 hut1 1144' t*llhI i 4 c'\'14 1411"'' 1)41 f-' t Illt1m "'IIIII" 41 \i4'it1114, o\it'lIl44J \liwi~ll Iii' S1 .11 c,1 ll"' ),-4
MElDITERRIANEAN ThEllATER 163

dationl wvas imnuied ja t el put int o force bY thle Director of Medical Services',

Who cel-a ted a. spet'iall dIisposit ion board of Which N Iaj. (hit er ( 'ol.) Itoy It.

6 riiiker., N I( , t he psy, chhit rist of thle 1 2thI Air Force, was thle American menber.

Thiis b)oardl itiiiuetiatelv lieg-an to function. and it providled a Ilvteedeti echlianisiti

for tliet' disposit ion of n~eIropSvcljijIa t nc patjeti(lt s -omingli to the rear inl tile British anid Amlerical fiillies of evalclation. Because of at shortage iii personinel , it,

was not possible to at taclitiln American psvcliat rist to thle 95thI Geiieral H ospital

ait that t un.

Onl 12 Fehriia i' 1943, ( 'olonel L owg flew (lown to -'Out hen liTunislia at t lie

iii red ion of, thle -im-gvon , N AIOV SA, to in vest I,( t e antd make rvecoi ienezdatitolis conicernin g tile t i1ea 1i mert antd d isposit ion ol, neivi rops'pliia t nc casualltie's

ill forwrlareas Thie sitihat ionl inl thle florwarti areas5 was, ver~ linterest ilic

Nvein-ops yehatici t castial ties wvere being Iteaitvd ti.withlou t segregat lionl, oil t lce

mu ed ica I wart s of, thle sulrgical antd e vacliatitloll mospji t als" by inlexj~el'ellcedl

intecrn ist s. The resultl was thlat ii lore gross hiyst ericalI anrd con ver'sionl nmialest ations" were ie'..eloping" t Ii a ii ere ever noted b~efore or sn I seq Iment Iy inl

forwar iI rs. va 11 v-st crica I1) binl nless, delt'ii less. a phionia :, an11d gross tlit's were

coind nant m vere, developing evenl Ill individu als who halia l ent(redti hle hmospit als,

witlli but mnilor a xiet v St at es. Treat iiint of' thlese patients was neither

inditi il itilizetl nor. Sta ndlardized . and thler'e was 2aiiiple evidence t hat th lit'neii'ojisYchinht ric dlistuiirba nces Were Sp~readling, ill thle ii inn neri of' all in fection, to

01 lie'l paIt eli t inl lthe nitlical wa rds of thle hosp1italts. After sp)endillg 6 (lays

inl oh-serving thle imiliageifvilent of these5t patienlts antd collecting datiuti ill respetct to

Imeiti, thlit conlsult aiit in1 riit'ticine ret urnted to AFI H) and rendered the following

rep~ort to I le Surige'on. onl 21 Ftebruiary 1943:

1.IThis replort is lhased( oil tat a01 ah~iint(l frorii tilet'Medical stall' of 11 Corps, and from

intt'rviews with inviviitial officers tof the 11th1 antd 77th Eivac'uationi llospijtals.

2. The piroblem'n of psvchiot u', psvclioneuiroti and axeystates ill the personnlel of then

A. U.S. inl N ATO USA is a rteal one(, and is becoming, more acmte as5 relat ivel *v new and unttrie-d troops are placed oil combliat tlilt.N. .i'Expeienitce inl this thevater, which is derived fromn

report s of the Ctenter Task Force antd 11 C orp~s show t hat when t rotps arte ill hatui t for tilt

first time, a consitderabile niumbner of p yci)5 tr'iUt c ('ashillt ies tina *lv e exipected. The clitrye of

-itch ('ashlaties is a sliar) tonet which wvill fall rap~idly as trIotops becomhe ac('jlimated to combtili

condtlitn bsWith the t'xtcept ion that a secoinlar 'v rise in thle culrve wvill lbe notetd wVhenh troops

are kept mintI(r Ilat ti tcondititons) for long periods of time, as has already happeunetd inl this

theater (Rth C omniantdos. limuiskilling lFusiliers, etc.).

3i. F"or tli'sake of tconve~n n'iev,ps 'ch(-iatrinc cond~it ionis can h 1roughly cilassified as ,follows:

a. P~svchot ic St ales. t'nfort uimatelY, a umnimt'r of itidividimnis withi histories oIf

tlrovimus treatmlent inl mental hospitals havte be'tn inducted into the AXrmy. These mtenh are

having reciirrences of their ps 'ychoses. The onlY p~roblem(h inl respect It) such individuals is

that the niat itre of their ps 'y Chosis lbe tpronlltl . re'cognuized' b.\ theit Medical Officer and the

p)roper disposition muatdt of t hemo. At the' 1)rt'sv'i moinelut , nainn of these p~atieunts art' beinga

senlt to U.K. This is riot thisirahili becauuse one theater (if operations shouldi not throw sut'ii

a burden uipon aniotheir. W~li'never it is possible, jlsYclot ic patie'nts should bet sent, directly

to thet U.S.A.

b. P., vvcht-Nerarotit' Sta:tes. The intlividluils who fall inito this t'lassifit':iiion are

I lnist whon geneorally l ave' pa:st histories which show that they' were' unstable it) civilian lift'.

They art' the ones (of whom it is freqmin'tt I said, "'The Army% will miakt' a mnan out of him.''
164 ACTIVITIES OF MEI)ICAL CONSILTANTS

Unfortunately, the Army has its difficulties in such an endeavor, and has instead, a1 problin

child on its hands. These individuals are especially hard to handle as ineml)ers of coinbat units and, in desperation, unit commanders resort to all sorts of subterfuges to get them

sent "down the line" with diagnoses of "shell shock," "gastric ulcer," etc. Upon reclassification, a fair number of these individuals will be able to perform sonie type of base sector

dluties. However, a certain group will be complete misfits in whatever unit they are placed, an|d because of their inalptitude or other characteristics should be sent honie to be discharged

runder the provisions of Section VIII [Inaptitutde anrd Undesirable Traits of Character,

AR 615-360], if this section is operative in this theater.

c. Anxiety States. Personnel suffering from these physiological and psychological

disturbances should be the special concern of the Army, because with proper treatment

many of them can be promptly rehabilitated for combat. duty, and the majority of the

remainder will perform well in the Base Sections. Individuals who are suffering from

anxiety states rarely give histories of previous difficulties. The factors which produce these

states are multiple. Among them are exhaustion, lack of food, equipmnent or munitions, l)oor

leadership, and extremely difficult, immediate personal tactical situations. Su|ddenly, when

these factors becoome operative, something happens to an otherwise balanced intellect. ail

an acute anxiety state is produced. Unfortunately, at the present time, the inception of these

(listu|rbances is frequently not being recognized by unit conmmn(ders or medical officers and

the symptoms progress to become full blown. Then patients are frequenmtly evacuated

with a. diagnosis of "shell shock" on their Emergency .Medical Tag. These patients all read

their Emergency Medical Tags sooner or later, and when they see the diagnosis of "shell

shock" they have something that they know of, and a fixation of the psychological component of their illness frequently results. Much can be done for this group if the nature of

their distir|bance is understood and recognized, and the proper treatment is instituted and

carried out in forward areas.

d. Exhaustion States. These disturbances are pri-•arily physiological in nature,

but are frequently misdiagnosed by forward medical officers, andl hence, personnel are sent

(town the line of evacuation improperly labeled as "shell shock," anxiety state, or p)sychoneurosis. Individuals suffering from exhaustion, in practically every- instance, can be

treated in the far forward areas and returned to their units within a very short time.

4. Treatment of Anxiety and Exhaustion States. At the present time the treatment

of these psychological and physiological disturl)ances in forward areas, frankly is not very

good. The reason for this is that many of the Medical Officers who deal with these men

really (1o not understand the nature of the disturbances. Sedation to the point of light

anesthesia is considered by many psychiatrists to be the basis for the treatment of anxiety

states, and it is not being used. None of the patients are arriving at the surgical or evacuation hospitals completely "knocked out," but instead, they are being given, for example,

l.• grains of phlnobarbital, 15 grains of sodium bromide or, what is worse. morphine.

Ilence, with an evacuation line which is long (12 to 18 hours), plenty of time in which a fixed

neurosis can develop is being allowed to elapse. The ideal place for the treatment of these

patients is in the evacuation hospitals, but there again, owing to the lack of a trained psychiatrist in such installations, the true nature of these dist urbances is frequently missed,

und improper therapy is instituted. There can be no question Il)ut that the addition of a

trained psychiatrist to those hospitals would not only be welcome, but also would pay large

dividends in facilitating the proper sorting of psychiatric casualties and the proper treatment

of anxiety and exhaustion states. As conditions exist at present, psychiatric casualties are

sl)read over the medical wards of the evacuation hospitals, and there is evidence that they are acting as foci of infection for tile spread of neuroses to other patients. This is an

unhealthy situation.

5. Availability of Psychiatrists in NATOUSA. According to -Major Grinker there is

a dearth of trained psychiatrists in this theater. Two are in the 12th Air Force. The 12th

and 21st General Hlospitals have trained psychiatrists. However, the senior psychiatrist
MEDITERRAXEAN THEATER 1 Wi)

in the 21st General Hospital has been transferred to the 64th General Hospital. In addition

to these mien, thereti re said to be three other psychiatrists in NATOUSA.

6. It. is therefore recommendled on the basis of the situation as it now exists that:

a. A dlirective be issued stating that the term ''shell shock'' shall not be used as a

diagnosis and that the teri ''anxiety state'' be the sole diagnosis p~ermlit ted oil Emergency

Med(icail Tag or Field Medical Record of patients who are suffering from the p)hysiological

and p) sychtological (list urbances dlescribed in p)aragrap~hs 3c of this report.

b. A psychiatrist be attached to each evacuation hospital, iii order that proper

sorting and treatment of psychiatric casualties can be carried out and p~roper instruction

canl be given to medical officers in battalion aid and clearing stations in the initial handling

of these casualties.

c. Psychiatric casualties be segregatedl from other patients.

d. Sodium Any tal, for intravenous utse in sterile 7/14 grain amiptles, be providled

for clearing stations.

c. Five additional trained psychiatrists be assignedl to this theater.

The Surgreon, NATOUSA, accepted till of these recominiendaitions. The

Sutrgeon, 11 C orps, onl being queried statted thait lie would be glail to hatve

1)S vliialtrists inl his evalcuiation hiospitails, and Maij. (latter Lt. (C01.) Louis L.

Tureeni. M( ', and Caipt. (latter Lt. (Col.) Frederick R. Hanson, MC, were aissignedl

to 11 (Corps, wvith understanding that Caiptatin Hanson would work in the(

forwardl areais. This stipulation wats maide becatuse of the lahtter's famniliatrity

with aictuad battle condit ions, which hie haid gaiined in the course of commando

rails mnid in the landling ait Dieppe. Onl 22 Mairch 194:3, Circulair Letter No. 4,

en tit ledl 'Psvchiot ic aind Neurotic Patients, Their N\ langenient aind Disposition,'

wats issulel bv thle Office of the Surgeon, Headquairters, NATOUSA. Before

tlie appearaince of this circular letter, supplies of Sodium Anivtatl (amobarhitail

Sodliuml) 1111( been made availahble inl aill forwaird aireas. Thus, thle policy wats

initiatte( of treatting neuropsychiaitric citsuailities ats fair forward ats possible.

The wisdom of this lpolicy Wats (lenonstratel (luring the battles for \laknassv

anld El Guettar (fig. 47), in tilie course of which aiptatin Hanson returned more

hamn 70 percent of 494 neurops *vchiattric caisualties to comibait aifter 48 hours of

treaid ment, ,and Ma2jor Tureen ratpidllv rehiabilitaited thle imajority of the remainder

for dluty in the( lIase section.

At the beginining of the battle for northern Tunisia, the consuiltaint in

inledicine lieldl at confervene withI the fotur psyc-hiattrists in the 11 Corps (two

new 400-bed evaicuation hiospitals 1aving been aissigned to the It Corps).

As airesult of thle conference, the I ( 'orlI)s commandeiiitr, Mij. Geni. (later General)

Omair N. Braidley, issuled, onl 26 April 194:3, the following- dlirective onl the

handling of Psychiatric caisualties:

E. vacualion Policy.-1Psvcliatric ca:ses sho(idd( be evalciatf-d. treated and~ disposed

of as rap~id] 'v as possible. The following evacilat lol policies wvill p~revail for Suich caslialtives

inl hospitals in II Corps:

a. 11th Evaciat ioii-- days

h. 150t I E'vacimatio - da (ls .

d. 9ith Evaciiat iomii 7 (lays
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MED ITERRiANEAN TIII:.%'rF~t 169)

Fi;I-Ri 50.-lirig. Gen. Frederick A. Blvsso, Theater Surgeon.

1w tilie consultant inl medicine (luring the sp)ring of 194:3 that onl mnin occasionis

lleclassifiedl lleurlolpsvehlt rtc casu~lities Werle glven(lldt ies that frequently, oft en

prompItly I, result ed it, th~eir exp~osure to eniemyi air raidis. Ultese ralids pro(iltCe(l

at rett urn of tilte acute sviliptomnis of anxiety inl these muen, Which necessitated

fuirt her lhospit alizat ion. Inl an effort to (lefinle miiore carefully the typ~es of

(Ililt v to Which reclassified l lellrojpsvcl tit t nc Casualties slhouldl he assigned'( ill tilet

base sections1, ( 'olotiel Long miade thle following recommendations to Brig. Geni.

F'redlerick A. Bless6 (fig. 50), thle Surgeon, _NATOUSA, oil 1 'May 1943:

1. ExIperience is shiowing t hat certainl type)(s of netirop~svcliiatric casuialties, cannot he

retutrnied to comblat (lilY hvem~ise thevY quiickly deteriorate and have to be evactiate(1 to thle

rear.

2. 'Many, stichl csi.tialties wh~en properlY reclassified and p)laced onl ditty inl quiet areas

slich as thle AIIM or NIBS5 [At lan~tic Blase Sect ion or Mfediterranean Base Sect ion] are able to

fidiltI their (lilt ies ill a satisfaCt or , manner. The' ise- of rehabilitated neiiropsvchiatric

casmilat jes inl the (p l jt base sect ion also ob)viates the need for a certain niumbelr of replacemnieits for suchl aireas.

:1. If, however, siicl rehabilitated castialt ies are placedI inl areas stich as Algiers, et c.,

wh ichi are stii~ectied to lhomin~ig and hence A A fire, nmany will revert to their ileirojpsycliialrie

'4 ate after the first bombiing. It is thlerefore plain that such areas are not to be used for thle

p~lacemuent of rehahilitated niii'lolps v chiatrie casualties.

4. It is therefore reconiniiti(le(l that a statement covering the types of and places for

(tlitt*y he preparedI and signed ) , ýtion and greneral hospital psYchiatrists for all rehiabilit ated

lleil1rolps * clhi~nte (;isiialt ies anid that their stat ements be forwarded to reclassification hoards

with th v4i)t htth b ceduo accordingly. If this p~lan ;., carried out more usefill wvork will he, go tteun oiut of Stich inidividuials and the chance of them repeating their ileuropsycehiatric sYnidroine will be, great lY lessened.

These recommiliendtlltions were accep~ted by the Sutrgeon, an1d fromi t hat time

it consiSCouis at tem'ipt wits Ilialle to assignl reclitssifie l netiropsychilat tiC (a'lltall ies to (lut ies ill (quiet are-as. Also, durinitg thle Tunisiatn camlpaigni, Ciap~tainl
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1 . A I I I f A
MEDIITERIRANEAN THEl~ATER 17:1

hvAdrocilloride) alo0ne wits used for tilie t reat ment of ma211-lari, the (loSaige Schiedule

should1( he clizinge(I to 0.2 gil i1., three tiiiit' dlaily, tItitil tile templjeratutrewa

normal1,1, then 0.1 grin.. thlree t imes, daily, aifter meails for -5 days. This revision

wits- mot ivat ed by tilie (desire to buildl up tilie Concentration of At abrine inl thle

tissutes eall i the disease and I ele, when the infection wvas known to be under

control, to mnaint ain all efiect ive level of tilie d1,1ru over at Period1 of (lays. The

(juinine-At alriile method0( of t reatmieint wats left unlchiangedl, ats were also tile' (irecil isfl for tilie Jparenltveral use of quinine 01r At abrine iii severe foris, of mailaria.

'Ihiles'e recommiiendlatIions were accepted anld were published Onl 3 Sept elinler

19431 inl Circular Letter -No. 32, Office of the Surgeon, Hleadq~uarters, NATIOUSA.

OnI the dlay after t his circular letter was publishod, reports were received from

tlie National Research C ouncil indlicating t hat Atabrine wats ats effective, if not

iiiore so, inl tilie thlerapy of inalarial t hanl (tiiiiiie (a conclusion also arrived ait ill

-NATOUSA) and giving (let ailed information concernimng thle p~harmiacology of'

At abrinie. Onl tilie lIasis of these rep~orts and of infornmat ion received froml tilie

Office of thle SurgeVon General, in addit ion to theater exp~erience, It wats decided

to ab~andlon the routine use of quininie and to recommend that At abrine be usedl

ats thle (Irtlig of choice inl thle treatmnent of mala11rial. Tlhis wats dolle iil sect ion

11, C'ircular Letter -No. 34, issuied onl 14 Sep~tembler 19431 by the Office of the

Surgeon, H eadlquart ers, NATOUSA. In I this circular let ter, the phatrmacologyof Atalwine was dliscussed, andl at (dosage schedule of 0.2 gui. of Atabrine every

6 hours for 5 dloses. followed by 0.1 gill. thlree times a (lay after meals for 6 (lays.

Wats recoin1 Mlendedh for t he t reat ilient of nmaaria. Tmis mlet hod of t lierapv, wh~icht

resulted ill ia redluct ion ill hiospitalizattion requiredl for mialaria to an average of'

II dhays for all caIses, wa-s Muaintainedl as the meth1o0( of choice for treating ilutlaria

throughout tilie life of thle theater, excelpt I hatt it temporary modlification was

Imlade inI resp~ect to the treatment of relapsing malaria in February 1944.

At this time, at conisidlerab~le niumbher of p~atienits were 1)eing seen with three.

four, or more relapses of benign tertian malaria. After consultation withI the

theater preventive medicine officer and the inalairiologist. the following uges

tionls for tile treatment amll dlisposit ion of pat ients ill wvithI relapsing mala11ria

were pultl)ishied inl section 11I, Circular Letter No. 10, 15 February 1944,

Office of the Surgeon, Headquarters, NATOUSA:

Relapsing Malaria

1. Experienice has shown that despite various treatment reg, imes malaria is a dlisease

prone to relapse, eslpeeially wlien the inifection is caumsedI entirelyv or in part b lasmodhm

i'iu'ax. This letter (teals with treatment of relapses and disposition of malaria patients to

the Zone of the Interior.

2. First and second relap~ses of malaria should be treated like a p~rimary attack, using

the system of therapy- out lined in Section 11, par. a (1), Circular Letter, Nso. :34, Office of

hel( Sirgreon, 11(j. N AT( USA. dated 14 September 19:13.

:3. Third and stibsequient relapses should be treated with Ii qinine accordling to the following 10-day regjm(':

a. ,uinuunlfate 1.0 grani (15 grainus) by mouth three times daily after meals for

the first three (lays.
174 ACTIVITIES OF MEDI)IAL CONSULTANTS

b. Quinine sulfate 0.32 gramn (5 grainis) by miouth three timies daily after iiieals for

the next seven days.

4. The use of adrenalin followed by Atabrinne or quininev (so-called,, Aseoli met liod) is

not recommendedl because its value has niot been demuonst rated(.

.5. Every method of adjuvant t herapy should he emnployed as indicated to restore thle

phyisical conodit ion of mnalaria patients. Of sp~ecial valuev are:

a. 11 igh calorie, high mecat protein diets.

b. i tilt ivitamnin pills or capsules.

c. Transfusion -when patient is very ane-mic.

d. Ferrouis suilfat e iii applrop~riat e doses.

6. It is not logtical to SOt up1 absolute criteria for disposition to the Zone of Interior of

personnel who have had one or miore, attacks of malaria. 'Some patients are in) let Ier phy' sical condition after several relapses than ot her patijent s after a p~rimary at ta:ck . Pat ient s

who develop chironic malarial cachexia. p~ersist ent splenoioegaly, or recailcit rant anemia

should 1e considered as subjects for evacuation to thle Zone of the I nterio

It is to be not ed t hat ill this (ii'ctilar let ter ti( he se of epinleplirine ill the(

t rent ment of maitlariar wias not reP meC tl~iidedl-2 -a move to count erac t the itifitiencve

of tilie t eacliings of Ascoli - andi that at policy for tilie d1isposit ion of patlentts ill

with reilapsing malaria Was est ablishied. That part of (Circular L et ter No. It)

that delent w~ith Iithe use of quinine inl tilie treat menit of relaplsing mnalaria Was

rescintded inl paragraph 4e, Circular Letter No. 41, 29 July~ 1944, Office of tlie(

Stirgeon, Headquarters, NATOUSA, after It became apparent thlit therapy

with qtujinine did ntot alter thle rate of relap)se itt malaria, It (Circuila r Let ter

No. 41, the imp~ortantce of thle [)lIt*ysical rehiabilitat ioit of malarial pat ienits "-as

again stressed, and a tdireetive that all patient-, econale-centi from relapsing

tmalaria shiotild receive 0.1 gin11 of Atabrine (lailv, for 7 da~s a week, regarolles.,

of Whethler' t hey were ilt a "'safe" or ''daitg-er-otis' area, was isstued. No ot her

(claniges ill policy for tilie t reatmeitt or dlisposit ion of cases of malaria were tladle

mit ii after the surrentder of tile enemy in uItal it, Ma ' % 1944, when it wasý

re'om~mendled verbl~aiv by the Surgeoit, NITOUSA, that pat ientts suffering front

frequiently relapsing malaria shotild lbe sent to thIe Zonte of Interior.

Dysentery

TIhte thireat of dvsentery -both b~acillary andl amebic-seemed great inl

lie enr * vpart of 194:3. As a result of tilie recommtentdat ionts Ittnale by C oloniel

L~ontg C ircutlar Letter No. 9 was issuied onl 6 April 1943 by the Office of tilie

Stirgeon, H eadquatrt ers, NA'lNUSA. Diagntosis andl treatment Were dhisctussedl

ill this directive. The hliightpoinits of this circular letter Were tile recomlmeti-

(lilt lolls t lhnt stilfagtun nlinile was t lie(ýIrtig of chioice for t(the ýtretmienitof hacillarv

(I' -seiite *'Iv and~ thlit tilie course of elliet itte htvdroclilloridhe to be tlsedl itt tilie

t1wirapv of anmebic (vseiit erY should be of 10 (lays' dutrat ion, rather thiatt tilie

(li1st omlary* 6 days. This latter recommelnd~a t ion Was mlade Iil)Oht tilie adlvice

of lie Britisli conistilt ing phivsicia ii, Who had hatd aill extenisive experienice Ill

lie treatment of amebic dysentery ill soldiers ill Egypt. It is believed that

hie wvisdoml of t his ad vice was- borne out bY tilie experienice of tilie thenater.
MEDI)TERRIANEAN THEATER 17 5

In September 1943, in paragraph VIlb of Circular Letter No. 34, the

more extensive use of sudfadiazine for the treatment of bacillary dyseniter '

was adlvocated, andl, in paragraph I11.a(1) of Circular Letter No. 24, 15)

April 1944, Office of thle Surgeon, Headquarters, NATOUSA, it. was stated

hlat for the treatment of bacillar Iy dysentery "sulfadiazine is thle drug of chloice

wvithi sulfaguanidine andl sulfathiazole following in the ordler named.'' This

recomnmendationi wa~s madle b~ecauise, under the conditions existing in the

I hieater, it had been found that sudfadiazine wsas anl effective, practical dIrug.

Tue inference that it, was tlieralpeuticallY superior to sulfaguanlidinle inl tile

treatmnent of bacillary (lvYseiterv could not lbe dIrawn, as bo0th appeared to be

equall 'y effective, but sillfallinazin tic -s easier to admifinister to p~atients b)ecause

of thle smaller (loses 1111( less frequent (losage periods requiredl for its use.

In the spring of 1944, during thle offensilve from thel Hitler to thle Gotblic

Line. til lie ospitals in) Italy -Nere w v-er 'v bus.Y, and it became colinnionl prac'tice

to (Iiscilarge from iiosjpitals patienits siihlcring from amiebiasis, wit Ii ins'tructions to take a second~ course of ciirlbasoie wbile onl a (lutv stat us. As a -onlseq uence, tilie second~ couirse of ciirliasone frequently was not complJ)et ed, andu

rela pses oft cii occurred. in paragraphi 3 of C'iicular Letter No. 41, 29 .1tlul

1944, Office of tile Surgeon, IHeadquiarters, NA'FOUSA. thils practice was

coti~eniela 11( inst ruct ions were gi ven t hat aill patients suffering- fronm amielic

(Il-vsen t cry shiould r~emai n Ilospi tahized until thleir treat menit hiad lcii(oii- ee 

plelt cd. It is unifort una te tat a t rue evaluiat ion of the effects of t lie recoinmendi~ed thieralpv for aInlebic dYsentery' in thle Nort hi African aiid M\Iedit eriranelan tiheaters could iiot, bie Bladle becauise adequate diagnostic criteriai for

tlie (disease could not be formulated, and relapses frequently couild not be

(list iiiguilisiledl from possible reinfect ions. Curiously enough, probably becaulse of good sanitat ion, aniebic infect ion was never a. real problem in

NATOUSA or MITOUSA.

Poliomnyelitis

In tile summer andl fall of 1943, 1944, and 194.5, the question arose coniceri'lig" t lie treatment find (dispositioni of p~atienits suffering from acute anterior

l)olion, 'veiit is. nie 1)oic.Y iii respect to tilie treatment of suich patients. based

lupoltilte reconmmend~ationis malde by tile Conference Oil Poliomvl' elit is of tile

National Resca reb ( olilcil -w6ic (hidl not recommend~ t lie Kennyv Treat ment

-Was laid dhown in C ircuilar' Letter No. 42, 1 November 194:3, Office of the

Stirgeoni, I ciHeadquarters, NATOULSA. Standard Driniker resp~irators were

iiot requlisit ionied l)'v tilie tlieut er, biecauise tiliese 'ould lbe biorrowedh from tilie

Bri tisli, and patients withil pa rnlv sis thlat persisted after thle a1ciite hlliase of

tlie (disease wvere evaClliatedl to t lie U nit ed States.

Infectious Hepatitis

Th'le epidemic of infectious liepat iiis, whichi beg-ani in August 19431 and

mounllitedl iripidlY to it,; peak iii November of t limit year, ciiugh t t lie Nort Ii
176 AC'TIVITIES OF MEDICIAL c( tXsvm1'At$\,

African theater inl a state of int ellectuHal and1 phlisical unreadlinesss. All miedical

officers were famililiar. with a disease calledl catarrhial jahlndlic which inl t heir

k-linii(al experience hiadl been essenltially a inil(I disease occ'urring~, withlout,

sequ ielae, inl children and young" aiduilts., It was difficult for theml to comlpreliend what was hiappeningr-and this was trute of others who didI not wvit tuess

lie epidemic when, wit hini 4 mionths, more than 14,000) cases of hepatitiS.

Were adlmit ted to hospitals. Thle%- sought aid from their textbooks, from

their elders, and from their consultant inl mledicinle, to lit tie avail, becaulse

this was something new inl thle experience of most medical officers-. To be

"sure, a num11ber of them hiad wit nessedl numerous cases of jaundlice following

vciaion against yellow fvrinl 1942, b~ut this nturallY occurring isas

appeared to be different. Also, none of the medical officers, wvith poss-ihdv*

two except ions inl tile theater, hald followed their cases of lhepat itis inl 1942.

with tile lie numerouis correla tions that are so necessary if the clinical picture

of a (liseas'e is to be ob~tainedl. Thus, tihe fall of 1943 canl be considleredl as

a periodl inl which medical officers begani to learn about infectious hiepat it is

at the bedside.

It w~as also a. (difficult periodl for the patients, b~ecauise with thle succvessful.

assaulit onl Italy, many hospitals movedl from North Africa to Italy, where

it took timec to set tip these inistallat ions, withI thle result that there was a ,onls-tant preqssure upon miedical officers to ret urn patients to duty' in ordler thaint

bedls mnight b~e madle available for add~itional sick and wound(le flowinv" into

the b~ase from thle Army- Air Forces and the Fifth U.S. Army. At thle samne

time, the B ration had become badlly unbalanced owing to thle substitutions

a u1d elimlina tionls always m1ade inl that rat ion (luring- periods of st ress. Tihe

total sit uat ion was (lifflcuilt-uuledical officers were dlealing wit h a, dlisease abloult

which little was known, hospitals beds were ait a premnium. and the hospital

ration was unbalanced. Inl tile course of a tour of inspection of hospitals

inl PBS (Peninsular Base Sect ion) and the Fifthi U.S. Army manle inl Dec'ember

1943, C olonel Long notedl that marked variations existedl inl the therapy, p~eriod

of hiospitalizat ion, andl dislposition of patients ill withi hepatitis. There w~as

no unanimity of opinion amiong mfedlical officers concerning tilie managemient

of tilie disease, anld it appearedl that unless act ion was initiated, a chianc(e to

make a fundamental contribution inl respect to ma nagemlent would be lost.

The Surgeon, Peninsuilar Base Section, requestedl the assistance of thle consul11tan t in medicine with this prob~lemn. The hitter recommendled that , as

soonl as the 12thi General Hospital arrived inl Naples, Colonel Barker be given

the task of assembling p~ert inent informa tion concernin~g thle (hialgnosis, t reat -

linent , andl disposition of patients suiffering from infectious hielpatit is. This

recommendlationl was maide because it was known that Colonel Barker had

stutdied tilie hepatitis that followed vaccination agrainst Yellow fever inl 1942

at ('amp C'uster, Mich. Colonel Barker began his work early inl 1944 and

obtainedl enough information to permit the consultant inl Ifedlicine to make
.MED:ITERlRANEAN THE1~ATE~R 177

tlie following rep~ort to tilie Surgeon, IPetinstzlar Baise Sect ion, on I MaIzrchi

1944:

2. Withbin thbe past fewv weeks, r'itirr'wt's of lielut itis with anit withoulit jaundice,

which are mnarkedl b)'y ano~rexj:a, dvNspt'psia. fat iguie, or e'nlargedt. painful or l ender liver, have

bt-ctue iicrvas.iiigly frequent. These recurrent mianifestat ions of liepatl is are very similar

to t hose nioted l intlie Course of tile elpi(eniiii of hiepat it is which followed iiioctilat joll wit Ii

ctrtain lot., of 'yellow fever vaccine. T~o date, however, thle severe instzlinces of thle disease'

mai~rked by a ralpidlV ' vrogressinig cirrhosis of the liver wvithI ascit es have beeni rare. Thus,

it lizs lbecomhie clear that iii thle p~resen t ouitbrteak of hepiat itis, the sequuielae which marked

Olit *j.1tt1iiule folhlowinig tile ,yellow fever jinocuilationt are beinig repeated.

3~. It is, impossible to state exacty Ivowv lmech of a1 role insuffhicienit hosp~italizat ion andh

ci) v a It scenlt care p)1 a'v iii the itprodi c(Ijtio of thle recuiirren ces or relapses of liepaitit is biecause ~ adequate data lupon this potinit are not available. However, evidence is accumlllat intz N\hich

show.,s that man' ,vCast's of lhepat it is appear to be discharged from hiospit als, convalescent

St '(lit 111, and1( eveu*n frtom per'so i nnel cen te rs be'fore' thle dlise'ase is complete' tly arreste anI:iid

is a re'sult of thbest' 1pr~inattiire dIisositioiis, recurrelices or relapst'sof thlit disease are occurrhin.

41. If t'x prielice rtepteat., it self, rtecurrinig wa~ve's tf lit'patit is wvithl and wit houit jatililidct'

Inay' heetxpectu'u inl this theater tint il tI'toti) tispersal is ehlt'cttd after the cessatitun tof host ilitites.

It is theirtefore netcessarY toemnuiciatt' as promptly as possible, thtoste cr'iteria which will e'nable'

meitdical tutlictrs to dhisptose (If Caistes of hepatitis as ('fhcieiitly, as potssiblet inl order that a maxitnmin oIf fit individuals he ret'turned to (fill\.. H~owever, absolute criteria for miakiiig ethicitnt

dhisposit ions are still inl thle experitiental stage aiid a finial answer awvaits the a(ceiiiiulatioui

of experimettutal dat a. Hloweve'r, certain observations have been niade which ar(' helpftil iii

letermuining I lit' physical statuts of patients who have been ill withI hepatitis. These are:

a. lr'd ifrmciiajtidewiIiaicruitlxviciswthtnormiallimiits.

1). 'lT'e absence of signs of anorexia, dy'spepsia, or food intoleraiice wheti t he paZttieiit

is placed tupoii th li'(xpt'dit iolarv force 'It' rat ionl.

t.Laklf fatigue athe end (of the daY, and the absence of aii-v liver elreet

pain. or tent'nitress late inl thlet aft ernoon afte'r the patient has bteii tip all day. Thle vnllargo'-

iniitii mt 1st lbt detetrminiied withl the patitent inl th liti prifjht positioni, and thlit tende'rne'ss call

beust lit elicited by a light qutick blow with the dotibled fist appIliedi jost below the costal1

mairgin inl thlit right anite'rior axillar 'v line.

id. Wtork and t'xercise t olerance muist. be adeqtuate andi( nott prodtuce jatindict',

I vspepsin, l ivter enulargtueiint , pain or tenderness. This is best dete(rmineiid by IutltIiitg

pat itniis con valescing from hepatitis thbrotigh a gradutat ed st'ries of exercises followved iimtti'(liate th vt after each (ex(ercis(' or wotrk pe'rioId b)y car('fmu observat ion for hi' atppearance IIf

jattiidii't' alitlrtxia, t1\.lvsjIe~si:t, tindtie fatigule. or e'nlairgted, painftul, or tendt'r livers.

5. P~atients stuttering frolm hepatitis withl or withlitit jaundi('i who shtIw a persistenict' tf

jauututice. anortexia and flvsjppsia, tindtue fatigtie or enlarged, paiinftul tr te'ndetr livers slitmiltI

be evacuiatet't frtoi field, stat iomn, and convalescent houspitazls tot general htspit als for furt her

iob.t'wm ition, t rt'atmen t arid th isposititni. All suich eases aiid all rtetiurrt'it or rtelapsing cases;

ttf hiepat it is sinhuld be earefiily~ observed acctrdinig to the stzggt'sted schedtile as oultlinitet

abtove. aniii if jaundtiict' tr dvspepsia petrsists or wtork an e11txercist' ttolerance tests (It) lit

show a protgre'ssive' implrove'mienit, and Ilt'e livt'r colltntines tto be'comeit large, painuitl or teidter,

hIlen stich pat it'nts shlitil(I he curt'fuull v consitd'red bY th li'iiedical dispositionl boards 1 If

gi-neutral ltusp~ita1 ls as ctdidtitlate ftir evacuatitn to tht' Ztine of the Interitor.

6i. Itt o~rdetr tot facilit atet thi' eflicie'mt handling (If pat ienits stutfering frtom hepatitis, thle

followving rectimniemidat ions5 art' made to Tht' Suirgeon. Peninstular Base Sect ion:

a. That a Suirgeon's ( irciflar uiptut the suibject tof liepat it is, Comnpiletd by Lieuitenant

Coloniel Marion Barker and t he Consultant inl Medhicine N AT( )USA, be issited immnudiato'l

tto all imt'tical c ,ice-rs ill PBS5.

5649170-- Col.--- 14
I. ii:1 II,1sili:11 cii . Inulim i uiiu (i ('~iu. f~ 14 tPBS urfiu- iI ii oll f ;ut- luI ililsdi:1 if lufuu tii r li

C. Ij I I ll 11,p f~~Is iI\l ie giprvdu Ies\ hiiI :IIII iluiui or vI: 1114. ill h pni- s eiuii'-' Ile if:

I.ictf- l:u1hiitiii au u~ voniiiciiol ~ss i u~ul co teitil the iu oiflhtti iii ~ip~~from5tuS~iiui 

4o :1lIllt('il rC ()iiiiI );lt l0 i ( s 1111 ;iltCl ordl lo i repoit WeIhis ig:11 umf- ept 1e:1 lvl I lie

1104i . hvtei :1(1(14i o l'l % vsele alot stesvhd f or I le s i l lok ''hitis iii I lw 225 14 a roitof (ofoils nlcri'e Mo ldav Ie61 oa- MzIn~-ite l)91I. , T h.s laos cld ho. 111:141v \fel(' . hYiu :I

l )Ie HroIMi the propoed. livIuilzir oetliiiv issuedli oY theelSm-itrvon thate.OVS
M EDITERHAN EAN THEATER 179

NArt'USA. This circular letter brought up to date the availableinomtn

in resp~ect to infectious hiepatitis and stressed thle therapeutic effects of at

high-protein, low-fait, high-cairbohydrate diet. Circular Letter No. :37 drew

severe creit icismi fromi certain officers of the M edical C'onsult ants Division,

Office of the Surgeon General, b~ecause of their disbelief in the existence of

ccertain of tilie Clinical typ~es of thle (disense that liald been dlescrib~ed, t heir (usiig~eeiiieit. with ttlie (litngiost ic criteria thlit hiad been est ablishied tiheir dislike

of the met 110( of treattinent t hat hand b~een p~rescribed, and finally their featr

lint thle reginlie em ployed inl thle trea.It itient of thlese lpat ients WouIld p~rodu~ce

psvclionciirotics. niat thlese crit icismns were unjutst ified wals (demlonst rat ed

lbv thle record of thle theater in respect to tilie dliagn~osis treatmient , land dis,-

p)osit ion of patients, wit h inf ectious15 lepaltit is.

lIn t ie( faill and early winiter of 1044, htepatIit is aigain becname epidemic in

NIT( USA. This I iiiie, tilie air. force anld base section troops (-litte off a11lmost

iuiscathled, e~nd thle bul1k of' th lenses were report ed froiii tile infaint cv unit s of thle

Firfth U .S. Arnti . lliis outbrelh1k p~rovidled aiiot her excellent I )1opp()t unit.% for

lie stli~ldv of' tilie (lisense. lImiport ant (ontribt 11)1t115were in ma11de by mted icalI

officers in resp~ect to tilie valuie of tilie various tests of liver func(t ion ill ('arilY

d imngolsis; thle imiport anlce of uisinug thle Itighi-prot eml, low-fat , iigl i-ca rhol ~diVrte

diet was couitiriiiedl; tilie tiecessit v of usin g tilie exercis'e-toleraiice test for estaU Ilisliing cure was reatflirmvd ; an tidmnport ant p~athlologicalI stiuldies were iiia1de bY

Mali. Thomas N. H oran, MC( , It. ( 'ol. Tralcy 1. Maillory, MC , land ('apt.

Leslie. S. Johlifre, MC( '. These inivestigaltors ultiliz~ed tile peritonleos'cope for

olbtainling biopsies of tilie liver iin various stagies of tilie (disease. It caii ble said

wit hout hevsitatIion that tilie Iilmanagemlen t of cals(s of' liepa tit is dutring. thle faill

and wvinter of' 1944-45 wats iifiuiit clv sup~erior to I lint of' thle previous winter.

The total experience of tilie thlenater regardinig tilie (diagnosis, treatmienit lanid

dpisilot ionl of paittents ill with Iinifectious hiepat it is was suini mied 11iP inl C ircular

L et ter No. 2 1. issuedl onl 20 June 1945, 1) the (Office of thle Stirgoeon. Headquart ers, TOSsubject: Infectious Iliepaltitis-.

Diphitheria

Alt houghli (lifthiteria never becamen epidemic in tilie thlenater, it alIwayvs

calise(l (conierii lecti use of tilie rein ti ye umiifit niinha t v of iiiost U .S. pra(ctit ioners

with thle (hisealse in *volung ail ilts an ml heauedn i rn pthe eeahvvs

tragic andi avoidhable. C ircular L et ter No. :17, issued onl 2 October 1943, bv

tlie Office of tihe Surgeonl, Heaidquarters, NATOUSýA, st ressedl tilie iniiportanice

of thle early d iangosis anmd treat menit of Ii phtliteria . In t his let ter, thle use of

large doses (fromi 50,000) to 250,00() uiiits) of antitoxin wals r'ecommndiediI~, and

tlie necessitIy for keeplinig soldi ers ill ivitlI Iid11ipl ithria iii bed for conisidlerable I

periodIs of Iim e (fromt 2 to 4 weeks, or more) was Ii~indicted. These inijuxnet ionus

"-ere based iipoti realization t ha t thle (definlitivye t reatm ent of thle disease iii

soldiers woul d prolial hdv occur, at ait lter' periodI thin I ill ci vilial p.iti pticIs. Wit hi

lie ajppalrelt delionost ratlonl wit hiii thle theater lint therapy w-it h penicillin
IACTii tin>1 FS 11 'i t'\1 I'll . i'\,,I LTrA\TIS

4-.11

loo
ii Ih! itii I14( l 'i'hii ic i st ()I I. * U4II ;ll dine,1111c IIIi Sii'xe [()e t -I iiii' t ,iI.u If):,se

III :411 (')\l j i 41 I441I114 i' 14 '4 I '-(44114 (4 I I i'. ( '11 44'la I 14:4 till N o. .- t iii l III(41

h- l,1 ) M ice ()I,~ I- 1 srl-cii ,I~ 'I l~ ,I ,k . I In rIi i v ui-. N AT ) 'SA .~ All :q ,in'ir

I I4 I Iit -I ''I ' I, * I j'' 1 1 Atr- 'IT I .. 'I g 19 ' I 1 ', i 55' (-()'it I II ( tIm i~- (f A I I In1, i:1111 11rii

\ ITO Hi 1 1. :1e h 1 11 . 1 11l I lc 1111 1o 1
182 ACTI VITIEFi OF MEDICAL CONSULTANTS

Organized immediately into sep~arate batt lions and then a gradual process of conditioniing

for combat shouild be instituted. Thet only care which imust be taken inl this program is

that it be gradual, that during the next, six weeks these men must not Ihe exposed to freezing

or near freezing weather under conditions inl which their feet itill be damp or wrel, and their

feet miust be kept dry and warmi. It might Ime advisab~le to have two medical officers, one

i'xlerii'ncett inl the treatmnejt of "Trench Foot"' and one inl orthopedic surgery attached to

1hues battalions during the training periodl. It would seem quite certain that if this progtrami couild Ix- act ivatedI immnediately. a considlerab~le grouip of experienceed veterans would

he' readyV for c'omba)~t by 15th of April, 1944.

D)urintg the late spring and eairlv summer of 1944. certatin incapaicitatinig

late sequtelaie of treiu'hfoot were ntoted, and, inl C irculiar Letter No. 41, 29 *Jul ,v

1944, Office of tdhe Surgeon, Headquarters, NATOUSA, it was recomlulende(l

thlat p~atientts showing, the following signs should either be placed on limited

dties or' be evactiatedl to the Zone of lInterior:

(1) Paini anid swelling of the feet after walking short distances.

(2) Loss of cormmifietl epit helium omi the soles, resulting inl tender -t issue paper"

skill which is ver * pronue to Inister.

(3) II l~erllidriisis withI vasomnotor changes.

I II igh rate' of epidermnoph'v ton infect ion.

()At roJph v of thlie sulbetitaneOuls [t issumesi amid imuseles oif t he feet which restmIlts

inl aiml i mite breakdown of thet transverse and lonigitudinal archies amnd whichl at I imlicits Iso5

imimrki'itllhat shoes of smaller size mnay be re(mitiredl.

En rl * in the faill of 1944. at conferentce wias held with the Surigeon . Pen insuthar Basle Siect iot, the theater consultant ill sulrgr-vv and cer'taini interested

iliedihial offic'ers Ilj)olt the sub~ject olf tren('ltloot. The r'e'ommllend~ationls Itiatle

In this tzrou~, aift er beingo 'oord(intat ed with Ittlie ,-;llrgV0II, FifthI U.S. Ar'my,

NWere incorp)ora t ed it) C ircula r L et ter' No. 2. issuled onl 2 *TanuairY 1945, b.% the

( )Hiee of t he surgonol, I leadq iti ters, NITOL SA. llThey read ats follows:

-1. 1T114 n1ilammgemnit'mmt of ''Irm'mchi foot'' inl thle first vech'loii

nu. U nlt'ss atli mu gangrm'iu or a stiperi'iiityosid clinical infect ion reqirtiiing imuniedlialt

suirgical ('are is foitmnc, all pat ients suftferinig fromi ''trench foot"' should Ibe sent to thle mledical

ýVrxvivvs of first echelon hospital units. [lvacmmatioll and Field hiospitaish.

5. Thel( mnmag'iinelmen of 'I rt'm(hi foot'' inl 0lie s-conld vechelonl:

'I. P31 iemIts smtit'erimig fromi "'In remich footl' umllicivntly severe to rt'quiirt evactiatioi toheit

secVOttl vechelonl mmsmlia .v sholild be trtawet inl g'mueral liospit~uhS. 1'at i'it-1. Will 1e :IdlmiuItted

IoIlt sini' rgi c:t I se rv i (' ili thlit seco n d 'chit 'It m hospitals ilpm n presen mce of ganigrenev or infi ftcion

for which siiirgit'al t realimemut is necessary. Otlit'rise, they wvill be senit to the nmedical

sen ice 4 f t liest' hotspitarls.

'Ip. lThe p~ropeitr disposition tif pautien:ts siatlerhig frtom 't remuch foot'' shtimmh lie :I minIti'r

of primary* conceern Ito the dlispomsition boards ili slat ion aund gt's'ra iosp~it:dls Of 114 hest'eOmud

i'cl~vo'hi. It in nsf he rv'epl beihrel thaut tr/ui/c, it is t/he pripmory did.'j oft the .1levitiral Departmenet

tip mafirtain ['onsri'rm'] manipolrer, p)atienIts sepit bark to general or lim ited as.%'%QigrimeIt.% inns/ he

alble tip per 'form the did ies reropiunneuided by the Mledical ('or ps. It is of little valule top sepidu back

(I 111MI1 Who it-ill promptly become at ph ysical liabilitY to a service or combat upiti. fllu'ce, Ilt'e case
MEI)ITERRANEAN THEATER 183

of each patient must be strictly individualized by disposition boards, and the type of duty

recommended be based upon the known fact that a patient who has suffered from "trench

foot" is very susceptible to cold and wet and may be unable to march or stand for periods of

timie without producing a return of symptoms. Therefore, the following broad criteria are

suiggested for the disposition of these patients:

a. General D~uty. The patient, must be able to pass an exercise tolerance test similar

to that outlined for hepatitis in Circular Letter Number 37, Office of the Surgeon, H1eadquarters N AT( USA, dated 8 July 1944. The skin of the feet should be normal, free front

lesions or loss of subcuitaneous tissue, and anesthesia, paresthesia or marked hyperhidrosis

should not be present.

b). Limited Assignment. The patient should be. able to stand~ a two mile walk or

two hours on giiardl duty. The skin of the feet should be normal, free fromt infection or

loss of stibibctaiieolis tissue, and anesthesia, paresthesia or hyperhidrosis shouild not b~e

p~resent. In recommending the patient for limited assignment it should b~e stressedl that lhe

should be kept away fromt the cold and wvet.

e. Patients not falling into the two categories mentioned above, should be considered

indvidialy s possib~le candlidates for evacuiation to the Zone of the Interior.

Fort unately, owing to thle provision of mnore suitable footwear and t~o tile

static Ilat tire of thle tactical situiation in the nort hern Apennines during the

winlter of 1 944-45, t renchfoot wats not thle prolbleIn that it had lbeefl the previotis winter.

Sandflv Fever

A mninor, though real problem encouniteredl by Colonel Long (luring 194:3-44

wits tile hesitancy' of mnedicall officers in makinig the diagnosis of sandflY fever.

In tile suimitner of 194:3, this dlisease wats prevalent, in runisia and Sicily* and,

later, onl thle Salerno beachhead. Despite thle fact that. thle clinicall picture

Wats Clear cut, thle diagnosis of saindfly fever wats made in only at smallII fraction

of a percemnt of tilie total cases, wvith tilte resuilt thatt FUO (fever of undetermined

origin) isrpre to it dge enirely out, of proportioni to its acttull

occturrence. This sittnation resulltedl froin an unfamiliarity with thle dlisease,

froni lack of at dhiagnostic test for it, and fromt intellectual laziness oil tilie part

of minedical officers. Despite an intensive edtucat ion camnpaign catrriedl out in

19431-44, it nia *v be said that it wats not until the sunmmer of 1945 that the

reporting of saindflv fever Ieeciulie satisfactorv.

Ttiberculosis

Late in 194:3, tile 46thI General H~osp~ital, Mediterranean Base Section,

lie 6ithI General Hosp51ital, Atlantic Base Sect ion, the( 24th General Hosp)it al,

Eastern Base Sect ion , and later, early' in 1944, the( 17th General H~ospit al,

Peninstular Base Sect ion, and1( tilie 26thI General Hospital, Adria tic Base Section,

were (designiatedl mis ('enters for the diagnosis, recep~tion, treatmuent , and1( dIisposit ion of patients suffering froii t uberctulosis. This plan of hospitalizat ion

was originally recommnended b~ecauise ( olouiel Long believed, Onl tile basis of his

observat ions ini stat ion andl general hospitalls, t hat thle diagnosis, treat iileit,

and1( disposit ion of tubilercul~osis patienits wits niot being very well llaitiagedl

becauise of at lack of knowledge of the (diseaise and lack of initerest , once-( thle
Is I Ac~'I Vnii-:i'> (ii, NiEDWttAL. c((NStJ.T.NTS'

d1iat'ttosts hi31( beeti itiadi. ()tt till. part of iiios't Ileivael(31 ofive't'. lDurii l till

lat ter' par it of 1943, thlese' cent ters, especial ,Iv the onie III th MwN edit errnetan Biase'

Sec'tion, funti(' onied well, biut owinig to a1 lack of iitIdvS(IIdts ithiti oil thle part of

lindedial offiv.ei's ill ot her hiosplitals of thle futidait ieitll1 purposes, of thewse centers.

liev d1idl not reach h1igh st aildil.d3 .l of elf H'ieticv utitit(i t1 following t"eioao i(II0*11 II I

d.lea " \%g-Wilt Iit hvi' futi.'til 101Wis publishied.lit first local llv iiitlie 1'eninsiiisar

Baset -Section, Aline 19144. atm nd ht cill Ci irtila r L et ter No. 41I, Offiche of tit1w Sur-

~et.N A'I(TO SA. 29 Ilti!%-1) 944

il t ill- gt'il'rai hilo..jlt ii. xlicht, m beenx dt''i esigna~ted' as~ "tihei~rviiit.i r''jd ioll cente'rs"

%\ii ll ml~ilage. :ni hdisposeM of all1 p1ie:tl 'I sutirt'iiig tromt active tubeiKrc'ulosis.

1). All pal iv;its ill \%holin tilt' act i\ it ' % of ai rt'et'i or oldi I iihervifiosis is a 11111itcr

iif dotidt will Ili- m'3ii1to a -'Ilihl'r'tiloio., r'evi'jtionl vener"t' for :illi e'xaiiat ion of t heir !i-tamIN

:tjtt if follow-iip elineks are' dt'~irahit' pat ients w~itliI doubthful leionllls wiii hll, re-t nrn'd to :a

"oIiit.reiaiosis r'et'-ption veeit'r'' aftcr f lit- adivisted initervali. for till( nv'et'ssar v diagitto~tiv

tt'is,. 'iht' -Itibitr'tilo"is rect'ption ventenrs"' xxillimi litalin inl their patient re-cord tilt' lu,,

ltllatt' rtecordis of pativnlt' inl whiomi tiit( diai~zio~s(i~ f Iilihircilosi. , k oilitifil. aind wxillim-rst'r-xv

:all X-raxv fills of ýuv paii 13:11 itItt 11iiti' Ow cam. is t'iomt'. These recoirds wxillh Il- adi availiablit to outer "ti iht'rvuiio~s ret'ept ion l'l'ltt'rs" 1113011 requenst.

v. It %%iii ihe then rt'-jlt3Iibiitii v of lthe colImmidiniiil offivetrs of flth- "t iiisretiiosis

rvt'('t'jion ,'t'ulttrý ito not ifY fltin' edievui oilie'r of all . onrttniaii/:i 13, ill xxicihi all ''(tjtt'l Cvist'

of tvibhtrt'ulosi6 is dii~eox'rt'd. of till- t'\istt'lt'' ttf stch a1 c'am%' midi it xxil ithen be, f lit- rt'spon.,ihilij x of i he' litlit filt'dival ttiii.evr ito inltiitite proiliptl lsucLh Attd~iv, n, a~rt' .'oil:ititrt' nltv'ssary

for flt-n del'tt'et ion f pulinonar * I uib'reititosis ill iit illi~ae co(tltacts of tile pa~tiet.ll

di. Pat ienlts suffetriniz. from activ nixt beIItrclosiits (or ill whom3l1 t here is a1 quetstionl (if

M-1' ixit V Whitlel %xiiill f'sl~t-SA :kIt follOXV-1u) tp itdi's. xxili ibe t'xaeit~itd promlpt IY from l nl iia'dirmitlit ng of stich pativie'~s, Ilt'e holspitali delt'tilatii lol(f till' pativ'nt xwiil Ili- poirtnenl(Itly tllote'

upon ttl iI) 'orin 5d2I.

Iollowuimr t he publication of this, circulair letter, the triiige of jpiti(tiets

sit Wren tig front iito liertillosts to t he "t libet'culosi, "eti t et's' becat tue ex~cellent ,

.1t1d withI it thle 'arte an td dispositioin of ti( plie ji teit ts 111rkedl Yiimptroved.

D ermnatologicail (iotuhitions

11 v hbe fitl oI.f 194:3. it becamte ev'idenit to till v'()tisitilt 1 t ill tiied icitie t hat

1111p('(1111(1 clidbe titade ilie tillwmthiods used for tit(w tInankt-enleuit of

pat ttients withI d iseltses, of t1 leSkitll. A ft .T' ('Otlid(i(('tig V'IIH 11 U 1 iieaStIt''S t 0

ii i'iOtlpii t his enld, lie ('Otlitti ttie(nited hli. vie'ws to thle Stit'gt'oi ,NATOUS A,

ili thle followitig let ter' da3ted( 13 Nov'etiher 1943:

1. t'rnlmltoiogicai (condtitionls (t'chiudiiig sxphiiis) aIre' ntlt being properly' tret'etdl inl

N ATI )I'A. This is i-spt'cialyInxtro' of t'czl'ila aini fuitiglias infect ions of tilt hands11 -%tll fet't'

2. Thre~ art' few qtialiheiv d'rmuat oiogist s inl N AT(it sA.v

:3. Twxo v'x't'Ilenl v * trtiiul'l detrmlatolotgists art' upon11 tll, st aff of tlit' .1thni Geneirai Hos)-

pital xxilie oile xweii tratinet'd and1( one fairl% xxt'ii tralillt'dermatoru lolt~gist alret' 11511 tilt staffT of

tooit' Iill felit'r. iilsslt:lit. lPS
3 EDITERRA 1 N iA N TI' I iAFE It 1s

FiciW1it 5,7.-611b k'uienerzti 11 spilal, U-1ghorii, Italuv, 19.-15.

pitali (fig. 57) 1118 be (i(~iiriated as dlermatological ceniters andt thati the faciitiiies of tiht~e

hlosptitals be aadt aivailable for c :'tifltai ion, diagnuosis and~ treatment of skinu diseases within

their respective Base Svetjotus.

Thiese recomnmend~ationls were accepted. Early in 1944, a third dlermaltologwc cenit er waIs op~enedI ill thle 45th1 General H ospita~l ill Naples. It calli

lbe saId withloiit hesitat ion thlit tilte est abllishmiient or thlese ('enters (reated a

rene1weld jut crest inl derinatolog-ic problem, .11d I lint a dehnlit e improvemnent

wvas eflivetd~ thlroug-hliot thle thlea ter inl tilie t reatment11 of dliseases of t(lie skill.

PEN\ICILLIN

Tile Iieicalcil use- of, penuicillini ill thle North Ahicn~~ t heate beu'le-anil uthtle

Iii e stliiiiuer or 19-13. At tha lit iii, because thle suppl* of tilie ag-ent was.

Ijiniji etl its use was rest rictedl to ca1ses ill Awhich stihl'ouiauiiid(e thierap v rehl short

or exp~ectat ions. Dutriiig thle I'all of' 194:3, thle supp)ly)Iv lcaile more abnliiuila

;111d, ulpon the recommendation of' ( 'olomiel Long, most of* thet penicillin that1

\%'.S nra ila Ide ror. imed icalI pumrpose's was, (levote((i to tilie trentimenlt or noirriwnc

\vhich had proved resistant to thler.1py withI thle sull roumnit)ides. BY tile enld o4

Ilie wiinter of 1944, enumoimlJ penicillin was available ill thle thlea ter to p~erumit a

111011ore geeral use of, Il. his anibiot 1 ic. The lill treat iilent of, all cssor g'1onorrheva
tititi 5V1)lilis With I jiiiilliit ~i Was5 tilitiit edl ott I August 1944. It was t lie

polic , iii thle North African t heater to Follow thle inst ructioins r-eceived frlolii

lIhe 0I Iice o t, lihe -;Irgeovon (I II enI Iea co I Icer.IIi I Ig t lhe 1i1et Iic-2l u Ises, or tetIIivicIlI II I

As at result, t lvTe Wats litt le exIperinlteittlt ion wit Iit Ihe p~roduict ,and it is felit

I hat peinicilliin was hot It ellect ,velv and ecolonoittczllY uised ill th 1t Ieiatetr.

D)ISPOSITION OF PATUIEN'TS TO ZONE OF I NTEIOR101

the Peniniisular BaWse Sect ion with its iiiiinlerolu' geileral hiospitali s (Tealted .i

pr'oblemi ill thle disposit ion of' patitents to t1 liel ote of' Intterior, whilch had not

exist ed to 211 li (elegre whlen thle geineral h ospi tals were sit uaited iii N oirtI Africa.

I uriiig. the hat e fall and1( winter of' I943 -44. many it patt jetis had to be evvacuaited

to N oirth Africa rrot i Ital v lin orifer that 21 relasotllabHe st 21 us of, vaicai it beds

uIiiit 1w heIiiailinituied for. ailv coni in igoeitcv thlit Ilight airise. Th'lis uiie(iuit t hut

Ii1111 * N piitieiits. recommiieinded bY the mediecalI (lisI)osit ionl boards of' geiierall

h oslpi tal s ill It 21lv, were sentt to hiospital1 s iii NorthI Africa (fig. ")S) to await i

vvlctillit loll to thle zone of Intter'ior. lit D~ecemiber 1943, compilaIintts were

fielird friolit tw l 'ieglternd hospitals ilt Italy t hat ii11iaitNv such pat ieitts. being reviewed 1), tilie im edia 111rds boa of' thle gvenera hospit als ill NorthI Africali, were

beinig rett iirue I to 21 geiIteral Iservice clit egorv. As at resutl t, thlese ittit~ we're

lieul rettir-Ile(I to their taitits ill I tatl, where, withlini short p~eriods of t itlie, t hey~

hrequiem t lY lilt( El I return~i to t heir orilgi itll (Iisellse and1( weire rellosIpi t illizedl, t herepeTWr~v k and ot her tievesslir , processing. BY tilie first of 1944, thle situatit on

i1e1i cted it1)point w I ere thle mi edIical Iservices of tw l vie etidi h ospitalIs ill ItlIIlY

li tid iii N oirth A rica begll i to qfutest ion eachl other's-- professiotil (I till11 lit ica t toils.-.

At tii lrc u ftleSi goitleclsl lltti Iiiedicitte tiladea lthfor-oiiifi

st Ild ofr this probldem and1( camelt to thle conluictsont t hat t li root of th le vil Illyv

ill a1 Ill istiittlerst it mid i 11g ott thle pa11rt of t he generad hiospitalis ill N oirth Africa O;r

lie vilv roliviiiet Ill coniiit ionis exist ing ill forwlid ~ll-iriiy, air for-ce, mllitd bllse

1i ielis. Upo P th le recommttendtlit ont of' thli conisultantt itt itieclictite, thle Sutrgeoii,

N AT( )ISA issued i ilist i'ii im iis "it C ircular L et ter No. 21 , (flited 3 April 1944,

(itt 111inei g the dIislposit itn of' pa1titeit frnts r i-i tled ical ser-vices. 'Ihiese luIstIIIiclions wverv based upon thle iii tIII-l i2l Iiist ory, of' certa l ii(Iisellses ats oliser-ve ill Ilit

theat er andt~ uplon lilt aipprilisill of' citvirotli tiett Inll fllct or tha ill thgh t inifluetnce thle

co01iI Or of e cell diu iseases. Il foriti111111t ihtg t his pl~oicy, slpeciild conid~(erait itn

(r25 ivenl to estab1)1ishl h si ii igelit tcriteria foi' thle c die Iisposi tioul of' key

('OiiIll issioitedl Ipersoitel andt~ Medical C orps officers. The imiportantt poinits

of' policy established werev its follows:

I. I'Tin' followijng iieniormiditim is based'( upjoni expvrietlee gaiiteil ii this Thleater an~d is

to he Itsef a1s a grili(Ie 1) N Ilnieitil offuiicers ill fortmlatI~zing thle (fisj)ositi 01 of certain p:0Imiiens

froiit field, evcu 'Vll~lil lhi( and saimi 1 Iusi~ituis to general h spitals mtid fromi the h~iller to lilhe

Zone of the Interior. Thuis tnciviorainluin is to 1e used :is a1 wtid, mid~ not as at dirclrt~,' jiold

suotiild he soI inivitereteI'i 1).N medical dlisposit ion bioards of genleral hospjita:ls' especiall.N wtu'ii

SlICh IMMAS:krvl at(IV deling %%ith tit(- die fsjOit iO -f meiidicalf officers or o1tier keY comnIllissiole( I
M.l )ITE'RIZANEAN TtIEATER 187

personnel. It is of paranmunt importance that the manpower needs of the theater be safeguarded, but at the same time it is incumbent upon medical disposition boards to make a

careful estimate of each patient's potential effectiveness, in order that effective manpower

rIay be maintained at the highest level, and multiple admissions to hospital, resulting from

recurrent or chronic disease be reduced to a miniilum.

2. A study of the natural history of disease in NATO(USA has demonstrated that under

the conditions which exist in this theater, the occurrence of the following disease entities in

pat ients may be construed as relative indications that such individuals should be considered

as candidates for limited service assignments (if medical officers or key commissioned personnel), or for evacuation to the Zone of the Interior. When the indications for evacuiation out

of the theater are considered absolute, such a statement will be made.

a. The existence of the following disease entities may be considered as an indication

that the patient should be evacuated to the United States.

(1) Virus diseases.

(a) Anterior poliomyelitis with persistent paralysis. (b) Encephalitis

lethargica (von Economno's disease). (c) Equine encephalomyelitis.

(2) Bacterial diseases.

(a) l)iphtheria with a complicating persistent (6 weeks) paralysis, or any

definite cardiac involvement. ('are should be exercised to see that patients in the latter groutp

are not evacuated! until they are entirely free from clinical signs of eardiac involvement and

essentially free from electrocardiographic changes. (b) Typhoid fever complicated by mulliple relapses or by perforation of the ileum, generally requires a prolonged period of convahescence and such patients should be evacuated as soon as their condition permits. (c) Recuirrent undulant fever. (d) Active pulmonary or other types of active tuberculosis. (e)

Mycotic infections such as actinomycosis, blastomycosis, streptothricosis or sporothricosis.

(3) Protozoan infections.

(a) Malaria with chronic cachexia, resistant anemia, blackwater fever,

repeated attacks of the cerebral type, or with repeated attacks of the disease and a permanently enlarged spleen. (b) Recurrent amoebic infection which is resistant to therapy

or which has produced a chronic colitis.

(4) D)iseases of doubtful origin.

(a) Acute or chronic rheumatic fever. (b) Disseminated lupus erythenmatosiis. (c) Sarcoid.

(5) D)iseases due to allergy.

(a) Asthma which is persistent, resistant to therapy, or to changes of

environment, or which due to frequency of attack renders the diseased individuad ineffective.

(b) Recurrent, treatment-resistant, disabling angioneurotic edema.

(6) 1)iseases due to chemical agents.

(a) Chronic lead poisoning with encephalopathy or hypertension and

vascular changes. (b) Proven, persistent damage to the hematopoietic system produced

by chemical agents.

(7) D)iseases due to physical agents.

(a) True sunstroke (not heat exhaustion). (b) Frost bite with gangrene

resulting in incapacitating amputations.

(8) I)iseases of metabolism.

(a) D)iabetes in enlisted personnel. (b) Proven gout. (c) D)iabetes insil)idus.

(9) Diseases of the digestive system.

(a) Proven peptic ulcer in enlisted personnel. (b) Proven cases of mucus

or spastic colitis. (c) Regional ileitis. (d) Recurrent intestinal diverticulitis. (e) Proven

chronic pancreatitis. (f) Cirrhosis of the liver. (g) Chronic persistent, infectious hepatitis.

(0) Relapsing or recurrent infectious hepat itis, with or without jaundice, which relapses or

recurs despite adequ'ate lperiods of convalescence and reconditioning.
/

k

"V

N

I
MEDTEIANA1,TEAE
190 AC'TIVITI ES 4)F" MED)ICAL CONSU'LTANTS

(10) Dijseaes of tile respiratory system.

(a) C'hroniei, pe rsist ent brotiichit is associaited with piv hsicalI sign s al (Id X-ray

changes. (b) ('lioiiiaI, radliograpihically proven, miodlerate or severe lbrolicliiect asis. (c)

Stiilaciite or chirontic lung ab~scess.

(11) D iseases of thle k idney.

(a) Parox ' smal livinoglobintira. (h) Acuite or chronic glonierilor or inlterst it jal nephrit is. (e) Nephrosis. (d) Proveni lyelonephrif is. (e') IPv - or hydrolnephrosis withI decrease~d futict ion il tOli ofther kidne v.

(12) D ise-ases of lbloodl-formilig omrans.

(G) Treat menit resistant sevond~ar 'v aneiiiias. (b) lPernivioins :iv~ilini ill enlistedl personnel. (e) Leukemia or Iivinpthosarcotiua. (d) H odgkin's (lisvasv. w) Idliopat hic

thrombilcy: topeiiic ptirpiira wvit Ii ellarged( spleenl. (f) Ileivlolyt ic icteivis. u-0 H emaophlilia.

(h1) lanti's disease.

03:) Di seases of f ie( circulhatory s 'vsteiii.

(a) Chronic valvijlar hevart diSease except t hoSe ilstance~s ill which the

lesions are minimal and there is no histor * of recevnt riennniatic at tacks. (h) S ' philit ic \a-.f

vuilar dlisease or aneinurstit. (e) Stibacmae bacterial endlicardiltis. (d) Proven. clironii. mlvocarflial (lise:se with signs of ftinctional failure. (e) Proven essenutial htYpertension inl Efltisle(

person Peenl. W f)'' irom il Hingi it is ud diiera is. (g) Prov eni corona rY occi uisiln oi r inisiinfticienicv.

(ht) Angina pn'ct ris inl cilistsd jpi'rsopndm.

1 41) 1 )iseases of t he ductf less glands.

(a) Exoplif halmic -goiftre. (b) Addison's dlisease. (c) P'roveni hvpo- or

livl)er-p~itratt hvroidisn.ii

(15) D iseases of the joints.

(a) Itecturrenit persistelit or cripp~linig rheuniniaoid arthritis. th) Still*. ulis1easV. (c) Ankylosinig sponnlvlit is. (d) D egenerative art liniti, mil which sYlnlpfons and signs

persist or inl which repeated clinical at tacks occuir.

(16E) Nvoplast ic dlisease.

(a) Malignant newoplast ic disease with the except ion oif nminior sniiperficial

lesions for which treatmnenit is a vailable inl the Theat er.

(1 7) Neinull isvch ia tric udiseaise.

(0) All inst anices oif p~rogressive inicapaicit atinug nueuirological (lisu'ase. (b)

rEiilepsN withl grand( nial attacks. (e) PsN choses. (d) Severe or frequent i\ recurring psychonieiiroses.

(18) D ermnatological udisease.

(a) Chronic inucaplacitat ing treatmeneit-resistanit or freutienitly recturrenut derniatuologival diseases which are prouuict ive of prolonged huospitalizat ioi.

1). The existence of t lie following ulisease entities iii mcuiuylci offiurcr or ili kf',, comnInissjflfcdl personfiflcl may lhe conisidleredl as anl indication that officer pat ienuts canl he reclassifled to at linmiteud service stat ins anud ret ainedu wit hini thle tntr

(1) D isease oif met a holisml.

(a) I iahetes Inellit s which is mild and for which adequiate dietary. and

treatmnenit facilities are availahie.

(2) 1Diseases oif filie digrestive svst eml

(a) Uncomplicated peptic ulcer for which ann adequatae dln'tary regimev canl

be provided.

(3) D iseases of t he hlood-formnjng organs.

(a) Perniiciotns antemia iti meiieucal officers.

0.) D iseases of thle circuilat orvN system.

(a) P'roveni cssctilf l hypert ensionn witht, t. sm \symptomis or signs of renal or

cardliac failure ili mediclial officers. (b) M ilud angina piectoris.
AIMTEIiRRANtEAN rm-:-vEltE 191

Followintg thle putblicait ion of I his cir'culatr let ter, the prloblems~ concernitiitg

the dispositm jolro pat jnt s werep nnwakedlv minced1 aiid were ra rely the causev of'

dlisputes bet ween hospitals.

LABORIATORY SERVICES

During the first 7 niotlitIs of his service~ ii tilie Nor th Africani theater.

Colonel Long supervised tilie activities of htospit al laboratories (figs. 59 and

60) by viritie of' thle fact that lie wits also act ing as tilie prevent tive med icinie

officer. Following thet est ablishmient of the Preventive MIedicine Service in thet

Office of tilie Suirgeoni, 1l1eadqfuart ens. N'lXM7SA, tile conitrol oif tilt, laboratories,

Ipasme( to tlids service 'FThis sepa at ion inadle for jtini ielinit d iflicutitvs biemause

end Iless (oor(Iiii at ion lit all levels, was litededl ill ord(er to htave tilie labora tories

ftunct ion in theiri pr~oper relation to thle clinis. It iiw ushe reuini erewd ut h

cljinical lab~oratoryv worký, like rovilttgeii( og-Y, is prnimar~ily ami1 adljunict to (hiat?-

ltosis amid thlerapyv and~ hence Shioumld be Suibordimnat ed to t ile va riouis cljinics ill

tilie hiospit al. This is thle policy ini effect in adi wtiversit v clinics and~ in thle

bet t r class of civilian itICKpit . Whenm such a syst ivt is uised ijt elli ient ly, it

tend,-, to decrease thle amiount of lab)oratory Work requ iired for pat ienit caire.

Whtich, oil tilie ot her hand, increases When tilie (lirectiont of labhoratorie's is ini

ltnd ~s ot her thanl ttoersosbefrh i ai f~le pat ient.t It was tlie consmIderedl OJpii olt of' C olontel Lontg t hat tilie Syst emt of orgalizatt ion Whichl p~laced!

lie supervisiont of lab~oratories under prevetitive itiedit-ine Was archai and that

tile supervision of laboratories elonmged to thle Nmeical C onulsitants Division.

PROBLEMS OF EVACUATION AND HOSPITALIZATION

Printciples of evacuattion andt htospit alization in thIe Mledi terranean t heat er

were fintally crystallized, b~ut only after at long process of evolution. Part of'

lie difficulty a rose Iromit thle fact t hat bothI evacuation and hiospit alizat ion had

dual aspects. These aispects 5Were litrgely adinuiiist rativye oP operationtal Iprol)-

lelis, it us t rue; hut it is equally true t hat bothI had basic cliinicatl comptlonent s

whivi chl n'11( ot be ignitrvd. At t unes, sonitc officer's in charge of evacuat ion

ili 'er'tainii base smebt 1011 (1(1iot.i unlerstd 111thIis fact. Thiis wans llart ic-ularil v

true dIuring t ite first I's mionthls of thle tife of tilie theater when some sick itd

Wouindedl were moved about in frantic haste.

In spite of' his, realizalthio of the import ance of logistic itnd other collisider-atioms. tilie (consult ant in miiedhiciie could1( not lose sigh-lt of tilie fact. t hat , whleu

(casuialt ies passed thtrought a iitimhwr or hiospt as, lmreaks in tilie even t enor of

miedical c.are, occurred, 3111( thleratpy wass in terruptedl. From at sound profesSIiillal viewpoiltt., tilie best interests of neit her thle Armty nor paitient would have

hieeui served if' thle consult ant ill ine(Iicille had not, cont inuious~ly interested hunlself h i mu?'I ma31t ter (''S311 sitwrogleM to keel) Iiti Iical car~ie at respect able levels.

(Von-tilmity (!f fruzt/my at was y'!' /ni'nu ;mipwaince in. 1hc cari of the sick- or U'(flhlald
t'1lo
M~~~~~~ ~ ANTIIETI ~ ~ 1- IVIIAN 

rr heicd It cxidm i to1 I the S -v iiictira1111 i NA O IIl'thtSk Ill v:i. lipm Ow 

ol, 1*()* I .4114,11 Pl s~llil's :11,4 4 \\'l. d il. ( . T hi 111 ie \-is~jI nt.\4v I
PtI rI\ ils ii\IbI\I. .41\sl .IA V\I'S

Ilk

~Ilk

9 It

v w&

blv- '4 ,,.,il11 'fill.. f-i-t .1 ffw

:1, w it, 14 i lc I 1: 1 1 " 1' ~

T.A:11111.

It Li i a V i TI I th-il-t i t\ iit- iijiijti I ititi i I. ltV ruh ljti t
MAll-AITEI:IIANEAN ThEATE.kr 195

I fCA

Ficuw URE . Ilouding of prisoniers of wvar.

pens. To accompjlish this, immediakte p~lans should be mnade in consuiltat ion with tliv Etigifleer Corps, Quartermaster Corps and the Provost Mlarshal, to cope with the loiisiiess of

prisoners of war. Ini addition to delousing, adequate stocks of lice powder should be available in the forward area.

b. Malaria. The concentrations of p~risoners in exp~osed areas, without the benefits

of mosquiito nets andi other physical methods of malarial control will resuilt ini many cases of

malaria if rigid prophYlaxis of the disease is not carried out iii prisoners of war. This should

he done by the administration of Atabrins- 0.2 grain, on 'Monday and Thursday nights

aufter the evening mneals from the 22nd of April unitil the 310th of November. The responsibl~ity for the enforcement of this scemene should be placed on the shoulders of the various

enemyII noncomm~issionled officers who will have certain responsibilities for the enforcement

of (lis cijline in t heir respuective prison pens. Inasmuch as there is no knowledge concerning

the enemy stocks of Atabrine in Tunisia and because of the possibilityv that existing stocks

might be de(st roved as a result of action on our own part, or that of the enemy, plans for the

p~rop~hylaxis of malaria among prisoners of wvar should envisage that the AUS will supply

the Atabrine needed to carry out this procedure.

c. lDysenterv. Duew to the necessarily exposed conditions of prison camps, the

lack of sanita;ry faci'litis an mosblt fsreening cook shacks and mnesshialls.

it is likely that dysentery wvill be a p~roblem amiong prisoners of wvar. To offset this threat, a

most rigid and severe sanitary discipline mutst he enforced in all prison camips in respect to

the disposal of hutman excreta and every effort mtust be made to remove fly* breeding sources

from the environs of all prison camps to a distance of ait least onie and (me-hialf miles. Even

if such mevasures are enforced it is likely that a considerable amount of dysentery will occur

andi that sulfagmuandine in large quantities will )e needed for thle t reatmen t ofthsdsa.
196 .t'Tl ITI IS t" Ot MEDlI'AL. Ct lNSI'ITAN.TS

Provisions should he nmade iinunediatelv* y for increasing the supplies of sulfaguanidiitic ill

N AT(T)IUS.A and for nmintaining such slupplies at: a high level. As far as it is kiiown, very

little if ally sulfagiaiiidiie' is produced in (Gvrnianuv or Italy, hencie capluired Stipplies will

probably Is' negligihhe.

The text of the 19 March inemoramdun follows:

Subject: IProfessional Services for Prisom-rs of War

I. The antlicipted mnimnlr of prisoners of war as laid down ill rcenIt ; 3 lop[crat ions]

re'ports will throw a heavy strain upon the medical Ie'rsonnel and facilities of the A.'S ill

N AT( )ITSA. In order to lighten this burden every effort should be itiace to initiate preventiive mie'aslures anid to coordinate medical services for prisoners of war.

2. A prilar'ry consideration imist be that of it-rsoemi, and to this end, it is sutggested

that mtedical officers he detail'd to each secondar.v forward 'once'ni ragion area to initi:ate

atid Suil5irvise sanitary and pre'ventive lproeIdiires aid to look after t.ie heatih of prisolers.

As this will he a disleinsary type of niedical practice. such supplies as are nieeded should he'

made ipl) and allotted to each concentration area ill advantce. It order to relieve the strain

pmon AT ndical m• personniel the services of captuired imedical officers should be itilizeed at

the earliest possibi) ionient ill tih nividic:l care of l)risoners of wNar. To facilit ate this,

plans should be made with the Provost Marshal to t(ihe end that entenmy m'edical ollicers

and mnedical corps lnv'l shouild be routed ais soon1 ais possible to ('eiiict'tit rat 1(1it areas wlll(1

that this sholld he donie with a nininnun of delay and red tape. Ini tlie, Middle East, tle

lrin itsh have uti ilized tIhe services of eneiny vmedical officers wit hill 2-4 htours aifter their 11aJ1t tni.

:1. The aim of the nmedical service should hbe to cut dowie the ave'rage period of hospitalization requjired for the treat ilelit of :1 i•,i 'e disease to a wiininl which is consist ent

with good medical practice. In tit,, hastalict, of infectious disease's which require hospitalization and for which there exist specific therapies, it is well known thal thie sooner Iithe patient

(comes t undter adequate treatneWit , ti- mire' prolniptiy is ai ('(Ure IC'orllllislhed and hence till'

shorter 6 tihe pe'riod re(liired for liospilizat ion. It is likely that :acltv infect ions will accoulin

for the inajoritv of reqluests for the hospit alization of prisoners atid ill ordler that their st 'v

in the hospital will not lx, prolonged, arranigeenets must he made for the' prompt and rapid

evactlation of prisoniers of war to medical instllahtions for the defiiitive' treatnent of infeIious diseases. This will remlire a plit which will cover thie' e'vaictlatiotn of ('nelniy i)2it nts

from forward areas, throuigh the L,.).('. :and in tihe MNIBS [Mediterralneali Base Sect ion] mid

A BS [Atlantic Base Sect ion] along tihe routets and ill t li, base sectclion hospitals, wiherc prison

ward facilitics should be designated for tint' rotevpttion of these patients.

U pon receipt of the mlemiorandutlt s. lite Surgeon, NATI()SA, had them

circulated to the interested staff sections. BV some accident of fate, instead

of their being returned to the surgeon's office, they were buried ill the records

section of tile Adjutant General's Office, AFlIQ(, and no action wits taken

nipo the recommentlations matde ill themn. By May 1943, tlte battle for norther1 Tunisia wits well under way, and prisonerS of \%-arll (fig. 63) egitrin to streanm

ill by the thousands. At that time, it was found that, tillrouight agl'treieits

ittaide att at general stair level, tile CaNe of f1i'iSoMTt.s Of wail' taIken iii northern

ITunisiat wouhld becomte the intitial rtespolsililitiy of the British. Afte," lill'i

pro(•eted, the matjorit y of (, aeriian 21a1d Italliat prisonters would then be turned

over t~o the U.S. tIool)s lit points inear ( 'onst(at t inte for t raItsl)oirt itt ion to comlpounildS int tilie Mediterranean and Atlantic Base Sections. The British were

therefore responsible for thie initial ste'ps to be tatken ill tile prevention of disease

ill prisoniers of war andi for the s-griegation and divisioni of protected pei'soinel.

lit the oti .'se of at tourth of illspectiou ita1 de h Ow lie cosultalit ill medicine
.MEDi ITERR1IANE~AN THE I ATER 197

63 ri lvr if 9. 3 -'..-~l 

4111-11g.II~v tleoI4sing 4hIa ' 4)1 l, c114' ii1l1miglin Ino 11m11(.-1 'l'lIinisin it wns noted

l11 t.1114 Ie 4),c iIlIiieI-l4e4 iiaI"I'('5e I4)m' 1114e PIi'v4' liiotn41 ()I* (ISVI~4 s4'.1111101111, j) 114MI 'll

-q-111 to) tie Pro4vost Marh al'iii (;emieI'l, NAI( )IiA, on 17 Max' 19)43:

iuuiu. iiii :1 it Iil4I ku ii hlvu prkwi jlruie;o N u uur fl-duail I)) I'll :[f441il vop i- iluueiiu ijtld Ii hiý.

il . 1I 4,1-utuu % clf ~~u -iguil ulo ji1ui di I IlliliI rl14AlfiI Ill-I ýiiiiitntid oig v illS4 pf 05 cc vi iof s..

:; . I ll- 4 ,14,r f, 14 ;mr liipp advquuior i v -h (of hu I c441 siv i 14 -d \~t icn11m S )I i ii~i-Iiv I is I ( t tiil -,it -

IVIOi f:illuu1h -f.ld 111:1 4t.11110 4( iruiil urolu. evitiuq pc201114 TheIh re)ta. ind ith i'theter until fuill14s;imlerI of1 \%:if- :11.1. :1 .~ c l

2. .\I'jiuuirr-()uI iii .n ljtI - i fih41hI tutiiiuit - 1--eivuutu a Iuuil'ulm IuhIilig ohi thuu f . ofi~ T.AlI .B.u~t

VrI qllw'lii'- 4 in:f .J11mnl li place 1polllipprrI 4'vr s At4''4' iI'III52 ) ns 1114'p holift-d

41144,--ip S~~Il'~VV4' 2.41 A Ci4'IJvulit hi, :.Stll)1ivil 201i Marc 191, 4'it'Ii4' : 4)111~f * \ -its 1
rc tlla 'l'l i- .11141 Llallla dk \\ rt aaalfII nil.2 IaIL lwc ,4 I k: II' ITI, I lm lc- :V':- w ill:ia 

I IW .14.1t aa I-'I I arla:1 pri' 11.2-a l l\a\:Ii Ia I'vlu id41:4- Ia kIk rt-m ail I lt I\ LI'llak. I I-i il

11111:1 111 lt Imi k :II: I , ,' . I 'ai kkl1,l ja~mlT akI\:LI .a i - T la lva~ laal

'I aia ri! I a raatIl'-, i 1,1 1'. Ill I i cj-aa [ ra I ill'\ I lar la r I' IlI aIa

i ll .k-a lilaI. ' \ k'-l'- 1Ia'' 1t prIT-jla La laa I~ajj t I" ll. t \:4 I.\- 1, :111. lL I ' f :,

4 'a - 'Lal' IIa' I 1:1 a III ha lit 1 a1. ha'l- Ilal I. -':iaaf 1;a 4.' :41''.l. 'I' :la~~-t t'a.'

liii-~ alaaI k'a ~ aI'-dIa'Iflila- Iair at il t~a hot Ill- it' IrIp:I \.:I \t r IL . - 1 t'*fa-1rla

kka 'I:a-, I l rar :Ill-1 Ill, I-'r t \\T aa' I kk1 tal a''Ic illI- a I4t~w \a :I lIiII -\ 4-:a ill I:al O wa 
MEDIlTEIIII.NEAN THEATER 1911

The fact that prisoners are coming downt the line with dysenitery constitutes a grave

health menace to American troops b~ecause the( infected f-ces will constitute sources, of infect ion all along the way. Immediate steps should h~e taken to elintminate unlsanit ary coniditions along the( convoy linle. Latrines, should be built at proper intervals and shoul1d bv

policedl daily. It is said that latrines have been contemj)Ilated b~ut that little hias-been donle

about themu, ibecaiise 110 service wvill take the responsibility for looking after t bein.

The consultant in medicine conferred with the British consulting- phyvsician,

and1( 1 hey ag-reedl that tilie consulting phy1.sic-ian wouildI (10 11a ll ii is power to brillg

ablouit 11i1 improvemient ill tilie care of prisoners of war before t heyv were t urnied

over to tilie Amlericanls and wouldit.I r to expedhite tilie mnovemnen t of prisonerof-war hospitals and the needled medical p~ersonlnel from tile Brit s-h to tihe

Amuericani atreas. Alter a furt her conference 1) these two officers withI thle

offlicer ini charge of p~risoners of' war inl the office of the Provost Marshall General,

NATrousA, tilie followin'z iniformnal miemnorand~umi was sent to the Provost

Marshal General, on I1 ,June 1943:

1. Tdvieiii% medical p~ersonnel shouild be segregated tint i classified and recommnendations are, made a., to their dhisp~osal by The( Surgeon, N ATOUSA. This scemiie w~ill providle

adlequhate medical p~ersonnel for t lie PO )W camps anid will p~ermiit us to keep tile neceded

sp~ecialist s iii th flie hater. This has h eeii agreed to iiiformiallv.%

2. The P. M.( a. p)lans for med~ical care of P(OW on ships returning to US or UK is conisidlered adequnate fromt a professional point of view.

3i. Those cadlres of pirisoniers of war which will remtain in the theater for any length of

tim~e shoiuld receive tlie( various immnnimizations p~rescribedl ill Army Regnimat ions andI nblodifiedl

ais to subsequent (loses iii N AT( USA.

4. E~very* effort shouild be made to maintain camip sanitat ion. Flies must be kept

dlowni to avert outbreaks of d(*vsemiterv. Flv' -swattimug squads shouild he onl duty daily in all

comp'" ?I iii the kitcemivis and arounid latrines. Kitchenis should be screened.

;). i-,very effort should be made to expedlite the( shipment of the captutred hospitals,

Ilif 7 tU(1iipinent aiid personniel, to the POW camps in order to relieve American medical

p isotitiel.

6. The( Consulting Physician (Br) and the Consuiltant in Mledicine (A) wvill be glad to

render any aid within their province onl the professional service aspects.

Un fort unately for all concernedl, at sweeping reorganizattion of the office of

thle, Provost Marshal Greneral took place ait about thle time this mlemorandumt~i

wats subint tedl, causing" fuirther (lelitys inl carrying, out time suggestedi changes.

At tilie opening of thle catit~mpign inl Sicily, the lpreparattions for the reception

and1( processing of prisoners of warl inl thle Eastern Base Siect ion w~ere still priunitive, ats wits ind~icatedl by tile following report made by tite consultant in~ mueticiiie

to the Surgeon, NATOUSA, onl 25 August 1943:

6. POTV .lfedical Service and Sanitatinn. One( wvould have imagined that the P.M.\[

[Provost 'Marshall, EIIS (Easternt Base Section] had never been previous-ly informed that anl

offensive operat ion was conitemlplatedl and that prisoners would lbe taken. (The( P~.M.,

EIIS, coinplained that he( had had little help fromt NATOUSA.) When tile first p~risoners

arrived th tckdswre half completed, latrine pits not dug, latrine boxes not flyproofed

kitchen facilities andI waste dlisp~osal were p~rimhitive, wvater andI rations wvere short, delousing

facilities were lacking, medical suppIlies were short, one( medlical officer was in the area, and

a battalion of the 1:35th Infantry' had to be' used to guard prisomners because but a handful

of the P.M. represenitatives were available. The POW (especially the( Italians) arrived ex
200N ACTIVTi IES': 4Jll' MEIC:~tAL. CO NSIULTANT*%

lialiltet aind ill with dyisenltery and ma~lairia. Scabies wvas frequen'it andI veiareal ulist.ai',

t, ivu nt titeiincommi. They were ht'rh'(I otT the LST'I* (onl which wa.tvir %%-is freqtn'ntl 'v

short), linedt tijl ill the hot slilt. andt thent maurchled along, lilt, mlalin roads to t he- PO W Colnpottiild. (Terestilt was alwa ' s anl impo(rtanit traffic Ibloik.) Ent route nianY fell out fromt

fitat exhautist ion or troit ot her ul11SeIs. ( )it ofetivovca~ioii a large i,,rotip of PO( W hurst t hrough

their roiad guardls like a hunch of wild1 animiials andi pract ically thlrew t it'insi'lvt's into a1 hadly

COtitatiniiiletti'(-itwl, so great wasj. their itirsl Sue It coudit imuis were tiitotiihtt'tlY respoiisibl v

for the( light jug tipl of chronic malarial inlfect iouis ill the prisone'rs, with the resuilt that they'

tootk ijl) hiospital hetis in lithe Iizt'rte-Matt'tr area which ot livirwise would have lieen available

for list, 1) ,Amteric an patients. The one inndical othceri inl thle ('(ompomind did a sterling job)

without tinlch assistaince. Ilie se-lected POW medical oflicers. and corpsmien as hlis aides,

and sooni had a smooth runniiing tiisjieusarY which took care of many of the muedlical itevls of

the prisoners.

As thle ot'gai tzaltion iand p)tllluifiiii inl resp~ect to thle care of prisonlers of

I hey WIN ' handled ittr , its is evidIen(edI 1)y : v the i C f (1 itig paratgraph j~taIken fromnt I

t(i)0i'rt Ititt(1t to thle Surgeon, N AIN)1t SA, onl 29 Seilt em vih I 943:

i. The following report is hase'd 111)011 (hitk a aVailahh' ill thet WIA) Ml) Forms 86:11) for

prisonei's of wvar. r'o obtain infotrmat~itont upjon the inoriddit\ . resultiiig troum eritainl diseases,

tie riecords of t he 561t11 St~itioni lhopsital, 161th Exaewition HoltIspital, 2 1st ( ;i'nral Hospital.

78thI St at ion H ospital, aind the 80th St at iti Hospital were stutdied. These hospitals were

select id beitcaulst' the bul1k oif the sick lprisonvi-'s of war who were hiospit alized bet weenl Junle

l5th antd Septumlur 15th. 'iitered t hese' hospitals.

a. Motrbidity~. Ill thei dliscuissiton oif iitorliidit Y the hospitals will be1 groulped( as

follows: (1) l5t1hi St at ion IHospit al. Mtill Evaicuat ion H ospit al, anud 21st (oeneral Hospital.

(2) 79thi St at ion H ospit al anid W1ill St at ion Hotsp~it al. This grotijulig hias beeni adopted

bicaiuse tOwi prisone'rs i'it eriitg t1 In' ospitakls list ('( inl the first group were Ge;rmanius and~

It al ians t aken p~rim a r ily iii t he Timiiis ian ecanmpaiig n, while t hoset'l ut he secon11( groupii were

p~rimtarily It alian ptlrisonettrs taken (hiiriing the first p~hase' of lithe Sicilian campaign.

1). IDeathIs. All dleathIs recordied upon the NlD Form 86ab for p~risonecrs have

beent grotijied as to cautse'.

a. 56tth St ation IHospjit al. Ili th p" leriod~ from June 11 to Auigtist 13, 1943. the

(total admissions intot t his htospitazl for c'ert ain iinf'ct iouls diseases were as follows: (1) I iphit hieria-- I5 cast's. (2) 1Pritnarv at vpicnil pneumioiia -- I I case~s. (3) Tuiberculosis-ti Cases.

(t) 1) )vst'nt er * - 532 ('asi's. (5) Typhoid fever- I case. (6) Malaria-432 cases. (7)

Jatiidice- --2S catses. (8) Smallpox-- 2 cases5. (9) T 'ypims--I e'ase'.

1). ImltI Evatcuat ion Hlospit al. F'roml June 181t1 uint il August 8th. 1943, the follo~wiitg l)risotiitr-(if-watr pat i'i(its wvere rect'(iv'etl: (1) I iphitheria-Ificase~s. (2) Primary at yjical

~)tilii~iii- v asi's. (3) Tuiberculosis-3 case's. (4) I )yv'nt c'ry 19)4 cases. (5)

TrYpitoid-- i cast'. (6) Malaria- :i10 case's. (7) F. U.( ).- 219case's. (8) .Jauitidice--3 v ases.

c. 21st (;t'neral IHospitazl. Fronm June 1,St i uint il Septem'beitr Hill, MI 1-13, the

following prisont'r-of-wa r patii'nt s we're receive'd: (I1) ITilvrt'rclisis-8 cast's. (2) I yst'iit ry

48 catsus. (3i TYphoidt fever-8 cases. (4) 'Malaria-I 57 cases. (5) Jamiuttiet'-8 (a':151.

(6) FX.OI. I. east's.

d. 78thI St at iitl H osp~it al. F'roim Juily 17 umit il Se'pt ember 2.5, 1943, the' following

pristiiiir-of-war pat iettts were, re'ctivt'(: (1) P~rima~ry at Ypical pneuniotnii- 12 case's. (2)

Tubetretifosis--11 Ii as's. (3) 1 )vsintvtrY- 4:3 cast's. (41) T~vpltoid----i cast's. (5) Malaria587 catse's. (6) F. UJ. ().- 225 )('UsE's. (7) Jaunitiitie- -12 case's.
MEI)ITERRANEAN THEATER 201

e. 80th Station Hospital. From July 24 until September 25, 1943, the following

prisoner-of-war patients were received: (1) Primary atypical pneumonia-10 cases. (2,

Tuberculosis-6 cases. (3) l)ysentery-20 cases. (4) Typhoid fever-7 cases. (5)

Malaria-609 cases. (6) F.U.O.-150 cases. (7) Jaundice-16 cases.

f. Total number of patients in each disease category received by the above mentioned hospitals lduring the stated periods.

(1) I)iphtheria-21 cases

(2) Primary atypical pneumonia-38 cases

(3) Tuberculosis-42 cases

(4) 1)ysentery-827 cases

(5) Typhoid fever--21 cases

(6) Malaria-2095 cases

(7) F.U.O.-411 cases

(8) Jaundice-1115 cases

(9) Smallpox-2 cases

(10) Typhus-l case (Another case was reported in an Italian prisoner of

war by the 23d Hiospital)

g. D)iscussion of observed disease morbidity in prisoners of war. The high initial

occurrence of dysentery in patients on admission to the 56th Station Hospital and 16th

E"vacuation Hospital (ABS [Atlantic Base Section] and MNBS [Mediterranean Base Section]),

reflects the unsanitary conditions which prevailed along the route and in POW compounds

which were not ready to receive the influx of over 200,000 prisoners which were taken at

the end of the Tunisian campaign. It is to be noted that as sanitation improved, admissions

for dysentery fell. It is inter(e.sting to observe that on the contrary in the 78th Station Hospital and 80th Station Hospital (EBS) [Eastern Base Section], the admissions for dysentery

were low. This was probably due to a short evacuation route and a relatively well sanitated

POW compound in EBS. The admissions for malaria follow a trend which is quite comparable to those noted for American troops so it can be assumed that the patients entering

the 56th Station Hospital and 16th Evacuation Hospital at least in part, contracted their

disease either in POW compounds or en route to them across North Africa. The patients

ill with malaria entering the 78th Station Hospital and 80th Station Hospital during July

and the first week in August obviously contracted their disease in Sicily. However, it

seems quite probable (and this thesis is supported by a shift from 10 vivax infections to I

falciparum infection, to 3 vivax infections to 1 falciparum infection in prisoners of war in

EBS) that many of the cases of malaria developing after the first week of August were the

result of infections incurred in North Africa. The high percentage of F.U.O. noted in the

EBS resulted from the non-recognition of sandfly fever, the treatment of true malaria before

blood films could be taken, and from inadequate laboratory work due in turn to the influx of

febrile patients. On some days as high as 150 or 200 blood films were examined in a single

station hospital laboratory. Jaundice has been increasing in the prisoners of war, but not

out of l)roportion to the increase of this disease noted in our own troops. There have been

42 instances of tuberculosis recognized. There are probably more unrecognized cases

among the prisoners. It is interesting that 38 instances of primary atypical pneumonia

have been noted. The occurrence of 21 cases of typhoid fever is indicative of crowding,

imperfect sanitation and incomplete vaccination. As steps have been taken through command channel.s to re-vaccinate fully all prisoners of war against typhoid fever, a lessened

incidence of this disease should be observed in the future. Twenty-one cases of diphtheria

occurring in a period of the year in which the incidence of diphtheria is minimal probably

reflects crowding, the non-recognition of early cases of the disease and a normal or slightly

high carrier rate. It is interesting to note that 15 of these cases were received in the 56th

Station Hospital in ABS and occurred in prisoners taken in the Tunisian Campaign. Two

cases of smallpox and two of typhus have been recorded in prisoners.
202 ACTIVITIES O1F MEIDICAL CONSULTANTS

3. Deaths. The following causes of death have been recorded. These data are fairly

but not completely accurate because deaths among prisoners of war occurring in other than

the stated hospitals are not listed. Those occurring in POW camps are included.

Cause Deaths

Malaria -------------------------- ------------------ 24

W.I.A .--------------------------------------------- 12

Hypertension -------------------------.------------- 1

Brain Abscess -------------.---.-------------------- 2

Dermatitis exfoliativa (arsenical) --------------------- 1

Acute Nephritis ----------------------------------- 1

Typhoid Fever .-.-.-- ------------------------------- - 3

Acute Amoebic Colitis ------------------------------- I

Acute Ulcerative Colitis ----------------------------- 1

Acute Infectious Hepatitis ---------------------------- 1

Carcinoma ----------------.------------------------ I

Dehydration and Exhaustion -------------------------- 2

Coronary Thrombosis -------------------------------- 4

Dead on arrival (?) --------------------------------- 1

Respiratory paralysis -------------------------------- 1

Tuberculosis ------------------------------------- 2 Suicide -----------------------

Killed by guards ------------------------------------- 8

Diphtheria ----------------------------------------- 2

Pneumonia ------------------------------------------ 3

Accidental ----------------------------------------- 1

Ruptured Appendix --------------------------------- 1

A survey of these deaths shows one striking thing; namely, that the case fatality rate

from malaria in prisoners of war far outstrips that observed in American troops. An example of this is that of 2095 admissions to prisoner-of-war hospitals for malaria, 16 or 0.77

percent died. When one considers the conditions of concentration, surveillance, supervision,

etc., under which the prisoners were kept, this is a high case fatality rate. The two deaths

listed as "dehydration and exhaustion" were undoubtedly due to imperfect handling of

POW personnel while in transit. The deaths from diphtheria are tragic.

4. Summary. The record of the prevention and treatment of disease among prisoners

is fair. Two great causes of morbidity (malaria and dysentery) could have been markedly

reduced if adequate preparations for the reception and care of prisoners of war had been

made. The following figures (which are based upon average periods of hospitalization

noted for American patients) show the number of hospital-bed days taken up by prisoners

of war who were suffering from diseases for which preventive measures are well established.

a. Malaria ----------------------------------- 31, 425 days

b. I)ysentery ------------------------------- -4, 135 days

c. Typhoid fever ------------------------------- 745 days

Total ---------------------------------- 36, 305 days

5. Consolidated figures received from the Surgeon MBS, show that 77 cases of typhoid

fever in POW have been admitted to POW hospitals #129 and #130 since July 4th.

In the winter of 1943-44, the German prisoner-of-war hospit, 1 was moved

from its former location to Prisoner of War Camp No. 131, and following this

move the personnel of the hospital lost their "protected" status and were

treated by the local compound commander as ordinary prisoners of war.

This violation of the Geneva Convention was noted by the consultant in
MEDITERRANEAN TIIEATER 203

medicine, in the course of an inspection of the hospital, and was made the

subject of tile following report to the Surgeon, NATOUSA, dated 17 May 1944:

1. When the original German POW Hospital was set up near Ste. Barbe, the German

medical officers and corpsmen were given the full status of "Protected Personnel" and were

allowed recreational facilities outside of the prison compound after working hours. There

was at least one violation of this status and the offending German medical officer reverted

to a POW statu,.

2. In December 1943, this POW Hospital was moved from Ste. Barbe to its present

location within a coipound in P\V Camp #131, and since that time German medical officers

and corpsmen have not been permitted to leave the stockade which in part is guarded by

Italian Carbinieri.

:3. In the course of an inspection of the professional services of this hospital made upon

May 10, 1944, Dr. Meyer, the German Surgeon of the hospital, stated that the restrictions

placed upon his medical officers and corpsmen represented a violation of the "Protected

Personnel" clause of the Geneva Convention of 1929, and that as a result of this violation,

he does not feel that he can ask his officers and corpsmen to behave as "protected personnel"

when actually in one respect, they are being treated as ordinary prisoners of war.

4. From time to time, the repatriation of wounded and sick German POW takes place

from this hospital and it can be assumed that when such prisoners come under enemy authority, they are questioned regarding the "Protected Personnel" status of medical corps

personnel in the POW Hospital, and that retaliatory measures will be taken against American

Medical Corps [l)epartment] personnel, now held by the enemy, if the ',"Protected Personnel" status of the German medical officers and corpsmen is questionable.

5. It is therefore recommended that the necessary steps be taken to insure to the fullest

extent the "Protected Personnel" status of German medical corps personnel now in our

hands.

Action was immediately taken by the Surgeon, MTOUSA, with the result

that the Provost Marshal, Mediterranean Base Section, restored in part the

" protected" status of the inedical (lepi1nitent personnel of the German hospital.

From the suniner of 1944 until the capitulation in Italy, German meidical

department personnel receive(d privileges that were pretty much in accord

with the Geneva conventions, and the sick and wounded prisoners of war

received adequate treatment. At the tilme of the capitulation in Italy, many

thousands of sick and wounded Germans and hundreds of German medical

depir tment personnel (fig. 65) fell into the hands of the U.S. Army. Tihe

decision was inmmediately taken to utilize all captured German medical installations to their fullest extent. Two large German hospital centers at

Bolzano and Cortina had been taken over, and the capacity of these centers

wias increased by the addition of isolated hospitals thn t had been captured.

Colonel Long made an extensive stu(iy or these hospitals in NMay and June

1945 and reported to the Surgeon, NITOUSA, on 11 June 1945, as follows:

1. This study is based upon practices observed in German General and Camp Hospitals

in the Merano and Cortina and ('hide areas and ilpon interviews and discussions which were

held with Col. Matisse, the chief consultant in medicine of the German Army Group in

Italy, Lt. Col. Professor tlorster, (Wiirzburg) Chefarzt of the German Ilospital in the

Palace Hotel, Merano, Lt. Col. Professor Schopper, (leipsic) Consultant in Pathology to the

Army Group, Major Assistant Artz Veith, (Freiburg) Pathologist in the Pathological Laboratory, Merano group of hospitals, Lt. Col. Professor Marks, (MNinster) Consultant in Medicine

to the 10th German Army, Lt. Col. Professor Bock, (Wiirzburg) Consultant in Medicine
A Il. I 11-ipi:I. 'I. ,TiTIll S iii I -r i'iTT' 1 T

V''' SI, It ij t i'T 'll I iT'i''STT. \'T ' I ' Sii ~ i ' -. TT-1 11111 TsT \i~i I ill\ I l' I'

\ 1i 1 p'' -'' I I Ii, T . ( 'I I -' rt I I li - l ' \1 Ii -T \ I I ' I' :11\ 'tii . :1 ,. I

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MElDITERRANEAN THIEATER 2 05

MTOUSA. This means that the average noneffective days' rate per patient was higher

in the German army. It also appeared that the criteria used for the discharge of medical

patients to a civilian status from the German army were less severe than those in force in

the U.S. Army.

3. In general, the bulk of the patients seen, except at Chide, were true general hospital

types of patients, anti in American hospitals would have been classified as "'C" for evacuation

to the Zone of the Interior. This same classification would have been given these patients

by the Gernian medical officers, had not their "Zone of the Interior" disappeared during

April and May. Ilence the eventual disposition of many of the patients will be a problem

unless some arrangement can be made for their return to Germany and their discharge from

the German army.

4. The following diseases were especially observed:

a. Field or War Nephritis. This disease was quite a prol)iem in the German army

in Italy during the winter of 1944-45 and a great problem every winter in Russia. Lt. Col.

Professor Marks states that at one time, when he was nmedical consultant in a hospital center

in (Germany, he had 3000 cases of Field Nephritis mider his sul)ervision. At the time this

visit was made it was estimated that there were about 500 patients ill with Field Nephritis

in the two hospital centers. The following are points of interest concerning this disease.

(1) Etiology. There is one school of thought in Germany which believes that

field nephritis is a virus disease: however, Lt. Col. Professor MMarks states that Volhard and

others in Germany consider tihe disease to have the same etiological basis as (foes tihe type of

hemorrhagic gloinerular nephrit is seen in civilian life. In surveying the histories of and

talking to ab)out 40 patients with this disease, a story of a recently antecedent nasopharyngitis (hemolytic si reptococcal infection) was rare and the onset of the disease was ordinarily

insidious in nature. The (German medical officers considered that sudden chilling or wetting

pla'yed an important role as a precipitating etiological factor in field nephritis. The average

time from the appearance of symptoms and signs to first hospital entry was 10 days.

(2) Facial and ankle edema were the most common presenting signs. Headache was uncommon. In a few instances a grossly bloody urine was noted as the first sign.

(3) ()n entry into the hospital, the common signs were facial and ankle edema,

hypertension and a urine which showed from I to 2 plus alblumin with ianvy hyaline and

granular casts and red blood cells. Clinical evidence of cardiac enlargement and uremia

were rare. In many instances the NPN was normal and rarely was it highly elevated.

Lt. Cols. Professor Marks and llorster both stated that abnormalities of the fundi were rare.

(4) The clinical course of the disease in the patients whose records were examined was quite constant. In most instances the edemna disappeared quite promptly

and the blood pressuire returnedl to normal within a few days. If the NPN was elevated it

also returned to within norm.al limits within a few days. From this point on, the course of

the disease had to be judged primarily from laboratory tests. The albuimin slowly disal)t)eard tbut there was a l)ersistence of microscopic henaturia for weeks and months, and

the diltition-concentration tests showed dfinite abnormalities over long periods of time.

lThese two examinations were the ones which were depended upon most and a normal urinary

sediment from repeated fresh morning specimens and normal dilution-concentration tests

were used as criteria iin determining the cure.

(5) The prognosis for recovery in the great mass of patients was said by the

(German medical officers to be good. Hlowever, it was their practice to recommend for

discharge from the army all patients whose urinary sediments and dilution-concentration

test.s were ab)normal at the end of six months' observation. None of the medical officers

had had an opportunity to ol)s(rve the eventual course of p)atients returned to civilian life.

Rlelatively few patients had died in the acute or subacute stage of this disease while in army

hospitals.

(6) The treattment consisted of absohlte bed rest, a modified Karrel diet for

the first three d(ays, this then followed by fruit and fruit juices for 5 d.ays, and then the

patielit was placed on a low protein (20 to 40 granms of protein) salt-free diet. Bed rest was
206 ACTIVITIES OF MEI)IC'AL (C(NSULTANTS

absolute for about one month and quite well maintained for three monthus. Lt. Col. Professor Marks also used tile "'llinger and Durst" regime for three-day intervals about once

la montihl in all of his patients. Lt. Col. Professor llorster did not use the "Hlunger and

Dlurst" regime. Both observers added salt in gradually increasing amounts to the diets of

these patients before they were permitted to be up freely, and it was generally 3 or 4 months

before the patients were placed on the normal hospital diet.

(7) Comment. It can be said with certainty that the type of kidney disturbance which has just been described did not occur in any appreciable amount in the American

troops who were in contact with the Gernmans in the northern Apennines during the winter

of 1944 45. No explanation for this difference can be offered.

b. Infectious Hlepatitis. This disease was first noted in epidemic form in the

Afrika Corps in the winter of 19411-42. Later it became epidlemic in German units in Russia

and there was -a high incidence of the disease in the German forces in Italy during the fall of

19-13. In the fall of 1944, while the incidence of the disease was increased, it did not reach

epidemic proportions. This, the (Germans attributed to tile development of a herd immunity

throughout their army. The Germans were certain that the disease was caused by a virus,

but believed that it was spread by droplet infection. They had no idea that the virus was

present in the stool of hepatitis platients.

(1) l)iagnosis was made generally after jaundice appeared. The only liver

function test employed was the Taka-Arata test.

(2) The sheet anchor employed by the Germans in the treatment of hepatitis

was absolute bed rest for 4 or more weeks. The diet used was of the conventional, old

fashioned, high-carbohydrate, low-fat type. The average period of hospitalization was

eight weeks. Relapses have been unconmnon since the prolonged hospitalization program

has been in effect, but were very common initially in the Afrika Corps when patients with

hepatitis were either kept on duty or were released from hospital when their jaundice had

disappeared. The intensive hospitalization program began about the middle of 1942 and

has been strictly adhered to since.

(3) The Germans have conducted fairly thorough studies of the pathology of

hepatitis by means of "liver-punch" biopsies. Their findings are in line with those made in

this theater.

c. "Trench Fever," Volhvnia Fever. There were hundreds of cases of this louseborne disease among troops in the Mediterraniean area in the winters of 1943-44, 1944-45.

It reached epidemic proportions in German troops in Russia.

d. Atypical Primary lPneumonia. The (;ernan medical officers insisted that this

disease was unknown (unrecognized?) in Germany prior to 1939. The first appearance of

t his disease in the German armyi occurred in Greece inl 194(1, at which time it was considered

a "new" disease. Following the lieblication of abstra(cts of American papers upon this

disease in German, tile trie nature of tile "(';recian" disease was recognized. Since that

time it has apl)eard sporadically in t he German ( army. It is the opinion of the consultant in

mnedicine that t here has been much more at'ylical lne'nnoniit ii the le rmin army, bift because

routine roetitgetnogranis of the chest were not made (only sparingly so) the (lisease was

frequently missed. At one hospital in which X ray films of tile clest were made frequently,

•ii al)proximately*v normal a"dmissions rate for this (disease was noted.

e. '"Trench Foot." As thie (erniams said, a word for this condition does not exist

il thle (erman language. Plenty of t rue frostbite was seen ill the lRussiali Campaign but

all (Gerina' medical officers stated that t hey had not seen "Trench Foot" in (German soldiers

in .MT()USA during the winters of 1943 44 and 1944 45. Ii fact somie of them said that

they had traveled many miles to observe American prisoners of war who were suffering from

"Trench Foot." They attributed this absence of "Trench Foot" to:

(!) Excellent foot hygielie and discipline.

(2) The easily retnovable high leatther (hernan field boot.

(3) The four pairs of thick b)ut loosely woven all-wool high stockings provided

to German forward troops in winter.
MEI)ITERIUANEAX TH'IEATER 207

f. Peptic I'lcer. Many patients suffering from peptic uilcer w~ere seen. All had

b ieen confirmied bY roenitgenogramis anid aill wvere' being t reated h.% low residliie (diet ivjllmnut

alkafic.s. Tilt Lverage period of treatmnent was 4 weeks. Paitients with initial1 severe symptomis, wvith gast roent erost(ilnies or with partial resect ions of the stomach were (lischlarged

4)to il( partijemlar ''Magemi" bat talion which rep~resenitedl their part of Germanyv. There

theY were given light (litties and low residtie diets based upjoni the accustomed diet. of their

part of (;trmni:N .

gr. D ipht heria. The Gernians have beeni exp~eriencing an increasedl incidence of

(lillit heria (huirinig the past year. A fair aitiounmt of dipht lierit ic paralysis has followed this

disease. It is t lie oIpiliiomi of thle nieflical commsulltauit that low initijal (loses of anititoxini

(10 20,000 units) wvere responsible for this increased inicidlence of paralysis.

II. Amoebic I )iease. St ool-Carrier st udies conduhcted in ( ernian troop~s in Italy

(durinig the fall of 1944 showed ain incidenice of 14 p~ercent cyst, carriers. Amioebic dysentery

is not uiicoiiiiioii and~ has b~eeni treat ed with vineiet in( and1( Yatrin with goodl resulits. Amloebic

hlepatitis alild amUoebic abscess h~aVe not been v'ery common.

i. St rept ococcal and t YphOid-paratyphoid infect ions occurred in the( German

Arniv in Italy somewhat niore frequtently t han ill the American armny. The treatmecnt of

these diseases was similar to that used in the( American army.

5. General (Comments.

a. G',ermian rations for tie staff and p)at ients ill hospitals iii the. Cortina area were

available for about, tenl days more at the t inie of this inspection. The (Consultant in Medicine was imiformned by the commianding officer of the 3I79th~ Collecting (Company that a.t. the

end( of that p~eriod1, the patients in Germian hospitals would receive t lie Anierictimi hospital

rat ion, while thle Medlical D)epartmient. staff will receive type "'(... rat ions. If this is correct,

theni litl IllII, chiapter 2, article 11, Treaty Series No. 846 which was p~roclaimed1 by the Presi-

(lent of the Unmited States, 4 Auigust 1932, is bieing violated, biecause it. is distinctly stated

" The food rat ion of prisoners of wvar shall be equal in qtuantity and q~uality to that of troops

ill base Camlls.'' It is being argumed t hat iniasnmuch as CGermiany did not observe the Geneva

Convenltiolo, We (io not have to treat. theirpIrisoiiers of war ill accordance with the Convention.

Such reasoniing is specious andl it shiould always be reniemabered that ''two wrongs do not

make a right.''

b). It is thle opinlionl of the C onsiilt ant inl Medicine t hat. our aini should be to uitilize

every iliet hod to get the German sick well, or if they are suffering- fromi known chronic dlisease

to give thlen a certificate of dlischiarge' for (disablility as soon as suchi a courise is feasible. To

this end it is thlerefore recomnmendedi~:

(1) That ouir treat menit direct ives he sent to all ( eriuami liospit~il inistallat ions

with imistruictions t hat t hey h e translated into ( remuimi amid be used as t lie basis for treatmenimt.

(2) T1hat penicillin be muade iumiiuediitely available for the( treatmeneit of acute

amid chronic gonorrhea, acute syphilis anld sl~immh other diseases inl which the use of t his antiihbiotic has heeni Shown to be timiisavimgr ilii the core oif disease. The piresent mlethods uised

by the G ermian Medicail C orps for treat i magomiorrhea have produced reýsist alice t~o silfomiantiide(

therapy with hi th result that t imne-consumning mlethIods (intermnit tent fever therapy, prostit ic

massage, irrigat ion, etc.) are beingiigusel ill thle treat iiiemt of chronlic infect ionis and~ patienits

are beiniig discehi-ried before : actmcrioloquual cuire hmums been affiected. It. wouild seemui iniportault to Ilse penicillin ill these lMutiemmtS becauise evenit ually a cerutuii miimilobr oif t hetim will

ret urni to tilie area beinig occumlpied l by v Ilie Amieriezimi Army iii Auistria or Germana\y amid there

wvill beconie foci of infect ion ill tilliecivilizumi piopuilzit ion.

c. It is recomiimended t hat C olonmel ( emmera Iemiardtms be sent to ( eruniami and be

discharged fror iihe(- Germmani arinv :t a lie eairliest possible miomenet. HIis presenice ini the

Cortimia-Meraimo area is iiimmecessarY amid sonmmwhmat Comifuisimig.

Ill Siiiiu11ttiitiv, it maitv be Said1 thliat duttinig 1943 andi( iitilY 1944, tile( conisultaltit iilli collicitie fr('(Ilenti ilicotlilit eied Seriouis problem d ill S ctTvI Rring (lilt. tble
4r- -

tivll l'''tilL vl 11iii Iltýli t h n(IIII1 a01 ullh ilaI prnlj a v iii Ili' ( vla I Ittli . A T he~ -ai
Amnerican soldliers, and~ the Jatitilary 1943 smtryreports (lid not mnilt ont

vii ailnin (leficienlcies anll cold atiiied few comptllaintIs iliout rat ions. The saimiSatry reports arriving in February andl thereafter however, increasingly mentti oned various iniadequtacies D~otedl ill Ole rations. Thlese complaints wer~e

esp~eciadlly frequent froni the Arity Air Force units, which, operating inl forward

areaVis whlere coniditionis were often (difficult logist icadly, were comtpelled to

exist for conisidlerab~le periodls of' t ime upon emuergency or unbalanced rattions.

It wats not uintil thle 11 Corps wits visited in lnort hernt rimisiat in April

and Maty 194:3, that( there were b~itter reports abouit thle rat ions, anld vitaitliiu

deficiencies wer~e niotedI. Bat talioni surgeons rep~orted'~ thlit t heir mnen had beenl

fed C ratt ions for suc(h long p~eriods of time t halt t hery hiad celtse( to eat thei-il and

that thIll conlt illlled l se of t livse rat io115 prodlucedl ]Iau,1sea, vomlit ing, andl diarrhelia.

Thiese surgeons s'talted also thait t heir illeli were' uiideriiloll rishit'd. The conlsmiltiant inl mtedicine checked upon t hese rep~orts b~y observing and interviewing

ittei of the 3d Battalion, 39thI Infaint i-v, and lpattients inl thle evacuaitionl hosp~itals.

Ife found himiself inl agreemtent with the battalion surgeons. During this saine

period, hie also observed patients sufferving fronm deficiencies of vitamtin A,

t himnintme, rilboflavin, nicotinic acid, andl ascorlbic acid inl thle evacuation hospitals

of the 11 Corps.

Thie extecnt of undernutrition ob~served in the 11 C orps promtpted the consuiltaint inl medicine, onl 1 Maiy 1943, to recommutend to thle Surgeon, NATOUSA,

that at boardl of officers b~e appointedl to aiscertaini the facts and make recomtmienitdtions concerning- the diet4 of combat troops in this theater. Tile coltsultanit's recommendation for the appointment of at board wats accepted by the

Surgeon and wats forwarded inl the formn of at nentoran~lmil to the depuity theater

comin~tan(er onl 15 Mlay 194:3. After b~eing circulated by t he C'hief of Staff to

G-4 (logistics (supplyv)) and the quartermaster sections, where it wats received

favorably, the tentorandum wats sub~mit ted to the Deputy Theater Commander

who returned it to the Surgeon, with the suggest ion tha~t the (lifficultyv lay ill

thle mtisuse of the C rationi rat her than the ration itself. The Surgeon thlien againl

recommitended that. at board of officers be appointedl, b)ut the Deputy Theatter

Commander negated this suggest ion.

The 2-month pvriod that elapsed bet ween the end of tile camipatign iii

northern Tunisiat and the opening of the Sicilian campaign wats onie of great.

aciiyalong the whole Northi African coast andl especially inl the East ern

Bse ection. Troops were being trained (fig. 617) for ampl~hibiolus operat ionls

in this period, and their (liet varied from C to fujllyA balainced B rations Sup1-

plies of all t ,ypes were b~eing poured into the Eastern Base Sect ion, andl there,

ilvi tahulY, thle B rat ion lbecajtte unithialnced. Calorie e'stimat es, preparedl b)'

the 561th Evacuation Hospital, (demonstrated that (luring Junie, Jul~y Aiugust,

ltnd September 194:3, thle average caloric' value of thet( B rat loll, ats issuedl inl thle

Eastern Base Sect ion, was in t he neighborhood of 2,500 calories per (lat*y.

Four of the six divisions enterling the Sicilian cantpatign had been, rehlittvely

or completely, inact ive ats farais contbat, witsconcernted, but thle ot her two diviSIOnls

had seen extensive service (Iuirilig the Tunisian caulipamign, during wvhicht, toward
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214 ACTIVITIES OF MEDICAL CONSULTANTS

Several sessions were held beginning 13 June 1943. At the first meeting,

it was pointed out that a common ration scale would save duplication of depots

as well as shipping tonnage and food supp)lies, both in the United States and

in the United Kingdom. Further discussions made clear that the existing

British scale lacked variety and many issues were too low in quantity. Brigadier

Hinde called upon the medical member of the committee to submit schedules

of the calories, vitamins, minerals, variety of foodstuffs, and similar items that

would constitute an adequate common ration scale. This was done after a

series of joint conferences and was accepted with a few minor modifications

by the committee at a meeting on 8 July 1943. The proposed scale was referred to the Quartermaster section and by it to Headquarters, Service of

Supply. The latter office added a few minor changes, and in addition, suggested

that a 10-day cycle and issue chart he prepared and that tile ration be fed to

test, groups of individuals from both armies before being formally adopted.

These suggestions were agreed upon by the committee on 29 July 1943. Nothing has been heard of the interallied common ration scale since that date.

Although the rations for combat troops became temporarily unbalanced

during periods of intense fighting in 1944-45, situations such as existed in 1943

were rarely encountered. [he nutrition of all in the theater was at. a relatively

high level, esp)ecially during the stab)ilization of combat in the high Apennines

during the winter of 1944-45. The breakout into the Po Valley, with the

subsequent drive towards the Alps, was so ral)id and through country so relatively well supplied with food that the nut rition of the force was never at serious

problem.

RECONDITIONING

The problems associated wit h the physical rehabilitation of sick and wounded soldiers b)ecame apparent in the late spring of 1943, when patients convalescent from various diseases and from wounds were b)eing discharged directly

to the replacement depots. It was found that, many of them, although convalescent and in need of no further medical attention, were in such a poor

physical state that they could not undertake the training programs then in

force in the replacement depots. Accordingly, the Surgeon, NATOUSA,

requested the advice of the consultants in surgery and medicine in respect, to

the physical rehabilitation of convalescent patients. At the direction of the

consultants, Maj. (later Lt. Col.) James H. Townsend, MC, 6th General Hospital,

and ('apt. Lewis T. Stoneburner, III, MC, 45th General Hospital, were detailed

to make a study of all convalescent and rehal)ilitation facilities existing in the

theater. After a study of the problem in the 2d Convalescent Hospital, the

Palm Beach Convalescent Canip, the 1st Replacement, Depot, in numerous

station and general hospitals, and in the 8th and 10th British Convalescent

Depots, these officers made the following recommendations on 30 August 1943,

which were favorably endorsed hy the consultants in surgery and medicine and

approved by the Surgeon, NATOUSA.
MEIITERRANEAN THEATER 215

* * * * * * *

S. Conclusions.

a. It is believed that there is a clearly demonstrated need for some type of installation

in this theater for the rehabilitation of men who have completed their treatment in general

hospitals and station hospitals acting as general hospitals, who by virtue of their long periods

of hospitalization and absence from their units, are in need of physical reconditioning and

mental reorientation before undertaking the training program of replacement centers.

b. It is believed that this can be most effectively accomplished with an organization

under the administration of line officers with the assistance of a suitable medical detachment

and continuous liaison with the medical department.

c. An installation organized as a separate training battalion with a slightly augmented medical detachment is believed to be well suited to this purpose. It could be an

independent installation, or attached to a repl'tcement center.

d. The outline of the organization and operational program of such an installation

are appended. They do not differ materially from what is already in operation at the

Combat Conditioning Battalion of the 2d Convalescent hospital, and at Palm Beach.

4. Recommendations.

a. That in each geographical center of hospitalization in this theater a rehabilitation

center be established to recondition men discharged from hospitals who are to be returned

to combat duty.

b. That such installations should be organized under line administration with

a suitable medical detachment.

c. That professional liaison be established between hospitals, rehabilitation centers

and replacement centers to insure optimum results in the functioning of the whole program.

The policy laid down in these recommendations, namely, that it was not

the mission of the Medical Department to train men for com-bat, or other army

duties, was accepted by the Surgeon, NATOUSA, who, however, took no

specific action upon the report of Major Townsend and Captain Stoneburner.

Early in 1944, reconditioning units, whose sole purpose wias to rehabilitate

patients to the point where they could undergo the type of training required in

the combat reconditioning companies and in the training sections of the replacement depots, were estal)lished in most station and general hospitals

(figs. 71 and 72) in the theater. The efficiency of these units varied with the

enthusiasm and interest of the noncommissioned and commissioned officers

who were in charge of them. However, with the development of exercise

tolerance as a test, for cure in patients convalescent, from hepatitis in 1944, the

physical reconditioning program was given a boost, and it, functioned in a

satisfactory manner during the remainder of the life of the theater.

PROFESSIONAL EDUCATION

From the b)eginning of his duties as consultant in medicine in the 'North

African theater, Colonel Long attempted to stimulate and plan the graduate

education of medical officers, believing that a program of graduate education

would materially assist in the maintenance of reasonable standards of muedical

practice within the theater. It has been noted earlier in this chapter that

medical officers of service and tactical units were isolated from medical thought.

In a report made to the Surgeon, NATOUSA (Deputy Surgeon, AFHQ) on

25 January 1943, the consultant in medicine made two recommendations.
Fir'st, ierve eflort Sholdo~ lhe iiiade to impr~love tw li Irores'-i(liaiI standardi~s of' lillit

llie(ldi(ci offic'er. bv* conrl-elo'e~os, shlort colip-seS, lectutres, niiietnignz ( fig. 73) ando

SfIl~l Ii methods(1. Such p)rogrl'Il)S couildl1 be cl-iCl-e out1 whOll oh visions andl

111111s Swere Inl rest a1rt'US. TheI colisilita lit St;hdl, N'Medical S'ectionl, -NAT( )SA

( A FI I ( ) , , kII(lI t IeI st air of genleral. shtiat 011, and evactiat loll hiospitaUls (could be

lused as ilIst rilt 01$. -;e(oilld, all circlanII; d',oirect iveS, and ot her Ii edliill111

dvl(;ilng, with the pr ioressiolial aspects, of' pati ent cllre J1t1 hatiiighit ol*riglialt( C lll)ii

the Niedical -'ectiloll. NATl'OSA (AFI'19.Slioilld be preparevd ill Such qlualit it iethat a c0pY or (';chling-it b~e p)Iact(I ill thle hal~ids or each lillij lilvd(icaI of Iicei.

IDuriruz his first tolil'. of, all Amiericani hosp1italIs lil NAIOUS.\, comipletedI

ii MNIarcli I!)4:; thle conisuiltani t ill iilvi(' cuiil laid noted that. .alt houtdi Ile eli

er!cilil)CI of, Iwolesslolial work lijpoll thle iliedlical ser.vICVS WaIs VxCelleiit.

lie lilbralries Ini c(.11t1 hiliospita;l, WvTe inot vCiV U .ccessIlblt or. coniijlet e, ;uid,

ill soflie liospit al. thle holdinig of' iiiedlical 'o~l hre iiee-(ý oI-' Stalil 11C,1(1g l~i

Ileeli ilabandoned'o. lipoii his reimoiiieialat ioll, ('ietilatr Left tr No. 2, (latedl

IS Nr.rch 1943, (M)lice ol' thle Smiriroli, Ileadylajlrtel', NATOUSA, waS dits11i'l)it('( to thle ('ollliiailidlilUZr o~f icer orl a.11d1'U(Iaioi~'iii T,, i(,II, Sitio, ('olIvaJe"sceit , :1lid -ileli(lal liosp~til-.1. It readuh as hollows-:
MEI)ITERRIANEAN TIIE.VrER ~17

F'tt:72. -R-ThCOOnit loling, 21st Gweneral H~ospitail, Italy, N-14I.

lbt IIIaI~le to mainitaini of. exViii li(*I'4ie till levvis of professionial practice. To this et-d it

to all membeilirs of the ho0sp1 ilA stairf mdi t hat th Inf(f~ice (of the Surgeon, N ATOUS.X. be noI itielt iliiiii((iat'lV v(of ainv deficiencies voted in niviiilal hooks and1 joiti-naliI.

b. Th~at fiiiitjcal officer, h le (couiraIgr( to) sld Nill thei cliniii~d comirs of intere,'t iin

gi .lij)- of patienhts wVill Iitlii viewpoinit (if collect iuit n(l(iiiate (hit1: a Ipoli whichi uxoilical :111d

slrin-6c:i repors Inay *i v b bsed. It is siigracsted t ha~t compijletedl snpe-' lhe :-Ilbiliiiivi to

h 1 Surgeon's Office, N AT( US., for edit og aind forvwading to The Surgeoi ( lral

c. That we~ekly v(linicia or clinlical p:It1Ih.-i()l:ida coiifeiiui(5 lie held bY diel slt iys

of all hospiit :ls ini N AT(USA.

dI. Tha~t %\I wi theI( oI)1ortiunit 'v arises, menheibrs of one hos.pital staff will visit nigehlh 'riuii, lo.pit:ils for t he Joirpiose of oliservinug professiona~l praictices.

As a iresuilt o, t(Ils lettIer, deficienicies ill thIe lilraulies of, losplii alS ere

cO treced wei W kv ,lI tli(lvicalI iiietingiiws erv jus,0t it iied as a regiular J)Io4'(Iuuie ill

all1 imsfpitalls aulld papers (lealiig, with di(isease fii the NoithI Al'i-icaii thel(itt,

lugaiNl to he suIlt if) 1*0r pIMiNeClt mi. lTIMS Was illitlta I(( a 'Outlmittiots Illi(-

"ruWii l (*prcicalt mitledlical ((illeat loll, whlichl lat '(Ite til-oilihoit thle IIIe( of' Ilie

Sliea ter.

Al(ct in o5 and ( Soc ietie's

Wi01thIi eu'goui auid 'olicelit~l loli iou l ( hiospitals ill cerlaili areas such

aOr)ali, Bi/ertc. Naples. Lelghmloui.111id Ill liev Fill Ii U.S. ii aieaY ll~. I t was;
21 Il i'''ti II tl' Xiil' ACT::' Ii IT~I.S 411., N .Il'''-'-III4, ) 1 v I s

Il1-~fII II ;l111 It XXI - li f11 tl 11' iII' '-1 l I X i X I PI I 11 11 1 It , I-ill

';Itillil XXIt111 t :1 l' 111111'. XX- wi" ll'''- 'iIl ti -'4)1 I1 lli114.( l;1, I ' ' 1". I111. 11'.-

It"' Ill ~ 11.41 I''t ln' XXI'XIII, JiIItI (Il ltlii1, ''i' (i\ ll , I \l I I\ I I I'l' P4.11111f iii :' 1.

1ill 1 XXV I'd 11:\ .. tll 1 41' I li'I ''- j ll wct;I 111:111 Iflw iiIJ)Ic: til II'-o'hi I i\tTIt III
l!Itral~e(I 1C(ti 1~. k\:gbt it lii t hit.1lo 1, fl ic . hI - ijia i ()I, ille '%I ll

E \(T liii- i ll."::112 I Ii.1 El X: ; 1 i- Il it t 411.hll .I;iiiL X14 h1t thti XXEl ihl

\\Il u qdthiitgI u Iil- Itutiiii . l 1 fil tutu 1:11.it hi l~l jtt i1i1ith tl- it uiIEI

;1114 (111114.1. Ill~ u114. tt itltE 11i12 1 X l t'c tlt'if I pti.i'tth luI ll Mtt :ith ( (~~tN

XIntiert X ied mitiI ini.\gsi. .\Diwing. 01 1. hht'iliti I'J .l \eivtthuti'hipi

IXi tl 1uhi)ptitThe Ill.- 4 XEihh 1\hi1io, iIide rIilicttI ,11 EEXit E N ilt'- io iit-jtiui-1
"_•'_Al \'"T"I\ 1"'1T I I • o I, M I)I '.\ I. I" \• I.'TA I\ s.

I i

I , I I I o I I:ril_'. (;'he Ipr o., ri•'l, o\. hIl.. .".o t, I ..A :. iv \rz. -1 :11 I l t, dX •,. rl.l•:l ,~ . t

l lIl t ", l l lI t :II 1 l~ ~ l I i l t I~ Ii,'. I:n• Id Il tl 1411 .P '; t lc 1 't l l 0 , (dl' I' -

t'' I IId c I I t ~ I ' ;1 . 1 \ )1 f ':. 1 11 41 1) 1 1-.l rf, .If~ l Ir Il~ t~ I I II, ,,• 1 t of ''..1 I ,f lil- ',I .

l T hr\ iln"" l• 1 ', 1:. I,+ l w ll (.,' : l t I] l -Ii' ll ll. I- l () 1ýl) 1 4 Y Ii , 1.11 c w~

I ' I liI :11 , :1 1d \\' 1-ý l; i',_', I ,Il l I'm 1. 11:1l ' v ' fll it " •.+, i, 19,1' , l\\ 1.•, fl , 2 + l + . i . :Ill,,1-..l•, d 4l l h.i fl, -lu .l 1vill l n• cIii, l : :t. i N ,, .ti+. l~if-. 'prlker th-w,,it ll u1',,11 ,_1 A .I II-I t , I, I, ,.it .,.I IO ll ti.oi r . II tlII +ItI I I111 1 • " Ii -,"• ., I"IIII \ IIII- , I', I,,,tc l 11- \\t :1l•

F f I 1. .1 - I I I I I I r ,' Ii', i • I J )'I' "...1 'J 1 l 1 : 1 1 1 11, I S'l ,- ~ I l'' I t Ii l -l , ; ' " 11'1il % I

i I T:• l, ., I I , I II ,,, I,•, - l l, tl'II', -i,_,l: II *1, lu ,. I v .t' I tI , 111i f I' I,, - %ltI . ,. 't, ii .: I I .I

'1"1,,.\ I ~if~ -l :1 i _ • 11 , 1 ! if - 111 t ) 7 1,1 X i 1If )I ., I I v tI t' ll; I I I )II if r ( -l,,4l1 i, i' l 1.4 111

I-]l I - ;I IIII I I II ' l ,'l I\ lli t';III l 1 il 114 -;11 liiif hl1.1- X I-, ". 'l'I ~ I I'' I ' i l xxi - 11 l' l' \\ t' 1

I l . 4 i 1 l l I,\ i,'II l il - :I Id Ii,l . I I I 14 .1_"l I I I i If -i-I lu l l-; II \\t if I 'l ' ,'- IIi l l I.,-;
MEDITERRANEAN THEATER 221

officers who attended were billeted in the hosptial. They were transported

to and from -Naples by air.

The fifth and last large meeting was the conference of Army physicians,

which met in Rome from 29 January to 3 February 1945. It was organized

by Brigadier Boland, the British consulting physician of AFHIQ. The membership was made up primarily of the officers in charge of medical divisions and

the medical specialists of British, Canadian, South African, New Zealand,

Indian, and Polish general hospitals and casualty clearing stations, but more

than fifty chiefs of the medical services of American hospitals in tile theater

were invited to attend. In addition, the consulting physicians from the M liddle

East Force, East African Command, Persia and Iraq Force, South Africa,

New Zealand Corps, Canadian Corps, and the consultant in mnedicine and thie

Surgeon, MTOUSA, were in attendance. Thus, a wide variety of opinion was

represented, and the sessions in which malaria, diphtheria, infectious hepatitis,

trenchfoot, anel)iasis, penetrating wounds of the chest, neuropsychiatric problems, and the medical uses of penicillin were covered, were well attended, and

the subjects were freely discussed. Ample time was taken out during the

conference to permit visits to places of interest in Rome, an audience was

granted the members of tile conference by the Pope, and the delegates were

invited to a wide variety of social functions. It was considered one of the

most successful meeting's held in tile North African and Mediterranean theaters.

Rotation of Medical Officers

The problem of continuing the graduate education of field service medical

officers attracted the attention of the consultant in medicine within the month

after he arrived in North Africa, when lie noted the paucity of opportunity

for these officers to do anything resembling the practice of medicine as they had

known it. It was almost impossible, because of the varying tactical situations,

to place these officers in hosl)itals for periods of temporary duty. In May

1943, at the suggestion of the consultant in chiemical warfare medicine, a flexible

plan for rotating me(Ilcal officers from service and combat units to hospitals

was devised. The plan envisaged the replacement of all medical officers.

after varying periods of combat duty, by general dluty medical officels from

army hospitals within the theater. This plan, which was never enlmnciated

as official policy, had as its purpose the professional rehabilitation of miedw'al

officers who had long been removed from the practice of medicine. Initially,

minor opposition was presented by conimanders of the field units and the

hospitals concerned, because 1)oth groups of commanders disliked giving up

trained and known medical officers for unknown ones, but, when the plan

began to function and its merits were understood, this opposition quickly

disappeared. As a result of this program, more than three hundred service

and combat unit medical officers were rotated from tile field to hospital services

during the existence of the North African and Mediterranean theaters.
22-2 At'1VTIvirs ()F NFIEDlCAL c()NstuIrANTS

Plans for Postarmistice Training

On 30 August 1944, the conlsultanlt in mtedlicinle initiated ain action by

send~ing to thle theater surgeon at Iieiiorandluii, subject: Proposed St aff Nfeoran11(l iti of' it Plan f'or thle 1Post artiistice P~rofessional Rehiabilit at ion in NorthI

Afiricait Theater or Operations, United States Army of' Field Service and

Admiinist rat ive Medical Officers, in Internal Medicine, which r-ead ats follows:

1. There are mtanyv mtedical officers itt N AT( USA who have not had ade(liiate contac't

with the practice of mnedicinte for extendehd periods of time. This is especially true of field

andi~ aidminiistrative service mewdicatl officers, many of A% horn have been out of the p)ract ice of

mnedicinie, as it is commonly understood, for fromt 2 to 31 years. The exp)erienice of this theater indicates that medical officers who have been in thle field or adlmiltistrativv services for a1

year or more requirie front 3 to 6 months training before thay can be fully trusted with the

care, of patients upon the wards of station or general hospitals. To date no plan for training

which will rehabilitate these medical officers in the -art of taking care of patients, has been

putt forth either 1) the War D~epartment or civilian agencies at home. It is b~elieved that

if thle following plait could he made effective in NATOUSA imnntediatclv in the post armiistice p)eriodl, that the morale of medical officers would be maintained and that this theater

wvould be performting at definite service, not only to the civilian population bitt also to tite

Army as well.

2. Plan for the professional rehabilitation of mnedical officers itt NATOUTSA.

a. Post gradutate training mutst be carried out upon at temp~orary duty basis, wvithI

the stndent medical officers assitining definite wvard responsibilities in the hospitals to whicit

they may b)e attached.

1). The periodl of training shotild be 6 wveeks in duration and the progriam canl he

carriedl oltt in all General and the 7th, 23d, 182d, and 225th Station Hospitals.

c. The jprilnary aimi of the rehiabilitation program should he to refresh medical

officers itt the techntiqutes of historY taking, physical examinitationi, the value of laboratoryi

diagnostic p~rocedures and the advances which have been made in medicine since 1940.

This caut best be accomplished by giving the student medical officers direct responsibility'

(minder competent sitlervisioti) for the management of ward p)atients. by formal teaching

ward rounds, lectitres upon special suibjects, X-ray conferences, clinical pithlolo~gical conferetices and journal clubs. The training program should concerni itself primarily with general

internal medicine, bitt special emphasis should he placed upon01 the nuewer aspects of the

diagntosis and treatment of venereal diseases, modertt concepts of dietary regimes, and a

thorough revien of indication for use atid the p~ractical application of )ettcillin. etc.

d. The mnodus operandi coutld be. as follows: There are approximately 100 ward

medical officers in the general and stat ion hospitals which have b~eett listed, and there are

roughly 675 field service mnedical officers itt NATOUSA. Obviously, it is impossible to

esttmate how many~ of these officers will desire t rainting in tinternal medtcine. It is suiggested, therefore, that, upon thle signing of the armistice a paragraph otitlinitig the scope- of

the program be published in a NATOUSA Circular atid that applicat ion for training be filed

through command channels. P~riority out trainitng would be given to those officers who have-(

been lontgest in field or administrative medical posit ions, irrespective of wvhet her such service

was in the Unuited States or overseas. It is the consensus of opinuion that fromt 45 to 50

mtedical ward officers (and ats the stirgical service will he light, surgical ward officers would

also be available) could be placed on 6 weeks temporary ditty with field tunits as replhacemnents for the trainees. Additiontal cantd~idates for the p~rogramn. for whomn replacements would

not be necessary could be ob~tained front the administrative services. Is it estimtated that

from 75 to 100 miedical officers could be rehabilitated at a time tinder such a system.

c. Iii order to assure the stnoothu futnctionitng of this program it wouild be necessary

to have a "school director" attached to the Office of the Suirgeotn, NATOUSA. His dutties
MEI*:Rll ITII\ANE-AN TElllA'TVEII 2231

wolild he to select caitidaits and to solj'r\'is., and ordhiniat . tht. proposed program. This

cellicer should he attahlieId to t lie ( )fli.e of tlie u•urge'oti, N A''t )tUSA, when t he, armist ice seenis

iinhiitiitt, ii ordl.er that i tl l program lty he started as sotit as thtl tactic:al situiatitol ill thlie

t hleater hbecomes stab iliz.edl.

TIh is ilenir ii uIhln Vas tI iorougll"v I isclisse, I wit II th le SIIlrgeonI, MT()TOtSA,

and upoii his i'e(OlllnnletlhlltiOi. it was decided to s5ispeil action upoi this plai

uItttil it al)pealred that the enemy was about to surrl'lelder.

Early i\ Niaircli 1945, the end of hostilities ill the .\[editverra neall theater

steemned immninent, and a committee, under the chairiauiship of ('ol. Edward

I). ( 'hurchill, MC[(', was formed to make plans for gradilite d(ilcation ill the

)toststrreinhir period. This grotip ield its first Inveting oi 15 April 1943, and

the following recommenedations were matde to thlie Surgeoti, NATO('SA.

a. A diretor of lProiessiomal Schlool Service should be- a:ppointed to tih' staIt of the'

Srgeoi. m.rTUSA, anid iiiplhmetited with clhric:d aid.

1h. Authiorizatioll of couirs.s as ollicial War l)elmrimviat school cours's slioild le

sectulre(d.

c. \'i'mi th I )rogr'imii hais lieti foriniulated, a1 circular letter or bulletin, des.rihiiig tih

program should lhe (list rihuled to ever.N itedical oficver iii the, theater.

d. ( emieral hospitals and thlie 71h, Stajt ion Hospital should hie reqliuested to submint plans

for a hasic courtse in a.cord witlli iih following geimeral policies:

(I) Nidiical officers at tiiclle'I t) a get ier.i hoslpit al fo r ai hasic course are to he r,-

gardetd as stidents atil will itot hie used for mily*v othier fiiction except iii a ,lli IiergetI.v.

(2) A luasic course of 6' weeks dlirattion will hie de'signied So that :i stitlet'it mlay

enter at any time anid, when esseitiial. deplart at anly tiill.

(3) (Gellwral hospitals will platt for -20 25 stmietts ,'avi, at a tie'; the 7Tth Staiioli

iHospital will plan for 7 stiudents.

(4) Supplemental l)rofessional teaching lm-rsioniel will lbe supplied, when avallahle,

by the dlirectcor of Professional School Service. The mobile hiospitals will he a source of

personIel for this purpose.

(5) Tin' couirse will inchlide' cliniical pathology, general medicine, getieral stirgery, lpreventlivtye tile. hicine. and twirtrosychiatry.

(6) Ward rouTtids iii ger' inl ' naediciif or gene ral stirgery will I, eomhUct'd h vy a

snidor officer. Ili additiont, ther', will bi ' cliics, ('lii olithohogic cotlfere iicevs, X-ray conf'rerices, didafiic Ive' lihres. rouid-tahh, disctissiolns and journal clhin metitings.

e. The director of lProfe.ssioiiil School Service shall also arratige elective courses, usually

of 2 weeks' duhrattion, ilti hle follohwing: Fiheld course iii pre'vei'at i', medicine. (malaria contt rol,

Iypliis, e'nteric (lisew'as, venereal (lise'ase'). In gemeral, thtiese should follow COmile'tion of

tle basic course.

The Surgeon, I [TO()'SA, accept ed ti e recomn da'iitl lions of tihe (committee,

and shortly* afterwards, Lt. (Col. Joseph 0. Weillaechir, Jr., I[(', of the (4th

General Hlospital was placed o(i temporai ryv dutly inl the ()flice of tihe Strgeon,

M (TOUSA, as director of professional school service. ('olohel Weilbaecl er

imuiediately made Ii detailed stdmy of the problem of setting ul t (lie desired

courses in tile general hospitals of ilte thealer, and, at the ('om1plet, ion of his

s tidy, he SlIbhmitted a ('Omp)rehensive plan for instruction over a 6i-week period.

This plan was accepted ly t(le Surgeon, M\[TO('SA, shortly after thli stirrehder

of thli tiem *v ill Italy', 13bit it, could not le putt into effect immiied iately beca use

of the redelploy'nlent lprogram. Afte(r th1, completion of the red('l)loym('int prograim early lin ,luly, it, Was founl that the staffs of certain hospitals hadi been so
224 ACTIVITIES OF MEDICAL CONSULTANTS

disrupted as to make them unavailable for teaching purposes, and in the end,

it was found necessary to shift from the rather formal course that had been

planned, to on-the-job training in the 33d General Hospital, Leghorn, Italy,

64th General Hospital, Ardenza, Italy, and the 300th General Hospital.

Undoubtedlv, some benefit was derived by the medical officers who received

training in these hospitals, but the experience of the Mediterranean theater

definitely showed the difficulty of organizing and carrying out postgraduate

training at such a time, and it appeared that completely satisfactory programs

for medical education could not be devised during periods of redeployment.

RESEARCH PROBLEMS

It became evident to the consultant in medicine early in 1943 that practical and, possibly, some fundamental contributions to inedical knowledge might

be mnade in an oversea theater of operations, if the investigative spirit that

lay dormant in many medical officers was stimulated. In the course of his

first tour of inspection of hospitals, interesting problems were noted in respect

to the etiology of diarrhea, the significance of chronic dyspepsia in the Army,

the treatment of gonorrhea, the treatment of anxiety states, and the description of exotic diseases, and medical officers were asked to send papers on these

subjects to [ie Surgeon General.

Malaria.-The initiation of the policy of universal Atabrine therapy for

the suppression of malaria in the Allied Forces offered excellent opportunities

for the study of the toxicology and pharmacology of the drug, and in a report

to the Surgeon, NATOUSA, dated 17 May 1943, recommendations were made

regarding the possibility of making such studies.

1. The next six months are going to offer unrivaled opportunities for the study of the

effects of Atabrine therapy in respect to its actual effect in suppressing malaria, the conditions

under which "break throughs" occur, the value of the drug in respect to the various types

of malarial parasites and the effect of terminal concentrations of the drug on the subsequent

development of malaria. In addition, the use of quinine could be studie:l from the same

point of view.

2. This same period will offer the same opportunity for studying new methods of malarial

therapeusis.

3. To date all of our ideas in respect to the suppressive and therapeutic aspects of

Atabrine or quinine therapy have been based upon empirical observations and there is good

reason to believe that with the techniques for determining the concentrationis of Atabrine

and quinine in the tissues and body fluids which have been developed within the last year,

notable contributions might be made from NATOUSA upon the suppression and therapy of

malaria. This will also benefit our troops.

4. Physical equipment such as laboratory space, benches, etc., are readily available

and unused in French civiliam institutions in Algiers.

5. It has been the policy of the Surgeon General's Office to investigate special disease

situations within and without the United States by civilians who are designated as consultants to the Secretary of War.

a. The investigations of the Board for the Control of Influenza and other epidemic

diseases.

(1) Under army auspices but with civilian personnel a large laboratory has

been set up at Fort Bragg.
MED)ITERRIANEAN'IIAIE25

(2) The civilian mnemibers of the variouis commiissionis have conducetedi extellsive jinvest igat ions~ iindler arin * aiisjpievs ill the( field ill th Vn~ ite StI ates.

1). Two inieuhlers of the Virus C ominhissioni have beeni dispatchied to Cairo to st tidy

sand fly fever and jaundice from the point, of view of the( cauisative organisims.

c. The artin'v has senit special investigators outside~ the conitiniental Inited States

to study certaini sp~ecial p~rob~lems since 1 evembilr 7, I1941. .Aniexamnple of t his is the inspection of wounded miade y1) *) rs.. 1. S. Ravdin and 1'. If. Long at Pearl H arbor inll 1941.

6i. The-refore, inasmuch as the p~roblemn is pressing and of great imiportaince and the

it is st roiiglv recommiendtted:

a. That thle theater commnnaider uirgently' retihiest t hat t lie services of D)r. .J1nmes

Shamiion, l'rcifvsor of Pharmacology, New York I miiversitY, one- jiiiior assistant and four

technicial assistantis, he mlade available imnmiiediaitel 'v inl this theater of operations anid that

permiissioni be given to permiti thein to bring those laboratory instruiients and reagents,

liecessar ' for theim to acompl)ish ivthir mission. D~r. Shanunon is the( ind~ividuial who developed

the nimethiods for the quai~nt itat ive dleteriminat ion of both b quinine and Atalbrine inl hod t issues

and fluids.

1). If t his recomniendat ion meets with Youir approval the following radio to thle

War lDepzrt ineii I, aktf' tii lo Suirgeon G eiieral, is sliggn-stedl ''Unrivaled opport uinit ies will

exist inl N AT( VISA duiring the iiext seven mniithis for the scieuitific study of suppressive andl

lierapvtit ii activities of (uinitivn and At abrine from the pharmacological a111( toxicological

po2iits of iw.Special experimiental stutdies tip)01 t his prob~lemn can be arranigedl easily with

French civiliani iiiedical alithiorit ies. Lahorat orY space is available. Information gained

from these stutdies will he miost valuiable iii its app~licat ion to the personnel of t his theater.

It is urgeiit l requested t hat D r. Taiiies Shan non of New York V idversity' , one designated

:issociat e, antd fouir t echiiicianls he semit i nitiediatelv under a civilian stat us, to N AT( )1SA

to stuidy* these p~rob~lemis. Suchl technical laboratory inst rumnenits and reagents neveded for

their nission should be hromighit with t hem. Because of the urgency of these problems priority of t ra iislportat ion is reque-sted.''

Thle Stirgeoil aceept ('( thlese re'omminendlatin a~n 11 d communicated inforinally withI t he Ch~Iief, P~reven tive M edicinie Service, Office of the Surgeon

General, eoilcevrtiliii tile p)ossibility~ of carrvinig out suceh studI~ies il thie Nor'th

African t heat er. tUlforti unate('I, the reply to this coininunicat ion was inisaldlressed and1( did niot arrive until September, when~i it was too late to (10 anyVtiling ab)out Such Stutdies.

Dysentery. Ini late spring of 1 94:3, a major out b)reak- of flybornle b~acillar *v

d(lvsent erY occuirred l II thle Nort ii African t heater. Carefill St udies upJoii tlie(

types of ill icro-orga1 nlisnil respon~sib~le for this outtbreak wvere tmade inl thle Second

M edical 1,a lhoral I 01W ill ('nsa blanca , Frenchi M\orocco, thle 1511st aitnd (191 StaI ionl Ilospi tills inl 0Ora n, Algerial, and tilie 713d Stat ion H ospital ait, (?onsta itn t e,

Algeria, wit Ii thte resilf (i tat not onldy was thle etiology of t lie tliarrlwa inl Northi

Africat clarified Ibtit al1so hit lierto iunrecognized species of the Ski ye/Ia famiily

were dlescrib~ed. These studi~ies were ('speciailly helpful inl Colniiterict ing tilie

French porn t of view thlit 1)iiillary dysen tery was uincommo10n ill NorthI Africa.

Tueit( rrivil of the 150 MtI \Iedical1 'Genleral La horn tory* (fig. 76) inl the fall of

1 94:3 accelerated t(lie temiipo of inlvest igat ion inl the thlea I er becaluse such at unit

cotuld fuuict ion ats tilie deletriigliotise for reseitrcl act ivit 's anid specifically

because thle stimuiilatinig Ipresenice of Major Mallory was felt by aill. The

56419701- C.1 - 17
226i1i4)' i Npe al i 94at Mi-(~alilii 'iai thMAt, tilie N SiVtA'

VelV i ~ ~ ~ eie'a ~ ~ 'sac ~ (tl- ~ iitIil ~ e ~ i it ~ ~etetr ~~A 

Ealyin194 tli ~irenNAI')SA ceaedaliaitlaONE-icr~I

ieuera l~ I.)4)'t, 7G le( iilt it i iine iii'iiie, aut liii' P.vei eiid15.i

1)1 mlimi 'i vi w~a5 stnbhit' (~u IIIa Nat les(' t)I l iill t 94a ii nnt ii'4l li t hat alt1CM ii sizi ht'IV (

VV\ II'thit'al v s at t'r hi . e(l V5ii'V Holrths t't'.h ac uiv t'in]e \61irj)(i'theIi sthe'rt''tni. eta

EaI u944es iennl thei flSurgeo n, l NA OU Il A cg.i relve filiet itsr (I* diii rs t 4oI 

'iii I i Iat 11v t heateirc . trt Th I i lht r.e oftiihi~liiuihrsdt, thsintd er 111 Ill tainlv natpe

G I )inn'inig 944 t 4.v, certai exannnpllt l('si l leinnit's ia Id 1)11v pnivolltvin labora tony

iiih I' lit' t ,Ie th i on t(taitllm ()I' t ei' eo~ arly i ll194 anle itli Wthi( (alt iinuittIm 11111 the

NJilt 114.3. Thesemc Adiitst. igBart nsciiluided .11'eiii)rt'hil-sive illiclvetilitonn an Ialit

swi't sltg ,imlsI'ol Iiisclt ch 1114 llagv i)u brlinii'al then's' ()Irt~giss. I111 or* ti to bi' rt t

hisv dist'l(ase. lch
MEI ITERRANEAN THEATER 227

Atabrine.-In the summer of 1944, an extensive study was made by Capt.

(later Maj.) John C. Ransnieier, MC, of the 300th General Hospital, on the

relation of the concentration of Atabrine in the blood to alleged breakthroughs

in the course of the use of Atabrine for the suppression of malaria.

Liver function.-During 1944-45, numerous medical officers studied the

value of various tests of liver function, not only in patients ill with infectious

hepatitis, but also in those with malaria, syphilis, tonsillitis, primary atypical

pneumonia, bacillary dysentery, and in normal individuals.

Trenchfoot.-Studies were carried out in the winter of 1944-45 upon the

capillary beds and upon temperature variations in the skin of individuals

suffering from trenchfoot.

Other studies.-In addition to these investigations, niany excellent clinical

papers were written dealing with malaria, dysentery, boutonneuse fever, sandfly

fever, arthritis, rheumatic fever, primary atypical pneumonia, leishm aniasis,

and other diseases, and the treatment of gonorrhea and syphilis with penicillin,

in the North African and Mediterranean theaters.

EDITORIAL DUTIES

Every effort was made by the consultant in medicine to provide tie

physicians in MTOUSA with the latest information concerning advances being

made in medicine. In this attempt, it was found that the reports received

from the National Research Council and the Committee on Medical Research,

Office of Scientific Research and Development, were especially useful because

they were valuable sources of restricted information upon such subjects as

malaria, dysentery, insecticides, and penicillin. These reports were frequently

reprinted in circular letters within the theater and were greatly appreciated

by all medical officers. The WD technical bulletins, medical,were also valuable

sources of information, but, unfortunately, in the Mediterranean theater, these

bulletins frequently did not arrive until after the need for the advice contained

in them had passed.

In 1943, it became evident that a means other than circular letters for

disseminating information of current value to medical officers was greatly

needed in the North African Theater of Operations. After considerable

thought and discussion, in which Col. Earle G. Standlee, MC, Deputy

Surgeon, NATOUSA, was the leader, it was decided to produce a monthly

medical journal, the Medical Bulletin of The North African Theater of Operations. An editorial board consisting of the chiefs of the various divisions and

sections in the surgeon's office, and under the chairnimnship of the Surgeon,

NATOUSA, was established. Capt. Carl D. Clarke, SnC, was appointed

managing editor. The success of this publication (the title of which was

changed on 1 December 1944 to the Mledical Bulletin of the Mtediterranean

Theater of Operations was instantaneous, and there can be but little doubt

that it was a leading educational stimulus, as copies reached every medical

officer in the theater.
228 ACTIVITIES O F MEDICAL. CONSULTANTS

Ili ,July 1944, following- coniferenices wvith various chiefs of miedical s'ervices,

thet cotistilitalit ill Ittedicitie (lecideti to recommiIendl to tihe Surgeon, N ATIOUSA,

that coin Iprehleisive monographs coverinig diseases of implort antce in thle theater

b~e preparedl lY ilildiviltilal Imledical officers, or boards of miedIicatl officers, ill

ordler t hat thle collected opinion of iuiedlica I officers conicerning t hese diSelaSes

mlight be recordled. Inl a memorandum to the Surgeon, NA'lOUSA, datedI

9 Sept emib er 1944, subject: C lintical D)escript ion of Disease inl Respect to

MIaiutgemnenit , D~isposit ion and Prognosis inl NATrOUSA, the following recomluliviIldat ioul was iula(Ie:

It is reeoniniviiended t hat comnprehenisive reports on the pr'oblems concerned wvith the

112imagelnient , (lisposit io liiand progniosis of thle following diseases ill N A'I' USA he prepared

by thle following meldical officers. it is ftirthleriiiorv recollinivnellld t hat iiiiniedliatelv, aft er

the armlist ice is signedl or before that occurrence if necess~arv, t hese medicalI otli ce rs Ie 0 1 ' e'

of) fl. . ide ta elI ed ur vice i in order t hat ti(% hey *n v coldlec t t he tin essa rN .dat a onl variot s

disease cnitii tjs and1( assemb~lle it. wit liolit being ilistiurhed by admninist rat ive or clinical diuty.

This recomumnemudation receivedl favorable, conisidlerationl fromut tihe Sui'geoii,

NATOUSA, and, tit his suggest ion it Was decided that two reports wouldl

be nuide inl each inst ance. A p~reliminiiary report., w~hiich wo~uld he prep~ared

ili the fall of 1944, and it final report, Which would he Written aifter the war

ti~lde( inl I talv. This (lecision wats activatedl by thle following letter, signed

b)*y the D~eputy Sturgeon, NATIO1'SA, (latedh W October 1944.

Subject: The D~etailing of Medical Officers to Assist ili thle P~reparattion of Clinical Monographls on D~iseaise Problems in NATOUSA.

To: Surgeon, Peninisular Base Section, APO 782 (Tlirii: Sulrgreon, ('O\IZON E,

NATOUSA, AP(O 750)

1. it is desiredl that clinical monographs be prepared onl the major disease prob~lemns

with which this theater has beeii conicerned5. The objective is to have considered, an1t horitative statements iii re-spe(ct to these various p)roblIems available before the termination of

miedical activities inl N AT( USA.

2. The pitrpose of these mionographis is to describe accurately the diagnostic methods

employed, clinical course, treat ment and the results thereof, and tilie dispositionl of patients

ill wit~h certain diseases inl N AT( USA. Special attention should be paidi to tilie problemls

faced inl dealing with1 these (diseases uinder the military conditions which have existed inl the

Theater since one( aini of these reports is to dlifferenitiate clearly those factors intluiencimig the

mana~gemenVt Of diseatse inl an active theater from those operative unider garrison or civilianl

Condiit ious.

:1. To facilitate this undertaking, it is r'equestedl that the dlesigniateid medical officers

compile and1( edit t(lie available dlat a 111)011 specified (diseases. These medical officers will

receiv'e the fullest cooperation inl their endeavors, and fuirnishied facilities such as secretarial

aidl, etc., necessary inl the p~reparat ion of rep~orts.

4. Ini the inst ance of certain diseases, two or more officers from different hospitals,

will constitute a boardI to collaborate upon0! the reports inl order that a broad critical anialysis

may he ob~tained. They will confer whienever necessary with each other or wvith miuiedical

officers inl the Theater upon01 t heir particuflar p~roblemls. The senior officer will act as chair -

Mall of the board. D~irect comimnulicat ion bet weeni members of thle g-roup or any,% other

medlical officer w~hio possesses pert inenlt dlat a is mi t horized.

5. As far as is p~ossib~le, the rep~orts should be based upon01 factual data and1 not tiijoii

imipressionis. To this end, all necessary records will be made availab~le to tile authors of
MED)ITERRIANEAN THIEATERI 229

the various monographs. Use should be made of the pertinent laboratory data accuinul11:1ted

by the 15th Medical General Laboratory and 2d Medical Laborator'y. Due credit will

be givenl for the contribuitions of these laboratories.

6. When more than one officer is concernedl in the preparat ion of a repiort, the individuakl

exp~eriences of each officer will be recorded first, and the final report will represenut tOe conisensus of opinion of the board. This will naturally reqluire a certain amiount of professional

give-and-take

7. Travel orders will be issued for such inspection of records, conferences, etc., as is

necessary in the opinuion of the authors, for thle completion of their assitgnled muissionus.

8. It is desired that these monographs be completed within 60 days after dlesignlation.

of the resp~onsible officers, and one original and four carbion copies forwarded through

technical channe'ls to the Surgeon, NAT( USA. These reports will be classified "Rlestricted.''

9. D iseases and authors.

a. (Commuon respiratory diseases.

Primary atypical p~neulmonia.

Streptococcal sore throats.

Lt. ('ol. 1). W. Myers, 0-4137966. 7th 'Stat ion H ospit al

Major E. 1). Matthiews, 0-4367:35, 24th G eneral I ospital

b). (Common diarrhoeas.

B~acillary dysenter~y.

Mlajor 1I. W. Ilurewitz, 0-1700449, 73d Station Ilospital

c. Malaria.

Major P. B. Bleecker, 0-:355041), 225th Station Hospital

Major F. S. Perkin', 0-470551, I 7th General Hospital

Major 11. It. Golz, 0) -318515, 182(d Station H~ospital

d. Infectious hepatitis.

Lt. (ol. NI. It. Barker. 0 A4090183. 12th General llospital

Major R. B. C'apps, 0) 386360, 12th General Hlospital

Major F. IN. Allen, 0--257301, 15th 'Medlical General Laboratory

e. Tubherculosis.

Lt. (Col. D). S. King, 0-41328:3, 6th General Hospital

(Calt. G. T. Mc~ean, 0-428031, 17th General Hospital

f. D~ermatological conditions.

Major C. B. Kennedy, 0-40:3771, 64th General Hospital

Major R. N. .J. Buchanan, 0-404505, 300th General Hfospital

Major It. C. Manson, 0-330183, 45th General Hospital

Major It. E. Imbhoff', 0-479552. 61st Station Hospital

g. Arthritis and rheumatic fever.

Major C2. L. Short, 0-178:366, 6th General Hospital

Major E. F. Bland, 0-397996, 6th General Hospital

Ii. Peptic uilcer.

Major X. F. Fradkin, 0-430698, 33d General Hospital

Major D. P". Head, 0-2:30608, 26th General Hospital

Major C. J. W. Wilson, 0-44.5:327, 24th General Hospital

L. Infectious jpolyneulritis.

Major J. IN'. Johnson, Jr., 0-468994. :300th General Hlospital

j. Allergic diseases.

Major H1. 11. (;olz, 0-318515, 182d1 Station Hospital

(Capt. A. C. Kalisch, 0-1 69532~8, 182d1 Station Hospital

k. Sandfly fever.

L't. (Col. William A. Reill *y, 59th Evacuation Hospital

Major Roberto F. E'scamnilla. 59th~ Evacuation llospital

( 'ol. P~errinu 11. Long, Medical Section. A. F. II.Q.
23ý'0 ACTIVITIES 0OF MED)ICAL CONSIuLTANTS

1. Venereal dlisease.

Capt. R. I. (;ttmvan, 0-169:3729, 23d General Hospital

mn. Leishinian jasis.

Major Alfred Kranies, 6th General H ospital.

For the Surgeon:

E. Standlee

Colonel. N. C.,

Depuity Surgeon

The iniitial tmonographs were forwarded to the Chief Consultant. in NMedicinle, Medical Conlsultants Division, Office of the Surgeon Genieral, in February

1945, for suiggestioti andl criticism andl were then rewritten all(i brought, uip to

date after the surrender of the enemy in Italy. This was (lone in compliance

with time (directive containedl in time letter of the Surgeon, \ITOUSA, datedl 7

Februmary 1945, subject: Clinical Monographs onl Disease Prob~lemls in

NITOUSýA.

MEDICAL INTELLIGENCE

Early in 1943, when faced with the prIoblemU of the mnedical care of prisomiers of war, Colonel Long realized that there was p~ractically no source of

Mnedical intelligence in thle theater. With this in mind, hie mnade thle following

report to the Surgeon, NATOUSA:

1. There is available in 'NATOUSA very little information regarding enemy imnmunization programs, medical field service, miedical practices and medical suipplies. The possession of such information would be of value in the planning of future operations and in the

medical care of prisoners of war. It is also conceivable that information or drugs might

be picked wvhich would aid the AUS in improving certain aspects of medical practice.

2. It is therefore suggested that an intelligent trained youing miedical officer be attached

immediately to the G-2 Section, II Corps, and that he be instructed:

a. To interviewv prisoners of war in order to obtain medical information from

them.

b. To inspect, photograph and describe captured enemny mnedical installations.

c. To inspect. describe and photograph enemyv medical ecquuipinent and supplies.

d. To report the eyistence, general type of, and location of capturedl enemyv medical

Su1pp~lies.

e. To send samples of new instruirnribns, drugns, etec., promptly to The Surgeon,

NAT( USA.

f. To file reports of his findings with G-2, N.ATOUSA.

The -Surgeon., NATOUSA, (hi( not take thIese recomnmendlat ions very

seriouisly anil (lid nothlung albout theil. When t his became evident., thle

conisult ant in inedicinie made arrangements withI the Docuiments Branch, G-2

Sect ion, AFIIQ. to have senit to hmimmi all thle capt uredl enleiy *(Vlocumnents t hat

relatedl to any field of medicine. Thtis arrangeinemit worked out fairly successfully, and somew useful hiformnat ion concerning time incidelene of ty' phus and~

tetanus, the prop)hylaxis of malaria, and numnunizat ion againist (disease was

ob~tained. However, it, wats always felt that inuch mnore valuable material

could have b~eenl obtained if a properly traiiiedl inedhical service officer hadl leeti

placed in charge of mnedical intelligence.
CHAPTER IV

European Theater of Operations

William S. Middleton, M.D.

Part I. Chief Consultant in Medicine'

HISTORICAL NOTE

In 1942, the organizational pattern of the Professional Services Division,

Office of the (Chief Surgeon, Headquarters, ETOUSA (European Theater of

Operations, U.S. Army), took its basic design from the organization set up

for the American Expeditionary Forces of World War I in France. Circular

No. 2, dated 9 November 1917, Office of the Chief Surgeon, American Expeditionary Forces, had listed eight directors of the Professional Services to

serve as an element under the Division of Hospitalization. Four months

later, it, was disclosed that The Surgeon General of the U.S. Army had, on 11

November 1917, proposed at Consultants Service of three divisions. However, he expressed his willingness to support the plan of the American Expeditionary Forces, and, eventually, 7 of the 8 directorships of Professional

Services were established in the Departments of Medicine and Surgery.2

Unusually happy was the selection of the two leaders of this movement:

Brig. Gen. John M. T. Finney in surgery, and Brig. Gen. William S. Thayer

in medicine. From the outset, however, the geographic dissociation of the

directors, located at Neufchateau, from the General Headquarters located at

(Chaumont, 45 miles away, bespoke difficulties that were exaggerated when

General Headquarters moved to Tours. On 18 April 1918, ('ol. William L.

Keller, M(', was made director ef Professional Services. Although his appointment afforded leadership and a measure of cohesion, his assignment to

the general headquarters accentuated the p)hysical detachment of the officers

whose work lie supervised. The unfortunate term "director" was changed

by definition to "consultant'" by Circular No. 25, dated 5 May 1918, Office of

the ('hief Surgeon, American Expeditionary Forces. Tie pattern of organization was most ambitious and was designed to be carried through at all

eclieh)ns of command; namely, army, corps, a(nd division.

In the Medical Division, under General Thayer at headquarters, there

were two senior consultants in general medlicine, (Col. Thomas R. Boggs, MC.

and Maj. Franklin Cl. McLean, NIM(; a senior consultant in infectious diseases,

('ol. Warfield T. Longeope, M('; a senior consultant in neuropsychiatry, ('ol.

Thomas W. Sahnon, M(C; a senior consultant in general medicine, poisoning

I Dr. Middleton, who is the author of part I. served as editor and -viewer for the remainder of the chapter.

2 The .Medical lDepartment of the United States Army in the We 1.1 War. Administration, Ameriam Eqlwditionary

Forces. Washington: U.S. 0iovernment I'rinting Office, 1927, vol. II, , >51.

231
232 ACTIVITIES OIF MEiDICAL CONSULTANTS

by dleleterious gas, Lt. Col. Richard Dexter. MIC; a senior consuiltanit inl cardioValscular (diseases, Lt. Col. Alfred K. Colin, MIC; and at senior conisultanlt in

tub~erculdosis, It. (Col. Gerald B. Webb, MIC.

As might be anticipated, this comprehensive plan, ideilistic in its conlception, failed ait many points thlroughi patent, sources or weakness. C1oiniiunlication wats (lifficult aIndl mobility limit ed. As late ats 2 September 1918,

in at communuication to tite C'hijef Surgeon, Amierican Exp~editionary Forces,

Genteral Finnev and General Tlhaverl indIicatedl their inalbilitv to control thle

(list ribut ion of skilled p~erson nel. This fund~a mient al (lefect sharply curtiailed

the uisefulnless of tile consultants anld led to anl almost. overwhelming senlse of'

frustration. Wit hout symnltathietic coop~erat ion at thle highest levels, b~ot h

withi til Medial Dpartent of tile Regular AXrmy and within the( commnand,

thle 1)01enitial or tilie conisult anlts inl fullfillinga thevir mlissionl wats not Well exploitedl.

As anl observer of the activities of the Professional Services at close range

in W*or'ld War I, tilie following inherent fauilts b)ecamne apparent to the aitithor:

(1) Overorganizaition ; (2) concent rat ion of highly skilled p)ersonneil ait consultant levels; (3) dletachedl leadership; (4) lack of cohiesive attack; (5) difficulties,

in transportation, leadhing to inimolilizaition; (6) inadlequiate professional andl

Military rapplort ; andl (7) insuifficient tune to correct these errors or organiization l and ol~erat ion.

EVOLUTION OF MEDICAL CONSULTATION SERVICE

With tile World War I experience ats b~ackgroundl, the o1)lort unlilties and

the responsib~ilities of thle Mledical Consultation S'ervice, Office of the Chief

Surgeon, Hleadlquarters, ETroUSA, in World Wair 11, stood in shiari) relief. lin

London, ats the Army Medlical. Directorate Consultants Committee to the

Director General of the Royal Army Medical Corps, were gaitheredl some of

the outstanding niten in British medicine. As advisers to tile Royal Canadiain

Armly Medical Corps, there were four leaders in the C anadian p)rofession.

The comnl~inied exp~erience of these Allies wats available ait aill phases of p)lanining

andI activity in ETOUSA. Their adlvice anid assistance were invailuable, an I

many pit falls were avoided through thieir sust aining counsel.

Organization

Onl 13 July 1942, It. Col. (latter C ol.) William S. Middleton, M( ' (fig. 77),

reported as C hief ( onsuiltant in M\ edicine, Office of tilie C huief Surgeon, H~eadh-

(quiart ers, ETOUSA, thlen L-cated ait Ch'elt enhiamn, Eng-land. Onl 21 .JulY 1942.

Col.JiunesC". Kimubrough, MIC (fig. 78), Director, Professional Services Division,

Office of time C hmief Surgeon, Ileadlquuirters, ETOUSA, p~rop~osedl to set uip tile

following four separate dhivisions of consultan tts: 'Medicine, surgery, IleumoPsychiatry, 1111d1 venlereal (diseaise (control. Colonel Mlidldletomi indicated certaiin

practical aind functional ob~jections to the separation of neurops *ychiiatrv and1(

venereal dhisease control from medicine. Oii 25 Julyv 1942, C olonel Middletonl

conferred with Col. (latter Maj. Gen.) Patul R. Hawley, MIC, Chief Surgeon,
EUROPEAN THEATER OF OPERATIONS 2;33

FDURE 77.-Col. William S. Middleton, MC, Chief Consultant in Medicine, Office of the Chief Surgeon, ETOUSA.

ETOUSA, and urged surveys of the British and Canadian medical situations,

with particular reference to the physical, tactical, medical, and educational

programs in these respective services. At this conference, an adaptation of the

British and the Canadian experiences to the medical needs of the U.S. Army

in the European theater was urged to avoid duplication on one hand and the

loss of identity on the other. In discussing the educational program for the

theater, the improvement of medical services for the troops wias the objective.

Past efforts had fallen short of the mark, owing to a failure to reach the medical

officers most in need of instruction. The interchange of medical officers of

company grade on the staff of general hospitals with those in line duty was

proposed at this conference.

In the eventual plan of organization, Colonel Kimbrough included, under

the chief consultant in medicine, senior consultants in the following subspecialties: General medicine, gas (lefense, acute infectious diseases, cardiology, tuberculosis, gastroenterology, dermatology, nutrition, neurology, and psychiatry.

With the concurrence of Colonel Kinibrough, nutrition was later imade the

responsil)ility of the Preventive Medicine Division, Office of the Chief Surgeon,

Headquarters, ETOUSA. In London, on 11 August 1942, Colonel Middleton

met with Col. (later Brig. Gen.) Elliott C. Cutler, MC, Chief Consultant in

Surgery, Office of the Chief Surgeon, Headquarters, ETOUSA, and Col. (later

Brig. Gen.) Charles B. Spruit, M[C (fig. 79), Deputy Chief Surgeon, ETOUSA.

In this conference, Colonel Cutler expressed a desire to have his senior consult-
ti Fi i 7S. Wit I: C lilaJames C. Kimtiim]lOii 'MCsIas ehiit111diii iit.thitil11 S.t'r ites lii LNtIit' .

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;l 1 l~l il ,• ' \\ '; 1 •1 \;1 "1 -. I 1 • ;1• \; l''ir ' \l l''I' vl , ,i ;• . , l ',, - \V I' r I \V -I I

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I{, \ ,'•l ; 1 . rl ', ', rl••. • l ',l •ll ', •l,,' • l•, -•. . , lli ., -+ ,l ( ' l, ll• l \'; llIoI v~

(';l~ )•I( l~l ll I ill ()vI{. 14 .\•,_,l -t ~ llJ ( ', l(,v .I li~l ll,. ,,I \V;+- k ,I I II•

I'\ ,1" • 1'\ I~ n I'; ' 'il I.•,,+,1 l\ .\ o \ N ,', i,'•l ', V'l - . ,'t ,. •1 •,l I II I -II•lIl I, I• , 
.)36 .w'Invri'is, OF MEDICIAL C'ONSULTANTS

Barracks, Aldershiot , England. Tabl)es of orgainizattion an plapi ns of' instruct ion

for gals defenlse were Cli'efully reviCewed. The realistic at titud o ofl' the school

officialls indi~catedl at sharp appreciation or the limnitat iouus in thierapy. For

exaniple, oxygen titerapv wais to Ibe giv'en to the ''blue'' subjects of phiosgeiie

p)oisoning hbut uot to tilie ''gray.'.I

C olonel Walker lprol)osedl to take front 10 to 15 U.S;. Armiy miedical officers

in eatch class, maltiher t hait thle existinug quotat of three, ats thle pressure of t lie

inilitairY sittuation increased. Oin 4 November 1942, Colonel Middleton attended the course at. the M. S. Factory, Randle, near Liverpool, where the

prograint included at demonstration of thle manufacture of toxic agents. The

p~revent~ive measures amiong workers anid detailed datta ats to the treatment of

the several forms of toxic gases , including hromiobenzvlcvani~lle and lbeuzylcvanide, phosgene, lewisite, and other ars-enic-contalining toxic aigents, were

(iiscuissed. Doctors Chiesmaln, Ferric, WVilkinson, and Stopford-Titylor and

Mr. P~hillips afforded it most, instructive day.

Meanwhile, the key position of gas defrense officer in the office or the

C hiief Surigeon, H~eadlquarters, ETOUSA, rematined vacaint in sp~ite of C olonel

Midd~leton 's imiportunities. When Lt. C ol. (Inter C ol. ) Perrin 11. Long, MC ,

was t raI'll 1erredl to General Hawley's office on 20 Novemiber 1942, lie wats

assignedl to duties of' Acting Senior C onsult ant in ( 'hemical Warfare i\ ldicinv,

ETOUSA. With characteristic energy, hle lent every effort to thle orient at ion

a1nd org~aniziation of thle available inforniat ion in ain unfainiiliar field, uunt il his

transfer to Ithe Not-tit African theater on 18 Decemiber 1942. At t his ilc

the presence of ( oindr. (latter C apt..) George M. Lyon, -MC , USN, in thle naval

office of' thle U.S. Euinhassy in L~on(lon., was frotluitous. A studlent of gas warfare

anll gais defense for utiitny years, ( oniiiian(ler Lyon brought recognized antuthorit v

to this field. Hius c'ooperat ion wit Ii tilie Aruiny and1( assistance during t his periodI

illustrates one of' Owli strongest justifications for the unification of the Arinud

Forces. Finally, C ol. Williamn D. Flemning, i\IC, tilie long-awaited gas defense

officer, rep~ort ed for dulty oil 2:3 February 194:3. Three (lays later, in dleference'

to Artily p~rotocol, C ol. Oraniel I-I. Stanley, M(C, Deputy Surgeon, Headquarters,

Service ol Supply, E'IOUSA, indlicatedl that C olonel Fletniing hand b~een assigned

dlirectly to General Hawley ats assistant surgeon in chiarge of gais dlefense. rfliis,

function wais thereupon remiovedl fromn tihe organizational pattern of the Medical

Consiultat ion Ser-vice. The gas casualty kit assenibled by Colonel Flemning is

shown in figure 80.

Dual Functions

With these Ilinnuot reatdj lst Imen ts, thle ultimatte plan of organization of thle

Medficall Consult at ion Service, ET1OUSA, was conipleted by thle add~it ion of

Lt. C ol. (laiter C ol.) Gordon E. Hein, MC, Ch'lief, Medical Service, 30th General

I lospitulil, locate n'I ear M\ ansfield, Englandl, as,- Senior C onsu~lt ant in ( ardiolog,

ETO'SA ; Lt. (Col. (latter C ol.) Yale Kneeland, .Jr., M C, Chlief, Medical Service,

2d General IHospital, Ileadington, Oxford, England, ats Senior Consultant in
EU MIAN*11ETE M' OPERAU)NIS -237~~

'rit t 1: 81). IKT( gasenivi ,~I~kI v re:atiiitet kit.

Inivet tols D~iseaises, EI()ISA ; and Ma Ij. (kiter C ol.) Ral ph S. Mhickenriiss,

N\I ( (fig'. 'SI), C oi i 111. iin ligil Oflicet', ( remieraI Mvld tal 141.1 )orU I 0 A, as D~irect or,

.11e(Iic Resear ch, l 'SO A. C oloniel Bai(IgeI cot) till le( to funct(1ion ill the

(111:11 cliI)2cit. . of* Chieif', MedI '(Iilil Service, 5~th IG'enieral H ospitadl, and Sej(Ilioi*

( (dit~l ll In'll ' herell osis. WithI the grow~thI of' the t heat er, the basic patteril

wasililmaintadinledI, always wilhi tihe thlolgli 1t of litt liziiig" thle 5eliiili colisiltait nts

ill (I ti11l capacities, wh er~e po0ssiblle. As time lied( d(evelop~ed, wh'bet er inl hosipit al

cenitees, base Sectijons, or ai maljor a1rlea sulch its thle I. nt ted Ki ngdlomi, thle sellio01

conlsil t Ulits ill1 iii ect toils (liselises, card i ology, and1( t uberLculosis coni tined to

serve mi t wo dist inct roles. Time prima121ry responlsibIili ties of' t wmse senlior con)Is1il 1.alits to it iospi t,1 al o a lameranliijlijstni'at e liiiit (hiospita:l vellt er, base

Sectionl, or IlilijoP. a leea) ill no \\-.1 Hit elI'viere withI theireleliipoll a itt hintit oil of'

dIirect inig the t hanter policy with li thIeir reesp~ect ive( sJecillit ics.
238 ACTI VITIES OIF MED)ICAL CONSULTANTS

Thle effectiveness or ainy p)lan vain be estaltlilise(I only b~y the trial or experience. As st atted, the atdminist ratt we loaid in neuiropsycluattry i111( (lernmltologv (including venereal disease) was aint icipait ed. Colonels Thompson aind(

P~illsbury, opera t ing frioint hlezidqluint e, (lisClniage(1 their OflCI'OUs (lilt ies withl

(listinct ion by (int of patinstatking planning aind aissiduouis effort. Tile earlly

occurrence o at serious probldem ii thle incidlence of lprinliary aitylicall pnieumioniai

led the C hief~ Suirgeon to eStalblisli at commit tee, coumpIosed or C olonels Kneeland

an1d Muckentuss and Lt. C ol. (latter C ol.) CJohb E. Gordlon, MC, Chief, Preventivye M\Iedicine Diivision, Office of t he Chief Surgeon, Ileaquairters, ETOtL 5-A,

to stumdy this prob~lemi. This group) wits continued ats thle Advisory C

1omnmit tee

on Infect ioums Diseases to coor(Iinitte t he inn t ial effort in this atrea. In the

interest or jprofessio-ial (overage froi con-sult at ion in isolaited units, the temporairy

MIC, D irector of Mv lical H&e.t:1r(I,

expledient of ret-ionail consuiltants wits invoked onl 21 May 1 94:3. Sevenlteen

Stich consul t ants in miedicine wvere natmed front thle chiefs of fixed hospitails.

Thle Plain of balse section consultant' s wats first estaltlilisedl in NortlIi Irelaind

Base Section lby the aippointment of Colonel Baidger. With the evolution of

the mnilitary lprogrnin in the United Kingdom, the next lphiase of thle Medical

Consuiltlat ion Service, ETOUSA, involved thle mnovemnilt or thle followving senior

consultants: Colonel Kneelaind to tile Southern Base S~ection, Colonel Hein to

the Western Baise Section, aind C olonel Baidger to the Eaistern Balse Section .

4

Eventually, lIase section consuiltants were aissigned to thie Unitedl Kingdlomn

(fig. 82), Brit tanm, Nornminandy, Oise, and Delt Batse Section. Thie Brit taly

Base Section hald at very shIort lire, aind its medicail consuiltaint, C ol. 0. C. McEwen, i\I( , wais given conmmand or at hospital. As time paissed, hospital center

consultaints were naniedl in 15 centers-i in thme Unitedl King-dommm, 8 0o1 thle

C ontinent. 'Medlical (onsuilt ants in each airmy afforded the (direct (hiannel

of comm unicat ion withI the fieldl. Tlie mnaes und aissignments of the mnedical

consultants who served in ETOUSA are listed in alppendix A (p). 829).

SCircular L~etter No. 89, Offlee ofChiebtiurgon, I (ledqu:1rters, ETOUSA, 21 Ma~y 1943.sahject: Regional C'onsutl~nts.

4 Nou.TE-he hovpit:LI cen ter dev~elop~ment soon mtade a single med icAd consultant tar the United Kingdom a nmore

effective agenit for coorhlin.1tin at these p2Tou;).-J. fl. C., Jr.
'Il 1 A l oil V ''dI. \'*I l\

( ' T .: , ,• . :,I 0,,j'- 1 h \I ,. •- 1, I I ,ri ,_' II;. . (l I . S • jor' ! tllil. \ I1 ' .w. , , Il' I,, I • .I d' , ,- , 

\ --•-I:,•h ,' t ' , • i ., I:., r. : l i.\ I', l~ , 1. . r, 'rtm , \I I Ih Il, ' ' i .' , • .• ' , ,lCl,

I i\ I-I,

,'4 1 li r 4i'; 1v pi w (III' r, l•.--~ I~o I I I~ I :vl '' , l. I I I.' I•\ n;•"l. I •

'4, 1 t'; li ,l 4: ',114411 -I'I j- ll' \ 1v 4 I 41'I - 4 1 4•1 11111 ' :111' if I ' ,,'.:4 ' I II ,li144 I .1 1 l i . II'I. 

IIl..r ':l•,,I'41 oI',' 44411 144! , :1 r4 4 I1,'l 11)l ,.,liI'tl 441 lt i ,ll Ii 4'l II tII.uf, .

114411 lii l I,',114 I :l'..',ill r,,' It , I I l- I , 1' .Il - f l: rI l I:11 ', II i l lii1.'

Ih•.r• ~ ~ v n ~ ~ I ',, I, I• I.i~ Vrit I 1•- 1,ol~~ 1. ;1 ,111;•• 4 ':1 n41. 1 to1I~~ll'' ' 

• ,,, i,'•l. X ,,iv lt''•l h 'v ll? . I1. :• \ :• :•'",' \\: -- '•'• V'i •'l •l :•t . ,l II :•I
9240 ACTIVITIE'S OF MED)ICAL CO NSULTANTS

ce(ntr'ifuigal since General Hawley's office, through this medium, was constantly

inl touch with tiall mnedical echelons of t he t heater.

Thie scheme of orgainizattion (lid not extendl beyond1 the level of the field

airms' into the corps andl divisions as- hand been planned in Worldl War 1. Although there had1( been early designs in this dlirection, it wats foundl inexp~edient

find ineffective to carry thle plain beyond the army level. However, through

the irm medcalconsultatnts, tin effective medium of exchainge exist ed on at

recip~rocal plaine. Through 5 arniy consultants, 15 hospital ceniter consultants,

aind tult imat ely 5 base sect ion consult ants, the senior consuilt ants in mnedicine

find( thle chief consultant in medicine found ready andl cooperative professional

coinim titicat ion.

Tile necessity for this dlecentralization becomes apparent in view of thle

existence of over 200 fixed-hiospitad units in the theater. Furthermore, with

lie OVER LORD nmovemfent , C olonel N\lidldleton aind the headlquairt ers-based

senior consultants, Colonel Thompsn fi01 nd C olonel Pillsbury, were Iftransferredi

to France, when thle Office of the Chief Surgeon, Headquarters, ETOUSA,

mnovedl to Valognes, aind later to Paris (fig. 8:3) find Vers-ailles. At this timle.

the (direct responlsib~ility for thle dlirection of tihe Mledical C'onsultat ion Service

in the Unitedl Kingdom devolvedl upon Colonel Kneelandi. Under his inimedliate supervision camie the organization find operation of thle medical services

witbin the total of 140,000 beds, representedl by the fixed hospitals in thle

U~nitedl Kingdonm after D-day.

GENERAL MORGAN'S VISIT TO EUROPEAN THEATER

The support of the Medical Consultation Service, ETOUSA, extenidedl

through the Chief Surgeon to tile staff of The Surgeon General of the Armyv.

In addition to the official interellanges of the Medical Department, informal

professional comminunicattion wits encouragedl between the m~emb~ers of the staff'

in Wats] ingt on. D.C., and their respective associates in tile Zone of Interior

and in the oversea theater. Brig. Gen. Hugh J. Mlorgan, Chief Consultant

in Medicine to The Surgeon General, utilized continuously this exp~edient of

informal commn unicai t ion ats at mnediun for reciprocal adlvice. TIlis ready

excliainge of professional information redloundled to the improvement of medicall

service in the European theater. General Morgan's leadership gaive initilialte

(direction to thle miany maiijor dlevelopments.

General Morgain visitedI thle European theater for a tour of inspection front

7 February to 21 M arch 1945 (fig. 84). A summary of the t our w~its made onl

28 Mfarch 1945 by C olonel Middleton to General 11awley, ats followvs:

General 'Morgan was afforded the opportunity to observe military medicine in four

armies, under field conditions. In three of these armies he followed the hule of evacuiation

from the lhat talion aidl post [statiouiJ to the evacuiat ion hospital. Typical fixed jinstallationis

of the~ Coll]in inicat ionl Zonle were visited onf thle Continent and in Great Britain. Particullar

pains were taken to cover thle entire range of facilitijes from tented tunits to uinits liouised in

~Imildlings of everY degree of adlequlacy. The miedical organizat ion of t he several 'clhelonis

was covi-red if) detauil by qualified mnembe'rs of t lie staff. Clinicjal sul)ject s of special intecrest

to General Morgan, such as cold injury, hepatitis, malaria and ''field'' nephiritis, were
IIL'ER T.itEN OF bi'ERA.\'l'1241

1'ii; Rv S3 .\v(I1I1 hlelhvr, PiNFraiiiev, shoit lmi secti(t on of b~uildings

ocrttpiedl hy. ()(lice of till Ch'lief Su~rgeonl, 1.1rWS)1A.

delli1Olistrated ill :l((it 1 inumber., to 1110t hli- re(flitrellivl('O Throtigh thle c~ooperatiton

of ~eflj1r the C ,ti ih a l~ .i I' sv ehi atr y and D)el lli t~ihtg Y s)4ci all f aieiliti i .. lli t i - field"

%Vere demionstlratedl to Generail 'Morgani. Thromlg Colotw~l. I ivele- .hi~ld Colontel Stillbii'Ii'd.

-. injilajr (1p1 )rti tutu jes were affoirdedl for thie -110%,l of thle prttgrall ill pliv~'caI rehtablitiiationl

(fig. s5). pea (.1,11l~tteco ioll of Ith1 .1huitinll'i rat ive alid clintical dhy jole' of all ecllel()le'

of the Mevdical D epart med nate t his tour osbv

Thle M Iedical C onsuilt at ion Ser.6ee p)rofitte(1 inmnilal fr-U tile firsthand (counsel( of General .~r~t on hi uOLli 111 l(i .

CONFERENCES OF CHIEFS OFTNMEDICAL SERVICES

('olonel Miidlevtotlini jtiaed periodic conifer'ence, of tile vihiers of PICehii'd

services, iltile in jt erest or tile coordntlil onl an vll((olidSlitt oll of miedIical pract'Iice

Withi tixtlie fixed h1051itakjl of the ( 'uiiilImicatin Z~tS/onet. Thie first of' these co01lferences Nvas hield oti 2.5 M~arch 1943 tit C helltenufham. Fourt evil of the sixt eell

chiiers of Ilted ivitw inl fixeld hiospitIalis ill til lt' eate(' ( Itt that t im e wee ill at -

('hii~il(' Rl~e~iltati ~('5Irlhte ()1live of thle ( lujl~ilefsug('ou I eatlqutlrS(vrs. EF IA dl~UI~ C oloniel Flemiuuuii Me'dical (1,as 1)(4411-P Of heel". C'oloiw

Kibiriotigli, D lirector, Prlofe'ssionl, si -'lVWi' i" D Iivson, Lt. C oh. Ia te. (Col.)
I i (I ,4~ I 4 \ . 1 444 Iil' '44 \IT 11 1, I TI. I T I-4

I I )O'rwilzthIwn : C~( ~Ifhir 'I'I444IlI-.4 , -- 44lrm ('411--4411:441 11V 1

1:4 ((:-4~4: (--4(41-. I14(41(4\ '~I4164-f.: 1i4441( 44.1 41 d III oil [I114l--:1

di--- l(1 -,11,14111im4 :4141 wi4I4:111ml4 %,I' 1441:1 44I-4:4': 14'1 'II-A4

ill (144:4 iii 11(':44'I jl4('41 444' 44 ((4i44i144(:4 4I4' i11':1,11'" _\ phill--:

pt)Il:4 l/4 III4 14 I(-(t4-- I 14 t14'4 'I :4 1-14114'l" h4':4(IjII:I141 I-' 1 l:41~

11 11 4 44 444- 4 i'(11''41 4i41i -I 4-\;- 11(1d1 :(4(4( :I I1:4

4144411 ( )- Iho ''. 1 41p I (' 114.I ¶1 l-r .. IlIii h)1 1 4(- fill-4 -44 I'- 41

Th\4( 4 -cr ll rm14144- iil tlor l'4 l(dI ho ch\, 4141'-''41 IT' II4'A -4(1 (,\ 4'r-\\I- I ltII ;1\ l'\ f(41ld(

411III r (m "'441411.. Allk I 1!1 i ( Thii r 1'4-41444: (111 l iw i:41\ 4.41\ WI.- .

4~~~~~ 1 ' 4iiiii.(I-. f444I4-- ~ ~ N I I - ' ~f4 1 :1 1 4i(1 11 I11 1144441114
D ivision: Co'loniel MN1>iiicli .'Ixeciit ive ( )l icvr, Col. Waller I, IPerr.v, N1( '

Consltant. I'iIIIe Dvrll Smploy: .1dCoI )iMoi ike1 lihiiJs'oi. D wire or, (ldia Rv-i~~i

'Ii'l. lie sublject-('0 cnidlered' were iiiilk ~IIppjIY feve'r t ifher)V ; ju lit v

JpiI)1('ill.' of thle tletu.iiieldiwlr IesI*.iiitoI'v iiid'v!-I loll'. iiih'ectIMIi 1110110-

pr)blv'ills. C oloniel (' iuie *v piev'iilted aji1 .11ii1, vIvs of thle probldemi of lioviiiV

tiilbercillo~'.i, Ill ( ',ral Bu'jt1:6u1 which wa, Oiiielv *aVid u''velliiiio.. Tlli pe ll'vilcv

of ii'Jpie-iillit ive'5 fromi thle 5te'i'aI dlivisions o1, ( elieral I Iwle ev's , office ledl

to li 1(11 oel ori'iii, w\itl Ii iost ip'ofitablvde(iscusiiioniS of, slch slillje't5, as plails

for Sp)ec'i~Il~ll lis oi~i~lil\(f specinl e(Iiuliliieilt, supply ;iild proi0('iil'eill'i

IIv 19411, thel thl'l('l hadi( -i'own to sucih all ex\tenit t hat it a 1 'si'

I'l'he first , heIld oil 26~ .faiiil v 194-4 incudedu~h'( tIv chi'(li( of thle uiiedical srie
I;I

ofill, medi' ici'lal serviii' fii ll-i hospitals of thev Soul Iieiii1 IBa's Secit io. At

flie two imie'tiing-s. 71) vhluek- of tli lie uvilic;1I sei-vices of t lie i'speeht-ly lmisjpitaIs

or Iwiii repre'vioniiit ve wile III a Iteviudl~ice. The lollowitiig ri'l-'svi'iat ives, of

(teiuiia Ilav.1t X'vs oIliivý look ctiv p.11 Imi IIt Ilit plIoieeiiviigs of fthese( sessiOlis:

Col. .1. C' ~rjl. NW, C hief. li Sp~itallzat louI seitioii C ol. Rex L'. IDivelv. v

(NW ).CNi( atlliv, I( ', In IOrpli/.at io Isivcit. Clo (l Fivouil'l iii NI . iC;IiisI )irietei off Nicdeal Clo''rli : ( 'ofoii'Che lPIshiiilveiio 'otiiultlit ~eiolone Ci 

cI)I~vvso ('apt:Co. 'uLeN. W. LPu'rlCivft \1(p , liv D ii ivi' NI'i~doleiii Thompsniiu

oi)t. II. I 1)(iniil. AI . Suppily I 'l~ivisiou;l:ilall [i NI RadpI.- Sxiz. L). ( I.

Mi M 'art 1 vl i's' N I ' Sl l ('loliil tt tIn I )iiI levisi on t llii'il I lici kol'..ai iatlll hs , I)I-
EUROPEAN THEATER OF OPERATION S 2 45

withI the report. of progress in thle experimentation on the prophylaxis of acute

uipper respiratIory infection, pnieuinlococcall inflection, typhus fevel-, sulfolnamideresist Iluit gonorrhea (penicillin thlerapy, fever thlerap~y) ; intensive arsenical

lieritpv of sy, philis; neuropsvchiatric problems, includling alcoholism; disposit ion of tub~erculous patients; certain abrt *vproblems; outpatient

dlepartimenit ; rehiabilitat ion ; and thle conduct, of p~rofessional meetings. In

tlie openl farumll, Vincent 's stomnatitis, disposition, dletaclhmenet of patients, and

evactia tion receivedl (Iue conid~~era tion. The Records Division, Office of the

('l~ief Surgeonl, Headquarters, ETOLSA, made at special appeal for the accuracy

of' diagnostic nomenclatutre andl stressedl the importance of maintaining formis

and of careful paperwork in support of statistical analyses, ats wvell its in the

soldhiers' interest, to estab~lish the service connection of' (disabilities. X-ray

supplies and equipment received full att en tion. Air transport at ion andl

evacua tion between Northern Ireland~ a)11( the U nited1 Kingdom andl between tilie

United Kingdom and the Zone of Interior were dliscussedI. The deliberations

of the earlier meetings led to the promulgation of at memorandunm concerning

lpolicies of procedure for chiefs of mnedical services, wvhiich p~rovedl both opportune

andl effective.

The conferences of the chiefs of the mnedical services hiad clearly established

their extreme usefulness. By' the sanie token, it ia(I also become evidlent that.

furt her similar conferences would prove unwieldy; hience, subsequent meet ings

of this nature were set uip on at base section level. Thle first, of these wats hield

onl 5 May 1944, in thle Southern Base Se-4ction under the leadership of Colonel

Kneeland. With the further dlevelopmnent of thle theater and the at tenidant

restrict ions on transport attion, these (c01nferences were eventually li mit ed to thle

hospital center level. All senior consultants, batse section consultants, and

army consultants were invitedl to these nwetin.-s, andl an opportuniity for thle

free (discussion of plinims and1( prolblenis was afforded to members of General

Hawvley 's office in a ttendlance.

INTER-ALLIED RELATIONSHIPS

The rapport of the medical officers of the U.S. Army, in general, and the

staff of' thle Ch'ief Surgeon, ETOUSA, in particular, with the medical profession

of Great Britaini was conspicuious. General Hawley and Colonel Kinibrough

cultivatedl this relationiship by every- attention to social and professional amnemnties. EverY courtes.y was shown to C olonel Nl~ddleton and1 his senior consult -

ants. Early in thle evolution of the basic plan for the Medical Consultation

Service, ETOUSA, Maj. Gen. Sir Alexander HI. Biggamn, RAMIC, and Col.

L~orte C. Montgomnery, R( AM(C C,( hijef C onisultants in Medicine for the

Brit ishi and Canammdian Armiies, i'espect ivelyN, inl every way~ helped to expedite

the org' Iizat ional phlans of' the U.S. ArmyN in the European theater. Colonel

M~iddleton regularly at tendled tilie monthly iieet itings of' thle Medicall suhbconimit tee of thle Ariiu Medhi('ii Directorate ( onistltan ts C omm iiitt ee to thle Direct or

General of' thle Royval Armiuv N\Ied ical C orps, miiider tilie ('imiiriianshi 11 of General
246 ACTrIVITIES OF" MEI:ICAL CONSULTANTS

Biggani. Thre following (list inguislied clinicians conist ituiited' the N led ica

Subco0lllnit tee: ('ileriwl Biggaini, C onsultant PhyvsicianI; Brigadlier D. B.

N idc(;Hgor, ( 'jsuit aut Rdii( Iloggist ; Brigadlier .1. It. Revs, C onisult ant IPsychiiatrist ; Brigadier G. NV B1. .Ja ins, ( lSmultatit P~sychiatrlist; Brigad~ier F'. 1).

1 loit t , C onsult anit in Ili sival N ledhiciie; Brigradier George Riddochl, ( oiistilt -

ant Neuirologist ; BrigadIier TI. F4". Osilionl, C on sult anit Velnervolog-ist ; Briga -

(Iicr It . NI. It MN ivcKn ni, C onsult ant D ermra tologist ; Brigadier .1. A. Sin tonl

(Consult anit N Ia Iriologist ; amid Brigadier Sir L ioniel Whit by, C onisultanut in

Ira nslision anid Resusci tat ion (figr. 87).

dIcl5Ci55ioli o;, iii utual Ipriob~lemsi was clivoilr-agre(. The r~egular neet inIgs of thle

Arn I Iy NI vd ica I D )irccto orate ( 'oiisn It alit s ( '01 ini I tee were Ielwl t 0i w(dmv af'ter

thle lInvetin1gs of' thle Nledical Suboloiminiitte, under the leadership of* Lt. ( enl

Sir Alvxainter I100(1. Althlouigh thlisv Ssmsioins were imlport anlt, thle proceediig's

rep~resenltedl ai duplicaitloln of' thei activities ol' Iwl~iv meical and surgzical StillCOi II IIi t tevs. 1 leuice, re(giiliti at t endaiiee, while~ invited, was decilieed d utliidaltit

'llilcr thle chanirmianshipl of' Prof'. Jlohni A. Itvle, thle Initerservices NMedical

C onisultanits ollillIit tee was organ izvd . Represenitati ves of* thle Royal An i iv

NIed ical C orp~s, RoyalI N avvy, RoyalI Air Force, Royal C anad( Iiani Armny Nteici IleI

( 'orpjS, EI4 rgeiicv Nledica ServicXje, I Ile [ TS. Armyi, and t lieý IT.S. Navy meit ill

Kelv in I louse, I iLondon, at, reguilair intit vals t~o disctuss mu nt iual probllemis. Air

C 11lommolore Alani Rook served ats its secreta rv. I poll thle resigna tloln of'

Prof~essor. Ryle, Surgeon Rear Admnda It. At. Rowlanids, R.N., occupied (ieI

FUNCTION OF MEDICAL CONSULTANT

Fromt thle stanud point of thle Armly, t-he fundamental aills of the N ledical

D~epa rtmiient, are (1) to estnal)isli and mainiitain high statndairds, 1)0111 physical

anud nmen talI; (2) to prevent, dlisease 1111( dlisability frouii trauillila ; and (3) to limiit

mlorbidlity v n m111Iiort ality' in (listmie and(1 Kaimia, l~tihtl n o ibite

Nivi lIi I11IIIIi iI t itII rv circlIes, t here calInIi X)e (f tiest ic I ts tO (thIu.e tp rei I e i II Ii port it I I e of

pire ventivye tluedlici ie inl reaching such objectives. Ii thle Euiropean itheia ter, in

G eneral hlawley's office, there was a conlpl('t niieeting of* the minid~s between the

lProf~essiona I Services D)ivision a 11( thle P~revenitivye N edIivi ne D~ivision. Few

(Ia vs paissed withlout, an iii Iercliange of in [on nit tion h~etweei Co~(lod5 (in lollk

and NMidd leton. As a rule, thie propinq(Iiitvy of' offices mlade suich cont Iacts very

silm ple. For ii short, period, th lie ((tachlle ii cui of the. 1Prcveu t iv y e eicinie dN 

D~ivision to L ondlon while thie lProf~essioiial Services D~ivision reuillaiile(I inl

( 'lull 'II ii was WitSlii idiate(ly fel~t its at (list inct d islocat ion bet weeii two (livi-

.510115 withI a coimmon01 objective. The in terlockinig inite(rests of' thIese dIivisionis

shlioi alwayvs b~e bl-olie in llmind in fut tire planninlg in thle initerest, of thev health, of

it COMi~iiMLl Their' misiiionls are iiiseJparablle, 1111( they call) op~erate vfrtevtivelY

only ~hienl in(t erldependll .

The miedical care of, Ilie 1)111 len is secondlary only to th lwlrevent ion of

(liselse find disaibil it y. Tl'lv form1iNie NISJM)oii bib t- IVI felClearly Withlin thie pirI-
1-TRI4PEA4 THEATE 4-)~l'4 1-' 4'Pl:III\ '-.I~~'111'4\411P1 4 1' 41741' 211u14l 

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I (4411--. 14 114I4411'----.14 11:4 -"''1, Suc 4'- )mi~l-i~l- i. X ;Il I II~-:14 :41 414X441-. A 1411.I'l4-- ill
6248 ACTIVITIES OF MFI)WAL, CONST'LTAN'T'

t he current incidence and t rends of (ilscase. The weekly statistical rep~orts of

delitit s presen ted lnilt u111sual cliiiilenig-e These weekly lists, were (liecked for

lmrevefltable disealses- by C olonel MIidldletonl. BY (lirect corresp)ondenice withi

tlie (di ef of tilie imedical service In tilie liosl)it al reimrting, suct deval s, at copy of

lie comiplete clinical record was ob~tained. ("eneral M edical I ahoratorvy A

slibiliit ted a1 duplicate set of' tilie lust ologric sect ions of tilie pathlologic uni1tveid

froint such subjects to C olonel Middlieton, so t hat all points or dliscrep)ancy

mighit lbe reconiciled1. The situiat ion having lbeen reconstruct ed from the avalilalible evidlence, an1 ainallysis withI apipropriate observations was forwarded to the

resp)onsibile miedlical chief. As ai'tmile, t his conist ruct ive procedure was well IVceived. Althloughi its valtue is imipossible of' est imiat ion, undloublt edly. thle restilt wals intangible dividends in thle imipiroved catre of' thle sick in t his theater.

PERSONNEL MANAGEMENT

The (onfhleiice of' thle ( hijef Surgeon, TOrusA,. it, thle mission of tlie .onlsuiltanlt s was evidlent inl hIls iiian1date to thlemii to offer direct advice to his Per.-

solniel Division onl the miovemient of highly trained Iiiedical personlnel. Inl

turn, thle Pers-onnel D)ivision dlependled imiplicitly upil)l tilie consult anlt s of' thle

Professional Services Division for stichi counlsel. In thle interest of thle best

miedhical ;ervice under existing condlit ions, t here intist be ain 01)1itnal ut ilizat ion

of tlie available 1)ersonnlel. Obviously, ext remie inequalities exist ed in many of'

the 11ospitals assigned to the ( omm uinicait ions, Zone. Ill tilie earlY phases of

(developmiient , dhisproport ionate professional st rength liwas evidlent , lpartic*ulairly

in thle aflilialt ed units. Withi tilie increasing deimandl uponl the (lecreasingo pool

ofimedical officers, in the Zone of Interior, this situaition wa1s eventulally reversed.

As already inti mat ed, thle existin professionidl ass-ets of tilie t heat er had been

carefully cat alogedl byv Colonel Mliddleton onl the basis of personal andl pr'ofessnilobservat ions ini the wardls of' the e~xisting units. Upon thle arrivall of niew

liospit alls inl tlie theater, lPeroflal interviews and staff conferences were arranged

to assess, lie professional qualifications and capabiilit ies of all1 medical officerls

onl the miedical services. Alarming discrepancies, 1)0thI quiant it ative and qualit at i e, Were (disclosed ats thle reserve of' medical officer-s in the Unitedl St tes

wa1s dleplet ed. Some ideal of thle magnitude of the p~roblemi miay be gathIered

front lie faict thliat, in 1944, C olonel Mliddleton Visited and1( interviewed the officers, of thle medical sect ions of 108 general and I11 staition hospitals fromt the

Zone of Interior aind 4 general and 2 station hmospitamls front NITOUSA (Niediterrmaneaii Theater of Opera!tions, U.S. Army)v. C olonel Kneelaund likewise surveyedl at group of these new units. To lileet obvious (leficienicies of skilled personnel in tiese hospitals in 1944, 58 new chiefs of inedical services were assign"edl

fromi thle reservoir of' qualifiedl and1 tried internists of thle affiliated units of' tie

European theater and those which had been transferred fromii N ITOU.SA.

The place of thle affliamt ed hospitainl (fig. 88) in thle reserve pat tern of the

Medicl(i Departimient hast- been subjected to sharp critIicismn in certai aimqurters.

C learly, superior professional qualifica tions nitay be antimci pat ed in these units.
I~i')IEN'iI'lEATER~i ()F I 'IIKATIONS 2 19

z
250 ACTIVITIES OF MEI)ICAJL CONSULTANTS

At times, the loyalty to the mother institution unav overshadow the greater need of the military situation. A natural pride in organization may bias the

judgment of responsible officers, but, upon a clear presentation of the prol)lem, cooperation in the release of highly qualified internists seriously required in

other units was willingly made in the European theater. Without this source

of support, the medical services of the fixed hospitals of this theater would have

presented a strange mosaic of professional adequacy, ranging from superb to impossible, annd the standards of medical care would have fluctuated immeasurably from one hospital to another. In this relation, the Personnel Division of General Hawley's office can not be too highly commended for their cooperation. Never was a recomnmen(lation for the movement of a medical officer in the interest of better care for the soldier made by the medical consultants without

prompt compliance.

The professional interchange of the consultants of General Hawley's office

with medical officers of the armies was intimate. Frequently, advices in medical matters from the field initiated inquiry or appropriate action at Headquarters, ETOUSA, to the ultimate advantage of the U.S. soldier, while, conversely, mIedical information flowed freely from Headquarters, ETOUSA, to the

field. In the movement of personnel, the prerogatives of the army were assiduously respected. Usually, in General Hawley's office the Professional Serv- ices Division,upon t1ht request, of an army consultant in medicine for l)ersonnel to

meet certain medical needs of army units, would advise the army surgeon of its

willingness to arrange, through the Personnel Division, for replacelents from

fixed hospitals of the Communications Zone. As mutual confidence was

established, at times the army surgeon, through the intermediation of the Professional Services Division, sought the transfer of medical officers from his

echelon to fixed hospitals for the better utilization of their special skills.

In his first, conference with General Hawley on 25 July 1942, Colonel

Middleton emphasized the iml)ortance of the continuity of medical care

throughout all echelons of the medical service. In the interest of sustained

professional efficiency and, in turn, improved medical service to the troops, an exchange of officers of company grades from the field units with officers of similar

rank in fixed-hospital units was proposed. With General Hawley's support, conferences were held in early August 1942 with ('ol. .Max G. Keeler, M(C. Commanding Officer, 5th General Hospital, Lt. (0ol. (later Col.) Mack M. Green, MC, Surgeon, North Ireland Base Section, and (Col. ('harles E. Brenn, M(', Surgeon, V ('orps (Reinforced), relative to tile implementation of such exclhanges on a temporary basis. ('olonel Brenn expressed his categorical objec- tion to such a movement on the basis of the inevitable loss of medical officers

fromn tile field to tile hosl)itals. Opposed to this viewpoint was the ol)vious bilateral advantage in tile professional improvement of the medical officer from

hie field and the cultivation of an unhderstanding of tihe hi(edical problems of tlihe

field on the part of officers on exchange from the tfixed hospitals. A pilot plan Was imitiated in the North Ireland Base Section between the l5th General Itospi- tal and tactical units in training in Northern Ireland. These temporary
EUROiPEAN THlEATER OF OPERATIONS 251

exchanges were well received and presented proof of the predicted bilateral

atdvantage. As a result, this basic plan was given general application in tile

theater in tile interest of the professional advancement of the medical officers

and the medical care of the soldier.5

A situation similar to the me(lical drought experienced by officers with

field units was encountered in the medical officers of the Eighth Air Force.

Indee(d, medical officers attached to the dispensaries and scattered units of the

Eighth Air Force became extremely (lissatisfied with their p)rofessional detachment. As a result of conferences with Col. (later Maj. Gen.) Malcolm ('. Grow,

M(C, and Col. (later Maj. Gen.) Htarry G. Armstrong, MC, a program of rotation

of medlecal officers from the Eighth Air Force, not to exceed 10 per month, to

fixed hospitals in the United Kingdom was arranged to begin 20 April 1943.

In the judgment of Colonel Armstrong, after certain early unfortunate experiences, the exchange of similar numbers of officers of company grade from

the general hospitals to the Eighth Air Force without. indoctrination was deemed

unwise. The assignment of Eighth Air Force representatives was, therefore,

unilateral. Although the plans were sound and although the Professional

Services Division in General Hawley's office made continuous efforts to maintain the flow of medical officers, operation difficulties and passive resistance

limited the success of the programn.

In a similar vein, an entirely different approach to the maintenance of

clinical interest, of medical officers in the field was attempted. Perhaps one of

tle most stultifying experiences for medical officers with field medical units is

the necessity for the transfer of all seriously ill patients from tactical units to

fixed hospitals for definitive medical care. Immediately upon such a movemient, an interruption of the primary professional interest, of the mnedical officer

with the tactical unit occurs. Also, the opportunity for clinical contact comnionly afforded through visits to the hospital of transfer is not available in the

Army because either the tactical situation, transportation, or comman(l policy

may make such sporadic efforts impractical. To meet this situation, the postcard Form 306, Follow-up Card (NMedical) was devised.

The medical officer of a line or detached unit merely wrote his address on

the front of this medical followuIp card and the name of the patient in whomim he

was interested on the reverse side. Pinned to the emergency medical tag or

placed in the jacket of the fieli medical record, this medical followup card was

filled out by the first ne(lical officer rendering definitive care and mailed to the

interested medical officer in the forward unit. The information on the card

included tile diagnosis, necessary clinical and laboratory findings, treatment

rendered, disp)osition made, and any recommendations. General HIawley and

Colonel Middihleton conducted educational programs indicating the importance

of maintaining this centrifugal influence of the hospital units of the theater.

The utilization of this very significant expedient extended to mobile hospitals

evacuating to fixed hospitals and to station hospitals evacuating to general

s Annual R.Ivort, P'rofessional Rprvits Division, omfce of the Chief surgeon, lleadquarters. ETO USA, 1943.
252 ACTIVITIES OF MED)ICAL CONSULTANTS

hospitals. In short, this expedient established a channel of medical or professional communication that afforded information as to the care and disposition

of evacuated patients and that could not otherwise have been ob)tained.

EDUCATIONAL PROGRAMS

Air Force Field Service School

The educational programs were the function of the Operations and Training Division of General Hawley's office. The Professional Services Division

was called upon) to assist in planning and implementing such programs. Under

the leadership of Colonel Armstrong, the Eighth Air Force developed the

Eighth Air Force Provisional Field Service School at High W1ycombe, England.

At the request of Colonel Grow, on 6 and 13 October 1942, Colonel Middleton

presented 3-hour lectures on tropical medicine. Thereafter, the topics usually

covered were the common cold, influenza, pneumococcal and atypical pneumonia, and the sulfonainides. With appropriate changes in subject matter

and at intervals lengthening to semimonthly and monthly, Colonel \Middleton continued to participate in this program until the discontinuance of the school

in the first week of May 1944. Not only did this teaching opportunity provide

excellent rapport, with the headquarters staff and medical officers of tile Eighth

Air Force but it also served to emphasize the vital requirement of the Air

Force group for- a broader clinical outlet.

Medical Field Service School

On 8 September 1942, with Colonel Cutler, Colonel MIiddleton studied the

prospects of medical teaching in the Army Medical Field Service School at

Shrivenhan (fig. 89). The program for clinical instruction as outlined by Lt.

('ol. George D. Newton, MIC, was deemed inadequate for the needs of the

theater. Actual particil)ation in this area was delayed, and it was not until

22 March 1943 that Colonel Middleton gave his first lectures. The initial 4

hours of lectures for medical officers were reduced to 2 hours. One hour was

allotted for lectures to nurses. Topics of current medical interest in the theater,

such as resl)iratory infections, enningococcal infections, infectious hepatitis,

an(i rickettsial diseases, were discussedl at these monthly sessions. Particular

ttention was given t~o the (dignity of the sick call. In the lecture to the

Army Nurse Corps representatives at the school, Particular attention was

given the service, functions, and responsibilities of the Army nurse. The

psychology of the sick and wounded wais discussed, and due eimpiiasis was

given to the role of tile Army nurse as the medical intermediary for the tending

medical staff.

The Army Medical Field Service School continued its classes at Shrivenhamn

until 13 October 1944. In the spring of 1945, it, resumed ol)eration near

ktainpes, France (fig. 90). With the altered tactical situation, the schedule
1:1 1,411'FA\ III' ()IT NAT 11 IN S

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A I t ' I t~

it~'' I~
EUROPEAN THEATER OF OPERATIONS 255

FIGURE: 91.-Lt. Col. James~ 1. Mason, NMC.

fell short of their goal or were actuially alaandonied hin thle turmoil of redelploylimint inl the suimmer of 1945. Inl retrosp~ect , all of I hese etIucat jonall planis

were sound and wort liv of support.

Specialty Board Certification

At first glance, the certification of the medical officers iin the specialty

b~oardls mighit appear beyonid thle interest or puirview of time Medlical Coiistiltationi Service. H owever, quaihifed miedical officers who were (leniedl the right

of exanminiationi anid cell ificat ioni lb reasoni of nuhitarvY service, particularly inl

anl overs-ea t heater of operationts, had at reasonalble basis for at senise or discrimniniat ion. As secretary: of the American Board of internal NMedicinle, ( oloniel

Middletonl felt at serious resjpoiisilbilitv ill at temp)titig to remove this potenitial

source of irritaition. O)mm 19 April 1942, the American Board of In1ternial Mediciiie aut horized regional oral exanminat ions under thle supervision of at member

of thle b~oardl ''to meet thle conveniience of metem in t(lie Armed Forces,'' and, onl

10 .Junie 1944, the lboardl took thle official action that ''while oil active (ulty,

( oloniel William S. Middl~etmi, M( ', USA, anid Captaini William S. McCannII,

MIC, USN, be auithlorized to coniduct special oral exainiiiationts for eligib~le

caimndidates wherever they tire.'' 'his spwecial att horiza tion1 was unu11sual,

particularly inl view of the termmiinatiomi of the legal tenure of office of ('oloniel

Middletonl ats of .30 Jumme 1944. Unider the authority so vested, the oral ex-
2 -5 A(TI'VITI5s ()F MEIDICAL ('CONSUILTANTS

Fim Im.: !)2.--- .Maj. Bernard J. Pisan i, M C.

amination of cmididat es Ir certification by the Anerican Board of Internal

Medicine Was arranged at the mutual conveiiece o1' the examiniees and guest

examiners. The followinig guest examiners cooperated willingly in this

enterprise:

Lt. Col. Benjamin I. Ashe, MIC', 1st '[aj. George L. Leslie, AtIC, 95th

General H lospital. General I lospital.

Lt. Col. Wardner D. Ayer, MC, 521 M1aj. Arthur S. Mann, M[C, 91st

General IHospital. General Hospital.

Lt. Col. Theodore L. Badger, 'MC, Lt. ('ol. Richard M. MhKeain, MC,

5th Gemnral Hlospilal. :3601 General Hospital.

Lt. Col. Elton R. Blaisdell, NIC, 67th 01[urrav, [aj Norman L. N(, l 6th

General Hospital.

AIaj. Donald J. Bucholz, MC, 9:d General hlospital.

General Ilospital. Maj. Arthur D. Nichol, M[C, 93d'

Lt. Col. E. Murray Burns, MC, 46th General Hospital.

General Hospital. \[aj. Christopher Parnall, Jr., MC,

Lt. Col. August us H. ('lagett., Jr., 19th General Hospital.

MC, 90th General hospital. Maj. Frank Perlman, MC, 124th

Col. Cyrus J. Clark, M(', 32d General General Hospital.

IHospital. Maj. Hlerbert W. Rathe, MC, 347th

Lt. Col. Sander ('olien, MC, 401b Station Hospital.

General Hlospital. ('Cap). Bernard D. Roseiak, 1( ', 49th

Lt. Col. Stanley ('. W. Fahilstrom, Station Hospital.

MCt, 108th (eiieraiIl lospital. It,. ('ol. Donald C. Wakeman, MC,

Lt. Col. Frederick \W. Fitz, M( ', 701h 217th General Hospital.

Station IHospital. 1t hol eneral A .s Wal.

Lt. ('ol. (Carl 1I. Fortune, M(', 49th IA. ('ol. Bernard A. Watson, I1(W,

Stalion lHospital. 36th (General lloslpilal.

IA. ('ol. Gordon E. Hlein, MCIC, 12th Miaj. Hlerbert B. Wilcox, 1"\r(', 2d

Hlospital ('enter. (General ilospital.

MIaj. Ilenry B. Kirkland, M(', 110 lM 1aj. ('arl It. Wise, \1[C, 2d (General

Generlal Hospital. Hlospital.
EUROPEAN TIIEATER O1F OPERATIONS 257

A total of 113 candidates were examined, and 4 candidates were examined

twice, to make a total of 117 examinations. The results of these 117 examinations are interesting: Internal medicine, 73 (65 percent) passes, 41 (35 percent)

failures; cardiovascular, 1 pass and 1 failure; and tuberculosis, 1 pass.

It is impossible to assay the contribution of these examinations to the

morale of the theater. The dependence of the Personnel Division upon such

tangible data as certification by the several specialty boards in deriving the

MOS (military occupational specialty) of medical officers gave this formula

unusual weight in the minds of niany individuals. To the cooperation of the

Anerican Board of Internal Medicine, especially the assistant secretarytreasurer, Dr. William A. Werrell, and to the guest, examiners in the European

theater, due credit is given for the successful discharge of this mission.

PROFESSIONAL MEETINGS

American Medical Society, ETOUSA

Medical society ineetings constitute all iml)ortant element in maintaining

an alert profession in civilian life. Me(lical Department regulations insure a

continuance of this activity in the Army hospitals. Where the spirit prevails,

the meetings help maintain high standards. Such was the case in the European theater. In certain hospitals, X-ray and clinicopathologic conferences

added to the superb tone of professional alertness. These routine hospital

meetings were supplemented by the American 'Medical Society, ETOUSA.

The seed for this theater activity was sowed in a meeting for the discussion of

hepatitis at the General Medical Laboratory A, Salisbury, England, in which,

1st Lt. (later .Maj.) William L. Hawley, MC, N\aj. (later Col.) Paul Padget,

M(C, and Colonel Gordon, of the U.S. Army; Dr. William H. Bradley, of the

British Ministry of Health; and Dr. James K. McCollumn of the Wellcome

Laboratory participated.

The occasion of the first anniversary of the 5th General Hospital in the

European theater led to a meldical and surgical conference in which Colonel

Badger discussed post inoculation hepatitis; Dr. John NIcMichael, traumatic

shock; and Dr. Eric G. L. Bywaters, crush syndromne.

The first meeting of the American Medical Society, ETOUSA, was held

on 23 June 1943, at the 298th General Hospital, Frenchay Park, Bristol,

England. 'rlme commanding officer, ('ol. Oscar C. Kirksey, M(', and his

staff were hosts. A committee on organization, coinposed of Colonels Kneeland and Hein, and ('ol. Robert, M. Zollinger, MC, was named. This coinmittee draftedi a brief constitution which was adopted. The following officers

wre elected: President, Colonel Zollinger; vice president,, Lt. Col. (later ('ol.)

William F. MacFee, M('; secretary-treasurer, Maj. (later Lt. Col.) ('lifford

L. Graves, M('; councillors, Major Niuckemnfuss and Maj. (later ('ol.) Edward

J. Tracy, .I(C 'TIhe second meeting of the society comnvened on 28 July 1943,

at the :0t h General Hlospital. The commanding officer, Col. Charles B.

5614970,-- 61- -- 19
258 v-"riv1T1ES OF MEDICIAL COI NSULTANTS

Kendall, NIC, and his st aff presented a1 very instructive prograim. Onl 18

Auigust 1943, tilie thbird iiieet ing of tilie societyv coniveiied ait the 2d Genieral

H ospitail. Und~er thle commilandinig officer, C ol. Pauil M. C rawford, NJ(' anid

his staifr, at Very profit aide Sessioni wits held. Thie last, meeting of the Amierican

Medical Societ v, ETO1'SA, wits held oin 26 April 1944, atit the 1 27thI General

1Hospitali, 'S')l~ldI Iills (near Tauntoni), Enlgland~, withi t he commiwandin g officer,

Col. ,Jaiiies L. Muriiichisoni, NJIC, and his stawff its hosts. C oloniel M idd~letonl

spoke onl thle catre of th lim iedical casualties frownt the far shore. Thiereaft er,

tie t acticawl situnat ion andtitlie number antd dispersion of medical units inlu I ý

fuirt her iieet ings of' tilie society impractical. This fuinct ion, in turn, devolved

lipow thle lIase sectjows and th lie ospital ceniters. Indleed, t he W~est erni Bhise

Sect ion hiald aniticipazt ed ti Is eventitnlity anid had arilawged fOr a inedical "wiwetlg

to he hldl at tilie 52d Geiieral Hosp1it al, Kiddermiinst er, onl 29 Decemiier 1943.

TIhis mleet ing wats at t end~ed by 200) medical officers.

Inter-Allied Coinferenices

M ore far reaching iii their in fIueiwi were th e Inwt er-Allied (Con ferences oil

War Ni eliine. Ill April 1942, C ol. Victor (ialleninaerts, D)irector, Belgian

Armii M ediical Service, sugg~est ed to thle Brit ishi Avar Office tilie est ablishm went

o oll ('i erewices owil War M edicine. At thlit t imne, thle (difficuilties in organ iizat ion

seviewi w((i insuperable)(, b~ut tilie early anid rapidly inwcweaswing numbiilers of miedlical

represeint w ives in thbe Armied 'orves of th li'wit ed States pavedl thle waly for a

recoisidltrat ion of thle subject. C olonel ( 'uter st iwnulate eti1his wiiov('wncnlt

thwoughi thle oflics of NIr. L. R. Brost er, then suwrgical secret ary of t it'- Royal

Societyt of N l('(iciiit. lIn tlie( pr'li liwiwiary discuss-ions, tilie Royal Society oh

MIedicine offered its facilities as a lineet ing p~lace 1111( clerical as-sistawince mor tilie

Owrgaiiizat ion of tilit meeting's. Thelu iieet iwigs wei'e designed ''for thle inwt erchiange and moin wiun iviat ion of wIi('(icwil experiences in tilie field and of tilie

pracica application ofri i iri ne to thlit nee(ds or warfare, and for tilit exposition of thle genieral p)iinviplt's of ahiiiinist rat iou anti organization of tlie( muedical

services." r, Th'e first of thlese mei(etings, at tendled b~y applroximuat ely 121)

winetical officers of thle. U..S. Armwy, wats hieltd at, the Royal Sovietyv of Nlediciiw

owi 7 D~ecembi er 1942. NI aj . Gen. Sir IHenry Tlidy presided (fig. 931). 'lT'e

ineetimgs were cont intietl ht ini M MYul 1945. A total of 24 con ferencevs, WaS

at twtlende by over 6,501) officers of tlie( Allied Iiiedical se'rv ices. Thise~t Sessions

St'Wv(I as at dcii im gluwowis for- tlie wa experiences of' thle Allied force.,. 'Ili e

topics covered th e vilin, w giw iiut of wid~iciwi an wihsuIrger'y as ('in lii emim undel(r

lie war condit ions of Ilt'e period. St ir~iug storis of first hand ('xl)(wiei('s at

Dunwikirk, Dieppe, Lake ('had, Arnihemii, Bast ognle, Buchienwald , antI ii titwe

Arctic cowivov h eld th line m rest oflar~ ge atnIdiewi(ts, (lewi vet frownt aill services.

Two hundwitred( an ut Iweui I spea kers appewa red befort lt'e counferenices. Aw inowg

Ithese wtere tilie ChIiief Su rgteoni antIa numer iit i of rep~resenitat ives of 111 liPIrofesI Inter 'k liv-1 i tontrtrttitc, on War Med icine, i0942-1i945, s I ite' iby 11. L.. 'I'Iy and J .. M. It. IKutsch~bach. I.London
I I'l 1 1l l•\ A N!. T 11 [ Ill'l.]A, 1 .\ "1• F I .\'lll IM,-•,••

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260 ACTIIVITIIES 1) 4F MEIIICAI C4NSTIA'LAN'rS

4" W

ColnelMidletn (ig.96) T le medical coniferenice conicernied itself With tilie

follow jug. topics: Neuropsyclijatric casualties ill tile Army, treatmenut of venereal

dliseases, Special iledlical. problems, fu11( thle proposedl Sill folun mlide proplu'yla xis

of ilifectious diseases. Participating inl this conference were: General Big~gali,

Consulting 1Phisician of the Brit ishi Army; Brig. E. Budmner, RANIC. Clonsuiltig" PlhIvsician , British 21st, ArmY Group; Brigaidier Rihloch, C onisulting

Neurologist, of the British Army' ; Col. J1. S. K. Boyvd, RAMTC, C onisuultinig

Patholog, ist , British 21st, Army~ Group; Coloniel PillslbuI'yv, Senior Consultant

inl Dermatology and1( Syphiilology-; C olonel Thompson, Senior ( onsuiltalit inl

I'sycli ntit r; Colonuel Badger, Senior C onusultant inl Tuberculosis; Coloneli Kneehaild1(, M\ edicail Colisllt.11u t , Unit ed Kinugdomi Base, anud Senior Conusultanit ill

Infectious IDiseases ; C~olonlel Ileut, Senior Consultant in Cardiology, Lt. (C01.

Nathanu Weil, .Jr., MIC, Conisultanit ill Mledicine, Third U.S. Army; Lt, (101 Guy

11. Gowent, "MC, Consult~ant inl Medicine, Seventh U.S. Army; Lt. (101. .John1

B. McKee, MC, C

1onsultant inl Medicine, Ninth U.S. Arm *;v Colonel McEwven,

C onstultan ill n M edIicine, BrittIany Base Sect ion ; C oloinel 'Muckentfuss, D)irector

of N\led ica I Researecli, auild C ommandjing Offticer, Gieneral M\ edical Ila boraln ovl ' 

A; and M aj. Alfred 0. Ludwig, .\C C(X(Ouisult-ait inl Neurology, Seventhb U.S.

Army.
I:II~II:\'~.'IIII~\I' V

A.%~ 44
ill j "i\i1'i i \ I . I' ,I il \(I I I t I ''\ - I 1 \ \ : I'>

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l•I+'_';•,i+,.r~ ~~~ -;~i•'. + Z~~~,,I+ ~~~~ II, I ~ l',' •~I II I,, II,I •,, t'~lI - ,
l.U'lIMlP.E.N "THEiATEIR OF' OPE.R.ATIOINS 263:

Kneeland, Consultant in Medicine, United Kingdom Base, and Senior Consultaint in Infectious Diseases; Colonel 1Pillsburv, Senior ('onsultant in Dermatology and Syphilology; Colonel Fitz, Consultant. in Medicine, Delta Base Section; ('olonel Gowen, Consultant in Medicine, Seventh U.S. Army; Colonel

'McKee, Consultant in Medicine, Ninth U.S. Army; Lt. ('ol. Carter Smith, )%MC,

C(onsultant in Medicine, Fifteenth U.S. Army; Colonel Weil, Consultant in

Medicine. Third U.S. Army; Surgeon Vice Admiral Sir Sheldon Dudley, RN,

I)irector General of Medical Services; Surgeon Rear Admiral Gordon GordonTayvlor, RN., Consulting Surgeon; Surgeon Rear Admiral Rowlands, Consulting Physician; Maj. Gen. Morrison C. Stayer, Chief Surgeon. MTO; General

Tidy, President, Royal Society of Medicine; Brig. E. Boland, RAMC, Consulting Physician, British Army in Italy; Sir Claude Frankau, Deputy Director.

EMS; Dean Charles Newman, British Postgraduate Medical School; Col. E. N.

Alling, Commanding Officer, 814th Hospital Center; Colonel Gordon, Chief, Preventive Medicine Division; Lt. Col. (ater Col.) Wendell H. Griffith, Smi('.

C(hief, Nutrition Section, Preventive Medicine Division; Col. Esmond R. Long,

MC, Consultant in Tuberculosis for The Surgeon General; Lt. Col. Hamilton

Soutliworth, MC, Office of Scientific Research and Development; Colonel

Cohen, Chief of Medical Service, 40th General Hospital; Lt. Col. Alva V.

Daughton, MC, Chief of Medical Service, 48th General Hospital; Colonel

Fahilstrtom, Chief of Medical Service, 108th General Hospital; Colonel Fortune.

Chief of Medical Service, 191st General Hospital; Lt. Col. (later Col.) Rudolph

A. Kocher, MC, Chief of the. Medical Service, 203d General Hospital; Lt. Col.

Carl S. Lytle, 'MC, Chief of Medical Service, 62d General Hospital; Lt. Col.

(later Col.) Herbert B. Pollack, MC, Chief of Medicine, 15th General Hospital;

Lt. Col. Leonard G. Steler, MC, Chief of the Medical Service, 198th General

Ilospital; Maj. Sarah H. Bowditch, MC, Assistant Military Attache, American

Embassy, London; Maj. Marion Loiseaux, Consultant of the Women's Armyv

Corps; Maj. Moses D. Deren, MC, Chief of the Medical Service, 194thi General

Hospital; Maj. (later Lt. Col.) Charles P. Emerson, Jr., MC, Chief of the Medical Service, 231st General Hospital; Maj. David Greeley, (MC, Americami

Typhus Commission; Maj. Richard Reeser, MC, Chief of the 1lMedical Service,

202d General Hospital; and Capt. T. E. Caulfield. MC, ('hief of the Meedical

Service, 230th Generml Hospital.

Upon the release of Buchenwald, Dachau, and other horror eeiaters from

German control, Colonel Pollack, of the 15th General Hospital, Icize, Belgium.

and ('apt. Leonard Horn, MC, of the 19th General Ilospital, Rennes, France,

had been ordered on detached dut('iv for service withi ('olonel Griflith to stud•

and collaborate in the control of malnutrition among the released military and

civilian prisoners. Colonel Pollack's analytic discussion (Jf the subject was a

highlight of this conference. The opportune presence in the thenater of Colonel

Long 111ad added greatly to Colonel Badger's master plan for the minagemient

of the recovered Allied military personnel coming into U.S. fixed hospitals

upon release. Some idea of the magnitude of the problem may be gained from

tlie fact that of 1,700 of these patients received at thie 46t i General llospital,
20 1 \I 'T I It IT I I ýs V M 1: 1 ICA 1. 0 I\ --d 1, 1' VFS

n ild it, t-f 111:111Y .

lind tulwi-culil-l- ()f Ilil-, wt-ro Vi .1 III-Iol-olo 141 1':Il*-

\\Illl vIt"Ill nrc:l- I'I'l. tho pII)jf.t-Ip)II III, the olld IIII-d ical p'.1-w illei.

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hold. 'It- cV-If,!Ir(1 Iw rorm-doll 1- :1 lllon--ýIllv III' tho -pirit Id

\\III :111d cm1hilcilre ofl_-olldrrýý(I IIIIqwz lilt,

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st PIT) %NI) t %4*1 ()F DM Gs

The 411, Ow Pn)fo-II)II:II D1\1,1oll III lhmlcv'-ý

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\\III, I'l. Ctd. Pcrklli-ý. NIC, III 4.11:11-c ()I* ýIlppllc- f4w Ille Arm It.

Dol):11*iIII(IIII, :11141 \\11III Nl:i*,,I- Goll.l.-dier. 11"'ANIC, .11 :;!) 11\414, POI*k

1.4m ,14111, *111 11 *ýIll'\V , \ III, Ille ;1\ i 1 44 B rill-li 'llid , .'ll"11114-.1k

fol. II-o 111 1114, I*.S. Arm B.\ III 'I'llidord, 'llmilic mcludil. 11whill-Z 1willf,
EUROPEAN THEATER OF OPERATIONS 265

British origin were checked against the U.S. pharmacopoeial standar(ls.

Where complete concurrence existed, no change was recommen(le(d, and the

assigned number in the Standard Supply 'Fable of the Medical Department,

could be used interchangeably. Where (lifferences in strength were found in

articles of uncommon usage, a change in the label was recommen(led. In onlyv

one important area did the U.S. consultants differ with their British confreres;

namely, the necessity for broadening the base of sulfonamides. The Briti-h

were limited by available manufacture andi supply to sulfapvridine. The

American officers insisted upon the inclusion of sulfadiazine at least. On

11 September 1942, Colonel Perkins and Colonel Middleton recommended a

reconciliation of the nomenclature by a listing of 14 preparations of (lifferent

strengths according to their values in the British Pharmacopoeia. Apparently,

these carefully considered recommendaations were not completely implemented,

but, on 9 February 1944. at the request of the Finance and Supply Division,

Colonel Middleton reported to Depot G-:30 in London to review certain available drugs from British sources with Lieutenant Smith, Sn(C. 'Fnie (Irugs

without a useful prospect were rejecte(l. On 5 October 1942, ('olonel .Mi(ddlton

reviewe(d the first aid kit of an MA tank in the 372d Tank Battalion with

Captain Moore, near Tidworth. The position of the first aid kit behind the

left shoulder of the driver on the lateral wall of the forward compartment of

the tank made it inaccessible to anyone except the (driver. Furthermore, the

kit contained no sulfonamide or morphine, and the burn therapy was limited

to tannoidl. A correction of these (leficiencies was recommended to the Supply

Division.

The necessity for the conservation of quinine led to the preparation of

Circular Letter No. 55, dated 23 October 1942, Office of the Chief Surgeon,

Hea(lquarters, ETOUSA. This circular letter recommen(led use of salicvlates

and coal-tar (derivatives rather than the empirical use of quinine. The directive

also stated that quinine would not be used for the treatment of conditions

other than malaria. Furthermore, it stated: "Since all malarial patients will

be evae.uated to hospital units, no quinine wilt be is.ued to diri.qional medical

installatioun.. Atabrine will be used for the suppressive therapy of malaria."

On 2 October 1942, thle faculty of Oxford University gave a reception for

the staff of tile 2d General Hospital. Colonel Middleton represented General

Hawley at this function. On this occasion, Prof. Howard W. Florey extended

to Colonel Middleton an invitation to visit the William Dunn Laboratory of

Pathology. With General Hawley's approval, Colonel Middleton arranged an

appointment with Professor Florey for 24 October 1942. At this time, Professor Flore acceded to a plan to supervise penicillin treatment andl to train

teams for each of the U.S. general hospitals. The plan was to be carried out

at the 2(1 General Hospital. The teams to be trained were to include a clinician

and a bacteriologist, and a week was decided as adequate time for the necessary

instruction. LIt. Col. (later Col.) Rudolph N. Schullinger, MC, Chief, Surgical

Service, 2(d General Hospital, had attended the reception and had anticipate(d

the official visit by making personal observations of the clinical application of
2f01 wt~rIVrns ()p O M11 uI(AL COiNSULTANTS5

peuclli(-ll ill several illstit-1itioiis ill tihe environs of Oxford. (Onl IS~ Mayv 1044,

lie slibilit te 11I report. ent it ledI ''vleicilliii ill thle Ireatmletit of Suirgical Intfectiois,'' lasetl oil thlese early: oliservat ions.) Whelei the 2(d Genlerall H ospitali

wits agreed upon0 as the trainling cent er, ( oloeld Schliilliig-er wats titi1lnet as. thle

logical meldicall officer of tlie( unit t~o serve as the ( Chief Surgeonl's repiresentlit at e

withI Professor Florey. Thle plain was Sihil)itIted to Genlerall I lawle.N, who

a1pproved. C omiple'te icq-liiesceiiev to thle plan11 camne from Profes'sor Flore iv

lhY retuirn mail, lie sligges;tedl that lhe would ulse his iflulence to have P~rof.

Aý. N . Rtichards sendl the Aniericani penicillini to Oxford.

Medicine caine nat iirall *v to its owl) ill the( application of penicillin to the

I reiit'iienti of inifect ions tliseaseIs. lit onie iiiei(if its apphivat ion, thle European

thea ter brokev new trails. Pleticillil ii was reconhmneiivde( inl t ie( treatmnen t of

d iplithiernil cairriers a11itd of severe clinical dIiplithlerial as anl a Ijuii vnt. to, niot a1

siilibstit utte for, (lijlithleria, 11 t1itoXil.7 Sonie measuire of suiccess atu-etded t his

jirocet I irle.

Tlhe tal fbscalwneis thle b~ible of the.suplyllI. officeris. Its p~eriodic

review anid correct ion is reqjuir'ed l in ile ('In ait ions, of act ive warllfare inl at forevi"'n

I Ieiat er. Ilii E'l'O)U.SA~~, thIiis lot fell to thle P~rofessionalI Service., D iv ision lin

( euierall I lawlev's office. It was ntot til easy one, whelei viewed inl thle li(rIit

oif til le a cciov t o(1(f titlie yea rs and ilie t rad it ioiia foibles of t hera penlt i(. Ilterest itligl, oine of thle mol~st (lujest ionibivl of aill t hera penltc l g-ents, andl one

wi oseI aCCOUlititug gives comtimanmd ing offi(*(eis of Al1i.N. hiospi tals thle greva tst

concern, iiIN.l, spirit us friinient i, proved to haive tite strongest defeniders ait

1lie hiighiest levels. Th'le tablvds for basic a Ilowa iicv----c lass I it emis for t lie

NorthI African camipaign were couliplletcd ill souite tiieasiire by, tlie( Professionaill

Sevrvices D i visioni. Ill thIiis inst ance, a l dbt ra rv figures for t he i liicitleie of

tropical I disealses wvere a pplie I to thle requiiirem ient oif specialI or specific ~ us

This probilemi did not prove as pressinig iii thle plainiiiiug for OVERLOARDI,

siilice t ropicalI disealses are noi it problemi inl nortivl hem Europe. II owever.,

cerll aii svecre adlvices, inmd ica ted anti u111suall inlcidencle of seriouls (Iipi ithlerial inl

inort hern IFratice a id thle ILowv C ounltries. Accor-dinglY, at disprop)ort iona tely

hil rge sui 1 lY (if (Ii 1)it livria anlt itoxinl "was st ocke I for thle in vasion.

HOSPITAL. FA(:1UTIE'S

'Tle ( hief 'Surgeon, ETl( V SA , encouraged at cloise liiiisoti bet weeti t ie

P roifessional Services ali ( tlie( HIospi talliza tion IDi visionis (if hiis office. Inl ani

arysurvey, 4 to 6 August 1942, ( olotiel N iddleletoti was request ed to repiort

to lie. H ospit aliza t ioit Div ision hiis observatlions of tlie( hiospit al sit ia~t iou ill

lie Norlth IIrelanud Blase Sect ionl. Th'lis area wats unu1suall inl its prm im t ilizalHoI itit itS itraitiitl ceniter for grrouitd troops. W~ithI thle coliiijlete coopierat iol

of ti( hlebse sul-rgeon, C oloniel ( iteen , thle hiospitazl facilities lit MI isgra ye Park,

Wamintgfieh I, rv it iet own, at ul I ot dota lerr-v were Su rveyvd frontit a jiivsia I as

".Vinfoiiifr~iiivo Memiiorandumiti Noi. 151. (lfiev of th iiC hu iarfimno,, ttliva~ivziri,'rs, ETW't' 15 . 217 Nov. tEH.M siubj&ct:

'Piolit ive t'rugr~im for I hv El~svrvit ho of tiii, fficacWv of 1-t'iciiihii ini th Ti rialmvii of tiphtheiiria.
EUROPEAN THllEATER OF" OPERATIONS 267

well as a professional standpoint. In this relation, one. detail is worthy of

record. At. Londoniderry, thle 10th Station Hospital was estab~lishedl il one

01(1 barracks-type building andl a series of dletachedl structures inl which there

ývas a serious fire hazard. Furthermore, Lo0ndonderry was at thle enid of a

narrow gage railroadl, and evacuation b~y rail depended upon a sliuttle pat tern.

Evacuation by sea requliredl shallow dIraft craft. D~irectly across the street

from the 10th Station H-ospital was a superbly constructed and equipped naval

hospital. Colonel Middlleton recomnmendled tilie abandonmuent of tilie Army

installation by tile consolidation with tilte naval unlit, as, anl economical and

Sound1( Solution to thle p~robleml. This conlsolilat ionl was part icuiar1-y feasible

by reason of the relatively Iiligt p~atient loanl of 1)0th h~osp~itals. General

Hawley indIicated his willingness to accept thet valilidt v of the recommnendlation

b~ut stated thait, unider existing, cond~it ions, suchi at pooling of miedical interests

ill tile Londlonderry area wvas Imp ract ical.

With the invaluable assistance of Lt. C

1 ol. ~John Douglas, RAMfC (f]g.

98), the H ospitalization D~ivision, under C ol. Eli E. Brown, M( C, secured

FiG URF, 98.-Lt. CoL. .ohn lDoiglhis, RAN\1C.

90,000 beds inl British installations b~efore August 1943. The Brit is!h facilities

ranlged fromi t empornry conversion camps to permanent construction and from

tile Royal Victoria (Nýetle.y) Ilospital a~t Southanipton Water to a series of

pavilion hiospit als newly constructedl under thle Emergency M% edical Service

for tilie postwar implemeneltation of tile white paper (later thle National HeIalth

Act) (fig. 99). hUnder a mandate of General Hawley, the consult ants reported

upon il te p)hysical details of strength and~ deficienc Y in these hiosp~itals. The

ab~sence of shower bat hs and thle limit ut ion of toilet facilities were amiong the

'omnmonest complaints. Inl manly of thle newer. hospitals and inl all of thle

tempJorary units housed inl Nissen huts, the source of heat. was two stoves

placedl at eit her end of the center of thle ward. n'iese stoves were stoked by

lift iing a. lid from the top andh pouring inl bit nmnlinlons coal from a. sceuttle (fig.

10)0). Thme resultant sniudge was inevitable, but this Source of lieatinig obtalined

ill the Unmited K ingdomn for tilie (huration. Ti'le( open) corridhors w~it hoid provision
.. Q .. '4t4., ~ rt,

r~4V .- I

ill.:! M). Ixjt 1 \IIJI .of 1I'Si MJ lt oit:I i('flh lIIlioll ill I'llitlld Kin~gdomh for V.S.

Ar .A. \ (?\I\ (fl)IIltlicii?1)31 iiiieI'waiva :it 14 s MIurs. lflgwo(l)(I. 1Ihims., IFuighilttid 13

'rccut! Ii flw V.r I S I
1-:1, 1"t 'I'l :.\ N* T I I I :ATI: 1, F ()I T RAT 1 "69

WIF "W7

AL

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OttM2 = 11 1:

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Now

Arm\ lwýjlil:lk.
ACTI\ Nll:lll( Al. I NSI I.TAV1`-

AIR

I- im-m hrenk \\crv vNctoijolk chised III -ý011111 Thl.

Pr(O'c"imi'll Sonices 111m loil vo()pvI-,Ilvd \\[III 11tv 11f),plializollml Olvl-ýItlll lit

iml 1'.14-ililies \\ hich, If(' kril *-.If phills, werv illadollmit.

ill ýl 111.11IM 1,"y of Ill 1114. '141:11)1.11 W it of vxl-ý11111-- hijildill'-ý, n ) llo,ýpllnl

pllrpoýo-ý, Iii-o linzords \\vrv (wc.ilmioll v m-orhmkcd. I, ot Iliv 51h Gem-ral

I I t), 1) 11 :11 :11141 1 hr I Ili 11 Sl 'I I Hill I lopll ill M ve Pn rk . I rolwid, fit(! -.it I ho

:)SIll lb)splini. Willf-III-slor, 1-:11--Lind OiLr. 1021. lit these in,ýtniicvs.

the cmi,1111ofils ro-milillcliflod oppr(q)I-1.1le pI*WvcH\v tivViCils. Tho vIvillefil-Z

(1(14*111%ý14)111*111Y '-wilil-Illed 111v n(kice. ()if 20 Orlober \\-fill Colmicl K11111-

olld Colmwl Z(dlIIl--ý(-I-, Cidtifiel NlIddIvIon vlý-Ilcd fill, 12th EvacualiOll

1) 11 11 ( 'n I-I 11. 11-111 v I I. W .I I es, 14) 1 i I I (I I I I ()(-. I I ed 111 :1 Iw v k v I t ýt I va t v .

Ior(,Ill I"1111 luld Illade .1 qliztt.ýIllilv of thc tolit :11111 dw vidi'led pvI-,0I1IlvI

:11141 ()Ilicorý ill IIwS-; fille wvro knoo-devp '!i nuid ond \vitcr. \ccdh--ý to So.y.

llw-w I-c-qmI1,11do 1,111, --w1colml 11 this lw cl-l-ed ill plolifilliu.

A 1,0111 f-11:1114-fl Lre nrosv In Ilic (-:41,1141SIIIIII-Ilt of Iiwd llospilnls ill tolovd

mill-ý lit Ow lirld. ()if 22 Februar 194-1. fit I surveY (11' Ilic 21ý,Olh Stoll(M

llo,1111;-.1 zil --ýhorl'-rvovv hil.k. voi fit it;) lit It'll b\ Col. 11(mord W. K. zellimi-fri.,

M( '. :ill 111111. 11:111,\ vilivivill o\pedicill \\:I-ý To cmillint Illud and

1141111,11,14,11. oll f-1),lik and pnlll-ý \\cre 1,1141 oill belmv :ill v coll-01,110,1011 " 0 1ý

Nik mill \\;I-ý PIT1111fled I() \\'Ilk ()If Ow ill. The cmil-rch.

\\crv hild ;[fill 14-fil, pilclied ns (mll Ilic collcl-vic dried ( IilIl11crc-llIlLj.\. n -ýIfllllnr pinn cmpi()1\od it the 29SIh Gi-iiend lloý;pllnl.

r Illider ( 'ill. WAl i-r ( i. Moddock. NN '. cmimialldill'-, oIlicer,

Ili- 1 11,1 '111:11 It'll I lit, fillidel ,I' lichl pol-fro Hill oll I Ilc ( 'mit I livill
I47

i i 1 ,t. 1. i l-.. 
Ii he lii E, I'(ti )i Ii-21aui

Il i.i- ~Ill i -It t1t1 11) t. it

itt Lt, \\i ll~ k -lIt 1

ic ni- lii' t II I~iti Ii'ttti'tu )tic t in t It c ll l'it i tt-. ittu'l ill'ti
F )PE :. N 1XI IIETE Fa*RT N

4L __ E,

':75

Fl;uz; S 03 1)1i II I III f :II d ll Ivled h sp ta ililt* . A. Al on sp tis

andflorfl p:111ed C m--ce s oln- h foe tntk ithe . t.Co pl'l-dhopial

5C 19 4, I- 4
274 AC'TIVITIES OIF MEDICIAL ('ONSULTAv'Is,

sit ila tionl ill thlese unilt s, theitse Officers r'eport ed a remiarkabuk goodl displositloll

r'CCOnA to (h'nerill Ii aw eY. 1111leed. thle quoted figure- of 0.5 perlcet' imiilproper

dispiosi tlljion proveI excessive.

The( jprohlelll of d~isposit ion to tilie Zone of Interior for iiietlitaI rellsoits

haiti initeretsted( tilie med'(icail 'onisultanits fronit thle he~rllillinlg of op~era tions.

TIliev ,c veirs ex perien ce to I Jlune 1943 wits, tlevined at reaisonit idle basis for

tildgiieiit . li t his period, 3,24S t ra iisfers for p~hysical caulses iald la'eii ma1de

fromi thle Europe'an t heater to thle ZoneW of Inlterior. Of this group.1) illedicall

IreaoliOs a Ccoi liltetd for 1,.01 5 t ranjsfers (3 1.2 percentiI). TFile into jila int (hiag'llOse's

in volved were liepa t itis. pe'pt ic 1ulcer. clirollij artlhint is, lan ut rollchnial alstIiiiial

11 epailit is a '(otil itt' for 352 (34.0 p ercenlt): peptic ulcer (20. 1 p ercenlt) was

llext ill order of fre(livillc ,v. Choi li ll-t rt h it is (10.9 percenlt) anid bronchial

IISt 1111111 (9_5 per'icet't) werte ap~preciable factors" ill tilie at tritioni of iliall1power.

l'illlilonlllr v t tuerculosis (3.6 p)ercenlt). bronichiitIis (2.4 pe'rcet' lt) , amd rlieuiiail t iv

heart disease (2.2 peti'c' lt), althloigli lesser cot'ltribultors to thle loss of 1111111-

p~ower. refleted(htt lit e ii prve tI~tret' s) c lin g b efore indu ct ion u a 1 r'epreset'edl ( tilit

otccalsio11 for 'oliitill iled vigilalict'v. Art erlil i hiypetenii(lion (1 .9 P eirc' lt) and1(

broicliiectasis (1.2 p~er'emnt) wteret th l nit' vll rt'iaililling 'ondtitions accoulintilig for~

iiore thall Ii 1 ercellt of tilit dlisablili tit's. All a inaisis of tilie recordIs, withI

p~art iculdar refereiice to thet oct'rlvi rtie of syiimptolis priior' to induclttionl, led to

lie recomminiidatioii thatl clirollic or reculrring, 'ondititions. suich als peptic ul1cer.

cliroli ic alltrt ii is a 11(1 brooich iii asthi lila, preclidte oversell aissiglillelent to till

active theater. of operationls.

CLINICAL STUDIES

Peptic ulcers. -~It this rela tion, th li h rt' lr ei~ e'xpterie'nce withI pepJt ic ul1cer

inl thlie Eu ropteani t heat er should be at mlatt er of retcordt. At th li'uirgelnt Ibethest

ot' Lt . ( 'ol. (bat er ( 'ol.) Joint M . Sheldon, \ IC Ch('ief, M edit'al Servicte, 298thI

(G'eneral I [ospi tal iti pilot 1)1111 for thlit llianagt'"Vl (n t of' petict I 1ceil(n'' wats inst iItited inl that unit. This planII proposedti tlit salivage or a1 groillf) of' solthiers WithI

pep'lti 11 ucer bY tilvit'i assignlmen'lt to limiited'( dity under via reftil c'ontrlol antI

rest rict iois, witliiii tilit llsii pt al mlit . '[ie diificul tit's illhlerenit ill su~ch al

dIill icai experIimen t beca ilt' evidet Itl a clv, and thlit trial failied tdespi te thle coopentrution of, (t( clt'('111111 di hg officer aind thlit sillcetrt' t'fort s of' th li' eitdivall st a fT.

'l'lit' simiiiar experienct's of swevtiall lt'ss wt'll-cont l'ollt't at temtsl lto5t retrlieve'

pit ienis with Ipeptic ult'er. for acttive Servicet't ill tilt theta t er tconfire l'it't helt conviction thait io siddlwr idrit ai hixtor of th is cond/ition should be assiuclu t) ain

m-irsm q fluaftr 4f op(Iat ios. TheI'iit a ~t'ge coo)It l'i 1)11tionl of soltieitrs withI tIilis

tot11ition~ t to lt'e waI'l teffort wits 31 111(111lihs of, mlort' 01' less initetmrruptet'd se'rvicet.

WithI I m'allsprt l'iat iol ait a P~'l peium and1111 hiospi tializa tionl dlou i *v t'Xjell'si ye ill

et'rontiiitl aind iia1tt'riel inl oversea thelit'atrs, fiul't her tr l'ias of' tilie litilizaltioul of

I hitst' pallit'ils. inl tilit Arlult't F~orces onl limitedl duty should bet restrlictedl to thit

Zonle of hit el'itr.

ill thit Eluropehin t heat er. Its t'am'lr incidt'nce wats explakined by its llollilo'gltis~l~
EI'R PE'AN TH'IEATERI 41)F OPERIATIO NS 275

5C1'lIim source in the yellow-fever vaccine, but its persistence dlependedl upon

Ie( l1iiit tii'ii1lY occu~rrinlg viruis. A survey of its ep~idemiiology kind cliuiical course

ii re b~e vonld tlie( puirview of this sSect ion. Tfie( interest from at hlistorical st inidpoin)t lies iii two dlirect ion~s. Onl 7 August 1942, C olonel Mliddlletonl p~roposed

to C olonel I lawley at plain to label tile recordl of aill paltienits, with Iithpaltitis.

with Ii thloughit to t heir batter Stutdy. Fuirthlermiore, it wvits prop~osed thait the

ident ifica ti10n taig of' all Soldliers Suiffer'ing front Ileplt it is be givel it (listinct ive

matrk aind( t hatt inst ructions be pron uilgaltedl to insure thle sect ion of tilie liver'

of' sluii Soldiers akt Sublsequienlt lapamrot omy or necropsy. Such niiat eriails were

to be forwil'(led to t ,i'e Arnmy Ni\edicall Musieumn to insure at carieful r'egist ry kind

(mit ribuit e to eXplininIfg knowledge of the evoluitionl of tilie platliologic (.'IlangeS

of this condi tion. Tile' Surgeon General rejected t his suggest ion, kind( at per

sonail let ter', (liated 27 hianmiry 194:3, froni C ol. hJinives E. Ash, N IC, ( uraltor,

Army Medicatl Musetim, maintiaineil t hat 'ompllet e histologic restoration of

hiepattit is miighit b~e exp~ected. Alt houghi t his p~osit ion p~rovedl to b~e t rue in thle

overwhiehiii lg iiia1jority of' inst ances inl which microscopic St udies of the( liver

were afforded Sublsequient to titt t icks of viral liepatit is, It. C ol. D. M\Iurray

Ang-rvvjne, MC( , in Greneral Medical l-ihborattoryAcletdsvn sics

Of tilie p)rogressionl of viral liepatit is to port id cirrh.1osis (Ilaennlec's)

]In conference onl 26 FebruaryT 1943 with (Col. John Beat tie, Director, Bernhiard Baron Research Laboratories, Royal C ollege of' Surgeons of' Englaind, att

Finchingfield, airraingements wvere maide to afford clinical falcilities inl aln Armly

hospitail for flt, study 0f the mnfluence of sifflhydrvls (sulfuir-contaiining amnino

alcids) onl tile cotirse of hiepaltit is. BY ana11logy w~ithI till' action of t hese uliftio

I('idl5 in p~rote(ct ing( the liver ai(ratinst toxic aigents, C olonel Beat tie predlict ed

(listinct anlvant ages in the Inana1gemlleult of llelpattit is. On 27 February 194:3,

C olonel Griffithi of tilie Preventive M~edicine Division of Generall Ha1wley's

office Supported t his lpositio OilO tile l)115i5 of his personal exlperimientationl,

which inilicatt('( thatt metblionine kind cystime protected tile liver aigainst cobailt

aind nickel p~oisonling. Grereral haiwley (designat ed tile 12thl Evalcination

Hospital~~ atBa1 ee nln, ais the proper location for thins st uidy. ['ponl

conferring with Lt . C ol. (latter C ol.) Martishaill S. Brown, M( ', ('apt. Aust in 1P.

Boheinan, Jr., M(', wais dlesignated ats thle nledical officer of this Ilospitail to

heal1 tlie( unlit.

On 6 July 194:3, after the trainsfer of the 12th Evactuation Hospitail fromt

hii, lo('at ionl, C olonel Middlleton (discussed I ie( prob~leml wit hi Colonel Beaittie

akind with ti lie stafd of the 121st St attion I ospit ii. Mliss SiiiitIil, of thle .5t(1i

( lenera llosj it itl, wals tranlsferred to t his unlit for laiborattory dutties, 1111(

Colobnel Iiat chier, ('011mimia 1(1 g officer', aind C olonel 'fvi tel bauliii , C hief, M ed ical

Service, 1f1'ordled tilie Supp)ort ing lealdership. i\ laj. ( liar1les St eele, N IC, aind

ietit. Daivid L. F'ingermiin, MIC, were in clinical control, aind ( 'aptain .JolinStolle, il tlie( Iiilrmorut 1.

In a1 conference Oil jatlim(li.e ait the Royal College of Surgeons- on 2:3 Novembi ler 1943, C olonel Bevat tie post illitied tilie lprOblbale exist ence of' two et iologic

factors, mill, X inl arsphnlivimmine Ilepattit is, aind Y1 i1 the immittini'illy occurr'ing
2 76 At'TIN'rrIES 4 )F Nam cm,(AJ coNsui.ANT's

hepaititis. 1'his is prolbiillv the firist public ireference to Such at distinct ion.

liI'l cliuuiciil experimi ent oil thle val ie of thle stillifur-conit alill" mug aiiio iicidls ill

lie( treatllteuit of liepat it is wals ext ended' to ciirlloll t et ralliloride poisoning aind

inftctiu mO5 iononuicleosis. ('erli am brillianlt results at tended thle intralvenous

use of inletlitonline ill varl'bon tetralvilloritle poisonling. Th'le results inl tihe

managemenI(Ilt Of inflect ious nionloniclleosis 1111d1 infec*tious hep~atit is maily be

Inranshit et inl tlie( Simiple termls of impijroved nuitrit ion. lit t his relaktion, there

aJppea r-ed no aldvanltalge over thle iigli-prot em dliet inl use inl the theatter. I low--

eve'r, thle reilapse ra1te a ii olong patients recel iving stil f~ltyd ryIs wats a pprecia Id v

lower t hanti lie prevailingll rule.

Motion sickness.- lit aill a mnpliibioiis andl airlborle operat ionls, part iculairl.-

those mnvolviig, S1111a11 sviearaft mid( glidlers, miotion sickness must be griveut

serou (osilerit ionl. Althlogli"1 thle professionlall responlsibilit y for t his study

residled ini tl( Nle~Iedicall ( onlsultilants D~ivision of Gveneral I lawle v's oflice, tithe

D~ivision's role priiialrilv wats aolvisorvy. ()n 10 November 1943, C olonel Mlomitgroine(rv, NlediclwaI Coonsult anit to tilie ( 'ana1ditan Arniv, anld th Cn (hief ( onustilitat

illiNMedicine, ETOUSA, conferred with at Cana11dianl surgeonl, IA. Williamil S.

F~ields. R( N'NVR. who hadt( been engoag"ed inl research inl miot ion sickness ait thle

N eurologicail Islisttit te. Nl lot real. Inl thle judgment of this grolip), 30 percent

of individualls ha1d at ps 'ychic batsis for t his experience. 'Ilie ( 'miadia i sealsick

elilvconisist ed of livosci ii hvdr-obronilide, 0.6 ug.; liyoscvalnun le. 0.3 Iug.; 1111d1

niicot iliic acid, 100 lug. Th'e ( 'antdiaiul results illdici~t ed .50 p~ercenlt protectionl

froml this agvent. ('apit. Jaiii1es C . Williauiis", MC ( , had beenl as-sig'ned bv (lie(

Army 'N Ground Forces for studies of miotioii-sickiiess prevenitive, U.S. Armiul'v

developmienit tv*lye, under simiiula ted inlvasionl eoullit ionls. Ilis results were

limited land iticotichisive. Ini stutdies; of trioops5 nirlborne inl gliders (fig. 104),

UA. ( 'ol. (late' (Col.) IDavid Gold, MIC, wvith the coolperaitioul of at regimienital

surget~on. 40thl Imifaint rY concudh(ed t hat there wals S011i0 Prote~ct ion in the

11101ioii-sickuiless prevenlt ive (Sodium Aiiuyt aul (au1lobarlbitial sodium) 610 1.

s('I~laliiie11Vlrh~o~li~e .2 11.,a tolile slfte0.1 ui (). O 17.Novemtber

1944, ill at stilt 11 rep~ort to GenleraIl I lawle iv oi1 tie( Iinot ioi.,sickuiess pre'venltive,

U.S. Ariiiv (developmient type, C olonel Mliddletonl report ed omil two groups of

soldIiers returu'ledl from te (- Conitinlent to fixed hospitails inl the LUnitedI Kingdoml

after 1)-day' . O f thle soldiers laml* vzed. 613 haid taken miot ion-sickiiess prevenltive, land, Its contr-ol. 306 soldliers 11ad totken no0 pr'eveiitive. A stiltist icail

a1m * N1-sis of Ilie resullts bY IAt. C ol. ,Johin 11. XWatkimis Sii( of thn' Medical

R~ecords; D i visioni ill Genlerall h11i wey s of ive 11(1ica ted no signli twa ut diffri-leiice

ill the two griollps. 'I'ie oldvei'se effects, na1mel1Y. bluJrrinhg of vision land unu11suall

sleepiness, obtained inl oiil'v :38 solohiers (0.6 percenlt). From the aivalilable

evidIenc~e, thle followving. dedluct ioiis were dra-1wnl

A. The grountds for the :idopti bi of M 01 ioti Sickness Preventive, U.S. ArmY I )velopinent Type, were not somtid fromt jparinaclt'ogitc mtl clinicnl staiit1joints. (otlthine(l potenit

(Irt)i gs ne~l(A not shtow z adit bOI ive effecIt't in I heir comnpos05ite i'ke:i tlot

It. The wide, rmige of dosatge and interval of mzidittist rat ion mtilitate azigiist nn atcimmviziu

st itlist i'l anaIl II YS is oft I li i'esu Its oft this l1artivuhihr op)erat ion : hot from th li vailahie evjdletue,
WF

1ý 1, 1. T I 1 .1 - ,I* F il- l A llicd A il-1141111i. A rIll.\ ill A I-1111--ill

lli-ýIu.-Ill -114m i-d 114) II1:IlIq.i:II :1,1\ :lilt 4.\ ,I. :I La u" v, )ill --n m p.

floo 6-11

A ll A.I* M ill i''ll ýirklll- Vn-\ I-ill i\,.. V .S. A rill\ I

:1 Ill. I \\ ;I- :I - illl-,ilh r ill' I i *1;I \:I I i,

l'- p- ill -11 ikillu rw ll 1,:I-l 14) 1 1w il. u-11:11 (4 l"ll-i4ill.

I n I I u t it'll Ill I I I ý I I f I I I I I I 1 4 11 1 1 o h o 'Id I-.I I if I I

if o I I t I I' 11-- , 1111 r. I I I I I ýq I I if I I I I o I I I. I I I

I'll) Sl( \I, ST V\D \ R I )s

T1w e'lobli-dililefil (4 pll.\-ýIrol -ýI.Illdnnk \\;1.4 .1 IV'pmIIhI1IlY (d Ow

VI-fd*(--,Iwl.I1 1-ý(-I-\Icc-ý 016-Iml Ili G-Ilend 11.I\\1o\,-;o1hvv: lionce. -ýrvnl lillorc-I

14) Ille BI-ili'll .11141 C.Illadloll r\polivilcl. Ill IIIU-ý cmlferriwe mi 21% Jime 19 12 \% it It All. mIIIIwdm-v ( (Wll\ bo'll-o .11111 Air ( ollill!"Ahwo

I \, if, k . I I I c d 1, -. I I I -(, I I -ý II 11. 111 1 " (I I I A I I- F it 'I) 1 1) 111, If 14 11 o f (III I

ImIll. of 111v I-ch.11)II11,111m) ()f pllol-ý \\[Ill pulSID \\qTv Ille BI-111-di dellmll(k fill. 111.1111)(m el. 111.11

plhll-ý under ;II-111irl.11 pill-Illimilmnix 111cropY hir 1111111ed pillillmi'll. IllcrIII IlIZI-d :I- I roillrl"ý. Apnrl fr(IIII I 111-ý Ill-porlill-v I'l-mll

Ill, \ cr.\ com-en oll 1\ I, pli'll Hill III' I ho I *.S. ArIll.y. III ll(,I* lot
2 78 ACT"IVITrIES OF MEDICItAL ((iNSULTAN"I'S

(10titprt'iseis' ill the jinterest of the 1120W. vo~itl)ete uit itltzation of British anld

()tt 7 fiullv 1943.4 tit thev mnittlil v inviietig of tht e Nieulcl ,;Ilh(-olI~ititvvte of

the( Royall Arii1t% Ni edicail oitsult a itts otiitluit tee. Bri-r. Fra litk 1). Iliowit(

H AN R(' ('lltstiltat itt ill iilsiv~icl ii ietlciitt'. rep-t)Vt o'l ilt his st ild , of tlie(

l)1*l1llENl'- mvstem ati plain121 of phlisicail I c111 v'rorizilt Itoh which hald beeit devise I

1) v tilie CII( ' atta ia, Itsaitd which 1tliorde'd it profile of t lie exa lillitted sol(Iierl b)y

svstelits so thalt it coiitlosite pictunre of til iiidiviultild could be gal liered lit at

glat lice. Stthseq ient discutssioins of t his subiject. pa tt iitilarlv- with Ii(olotvil

Moloittgoliter of thle ( 'a itadia ii Ariiiv, lelt ito doltilitas to its genera I atppliclibilit v.

Ilie eatre1ftill studies of Lt. C ol. (la1ter ( 'ol.) (ieor.4ze G. lDurst . NI(, '.ed ito its

adoptioit lhY the UVS. AriitvY as. thle WIAMIE'S (Pl~ltvsjall cajpltit Y or sta11iiiiita

Umwi~erextivreliti tis. L ower t'xt lviliti i s. liv al ii h., E ves. xviel-opsvchltr ic stilttus)

pilisIcatl profile seriatl. With lit(li prevssure of redeplo mvi teli MIali ( liarles D M atv

Wai5ts ClIed to II ettquljlatrters for I~ le(u er-p ret ait ion of t(ills svst eutt.

Tlle prograilil1 of redephwviiaeit pilaIcvItllai overlvlieliiitiill" bitr-ile uilli t li

I-ersoiaiiel D ivisionu ill ( eiteral I liaimlev's olhice, whlicli rvyjiired t lie colit itiiolu~s

suppi 1 ort 11t11itd atvice front d ie Professioital Servivices, D ivisiont. W~itlhll t heir

resliect ive divisions. 11he coiltsiltaitlts were-t required to atet iipoii t ite quiallifeatl ionls

of till iiedicall offliceirs inl tlehea ti aler. Tlhte point sys eii l t- logethlet with Ithle N l S'

lesigna it loll beiCVII Iit' lertmtiing fatct ors Ill (lecisiolts ats to tiw ieilt ii ita t d isjosit ioit of t ie( itleieltl of licevis. Fort utiattel ,v, thle i ti ntj iterests of tilie service

211dthiIIle concternted tleivieltl offhcer coialul it, 11jrt of iitsttitlces, 1be prtit ct ed

l)iv t it coitsuilt 2ii t 5 p'ersomtat kitowledgre of thle officer 's qujatilicaett itns. Not -

Wit lista1t11itll".g t his iitodifvim iicircI itst tilace,' tlie( eXigeiivies of tiIt(. sit lintIituli

wcte suchI ats it 14 rsolNve itt ucl of th lie at ilil redlellovltieilt to lie cold hiiviares

Ont 10) lFeruaarv 1945, C oloinel Kittlibrotiglt v iiriiellv to t lie Zoite of iltt rior

figr. 1015). C oloinel ( Ittler. waaiai Iiiaed it. t he litew direct or of lProfessiotialI

S-ervices D iv isionit iiitlie Ch'ief Siirgeomt s ( )flie, 2211( C oloitel lPisat it bvea iit

olttl tlv'ti iiltr lcr.Tie txei IedictI 'tstl a tio er iET( ISA.

Itait reulit iiited rcvililI-iltkai Nv sI at We tI oliroia llot Ilipeod faiivt fIlethat'.

,ktitoiig tile Seitior. coiisitlt nilis, olitv C oloniel I leiit litld vi lui lost by reaisoii tif

a lilt *ysicatl disailnlit *v. II is posit ioit of senior votistiltaitti ilt vatr-diology \\ats noti

re1fille~d. The tot iii piittilre (if t ie( Nledivail Coitsialt ait ion Set-vice ats o;f 3t) .11iiic

1945 i1122 bv resolvedl hv refereitee to 1121v list nir of cotastlt itlts shiowin ill aipIwldi'thx A, 1). 829. IltIlit'. iintere'st tif at (olipiilircltesiv(' pijdt un of tIn' operallion, tlit'. ita11i4es of aill Itiedivatl cotisutilt iits airev iitliaelld, its I heir jitchiasioti grive.,

sonic ideat of 11vIflid'hinit v of the Ilaldicall sit iiat ioit aiitd, lYv the salute tokieit, of

lit'- chiattigiitg reqiiireciviiet for coitsiillt atioi serviev.

WitIifi at sligrlttIZ~ lagafifer N' I. I )atv, S Nliv 1945, flit uii'dival situnatiou inl I li

Etiropt-ii m aatriilret r~apid chiaiigvý lipoti I mip tioveniiitt aiid4 rev~vdeploylit-iiit. Tl'l eNhdicaill ( Thsiilt tioit Servicev e-xptieiltced mot'tittre'ia~ a1ilt r21111-1
P I.-, I I fil V. . I -i - I I ~I I I

:1 I:114,1IlI\lthI- I I i ' I

Ii II ; ~ ~I I I. I( I lw- I I I Itl k I -I 1 I- I I I I i '. I- . I 'I

LITI -- I VrII\- N1II 

it I - t i :1 T I I i l I 1 w -I-:1 lk ;I - I I I I I i I .I ,
''SO ACT~IVITE 4Wii: i MED ICtAL CO NSUL.TANTS

0111,111111a11 ill MIetlivinev. 011 27 -lnitv 1945, C olonel NI iddlvt on wit, ordered4

it Washiingt on bY Tht' Surgeotm ( 'ieneral to at tend the Pacific coniferenlce,

whlereiipo h)1 is dutiest itdtevolvt't upo Cs" oloniel NIcEweti.

SUMNMARY

Ini rev iew~ingi t lie rvetrd of t11 li' etIival Consu'41Iltan ts S'ct ion, Professional

Se'rvices' I iv ision , ( )hive of the ( 'i ef Surgeon, l lq tywienutes ETl( U SA. certium

signiifican ii tet~ii us collit' into sliartiewr ftocus. H'it' orgail iza tionizd patt ern wals

S011114l aitivite from th ltltitdicail .otistutltatits of the Brit ishi and ( anladiaui Antnit's.

For I lie dlura tion of aictive' ImiiltanrY t1)t'ni lolls, th lr'~a1pport withI thle lritishi andt

( '1111mian medical vosililt alit, was in1timatxe 111d livotitblde. T1hrough tilt limitaltiouis imp~losed bY ITie Suirgeoi (elneral. liieticiii (Itlive'rs ill t ie thleaiter werte

etiiloltYt'Iill it conlsultinig (1)p11(1 tY, lit ilizing.it t heir specialized skills, ralthele tha1)1

irlnwing fiin-th Iit'n l th)1)1le dvti ed)et( proft'ssionall resources ill t lie I tiitt'd Staites.

Ill iicctirtliiiict' withI thle pnlcll'of t11 le ost compljlet e uitilizatIion of t illeiit

whlere'ver poss5ible. vot isiit Ilt aut were uiset iin at (111111 en pacit, v. Their jpniillian.*v

respot isil alit v rema ii icd ill their assignmnie ts its eli iefs of ii( ie ed1(1)1il sernvices of

fi xed hiospitials, 1111(1 lit thle sait nt t imte their special t ait'n ts were used inl cotistilat tivt relt'IiIiolislipls to th lt' Iliteittr. WithI thle growthI of tilt' I lien? tr, t Iiew

keymenti wtrt' assi gie tllangt'r responsibili ties in hospit utl enitet's alitd I ase st'ttions whlett conitinuiing Ito function ats setmor constilt ants. iii tht'ir re'spectivte subspectiult it' of mt'leivint' for. Ilivt'h lea ten, at phlan which paid lit'avy dlividends illa

vtlleit'iv'nt'ss. On Iv two of th li'Sell itin 'onisultat 1)15whoise' ad~mtinistrnatIive dtie ts

WNT't tevlledt full t imt'. 111amelY, C olonels ilsuyantd Th'lompson, wt'nt' sta-1

tiolledt lit Ilit'ui till ulan ens.

Betfore' 1)-tnY, thet pat tein of organization liatl umndergone at fair trial imnder

r-t'at ivt'lY quieit cotdititon~s ill tilit' United Kingtdom, whitrt' by ( his t it'i a11lmost.

1 4t),t000 bedts hatl beten pt'vpai'et. 'I'l'(, Chijef Sllngtoli, JTlOUSA, was coinlinittedt to t lit' t itsis thaiiIt lt'e oly~ rt'asoll for th li'existetnce' of th lit' Ieticall Iepartilivitlt ilth .1IN iste prvnttit loll and1( care oIf thle sick antd injuriedl. HIis

completet couifidencet inl tilt mlissionl of his P~rofe'ssional Snv it'ts Dijvisioni insured

lt'e Ii ightst possiblet le'vel of coordnlua tion aln1olig thlit sevt'nal dlivisions of his

officet. Fromi atn operat ional standpi 1 oinit, uiiquitstionalu YI the ability to control

lit dlistrnibutition o~f t raiiit't prolfessionalu. pt'isoii itl to t lie greta test atlvalt agre of

ilit' sick andit wVoundedti'tIws t lit' mlost imlportan11t dividendit fro'm t his farsightedl

pl t~i c. WithI thlit sup1port. tof lthe ( 'litf Surgieon, inivaluablelt chantise. o~f dir'ct

ct01ti11i1nliiatliont for. tlit' diss'llmint ion of proft'ssional informat ion were' encuitrnott h'alst inl lt'e finlal ittialysis, tilit' mt'dival tconsultants inl lt'e Profe'ssional Service, Di v isioni, to w honi haii ld t't'h assiglit't tb lit'tsk of dltiivt'rilg t lit be'st. 1)5-

silile illi'' Iical tart' to then soldlit'rs o~f t lit' U'.S. Arm i* ilit'e t Euiropean thlit'i tt',

pt'i~onni calpabilit it's atid limitationis tof th lit'idtividiials ctitnlit'ti, tOlie mniastln'

of t heir suicc'ss ill fuilfilling ,t his mandai(t t' 1))ust rt'ston t lit ntcontl.
EURO PEAN THlFATEIR: 01" OITIIATIO NS 1

Part 11. Senior Consultant iii Dermiatology

and Syphilologry

EVALUATION OF THE SITUATION

C oloniel Pl~ilsbury (fig. 10(') arrivedI lii tile Unit ed Kinurdoni dur~ing Decemiber 1942 and was, assignled as onle of two full-t unie conisultants inl dieMedical

C onsultation Service, Professional Services Division, Office of tilie (Chief Suirgreon, HIeadqunarters, ETOUSA. Colonel( Pillsb~ury filled tile position of Seiiior

C onsultant in Dermatology andl SyphidologyV, ETOUSA, the other full-time

p)ositionl was that of tile Seiiior C onisultanit inl NeuropsvchiiatrvY, ETOUSA.

F"iguire 106h. -Col. lDonaldI Mr Pillsbur. v,1 NC. S1.uuior Cons-ultanut in Der111atology, Officie of t hie Chief Stirgeon.

ET(WSA.

M1aking, immledliate contact wvithi his counterparts inl tile forces of the

Bri't ish (CommoniwealthI of Nations, Colonel Pillsbury found a valuable source

of information inl Lt. Col. (later Brigadier) R. M. B. Mlachennia, ( onsuiliant inl

IDermnatology- for the Royal Army Medical Corps. Colonel Machenna was

able to recount the skini diseases most frequently found inl England, tite Imne,

tires undlertakeni by the British Army to prevent and~ control them, and thle

av-ailability of (lerniatologic supplies in the United Kingdom. Lt. C'ol. M iltoni

11. Brown of the Roy, al C'anadian Army Medical C orps was particutlarly lIehlpfill

b~ecause of the exp~erimenlts tile Canadian Army* was condluctinig in massive

arseliotiernpjy of earlys- sphilis, a. subject of great immediacy inl view of the

marked military adv-antage some shortened metlhod of treatment would have.

C ont act wit h the Brit islh Emergency i\ Iedical Service was mlaint ainied iii

'iThe narraitive for patrt 1i was compiled by MaIj. James K. Arlimi. NISC, The Hlistorical U nit, 1'.S. Arniv Ntedic ii

S.'rv icei. tinc lazhorit ion witlit Donald M . Pillsbuury. Ni. I).formetr Senrior Conist!thinit ini I )vrTma:t 019N'it Zy Mjiioll~Ogy. 141~ 

ETOVSA. D~r. 11illsburyv cetrititrib thed stin( utit ary ini rvt rostw t itn May i g54i.
22ACI~rVITIE1S OF MED'IC~oAL. (4)NSUI.LTA N*Tr

coliuect ioll Nvith ti I eat mleit (if siic-I 1. S. p'-soiinel ats wt~vere aidmitte d to

Entieigt't cy NMedIicalI St-i-vice hospit als.

D~erma iologv

Oil his; arrival ill Emdgainl C (olonel IVilishlalrv found Scabies, siI j)Cr1f icial

pvogen-nc infectiaon., of tilie skill. cont act derimiat it is, alild ch ronic vezelinii ous

vrlipt lolls inerviasi nmz [it ijiciteleice. lPe(Iictiltosis alliit various- Iv pe(s uof 1.1! iworl-ll

inifect ions als'o a ppea r-et to lbe it priloiill'. Intsj)Cct iouii of Ilosfpitila k and(ts lipelsil~l rits sh owedf that val-v. (lilrtI , '1Z'i0,.is wVithI appropriate trenilleatnwt ill field

unitis a1li41 h ospital. 4 N115 a livt'(ICd ill 11111 VI Cs'Cs to p~revenlt dalt. I'l the

chirolnic lerina oses. suich ats ait ojic delt'r1itizi tit i aid Severe psoria1si, earll-Y classifii'.it 11iolitan tlett'i'ii tiii oU of prognosis would ideiit ifY pa eis who, with no i

reastinli I )Ie lprospect of earllY pt'i'iia lit'!t iliijprovellivit 'it shisl ile bI ret iiiii et

prompt I *X to the tonle of Initerior ill order to prevent I heir. liecmiingitu eavilY

load onl IlildicaIl anti4 tilirsilig personnel'. Mlany soldiers who had marked senIsitivit v to such it emsl als wool, dIt'. ld14-1(1t'ither were. ilcalpa ible of fuill dilt tv.

N\la~l *v hiald hlad t~w dise isalbilit ies prior to indulictilonl and4 shoulid not Ihave beenl

Sent to tite theater.

Tilte jrovi(Iill" of tlernill tolog-iv suppl~lies, inl tidetuate am11ounts 4111(1 thle

(IevCloit~llellt of ne~w drungs and1( viluit~lson wee(olicoillit ailt priobldems. For

exallii III, ieiiz 0 14Cli.oiitte ireaitn11111t of sca iaes wais ti liougit to fite suita ide for

use Ill fiCi(I unlits. buiit thI en. were problvideit 5s to Suipply, .prepi-l it loll, ii td t he

best vehIicit'. A slan1(14 r ni n ullsioil on itil 1(11 as t Nvehicle, for' Sillfotia Iilides a11

other lilC4IicillaI1 agenits inl tilet t rent iiieit of sulper-ficiall pyogellic skill infiecttions

Wits Ilso needed (p). 285 and p). 31t2).

Theii field of, syphillology wl4s15 ift. with problemsII'l of imillledliate colicertil. A

schiedl ih. of, tivta1t i lenit for 'veilerenI diselases Wasi pr'scri I 44'( ill 11 (Iir-oie i fI'rromI

Thl e Sn rireon ( 'enlera I P IThiis scheietInle. h owvever, wvas not fen ollowedI ill all1

unlits hecai us of' difficult v ill obt aililing" NI n jdia iseii koxopI iviinrsuile hydrl lochlor'ide ). Ill somie ilist illice4'. thiert. lhad t'vell bel)C' 41 comI4plete C ilui'e ill thle

f Iist rililit ion of' thlis (1m-tg. ( otllsequIellt lY, Amlericanl Nalpluirseii, Illit ishi

N [aph~al-sitlt. 4111(1 livozlk jdlelitll.Ililiv were t1l1 livinig uised. Becaulse of thle coilflict Ing evitlelic4'e rdg~ n int lg, thet( t oxict'iI of, t hiese alt i isY phlilt ic trlIgs. cotisideralde

c'on~fusionlulhd 11iriseli ill the mindlus ofll11,11VY 114'diclil officers. The subject 11414

to bv 1Iiivtst i-att'tl full11(v an 1i t rial of' lrit ishil Napinirsitle illit intetl. Suich

l14131t tens 'C ulrewIc thle closest coortli lilt t ioli withI thle NIedica I~l~ll Div~isioni of

( enleral I lawleN's oflit'e, aInd It. (Col. H oward I logan., NI( , wvas []lo1st livipf'ill ill

vi1 rli i'(lital -i su pplY' sit iait loll.

(ololtvi Pillsbury. foiiuld tha41t tIle Standailzrdl of' s vjhl~iis t rtat ineuit ill solille

hiospi ti41 s collidt be4 illmproved andl that1 he vouId h11ve ito inlVesjjt ig , Ie tatar

4 ircitihr Let ter No. 74. Officm oft lie Suzrgeon General, V.'S. Armiy. 215, tlyl 1!, 12, iif'j'ct jirr' ol r': tet I

Ow)t Vvnreretii Di )M.vws4.
EUROPEAN THEATER OF" OPERATIONS 283

inl field units. lin the ULS. Arniy, ats inl tile Canadian Ariny, it would~ lbe necesSanv to ho01( occalsionaml con ferenices of Itiedicall offlicers t reat ing Vener'eal (lis'else

becau11se a(Iequatte dIirci'C' on 01. stillliulatioti of' initerest ill SVJiliilothlieni ,~ x((culd

not h~e callrried out i),w !et ters an id (irect ives ailonle. Various IabIora tor.'y prove-

(lili's, pari't i(llirlY facilities for (Iark-tieldl and1 serologic diagnosis of sYl)Iii~s.

allso nieedled illnpiovelnenit.

As the netw v(ear, 194:3, (atile, "'The above wouild indlica te",' wrote C olonel

PillsburN , *Ihat t' this Consultant ha2s plenity to (10. It is b~elieved that

work a long, t hese lines (-til produce it significant dlecrease ili disability inl ET()

(tile to (lisealses included inl tile field of deri'natology an1d sypliilolog .'' 10

FORMULATION OF POLICIES AND PROCEDURES

During, 19431 the problenis of dermiatology and syl)hiilologv7 becamie inioie

c'lear'ly dlefinedl, perniit ,.., relativelY- clear liles of action to overcomie theni.

nIit, greatest i'oon11 foir ilniprovenlelt ili the field of derniatology lay ili the basic

prlo'esses of (liagnlosis 2111tieatnwii t ill thle mlore easily cili'alble, mlost prievalent

condhitions. To C'olonel Pillsbury, these two questions were paramiount: (1) What

1s lle('essa , y to keep thle soldhier, par'ticularly tile cotnbalt soldier, fronli inaii1-da 'Vs

lost als at rIstilt of' preventable or easily curable dernantologic cond~itionls, and1(

(2) what types of' goodl treat nientit are niost, applicable inl forwvard units? Thie

thieater senior consultanlt inl dermiatology and syphluology hand to aivoidl scrupuilously tihe tenipltatioli to investigaite rare and iliterestuig coniditionis or' to coniquier the 'oniditionls with at reputationi for crnit.Tlie 'year also saw the

enga genlen t oft lie etieniiv inl the Noi't Ii Africa nand1( t lie N\ [edit erralleilmi1 area1as. The

cii in paiglis ill North Africa provided anl opportunity to out linle clearly tilie lprohlells---pairticuhu'ly Hi the venereal (hseaseS--thlat. would be 111(4 und~er ('olib~itt

cond(it ions.

Dermatology

Owing to an un faniiliarit , nin anyin Iinedical officers of the various,

leritllatologic conditionis, thle iniportance of skinl diseases ais at source of mian-

(hays lost wats often overlooked. Of 2,093 wdniissions to the 10th StationI [lospita1 during', the later niontlis of 1942, 10 percent were for at prinilar 'y diaignosis

of' skill disealse. The 5th Gi(ener'al H ospitalI found that 6.8 percent of 7,049

adi~ltlliosiO were for a priniar ,y diagtnosis of' skinl (disease. There were 14,408

a1(fillissiotls to till hiospitals ill the Europeant theater (luril..g Novenilher and

Deceniher of 194:3. Of these, 1,033 Ucase wei'C iidiiittedl w~ithi a pritiary inV(hgnlosis of' skini disealse. This wats about 7.2 p~ercenlt of tota h1 lospitazl 211 iis~iotIs.

But lhospitazl 21(11i55i0115 alonie (lid not tell thle Wholoe stor 'y. Colonel PillsburY

ilt erviewedl nitztinv ned ica I officers ill bot hi thle Eur'opean ii 211( North African

theaters and1( found that tile inicidenc(e of skini (diseases at sic'k ('211 ili service and1(

('onibait units rang-ed front 15 to 40 percent of till patients seenl."

10 Annual lHeport, P'rofessional Services D~ivisiion, Office of the Chilef Suirveon. lleaff(2,zarters, 'T'OUSA, 1912.

It Annuital R2eport. tProfessional Services D~ivision, (M(ice oif tite ('ii ef urwen'n. I 1ewlq' uarter~z l' ( IVS A. 1943.
284 ACTIVITIES OF MEDICAL CONSULTANTS

Scabies an(1 its coin l)licait iofs, S~priitrCial pvogenliC inflect ions, funlgus,-

infect ions, Sebl-orrheic (lerniatitis, p)soriasis, andl Various types of (lerilat it is and

eczemla Conlstitutedl over 95 percenlt of tile cases. It. wats not too mu1lch to expect

of aill unlit andl hospital mnedical officers to dliagnose p~rop~erly this 95 percent, of

(lerniatologic cases, but1 miany couldl not. M edical officers lin ETOUSA were,

in general, less well t rained1 in tile diagnosis and t reatmient of skin dliseases than

ini any o ther specialty, W~ith ti lie possible except ion of opit halmuologv. I t wats

the except ion, rat her thanl tile rule, for general hospitals, supposedly equ1ipped

to rendler the ultimate standlardl of medlical care to the soldhier, to have at trained

(herlliltatologist Onl thle professional staff. Thiere were Only five medical officers

in tihe theater wNho l)ossessedl at certificate front thle. American Board of Dermiatology andl Syphilology.

Colonel Pillsb~ury made particular efforts to train competent youing mledlival

officers in (dermatology. This training, had to be continuous, with regular

sup)ervision by thle Senior consultant or regional consultaints inl (dermnat ology, in

ordler to insure that thle t rainling efforts were b~eing reflected in better standards

of care.

Oilne mans of reaching tile officer in the field wats through meetings anid

talks. C olonel P~illsbury. gave lectures Onl tile (diagnosis and treat ment of skill

diseases inl tlie( field ait 1)0th tilie M Iedical F~ield Service School, Shirivenhamni, and

lie Field Service School of the EighIth Air Force, using at serieso w-nay

owned coloredh lantern slides. The British Minlistry of Hlealthi filmn onl scabies

wats also shown at, the Medical Field Service School. Duimring thle year, C olonel

Pillsbury led dliscutssions, by invitation, at staff mneetings of' 10 ho0spitals in tile

t heater.

Onl 12 November 1943, a meeting, sponsored by the Chief Su"trgeon's

Office, ETOUSA, was hieldl ait the( Royal Society of Medicine attendhed by 25

tT.S. Arnvmy iedical officers andl cert ainm guests of thle Unit ed Kingdonm and

( anladianl forces. C oloniel Pillsbury b)elievedl that thlis wats thle first meeting

dlevotedl to (dermiatology ever hieldl u~nder auspices of t lit U.S. Army. Various

a spe('t5 of thle diagnosis, treatment, and mlanlagemncltý of scabies, lpyo(ernla,

p~sorialsis, eezeni a, andl cuit aneous lesions associated With mieningococcemnia were

c'onsidered in individual sessions. There were discussions onl (1) t he sup~erficial

X-ray t reat muent, of skin (diseases, (2) thle types of skin (diseases requiring

"b~oairding" o1r prodlucing recurring disab~ility or bothi, (3) thle factors dt'laving

involuition of common (hermnatoses, and (4) the( (lerniatologic dlisab~ility in coinbat units. lin addhit ion, Brigadier N lacKenna gave at talk onl tile onrganization

of at (erliatologic se'rvice. Maj . J. II. Twvistonl Davies, RANI( , (dernmatologist

for the(- Sout hern C ommlandl, discussedh recent e'xperie'nce's in military (lerluatology. A subject of c'onsiderab~le iniportanet ait the time, andl one in Which tile

averalge (dermlatologist could not, be expected to have hiad inii chi ('XieIiellce,

wats thle derniatologic Condhit ions t hat Would occur should til chi(enemii choose

to list che'mical agents Onl a1 large Scalte. This subject wats e'xpoundled admirably

by C ol. Williami 1). Fleming, NI( , Ch'lief, Gas C asualties D~ivision, Office of the

('hiief Surgeon, Hieadq~uarters, ETOUSA. Material emierging front thIis ex-
EI'ROPEIAN THEI~ATrER OF' oI'ERA'IONS 28.5

chlaige of views ktfld information was latter published in the M'edica! Bulletin,

E'IX)USA.

Ini thle European theater, the vehicles for communication dlirect ed to thle

bul1k of inedlical officers wvere circular letters of tile Office ý' 'thle Chief Surgeon,

H eadlquarters, ETIOl'SA, 1111( tile Ale ''cral futlltia. C ircular Letter No. 77,

8 Mlay 194:1, was entitled ''Dliagnosis and1 Treatment of Scab~ies.' III it,

C olonel P~illsbury st ressedI the point, that ''only by pr1ompIt recognition of the

dlisease b~efore complIlicatijon- have d~ (e- .O1)ed andl before other miembers of tilie

unlit have becom e in fest ed, canl Scab~ies be controlled Slit isfactorily.'' It. Was

p~ointed out that.: "'Unwarrante (11 numbers of patients With) scabies are being

ad~muitted1 to hospital in E.T.O. It is essential that medical officers shouildl he

famiiliar. With thle clinical feat ures of this dlisease, so that anl early (liagnlosis

illay b~e till(Ie. and p~rompiIt effective, treat ment. carriedI out, in /I.

Four articles onl tile recognlition andl care of dermiatologic condhitions were

pub~lishied (diring tile year in the Afedical B~ulletin.

(Colonel Pillsbury coniiitnued to maniiitain thle closest, liaison with Canadian

andl British miedical officers in dlermiatology. IHis relations with the Armyv

Air Forces were. extremely cordlial, and readly agreemient. on improvements in

thle treatment of skini diseases was always obt1ained. On 2 July 194:1, tilie chief

addhress at. the British Association of Dermiatology aind Syphillology was given

hy Colonel P~illsbury, Onl invitation. In his annual report for 1943, Colonel

Pillsbury ' commentucdel, as follows:

This consultant has attended all meetings of Command D~ermatologists, British. Participaftijon ii t he dl5iscusions at this meeting has been act ive, onl request. Brig. It. M. B.

Mac Kenna has been extremely cooperative in making available the( collected dat a of the(

RA MC and his own wide experience in milit ary dermatology. It is felt that our relations

withI British in this field of medicine have been particularly hlapp~y, and futuore complelet

cooperation is assured. This is particularly valuable, in view of the absence of any direction

in ihe field of dermatology frorn the Office of the Surgeon Gleneral.

Special problems.-In any foreign theater, new medical problemis arise

t hat require special treatment mnethiods. Ini thle. United Kingdom, the U.,S.

Armyl '(vepended onl British sources of supply for dIrugs andl special equlipment.

for derinatologic treat ment. For example, Colonel Pillsbury realized upon

huis arrival in Englandl that betizyl benzoate would b~e the idleal dIrug of choice

for the field treatment of scabies. The British had shown that it was greatly*

superior to sulfur. Thle, vehicle used by the British, a liquid I'anct te wax

emulilsion, hadl certain disadvanlt ages for use of troops in the field. Iii collaboration with British indhustrial chemists, an indefinitely stalble andh highul.-

effec(tive thierapleultic prep~arationl w~as dlevised for U.S. Army use (fig. 107).

Thlme dlevelop~mmen tal Work with sulfonamide emutlsion ointments proceedled as

planned inl conjuniction With tile C onsultant. in P~lastic Surgery, ETOUSA,

alt homigh suich ointlitienlts were later dIiscontinumedl because of their sensitizimiig

p~roperties. A very usefull preparation, benzovlI peroxidle ointment., was add~ed

to tilie nonstand~ardh list and p~rovedl its value immnediately (p. :312).

Stuperficial X-urav' t herap'y becamle desirable for the treatmecnt of certain

skini hesiotis. Ini conji ii't ion wit h the Senior C onsultant inl Radhiology,
FvpeIiiitm:17 ~ iva -d I111 oherq.- 211( (veW pled . here was zY lackof11 cotrol ol' lie fo

Irv14'itlielit tzivvi1. iald tde possihilitY vxiste(I that Owe rcords of dIosag.e wouldI(

lbe lost . A pproxilniat el ,v six such units were liededll but tw ,ey were not avail2t hble. It Ilav be4 conicludedh t hazt supriciaelI 11 X-ray thlerapy~ is not at tIlet 10( ofl

tleei ilehit I(adaptabile for Iuse ill all aIctive thie~i~er of ojpeVrtiohi5. Thie iac

21111d Suijijil D ivisioni of G( ienera I Ialev's office was able14 to provide adiditionial

lilht rnviolet-t hierlihpY c(Ilpiiviiht. which w\as hleded ll( i Enll2Inid hiecauise of the

lack of1 siitishiiiie. Electrodesivcat ilit liiiits for t(114. remiloval of partiall i2d\uis2I1

)lihiý waIls and14 lpaIi~lionas were 'aiso provided and proved lise-fill inl tin hand..d;

of conipet~l ctIli4'qiciil oflelices. Suichi units were subhject to ullisuuse. however.,

Inl the ha,11ds of I114.\pv4''iehIeevl ihivsicliauis.

AmIioun othio'i, collaboarltionls re('(juire4I 4)1 Coloniel 1Pillshuiry wven, t wo

spec(ial st 114111s. Thiv first of Ills h 12 ad54 to (14) wit hi l114 dl('t4'liiii2tioihi of toxicit Y

(if clI a111(ihlioulhfaitr oliht ilivi'hit heiuig, dvvopee do( bv tit ll' 'hriulIt'I'rS ( 'olrps.

'Ilel(- lest ihvoilveol 2 samiple ofi 2010 men'u (ill w~homh sich 01111 uieuits were triedl for

Irritant effect 111141 sestiig aact. It jliidta ti'iiiiiit

were' SlIit s121cto. "x - ii h4 I tlie forui II'il I coiiita21 ied Ill thei(11 was reh)12i4'e lit bY 
EURO PEAN THEATER OF OPERATIONS 287

nonsensitizing inn-'e(ient. The other was a study conducted in conjunction

with the Preventive Medicine Division of General Hawley's office to ascertain

causes and incidence rates of disabling fungus infections, which were markedly

on the increase. In addition to certain (leficiencies in preventive measures, it

was found that, the wearing of heavy British-issue socks during mild or warmn

weather was deleterious, and proper recoinimendations were made to tihe

('hief Quartermaster, ETOUSA, to remedy this situation.

Syphilology

Tle probhlems that existe(d in the treatment of syphilis were brought to a

sharp focus in March 1943, at the first general meeting of hospital me(lical

offic¢,rs in the theater for the purpose of discussing the treatment of venereal

disease. This conference was called b1 Colonel Pillsbury in order (1) to

Drovide an interchange of ideas and discussion of mutual lproblems in the

field of venereal diseases, (2) to arrive at a mutual understanding and interpretation of various letters and directives froom The Surgeon General and the

Chief Surgeon, ETOUSA, and (3) to collect information for the Office of the

Chief Surgeon, Headquarters, ETOUSA. The majority of conferees consisted

of medical officers, laboratory officers, and nurses who were concerned with

the control, diagnosis, and treatment of the venereal diseases. Whereas in

tile highest echelons, treatment and control responsibilities were clearly

divided b)etween professional and preventive medicine divisions and treatment

responsibilities were further delimited with respect to gonorrhea and syphilis

between the surgical and medical services, respectively, this was not necessarily the case in the field. In the smaller hospital units and commands, all

of these responsibilities were, often as not, entrusted to one individual medical

officer. Thus, attendance at this conference could not be confined to those

officers whose treatment responsibilities were limited to syphilis alone.

Accordingly, representatives from HIeadquarters, ETOUSA, also included

Colonel Kimlbrough, Chief, Professional Services Division; Major Padget,

Venereal Disease Control Officer, ETOUSA; Capt. John R. Poppen, MC,

USN, from the U.S. Embassy; and Colonels :Montgomery and Brown fr'om

Canadian Military Headquarters.

TIhte primary problems discussed at this meeting were concerned with

(1) deviation by medical officers in the field from treatment schedules specified

in the 1942 Circular Letter No. 74 from the Office of the Surgeon General.

(2) treatment of sulfonamide-resist ant cases of gonorrhea, (3) interpretation

and use of dark-field and serologic tests for syphilis, and (4) maintenance of

proper records of treatment for syphilis. In addition, papers on the following

subjects were read and discussed: (1) The diagnosis of early syphilis, (2) tile

treatment of sulfonamide-resistant gonorrhea, (3) the treatmennt of syphilis at

a replacement depot, and (4) the difficulties in treating syphilis in a general

hospital in the European theater. There was also a discussion of plans for

tile trial of intensive arsemmotherapy of early syphilis.
288 ACTIVITIES OF" NIEDI)AL CONSULTANTS

It was fortunate for Colonel Pillsbury that so much of thre discussion

(-enteredl onl the treatment of gonorrhea, which, at a later date, was to conlie

into his field of responsilbilit 'v.

As a result o1, this meeting and from experience gained through other

Sources, Colonel lPillshurY listedl the primary problems in the diagnosis and

treatment of syphilis to be (1) failure of conitinluity of treatment in units,

(2) inadequacy* of any' method of prolongedl treatment in meii or units subject

to repeatedl movement, (3) probalble complete breakdown of ant isyphili tic

treatment in troops in combat conditions, (4) difficulties in maintaining adequate recordls andl in insuring followup studi~ies onl completion of treatment,

(5) inaccuracies in dark-field andl serologic (diagnosis of' Syphilis, and (6) dlificulty iii coordlinating tile efforts of all agencies concernedl with tile control and

treatment of venereal disease.

The syphilis register and the supplementary record.-In order to assure

continuit v of treatmenit in patients on the standlard 26-week schedlule of therapy,

a form calledl thle Supplemientary Record of Treatment, ETOUSA MD Form

:313, was dIevisedl to lbe carriedl by thle patient. This form was niot intended to

replace the s 'lyllilis register but to supplement it. It was dlevelopedl after

much considlerat ion andl after similar forms hadl provedl their worth when used

lwv the Roval Army 'Medical Corps and the Royal Canadian Army Medical

Cýorps. colonel lPillsbur 'v believed thait t hie nlewly- dlevisedl form would lbe useful

to the indlividual patient after his dhischiarge from time service as well as provide

essentit al iniformat ion should his syphilis register become misplice(1. Circular

Letter No. 93, 24 ýMay 1943, Office of the Chief Surgeon, Headquarters,

ETOUSA, was published to govern the use of the new form. After a 6-mionth

trial, Colonel Pillsbury was able to report that this supplemental record had

dlemonst rated its value lbevonld doub~t.

Circular Letter' No. 74 from the Office of the Surgeon General providled

that, onl completion of treatment for syphilis, time patient would have a filial

ph 'ysical examination, a spinal fluid test, andl a blood( serology (Kahn) test.

Following this, if the results were satisfactory, the patient was placed onl probatioin from treatmeint with serologgy (Kahn) tests made at intervals of from 3 to

6; monthus. The regimen was thIeoreticallv sound, but in practice it biroke (lown).

The key' to thle breakdown Ina v in thle hiand~linig of thle syphilis register of tilie

individual patient. The regist ers were filed aiidlrnot conisultedl or, worse still,

mlisplaiedh. Colonel lPillsbur 'v found tilie answver to t his p~rob~lem in thle central

insp~ection and control of tile syphilis register. Circular Letter No. 10(6, 25 ~June

1943, Office of the Chief Surgeon, Headquarters, ETOUSA. dIirectedl t hat tilie

syp~hiilis regrister be Forwarded to thle 'Medlical Records D~ivision, Office of the

Chief Surgeon, Headquarters,, ETOI.USA, upon comp~letioin of treatmenet.

Colonel Pillsbury' theni inspected registers that conitainied (liscrepancies. If

there wvere Serious dleficiencies in thle t reatmenit or in thle te(st s of cure, t lie register

wats returnied to thle forwarding uiiit witIil appropriate iilist ruct ions. Othlerwise,

the records were tiled in thle Medicall Records D~ivisioii, aiid requests for followup

tests were sent out to tire ind~ividhual's unit at tire proper time. After a 6-month
EUROP'EAN TIEATER OF OPERATIONS 289

interval, Colonel Pillsbury assessed the advantages of this method to be: (1) It

furnished a valuable means of determining that the soldier's treatment had been

adequate and of correcting deficiencies early; (2) it gave reasonable, although

not absolute, assurance that followup Kahn tests would be done; and (3) it

offered protection against loss of the syphilis register. It was expected, of

course, that certain difficulties would arise in the system once active combat

operations commenced or when the theater was dissolved at the end of the war.

Moreover, it was recognized that such a system might not be applicable to a

less compact theater.

Success in establishing this system of central examination of the syphilis

register was in large measure due to the wholehearted cooperation that was

given by the Medical Records Division.

Laboratory problems.-Early 1943 found the situation in regard to serologic tests for syphilis unsatisfactory in several respects. Although British

laboratories were very cooperative and helpful in making up for the lack of

U.S. Army laboratory facilities then available, their standards varied considerably; there was no way to control the methos(s employed; reporting of

results took many different forms; and no central reference laboratory existed

for cross-checking their work. Furthermore, the inexperience of many me(iical

officers in the field compounded these difficulties. Samples were being collected

improperly. Both Colonel Pillsbury and Major Padget were highly concerned

because patients were being submitted to unnecessary antisyphilitic treatment

on the basis of fallible laboratory tests, when the case history or proper interpretation of tests would indicate that the diagnosis of syphilis was highly unlikelY.

At, Colonel Pillsbury's instigation, a conference was held in January 1943

between Major Padget, and ILt. (ol. Ralph S. Muckenfuss, MC, Commanding

Officer, 1st General Medical Laboratory. As a result of this conference.

Circular Letter No. 22, 4 February 1943, was issued by the Office of the Chief

Surgeon, Headquarters, ETOUSA. In October 1943, it was revised and

reissued by that office as Circular Letter No. 148. This directive specified

control procedures, methods, and policies by limiting the performance of

serologic tests for syphilis to those laboratories (fig. 108) specifically designated

by the Chief Surgeon, ETOUSA, setting up the means for rapid transmission

of samples and reports, specifying in detail when and under what circumstances

the various laboratory tests should be performed, and establishing a system of

interlaboratory checks.

When the meeting of hospital personnel concerned with the control and

treatment of venereal disease was convened in March 1943, Colonel Pillsbury

was able to report continuous improvement in regard to serologic tests for

syphilis. With the cooperation of Colonel Muckenfuss, the laboratory situation was reaching a point where it was possible to lighten the load the British

laboratories had been asked to carry. In addition, facilities and apparatus

for dark-field studies had also been considerablY increased.

The closest rapport was maintained by Colonel Pillsbury with the Preventive Medicine Division and the Director of Laboratories throughout the year

51;49)7" •- f--21
I'&III 
EVROPEAN THIEATERI 0 F OPEIIAT10I ) 29.)1

in maintaining better performa nce of (diagnost ic p~rocedlures for sy-philis. Thle

Iieedl was demtonistrated tiune and again by~ instances of gross err-ors inl the,

Ilerfornilance of (lark-field examiinations anld serologic tests. Necit her was a

s~implle procedlure to be p~erformled by aniat curs.

Intensive arsenotherapy.-It. would not. 1e proper here to discuss (details

concerniiing the int ensive arsenot herapy of syp)hilis. The subject. is adeq nat ely

COVereti elsewhere ill thlis series of Vohlinies onl internal medhicinie in World WVar 11.

It wouldl be most app~ropriate, bowever, to record hiere the part t hat thle Senior

(Consultant in Dermiatologýy and Sypliilologvy of thle European hetlctter p)layedl in

pioneering the ap~plication of this imethiod in militarv iiiedicinle.

In a letter dated 16 March 194:3 to Colonel Kimbrnough, C olonel Pillsbury

recommended thle adopt ion of a 20-day schedule of int ensivo thlerapy using

Mapliarsn or Maphatrside. At that. timie, this was a grave and~ unoniiieutoils

decsiona sulject t hat hadl enlgaged Colonel Pillshury-'s at tent ion froml tilie

first, dalys, of hIsk arrival inl tile theater. For his guidlance in ma king this tieCision

there Was Very lit tie of tile dlata oil thle subject, alt hough eventually '(vata lbecamle

Volumiinous. Ilie hlad, however, a soturce of informat ion inl his close association

with the Roy' al Canadian Arniy Medical Corps, which had already embarked

Onl the Plain experiiu entatll 'V. Ilie had access to iniformalltionl front the Subcommiit tee onl Venereal D~isease of the National Research Council. Ilie had

p~ersonal corresp~ond~enc!e wit hi 1r. John 11. Stokes and( Dr. Josephl Earle Moore,

and Major Padget, also provided inforimationi and correslpondence with authorities Oil tilt slibject..

Thle Opiniions, of those closest to the studies connected with the intensive

arsenot herapv of s *yphiihi~ valriedl considerably withI resp~ect. to toxicit v anti

Schedules of 01p ti~liln treatmtuent. 'I'lie INat ional Reseitr('h ( onuilcil. had not.

ap~provedl anly plan for thle Armied Forces. In fact, as late as October 1942, thle

( 'oniiiiittee onl Medicine. of the National Research Council had recommnendhed

that.:

* * * initensive arsenotherapy of early syphilis (including the five-day jintravenious

drlip iniethd l1w~ ci. onsideredi ws still ini the, experimiental st age; that the opt inI111 tin iii-dose

relat ionshij) still rv(liiir-es to bv est ablishied h)*v furlther aniiiiial and ul sihe(jplelt clinical experinient at oll awd tlhat at presenit thle mnethlim cann~ot he recoiiiiieidetl for routitine use byV

the Armied lForces.I2

The committee, following a full dliscussion at, th liemeting arid later study

of data circularizetl to thle comuiiit tee, Somewhat tmodified its previous Stanid

by* reconiiiteniting a reconciliation between certain experi mmental (lit a auth the

dhifferent t *ypes of suggested niethiods of therapy. Pending thle acquisition of

these data, the contiiiuittee thought that.:

* * * it. seenis undl~esirabl)e for the coinmit tee to recoiniimend tile a(lopt ion of amv very

short and intensive nimet 110( of treat meit, as at general procedure iii thle Armied Fores.

flowever, the Arm(.d Forces mnay well investigate the appl)icab~ility of these mnethlods to their

own lprobleiis uinder certain condlit ions.

12 Minutes, Thirteenth Meeting of the Committee on Medicine. National Rtesearchi Council, 16 Oct. 1942.
Dr. Stokes, a mtember of the SubIcommitittee oil Venereal D~isease, had

writ ten inl November 1942, ats followvs:

It is ezisily euicevivailel t hait thlerv will bv' sitvizt ions inl which ***thew met lod. itmils

akl(i Sho0uld be emiployed. The decision to eviiploy thewm ill this f~ishionl does not lie- wit hin

I li reconiwndatory. power of tinytadvisory body, ais thew Nit ioiml Iteseairch Counicil V'enwreAI

DIvtv )~subi-('omiiiit tee hals inldictemd, tililess t hat power feel-s it cilan tssunie respoitsilbilit v

for ant is yet unevaluat e( midl not int rinsic~tIlv uncrit icizaiel e-xpetrient i.13

Oil thle other hn111l, thle mlilitary situnation faicing t ie( commnand inl Europe

ind~ie te ecl early t hat any prolonigedl miethod of treat tielit of syphtilis wits

likely to be intterrup~t ed for vitrioits reaksotis, its it freqjuenlt ly wits altiong operaitiotmal aiicrctaft cr~ews. It atjppenreI dloubtfCul thatt adequatte contitnutious treattinetit ofr 5 pilis )I couldI be ittajittalittet illttall syphlilitic p)ntiefltsi by eveit till

miost comp jetentt land~ cotnscient iouts itiedicat officers tund~et cotidit iols req uirinrgext ensive mtovemientt, intiaeuver-s, or conhiat. FurthIermiore, early-. svpli ilis.

whinch liad to be treated to thle point of no0ttill fect iolusttess 2and an~(leqtlate protection aigainst intfect ious rehl)se, wits thle only real p~robl)em. TIhere Avi

tiowitere Iieati' thle tnumber of catses of lattent syphlilis found ill civilia it prac-tice

itt thle United States. Alt houghi it walsdesirnlbte t Itat anyi mtet hod of trtealt ietit

futrnishi Irllsotlibhle protect ion agakinst thle (developmetnt of it te viscerail s phlilis.

it cotuid lhe Contsidered u tttltstifial)Ie to emtploy it timte-contsumting landt difficult

lieralpy illtil anictive t heater becaluse of somte slight reductic ont ill tile intcidlence

of iall te phtilis 10 or 15~ yeairs latter. litt this resp~ect , t Ite treatittmett schedule

outlinedl inl ( ircultir Letter No. 74 of the Office of tilie Surgeoni Generail wavs,

inl itself, experimettleitl. It wa-is at 26-week comtipromise w'ithi thle stttinlaird 12-

to 1 8-mtonttti regimen, land there wats insufficietnt clinlicall evidenice to prove

cottcllisivetv thalt it wa-is adequakte.

The chief disald sant aige of the intensive treait inent of S *yphtitis wats its

inhieretnt I oxi('it v. Antothter tlisaul v'atit alge wats tilie facet thalt initetisivi. treat(-

tnitett tmethiods woutld reqjuire mlore hlospitall beds. Balsed ott the prevaliling"

incidctltte, itt cert'tiiiti ttits, of thle tnumbter of pattients givet i itinl treat umntit inl

qual'atiers cottkipaed to thle Ittituber treated ill htospital, thle Niedicail Records

I )ivisioll of Gleterin I I lwley 's office est itiated thati, under the existinig schlueditie,

1 .7 beds per 1,000 troops were reqjuiredl, while 2.6 bieds per 1,000 trloops wouild

be requlirIed under miethods(1 of intenisive thterapv.' This considlerait iot wats fillouttwetghiedl, however, by thle savings ill t utie of titetlicall officetrs- lmtl tihe solving"

of p~robldems iltcilettt al to treatmtient ill untits.

Tile outit-altl-out al(ivtinit ages of int ensive miethlods of treattitetit were

signiificantt. It wats est itliitedl t hat inifect jolts relapse, if it occurr~ed, wvouldl tevetld

itself wit huut 1-yeari liftetr cotimplet ion of treat mieit , t hereby tiecessit at ing j ust

at I- *ear foltowup ittst end of thle p)revnitiltg 2 Yeairs. lteat ttettt could1( be cotitpheted ilt 95 percenit or more catses, %%-til(. being cotllple(edh ill ftot nmore than11 halif

'3.9tokes. 3. If.: The %%Wart ime (,nmt rot or VenOereal Di Iseji. I.A.M.tA. U11t: H013 11199(M, 5 t ev 1142.

it Let ter. TI t.'ot. 1). NI. tI t'1hi try, Setif( r ('onsi zlt:i iI i it Dermal oIovy, lFT I) V! %, to'ol, 1. C . K im bromgh. I 'I reetor,

t'r,,IesLAlomni Services D1 li idon. I(Mice' oif the Chietf Suirgmri,, Iltendfivireisie F.TWA Wl Mt*tiNar. i 113 s.ibt~i',ect. Inteui'ih

'Tremut ent for Fartý S~pitil~kisasa Suabstiftilte'tr lt( t, tr'e,pi SixNtoutit Schehiieue.
EUF OI'EAN THEATER OF I'EIRATI•)NS 29,3

tile patients treated otherwise. '[iie centralization required by intensive

therapy would afford better control, place responsibility for treatment in the

liands of few, insure proper completion of the syphilis register, and ease probhlems

in nledical supply.

The decision to embark on intensive treatment methods having been made.

there vet. remained the question of determining total dosage, dosage per inject ion, frequency of injection, and tile total time over which intensive therapy

should be given. Experimentation in animals and hunmn beings had shown

that slight modifications in tile last three of these variables l)roduced consideral)le differences in results, particularly with respect to the maximum tolerable

(lose. There were positive indications in the experimental data that the longer

the tinie over which the total required (lose of arsenical was given, the less

niortality there would )e from treatment. Dr..Moore had suggested in a personal

coiii1iication to Major Padget that a 10-week treatmnent schedule be used.

This, obviously, was too long a period for hospital treatmnent, and such a

schedule would nullify the advantages of intensive treatinent. Colonel

Pillsbury finally decided on a 20-day period of treatment with a total (lose of

approximately 1,200 mug. for at 150-pound patient. The total (lose would be

given at the rate of 40 mug. for the first day and 60 ing. for the succeedling 19 olays.

The program as recommended by Colonel Pillsbury was approved b)y

General Hawley and put into effect omi an experimental basis in tile 2d an|d

298th General Hospitals. It was subsequently exten(le(d to the 5th and 30th

General Hospitals. The closest supervision was required on the part of the

theater senior oionsultant in derniatology and syphilology, necessitating froni 2

to 3 visits weekly. Following the successful trial in these hospitals, General

Hawley approved further extension of this treatment to all general hospitals

and certain other selected hospitals by ('ircular Letter No. 138, entitled "Intensive Treatment of Early Syphilis," issued from the Office of the Chief

Surgeon, Headquarters, ETOUSA, omi 10 September 1943.

By the end of 1943, approximately 1,200 patients with early syphilis had

received intensive therapy without mortality. Tile average period of hiospitalizattion for each patient had been only 25 days. Although no final statements

could be made at that time, it appeared that the incidl|ie of relapse would be

no higher than, if as high as, with the stanidard 26-week schedule, and the

serologic reversal rate was apparently satisfatctory.l' The Canadian Army.

which had suffered 4 deaths in 681 cases treated under its 6- to 10-day regimen.

also adopted the 20-day treatment provided U.S. troops. In September 1943,

I)r. Moore visited the theater and was apprised of the results of intensive

therapy at a meeting attended 1)y both U.S. and ('anadian medical officers

engaged in supervising and operating the program. Dr. Moore considered

the results highly satisfactory, advised extension of the type of treatment being

given to all troops in the European theater, and wholeheartedly recommended

that the 26-week schedule be abandoned entirely within tile theater.

13 See foot note II, p. 28-3.
294 ACTIVITIES OF MEi.:IuCAL tONISLTANTS

Recommendations Based on North African Experience

In late 1943, Colonel Pillsbury toured representative medical installat ions in

North Africa for the purpose of observing methods of prevention and control

of venereal and skin diseases. Between 15 Noveniber 1943 and 7 Decemiber

1943, he visited all base sections of the North African theater, with the exception of the Atlantic Base Section, and inspected 10 general hospitals, 6 station

hospitals, 3 evacuation hospitals, 1 division clearing station, and 3 general

dispensaries. The results of his tour were reported in a letter, dated 10 December 1943, to the Chief Surgeon, ETOUSA, through the Surgeon, NATOUSA

(North African Theater of Operations, U.S. Army).

In addition to reporting conditions as he found them, Colonel Pillsbury

Made the following recommendations with respect to the control and treatnient

of (lerniatologic conditions and venereal disease in ETOUSA.

With respect to dermatology:

1. Continued attempts to inform and train field and hospital medical officers concerning

the lprolper met hods of initial treatm ent of pyoderma, fungous infections, and acute eczematous infections of the skin should be made. The early initial treatment is a crucial period in

preventing undue disability therefrom. If only harm from treatment can be prevented,

consi(leral)le will have been accomplished.

2. Bathing facilities for combat troops in ETO should be checked with a view to increasing their availability. It is believed that a considerable proportion of fungous and

l)yogenic infections can be entirely prevented by more frequent bathing.

3. Continued emphasis must be placed on the iml)ortance of good foot hygiene, and

this must b) appreciated as an essential command function. Arrangements have been made

for (listribut ion of four pairs of fresh socks weekly to combat troops in NATOUSA and it

is recommended that plans for this be made in ETO.

4. Adequate consultative service in dermatology should be available to evacuation

and station hospitals which have no officer trained in this sp)ecialty. Severe and chronic

case.s should be referred to general hospitals for special treatment or other disposition as

ral)idly as possible.

With respect to venereal disease control:

1. It is recommended that resolute and determined opposition be offered to any policy

t hat condones t he ol)erat ion of houses of prostitution under Army supervision or cooperation,

direct or indirect.

2. The paraumount importance of immediate venereal disease control measures in occupied territories should he appreciated. A venereal disease control officer is an essential member of the initial medical organization.

3. It is recommended that active measures for venereal disease control be taken by

whatever organization will be responsible for civilian administration. This is vital to an

adequate program.

With respect to venereal disease treatment:

1. It is recommended that intensive therapy for early syphilis be continued in combat

troopis as long as the supply of hospital beds so justifiets.

2. It is recommended that resistance be offered to any attempts to combine disciplinary

measures andl the treat ment of venereal disease. It is believed that venereal disease stockades

and rehabilitation training battalions as applied to every patient with venereal disease are

unjust. and frequently interfere with adequate medical care.

3. The supply of penicillin available for treatment of sulfonamide-res-istant gonorrhea

should be increased as rapidly as possible consistently with the saving of lives in other infections. The saving of man days lost made possible by this method of treatment is very

considerable.
EUROIPEAN TIIEATER OF OPERATIONS 295

In addition, Colonel Pillsbury realized the seriousness of the problem

of inmersion (trenchfoot) and the fact that treat ment had been unsatisfactory.

He reconmmended that every clinical and laboratorv facilitv of the Office of the

Chief Surgeon, Headquarters, ETOUSA, be made available for a thorough

study of this condition with prompt transmission of results to the Surgeon,

NA'TOUSA.

FULL-SCALE OPERATIONS

The period 1944 through the early months of 1945 was most characteristic

of the act ivit ies of a consultant in an active theater of operat ions and, of course,

the busiest. First, there was the planning for the invasion, then the invasion

itself, and, following that, the mushrooming expansion of the theater in both

troops and area. The initiation of active combat meant a preponderance of

surgical casualties and a relative shortage of hospital beds for the treatment of

nondisabling skin or venereal diseases. There was frequent movement of

units and hospitals with continuous changes in missions and functions of the

supporting medical elements. Evacuation policies had to be changed frequently in accord with tactical and other considerations. The main portion

of theater headquarters moved from the United Kingdom to the Continent.

During this period, there was a complete revolution in the treatment of

venereal diseases. In addition, the Medical Division of General Hawley's

office was given responsibility for the diagnosis and treatment of gonorrhea,

a responsibility that previously had been vested in urologists under the Surgical

Division. Also, all the practices and procedures that had been carefully

established during the early days of the theater now required the greatest.

effort and closest attention by the theater senior consultant in dermatology

and syphilology to keep themn operating as originally planned.

In late 1944, Colonel Pillsbury was ordered to tile Office of the Surgeon

General for a period of temporary duty in the United States.

Treatment of Venereal Diseases

Intensive arsenotherapy.-A total of approximately 4,000 patients with

early syphilis received intensive arsenotherapy between April 1943 and July

1944 without any deathis from treatment. In mid-1944, however, this type of

treatment was replaced by penicillin therapy. There were some indications

that intensive arsenotherapy mnight still be required for penicillin-resistant

cases and those suffering relapses. While intensive therapy was in progress,

careful and constant supervision was required by the theater senior consultant

and regional consultants in syphilology. The resulting absence of deaths

proved the value of this supervision. Incidental to this mode of treatment

were the careful keeping of followup records and the preparation of papers and

speeches in response to many requests for sumnmnaries of the U.S. Arimy's
296 ACTIVITIES OF MEICIH'AL ('NSULTANTS

experience with the mnethod. Altliough Colonel Pillsbury believed that tlihe

tinal cure rate would be somewhere between 85 and 90 percent ,j1 he doubted

that intensive therapy could have been administered successfully under the

conditions of later 1944 because of the shortage of hospital beds and the steady

decline in the level of professional attainment of officers in hospitals arriving in

the theater after July 1944.1

Penicillin therapy of gonorrhea.-The initial experience with penicillin

therapy of gonorrhea in tile European theater resulted in the cure of 94.7 l)ercent

of the first 1,000 patients treated. This therapy called for all injection of a

total of 100,000 units of penicillin in from 5 to 10 divided (loses. Its use was

restricte(d to persons whose services were urgently needed and who could not

carry out their ditties efficiently while receiving sulfonamides. Later experience showed that penicillin therapy was effective in all but an almost negligible

number of cases, in contrast to only 65 p)ercent of cases successfully treated in

field units with sulfonamides. Even after treatment in a hospital, there had

previously been a residuum of from 10 to 20 percent of patients whose cure was

very slowly effected, with complications of various sorts.""

The availability of penicillin had almost solved this difficult problem of

military medicine. There remained for tile consultant and others in sul)ordlinate positions the constant effort to have this treatment performed as far forwardl as possible. Eventually, Circular Letter No. 107, Office of the Chief

Surgeon, Headquarters, ETOUSA, was published on 25 August 1944 prescribing

the penicillin therapy of gonorrhea on an outpatient status as the method of

choice, except that female personnel continued to be treated in hospitals.

Colonel Pillsbury, realizing the great savings in manpower and hospital facilities

with the use of penicillin, paid constant attention to tile penicillin supply

sit uation and, when the opport une moment arose, recommended that penicillin

be used in the treatment of all cases of gonorrhea occurring in the theater.' 9

Penicillin therapy of syphilis.--In early January 1944, it became apparent

tG.at penicillin was also destined to occupy a preeminent role in the treatment

of early syphilis. Keeping close watch over all the research that was being

conducted, Colonel Pillsbury was convinced t hat penicillin therapy would offer

a method of treatment for combat troops superior to that b)eing used. His

observations in the North African theater had shown conclusively that treatmnent of early syphilis withiin combat units was interrupted and unsatisfactory.

Although no one could foretell what the final longterm effects of penicillin

therapy would be, it was also known that inadequate treatment early in the

disease was often worse than no treatment at all. On the other hand, there

16 l.ater surveys of such patients, though Incomplete. Indicated that Intensive arsenotherapy had an effectivenes,;

at or ne:r that of penicillin in terms (f absence of relapse and the pwrcentage of negative spinal filu examin:t tons.

However, it was obviously much more toxic.

I? Annual Report, Professional Services Division, Office (if the Chief Surgeon, Headquarters, ETOUSA, 1944.

"11 Ibid.

19 Memorandum. Professional Services Division for Chief Surgeon, ETOUSA, 20 July 1914 subject: Penicillin

Therapy of Gonorrhea and Syphilis.
EVROPE'AN THEATER 01" ()PEiATI( NS 297

could1( be no trial of penicillin therapy for early Syphilis wit hin thle theater 'If

there wats ainy (danger of jeoparl-dizinig thle Supply availaidbe for coln(li tionis

threaten~ing( to life or for sulfomiiaide-resistan t gonorrh.1eal in whiich penicillin

wats practically always culrat ive. Coloniel Thllshurvy dIiscovered that supplies

for such purposes wvere adlequatte and that 1)05511)'1X some of tilie Supply miighit

not even be used before it b~ecamle out ilodedl. Akccord inglv, Ile did not hesitate

to recoin nenl at trial, in the European tilienter, of' penlicillinl inl tilie early t reatment of sypiiilis.3' The plan wits approvedl find( thle exp~erimienit enitrusted to

Capt. (later Lt. Col.) C. R. Wise, MC, at regionlall conlsultant stationedliat thle

2(1 General Hospital (fig. 109). When Coloniel Pillsbuiry visited the 2(1 General

Hospital on :3 February 1944, five cases had lalready receivecd or- were unldergoingtreatmnent. Three of tilie patients had marked flexhieimier's react ion--fever

and increase inl the cutanleouls lesions after the first injection--but, thereafter,

thie early lesions dlisapp~eared1 with it rapidlity surpassing anything lie had seen

aifter arsenical t herapy.

At the time of Colonel Pillsbur * 's visit to tile hospital onl 19 Mlarch 1944,

a total of 15 cases had been treated, 8 with a total of 500,000 units and 7 with

I million units. Tile Inetdiodl of treatment., as far as tlheralpeuitic response an(I

absenice of reactions was concerned, appearedl far superior to either initenlsive

or Standlard1 therapy.

Onl tile basis of these 15 cases, the 7 March 1944 minutes of thle Penicillin

Panel, National Research Council, and personal letters fromt Lt. (Col. Thomas

H. Sternberg, Director, Veniereal Disease Control Division, Office of the

urenGeneral, Colonel Pillsburv- recommnendled, onl 26 April 1944, that, a

conmbined peniciillini-bismuiithi-MapliarisenI treatment be adopted for use in the

treatment of combIat. troops and in thle small iinumber of patients in other units

in whomi arsenical therapy was not possible because of sensitivity to

MIaphlayrsen. 2' At, about thle, same time, hie personally recomnmendled to tile

Suringeon, Eighth Air Force, that penicillin treatment for syphilis be mnade

available for operational crews. Thle. Eighth Air Force surgeon requested slich

permiission front thle Air Surgeon, but it was denied.

Before his recommnendlations could be implemented, Colonel Pillsbury

received front Dr. Stokes a personal letter dated 28 April 1944. Dr. Stokes

statedl that the Subcommnittee onl Venereal Diseases, National Research

Council, had recently* recommnendled tile use of penicillin in thle treatment of

early sylphilis, by the Armyv, undler condhitions in which continuity of standard

treatment could not, be maintained. In his letter, Dr. Stokes also indlicated

that miodification of the previously recommended plan of treatment was

necessary. While these nmodifications were being considered, The surgeon

General, in a letter which arrived at General Hawleyv's office on 1 June 1944.

'0 Memnoraindums Senior Consutai~nt in Derma~tology for Coln. J. C'. Kimnbrough. Chief. Professional Services Division,

Office of the C'hief Surgeon. Hreadquarters, ETOUSA, 9 -Jan. 1944, subject: Penicillin Therapy of Syphilis.

21 Mlemorandumn, Professional Services Division for Chief Surgeon, ETOUSA, 26 Apr. 1944, subject: Penicillin

Therapy in Syphilis.
I-ISIL AN '

U~~uAct

IId A.T d ;n r t 1 v It x~n . 1:11 141 ktl- )1))Iýpcllvlilc

iw if a l
EURO PEAN ()IAi'l FOTAI N 299'.

awihlorized thle use of periiillii ini thle tratnient, of early syphilis, wvith cert aini

liriutatioliS and Suggestions, as follows: 12

Because of the recognized dlifficult ies in carrying out the ninphiarseni-hisin tit li therapy

iof early syp~hilis in active Theaters of O peration, the following recommnendat ionis concerning

thv inxinediatt' xse of penicillin as a.n anti-syphilitic agent are made. It is intended that

this recommnendat ion shiall applyl only to previousl~y untreated cases, and that those cases

in which inapharsen-bisninuth therapy hias already been initiated shall continuec on suich

treatmient.

a. That all new cases of primary andl secondary syp)hilis be treated with pericillin in

those areals or theaters where, because of the exigencies of thle military sitntation, it ma1.y he

expectedl t hat routine arsenical-hismlnithI therapy will tiot be carried out regularly.

1). That the schieduile of treatmient. he 40,000 units int ranmuscularly every three hours

fr a total of 6it dloses or 2,400,000 units per case. P~reliminary experience wvith t his dosauge

schedule indicates that better results than those ob~tained wvith i1,200,000 units may be

exjlectedl

c. That followup examinations should be obtained at mi-onthly intervals for a1 minimium

period of one- year, in order that relapses "may he detected early amid inalpharsen-lbisnitith

thlerapy imnit iated without delay. The spinal fluid should be examniued between thle thuird

and sixth nionth following treatmienit..

dI. Thie syphilis registers should be p~roperly mnainita~ined andI t ransmiittedl with each

niove of the patient to :ussmmr a~lequMat folowup Additional met hods of earmarking these

lpatients, such as central registries, may be considlered desirable.

Following t his, (Anicuar Letter No. 836, Office of the Chief Surgeon,

H~eadquf art ers, ETOUSA, sublj ect : Penicillin Therapy for Early Syph rilis, was

pubrllishiedl onl 22 Junes 1944, citing penicillin as thle drug of choice in thle treatinent of early svpilifis ini fiel.d and air forces. rhie lpeci hed0 treatmient followedl closely tile recoilinieii(lations of Thle. Surgeon Gieneral, but followvup

proc)(edurles, pl-at icularly wvith nwrepect to serologic andl spinal HI iidl examinations,

were miodifiedl to fit the iieeds of the theater.

Thus, it is seen thati an essentiajl part Or at consultant's fuinct ions is- to keep

albreutt of new (ievelopluieits, (lificlilt as t his is in an overeat t heat er. Al

thiough, evenltulally, specific recommndier~at ions r'eache liel theIheater from The

Surgeon General , tilie prel imiiinary inivest iga tions that hud b leen conduiet et

w~it hin i lie theatter provedi ext remnely valuable. Before The( Surgeon General's

letter ever arrived, Colonel P~illsbury was able to coordiniat e in adva rice tile

nil, pleiimert at ion of petijdliri thieralpy With ti lie Surgeoni, Thlird U.S . Armnlv; tilie

Consulitant in 1meidivii anrd Venereal Disease Control Officer, First U.S. Aruiiv

and tilie Suirgeoni, U.S. St rat egic Air F~orces in Europ~e. Wheni Thre Surgecon

General 's letter ar1rived, Colonel 1Pillsbrrrv wals ab~le to evaluait e its recoinriieiitalioris iii th lie ght of first hand exlpersien anrid withI duie corisidera t ion for

lhe desires of t hose in thle field. Had1( there been no prelimrinaiiry experience

with this type of tliemly, a siridiar tIdal period would undoubtedly have been

niecessaury. A few miont us cani be very impijort ant (luring wart inie. lIn t his

case, t hie significance of t lie fewv months' hieadst art which, thle 1Eutropewan t healter

had( in planning for Jpenicillir therapy of syphilis is miost evidhernt. The( Suirgeoni

221,itter, Thei Svirgen diemerzil. to Conmmrinding (Ieneirai, ETOVSA, Attn: C'hif Surgeon. 24 .iMay 1944, subject:

r'inierrr n Treatument of Primary and Securuuiury Sywffnis.
300 ACTIVITIES OF MEI)ICAL ('ONSU'LTANTS

General's letter was received oln 1 June 1944, less than a week before D-dav,

(; June. Subsequent experience showed, too, tihat there was no reason to change

the l)asic principles of treatment, followup, and recordkeeping that were

initially estal)lished.

When the suppltly of penicillin became sufficient, its use in the treatment of

early syplilis was extended b)y theater Circular Letter No. 107, August 1944,

to all cases occurring in the tiheater.

Laboratory procedures.- With extensive (leployvnent of troops on the

Continent in 1944, specimens for laboratory examination had to be shipped

greater distances while, at the same time, courier service became more tillreliable. Tubees for the collection of specimens were not kept in proper sanitary

condition, and tlie drawing of specimens wats more likely to be performed

carelessly. Disrup)tion in the supl)ly of stains and antigens also interfered with

the essential lat)oratory tests.

Again, close liaison was necessary with the Preventive Medicine Division,

Oflice of the Chief Surgeon, Hleadquarters, ETOUSA, which supervised the

laboratories. In the latter months of 1944, Lt. Col. (later Col.) Arthur P.

Long, MC, Chief, Epidemiology Branch of the division, investigated and,

together with Colonel Pillsbury, arrivedi at some remedial measures. On the

Continent, prepared tubes containing a requisite amount of Merthiolate (thimnerosal) were put into use, and, in the United Kingdom, the practice of placing

4 ing. of sulfanilamide in spinal fluid specimens was adopted to prevent contamination. Problems in courier service eventuall]" were alleviate(d to some

extent by performing all spinal fluid tests on the Continent.

Other problems.-During this period, Colonel Pillsbury was also concerned with tih- itma-.,igement of cases of latent syphilis and neurosyphilis, the

few cases of penicillin-resistant, gonorrhea, and with experimentation in the use

of' BAL for the treat:,ient of agranulocytic reactions to intensive arsenotherapy

(p. 313). TB MED (War Department Technical Bulletin) 48, in early 1944,

established policies and procedures on anl Armywide basis for the management

and treatment of neurosyphilis. M[any provisions of this technical l)lletin

were obviously inappropriate as applied to the European theater, and a suitably

abridged and condensed version was prepared for promulgation within the

theater. Satisfactory provisions were made for the treatment of penicillinresistant cases of gonorrhea by transferring them to the Royal Victoria Hospital

for fever therapy under the expert supervision of Lt. Col. Ambrose King,

RAMC.

The syphilis registers.-The practice of holding syphilis registers centrally

at the theater headquarters and reviewing them there required the frequent

attention of the theater senior consultant in dermatology and syphilology. The

p)roblem of finding the necessary time to review registers b)ecame more acute

when the theater headquarters was divided into two portionls, one on the

Continent and one remaining in the United Kingdom Base. Colonel Pillsbury

was ot the Continent, and the registers were kept at the Medical Records

Division, United Kingdom Base. As time passed, it l)ecame more necessary
EUROPEAN THEATER OF OPERATIONS 301

for Colonel Pillsbury to scan these registers personally since they were used to

assess and collect data onl the results of intensive therapy an( penicillin therapy.

Colonel Pillsbury eventually found himself spending 2 or 3 days at regular

2- to 3-week intervals to review the syphilis registers on which there were

questions as to the adequacy of treatment provided.

Colonel Pillsbury was able to report, in August 1944, that, through 20

August, 8,471 had been received in the Medical Records Division for advice,

closure, and holding for followup checks. The medical decisions on all these

were rendered by the Professional Services Division. An analysis of 1,920

registers received between 15 June and 22 July 1944 showed that 536 (28

percent) had been returned to units for information essential to closure or further

treatment, 925 (48 percent) had been closed and sent to the Office of the Surgeon

General, and 459 (24 percent) were held for followup tests. Colonel Pillsbury

considered this analysis representative of the usual workload.

In a letter to Colonel Pillsbury, dated 18 September 1944, Colonel Sternberg in the Surgeon General's Office wrote of this system in warmly laudatory

terms:

We get in fifteen hundred registers a week and we have to check them all over to see

that they are satisfactory and return those which are not. It is a real pleasure to get in a box

from ETO and it saves us a tremendous amount of work. I would like to adopt your system

for our method of handling in the ZI but it is al)solutely out of the question because of several

thousand new cases of syphilis a month in addition to eight to ten thousand inducted syphilitics per month, which would require a tremendous office staff just to handle them.

Treatment of Skin Diseases

The treatment of skin diseases saw no such dramatic changes as those

that occurred in the treatment of the venereal diseases. The only advances

that approached these in significance were the local penicillin therapy of certain

dermatologic conditions and the use of DDT in combating pediculosis. hnprovements were made by the strenuous application of more superficial measures, such as emphasizing standard methods of treatment, shifting skilled

personnel to where they could do the most good, insuring adequate supplies of

drugs, and centralizing hospitalization facilities for the treatment of skin conditions. It was still just as essential during this period, as it was during the

earliest days of the theater, to emphasize to the point of monotony the dangers

of overtreatment.

To a considerable extent, the difficulty lay in the inadequate professional

training of many medical officers in the diagnosis and treatment of skin diseases,

a deficiency of medical school training that the Army could overcome only in

part. On 26 June 1944, in a letter to Brig. Gen. Hugh J. Morgan, Chief Consultant in Medicine to The Surgeon General, Colonel Pillsbury wrote:

I have been very much impressed with the extreme variation in training in dermatology

which is offered by various medical methods. The teaching in this specialty in some schools

is very inadequate, either because of lack of time on the curriculum or because of poor pedagogic methods. I feel deeply on this score, and intend to do something about it after the war.
302 AMVIiTIES OFI. MEIC:)(AL. CONSULT'IANTS

There is~ no reason in t he worldi whyi every medical stiidt'tii sliotil( not Ibectinielperfect ly famiouinr w~ith tIt cha lracterist ic piet tire andi the chief variat ions of t he tight or liii diseases which

will coiltjrisv over 9t)O% of all skini cases. ife shotild also he well ingrained ini t1l4e stanidardl

nilethtots of treat itelit. at least to tht lpJotint where lhe wvill nott (10 Iarni by treatinent. (Coinpeteit hinterntists are often suirprisintgly iniept int(tiaoojeda~iss I t hinik t his is largely

attrihut alde Ito poor teaching iliethlods ini the past, to a failuire to arouse thevir intere~st, and

to thle atliniifjiably conililex termintology of dermatology.

()It tilie othier ]land, t he difficulty aliso lay in the fact t1hat t here were somne

baicis (list 1iirhatices inl skitl physiology for w-hich aviiaiiihit niet hiods or 1 rea t nent

wvere. at best , un11sat istact 01W. Thie only solution to these h)Io)hlt'iis lay ini

exteinsivye scienit ific ini vest i'at i onis Onl a inuich b roader physiologic hiase t121 hitll

lie patst. It thIle letter to Gienerail \ Iorgatn julst mevlt i oned, C oloniel hPi11sbur.'v

sttilldthat111 thIle followinig condition ru ailing~ it, this cattegory NWere of part1 icular1

siigtiiticaiice in ile 1( Europeain theater: (1) Infhztmmnlatory eruttjtionis of tilhe hand'l~s

2111( feet, imtcudling vsjpecltly tilie (list urb~ed VaIsonltol,~ stat11es t hat r'egularlly

liCCOlipatiie( t hem ; (2) it chi; (3) psoria~sis ; (4) seborrheic (lernilt it is; (5) flingtis

inflections, of all types 1)01 Iil tnIheir prtevent ive anld t herapeut ic as"pects: Ii

aller~givc(ondthitons or vairbols types, includ~inig 1t opic deriiiit it is, inl which

mItethlods of t retIttient m-cert highly tinsat ishactor " and( too cutt hersoune for

iliiiit'ltpY ittedici tie; (7) pyodlermnas, wvith a grealt neetd for m~ore rapidly alct 11g.ý

nomisemis-it izimit, iiethlotis of redulcing: had erial flora of thle skivin; and1( (8) warts,

In1 spilt' of' 1ie( (difficulhties encounttered, t here wvere, nonethieless, ind~icat ions

that thle efforts itittle Ito imlprove ca2re and1 Irelt utenit of skini diseatses were

payi hg(liyidteti(s. Scabhies, al1t houghi posinga c1 onstant thI realt tiever a l)roaclie(

tile ' 511 &geriiii rate. t (' 0 f or1 Watr I, whmenl it Avat5 resp)on siblde for- Soule :30

p(r('enmt 0f' 211 eautions5 'Xl 12 front lie( Brit ishi Exped itio(na21ry Force. The nuim iber

of pattients eyactltt ed to thle Zone of Interior for skin (diseases reminained(l constantlv low, approximiately fronit 30 It) 40 catses per itint h.-

Phainmiiig for hivasion of the Continenit

Venereal diseases. -After visitinig tilie NorthI Africanl theater, Coloniel

h

1 ilshurv was i lllhrvssev withI thlie absolute liecessit ,v of' Coordinatedl plan--, for

tilie preventio and c1( onitrol of veiteretti disease Onl t(le C1ontinienit after 1)-day.

There wvere also inttelligenice reports which indhicaited that Venereal dhisease

uintotg I hie civhaiin I)ohplat on of Fnamiv ad i(h le Low Count ries was iMlcreaimlg.

T'his fact or, plus thle Short age of' d rugs anl phiysicianms ini those count ries.

indicatt edl12 tht expiosuire of U.S. soldiers to persons withI in fectious Veniereal

dhiseaste wouldl lbe greatlyV inicreaisetd and t hat a rise ill tit' Venereal dhiseaste

rate couldl be expeotet. It w-as, obviouis, owimg to Sever'al fact ors, t hat vemiereal

dhisease in combhat sOlder would lhe hadlyr hailnhed W hitniu tile artiy areas, unless,

sp~eciall provisions werte nitade. Thierte wouild be a shortalge of facilities ill field

ani e11(vacluat ion htospit als for adequate diagnosis, anth tile lairge numnber of

surgical ( asualt ies wouldl have p~rior'ityv over pat11ient s vithi Vtenetreal disease.

Sce P r'it ot' i17. 1). 1%t~.
Ini NoirthI Africa, thlese facto. had 11( led to eriroiieous ling~lioses and~ untwarranl~tetd

('actiulation of' pattienit' to fi~xedl hosp~it als; Avith ti lie resiult anlt loss ill manpfower'.

It wats nom- By iivartlizeti tha iiit patpitent NvithI active venereal (diseaise Would

prove to lhe j ust ats mli(ltic a casuialtyv fromt tilie st anudpoinit of combalit t is'eul'lies.

I1s at 1111111 wvith at cripplinig wolund~ and( presenitedl. moreover., at great oppIortuniity

to redluce uiouieffect i veess withlin thle armies. Imiproved methfods of' t reatmneit

hadi( made(I it p)ossib le to mmi' il(le(pitlvk for such diseases eui tire1 v withlin tillu

armly area and1(. ini aditiost till instanices. to ret urn tilie pat ieiit to his unit ent irelyv

culred. Obviously, t im closest cor~t~eit ou of dIutits and itiirspioisibilit les of

Vaio uiis miedical oflicers conicerniedl withI venlereal dhisease conitrol and( treat ment

act ivt ies was indi~icatted.

Onl 4 *January 1944, in at nientorandtlum to Colonel Kiunlbrougli1, Colonel

Pillsbtury recommendiedil~ thlit at leetilig, be heIld to c'onid~~er t11il spects of tilie

Veniereal (disease p~roblem anid to formnulate planis thait wouIld better anticipate

andt( provide for tilie 'omiple'x problemts tha~it (coul( b~e expected'( to arise. Ini

add~itilon to himiiself. lie sugpgest ittlefloing, -4 at tend~: Ch'ief. Prieventive

Me id inile D~ivisioni. anid Chlief. P~rofessioinal 'Services D~ivisioni Office of tilie ( 'Ilijef

Suirg-vou. Hleadqularters, ETPOUSA; VeuetMa D~isease C ontrol Officer. ETOUSA:

Conisult ant in U rology, ETOUSA; and( r'epreselintatives front thle Eight ii Air

Foirce and~ First U .S. Army.

The meveting wa-is held on 29 Janiuary 1944. (Colonel Pillsbur *vand N lajor

P~adget wvere directed to formanlize tilie recommend~at ions of this ad hoc coinlmnitt cc. TIhe memiorandu ptIllllr(epared Iby thfese two officers- onl 1.5 Fe1 ruar ,v 1 944

atil( p~resentedl to Genieral Ilawle , ihiscliiSsed general 'onisidlera tions oii wh ichi

tlie recomm iendhit ions were based aund I inuite specific recommneida t ions withl

resp~ect to p~revenition. pr'ophyvlaxis. puniit ive mleasures, (diagnosis. andi treat -

mien t of veniereal (Iiseasevs.

The r'ecomimendahtionis withI resp~ect to (1iagnosis wvere (1) that facilities

for tilie (diflreit ml (hiagiiosis of ulcerative penile lesions be made availabe as

far forwar'd it, possible--it was bemlee that evacliat ioi liospitals were lie

mlost ad Iva nced hiospit als in whIichl tilie niccessar prv 1 ioceduires c'ouldl Ihe carr'iedI

otsat isfact oril y-anud (2) thlat Kaliu tests for' syphiliis be p~erformiied onily as

far. forward itas st at ion hiospit als.

nThe recommiendalt ions c'onc'erniing trleat ment wveue fourfold, as followvs:

1 . Thiat thle lpolicy of t rn~tmerit of gorionrina ini units be continueite.

2. That treat men t foir ac'ute ('uret liiit is be given lpl'iflpt y. whet iet or' not

laboratory facilities for tilie examinilat ion of smeliars were available.

:3. That illt ensive treatntmen t of eni'l syphilis he ('ontiuitue mnd thlit it l1w

adminiist eredI as far foirward ats facilities would permit . The policy of giving

Such t reatmienit oiily- in fix.ed hiospitails (designiat ed by tilie Chief Suu'geonl.

ETOU,'-A. should be colntinued.

4. That at strlong policy be ad~op~ted against tilie (establishimenit of Vener'eal

(diseaise stockades or othleur similar t reatmfenit ceniters ill whiih diiscipliinary aind

Punititvle iiieasliures mlight interfere with titlie adlequat e miedical care of p~atienits

wsithI vene4real dIiseaise.
304 ACTIVITIES OF MED)ICAL CONSULTANTS

Following this conference, Colonel Pillsbury was busy coordinating

activities with other divisions in theater headquarters and particularly in

working with representatives of the First U.S. Army and, when it arrived in

Europe in March of 1944, with the Third U.S. Army. In addition, it was

necessary for him to confer with the many subordinate consultants in the various

supporting commands and fixed hospitals that were designated to receive the

evacuees.

As D-day approached, Colonel Pillsbury was able to report on the problems

that had been given first consideration and the plans that the First and Third

U.S. Armies had completed.2 4 At this stage, it appeared that the following

were problems that would have to be overcome:

1. Misdiagnosis of penile ulcers because of a lack of dark-field equipment

or unfamiliarity of medical and laboratory officers with dark-field diagnosis,

unwarranted dependence on spirochetal stains or on gross morphologic characteristics of ulcers for diagnosis, and misdirected attempts to do diagnostic

serologic tests for syphilis in evacuation hospitals.

2. Evacuation of venereal patients too far back in the combat or communications zone because of a lack of facilities for proper diagnosis, the pressure of

more crucial medical or surgical problems in evacuation hospitals, and the lack

of interest on the part of medical officers in forward units in properly caring

for the venereal diseases.

3. Regarding all venereal disease as an offense requiring disciplinary

measures.

4. Serious and dangerous interruption of continuity of treatment for

syphilis.

5. Persistence in sulfonamide therapy for gonorrhea for unjustificd lengths

of time.

The medical personnel of tile two armies had fully accepted the general

principle that early diagnosis and treatment of venereal diseases had to be

accomplished within the arnies and that the administrative and technical

means were at hand to achieve this end. Accepting also the fact that very

few medical officers were really competent in the diagnosis of ulcerative penile

lesions, they were in agreement that some centralization of facilities was

necessary. Accordingly, the First U.S. Army planned to set up a center for

the diagnosis and treatment of such patients in a convalescent hospital. The

professional service of this center wias placed in charge of an expert venereologist,

Capt. (later Maj.) James M. Howell, MIC, transferred thereto from the 10th

Station Hospital. A unit of the army laboratory, with an expert dark-field

technician and serologist, was also attached.

The Surgeon, Third U.S. Army, however, favored centralization to a less

degree. He l)lanned to attach a platoon of a clearing company to each of three

evacuation hospitals to care for venereal disease patients in tented expansions

to these hospitals. A medical officer trained in venereal diseases was to be

24 Memorandum, Colonel Pillsbury, for Chief, Professional Services Division, ')Mice of the Chief Surgeon, Ileadquarters, ETOUSA, 14 NMay 1944. subject: I)taen(Asi and Treatment of Venereal I)isea.se•n the Combat Zone.
EUROPEAN THEATER OF OPERATIONS 30O5

assigned to each of these hospitals land dark-fiell and serologic facilities provided front the army laboratory.

All concerned generally agreed that penicillin should be used for the

primary treatment of gonorrhea occurring in combat troops and that, under

any circutustances, persistence in sulfonamide treatment for ptciiods longer

than 10 days wits inadvisable. The surgeons of both armies wanted to introduce

the penicillin treatment of early syphilis as soon as possible.

As D-day became imminent and it was realized that, of the two aruies,

only the First would make the initial assault on the mainland of Fortress

Europe, a meeting was held in the Office of the Surgeon. Headquarters, First

U.S. Army, to make final plans for the diagnosis and treatment of venereal

disease in the First U.S. Army. It wits attended by Lt. ('ol. (later Col.) John

W. Claiborne, Jr., NIC, Commanding Officer, 4th Convalescent Hospital;

Lt. Col. Cornelius A. Hospers, .MC, ('ommanding Officer, 10th Medical Laboratory, First U.S. Army; Lt. Col. (later Col.) Tom F. Whayne, MC, First

U.S. Army Group; Maj. Samuel L. Stephenson, Jr., MC, Venereal Disease

Control Officer, First U.S. Army; and Captain Howell, 4th Convalescent

Hospital. The final plans adhered closely to the original plans just described

for the First, U.S. Army. In addition, the decision was Imade that penicillin

would be used for the treatment of early syphilis. Personnel from First U.S.

Army agreed to provide necessary information on cases so treated so that there

could be proper followup of these patients. It was also agreed that the number

of spinal fluid examinations at the venereal disease center of the 4th Convalescent Hospital would, initially, be kept to an absolute minimum. It was

further agreed that routine tests for closure of syphilis registers were out of the

question for some time. In addition, Colonel ('laiborne and 'Major Stephenson

earnestly requested that Colonel Pillsbury participate on the spot in helping

to set up and initiate operations of the venereal disease center. The Surgeon,

First U.S. Army, concurred in this request, and it was approved by the Chief

Surgeon, ETOuSA. 25

As the Third U.S. Army made final preparations to cross the Channel in

July 1944, the Surgeon, Third U.S. Army, voicedl a desire to modify the preliminary plans. He wanted permission either to conduct intensive arsenotherapy in hospitals within the army or to use the standard 26-week schedule

of therapy.26 He wits issur, d there was every reason to believe that tile supply

of penicillin would perni;' ts use in all cases of early syphilis arising in the army

and that provision would be made for transfer of patients to general hospitals

for intensive arsenotherapy should penicillin be unavailable. The Third U.S.

Army surgeon, nevertheless, stood fast in his deimands. Accordingly, permission was granted Third U.S. Army to conduct intensive arsenotherapy in

specifically designated hospitals, when and if necessary, in place of penicillin

23 Memorandum, Lt. Col. D. M. Pillsbury, for Col. J. C. Kimbrough, Office of the Chief Surgeon. IHeadqu:arters.

ETO USA, 21 May 1944, suibject: Venereal [)Iseame DiagnosLq and Treatment in First Army.

26 Memorandum, Profemsional Services Divksion, for Chief Surgeon, ETOUSA, 3 July 1944, subject: Management

of Syphilis in Third Army.

564970 61 -- 22
306; A-ivrI E : m. iFMlI mu~cm cAL('4 IsuuIANTS

thIerap~y. The st iplatitloll wa added~N that at iIt'clicitl officer t rainevl ill inte(nliv e

a'senlOthlura pv mlust lie t ransferred1 to thle hiospit al So) designat ed.

Whlem p)ut to t est inl coiniotwt, thle plans foriniitmlt (A bly First U.S. Army

provell outstanin~llgly sttccesslui. J)triiig thle first 4 imionlits of operation, 947

ptat iet'ts were admiiitt ed to thle venereal disease ventter or thle 4th ( ojivalescentt

Hosp5jitali. Of thleste, SS hlln to he4 t ritlsferrell, eat her to antot her sect ion of thle

coti 1itIesci'iit hiospitaZl or' to at genleral h ospit al. Tlhu ts, over 90 percelii of those

aIldilit ted were ret iiriied directi 'v to dutyi . N% loreover, t lie dhiagniosis of at venlereal

diaSease W21uS tiifilriiietl ilioly 091 * )Of the 88 pat tiets niot rettlliit'(l directly to

d lit y. The4 p~ract ice of treatin~g Venereal di(lIise is t ole centII rId laCe cOItst'rlvetl liets ill Iiiore active in stallaions and 11( permiiitt ed thle concentrat 111ion of

trained( persoliiiitl sti that iliore( efe ie t ('iit iiient co0111tl 1be latljiiiiiSteýr (A.21

The plan11 workedI best, hlowever. wvlieit th 114,'1 *rii' was ('onifit'tl to a r4'ltttivelY

small11 front Ti.I'm' armY laborator-y (fig. 110) wvas located withI the convalescent

hospital. a111( it wvas not nlecessar ' to de(tachi a unit to p~erformi the( dairk-field

andi( Khnt~ e'xainaiiit ions. As t( lie ,r1iY VeXal~ldtedl andit the situation b-catiie

Iiioliile. tile hiosp~ital 111141 laboratory sepaIraltedl, and( patienits bad1( to lie Iiioved

froim 5 to 100 Iliiles. for laboratory, examiiiiatioiis, at a timie whlu'tt transportalt ioli

was scarceV and t li vehlicilarll routes congrest ed. Eventna~l,~y a portijon of thle

laboratorv hiad to lie assigl('( to the hiospital as called for ill tle or-iginal plans.

('onltriir-v to thei' avlv i ie( plan iii hg, the i labiorator pivjerfor-Itied extenlsive spinal11

jiuilict llrt', nott OllYv for diaigiiosis buiit for thle Closinig oif sYphlilis regrktviS 'Irg

fluids wetre' t rI'llisliort edt to th 114'Ittite Kinigdomli by~ aircraift , but duzrring tile4 first

1114)1 ttI oif oi~era tioul over 5i( petrcenit of thle specimens(1i reatch edl tlhe central

htboraItor.v inl til 1imiszttsfactor.v condtitioni. Agaili. (the wisdoml oif till. advaicev

ilittis will suppilort ed. Spinatl puilletiun's for thle closing of syNphillis registverS had

to li( llefelrr('4. Above till, the( greiit4'st probilemi wvas tilie iiiiiiiobilit *v of thle

VV'It'r4'aII (isl5 se54 cenht er as115 ~rt pa of ii coliviilescenit liospitail. The4 fronit itt 4)111

time' so oilt 4list ii ticed thel( centiter thaiit aniot her unit had to talk1(- over its funct ions1

teuiporiirilY. There was not eiioiigl t rallsIportlittioli to Iillov4 th ci'en(lter and

not1 mit'iliN. elolighil p)4rsonlilel o4W equ~ipimenit, to (estabishi twvo eniters that. couldl

conitinuie t4) ittviiic'liv by eilpfrtiggilig.

Whlen thle list' of penlicillin iihd piroved itself inl thle (lilt ,v-stat us tretttniiit't

of gotiorrlita and inl the treat itielit of early, s , yliilis. the vellIIereit dist'ase treatIiient planl for d iv Thlird U.S. A l :vwas evetitutallY miodlified, iln practitce, to

parallel t hat of thlit First U.S. Arm i N.

Dermatology.- The plannlin g for care of (el trilli t ologi at' ie tnts was basedl

Onl thlit fact thaiit th lit' dtrilli t ologit' loatd ill a hiospitail was tlirectl lyN prprt)Otionail

to its st at ion hiospital funictionis tand tlit' nun11bt'i' of tr'oops ill its imiitlleiiltet arela

of' rt'spitlisililit ,v. 'I'lils Ii1('ilit that the tiia1joritv' of the'se patients wvoultl

t'vtntuahlv lhe s'en till th li'Cont inet'lt. Fuirtheitrmiorte, anv livted to t'vat'tiat e

piatie'nts frolil thit C ontinent to thet U'nitedt Kinigtdom Or thie Zonte of Interior

wotiltd repn-,rt s it aserliouis failure inl professionil ser'vice sinice ill miost (lerllia2'.Annual~ Rteprt. i'rortmIonaI Service.% Iivblion, tOiiice of the Chief Surgeon, Ilezadqua~rters, ETOITSA, 191,. with

Exhibit 1), ther-to,
I-:1,11 1'I.AN THEAER "II., "PERAII~It(rINS : 1

1'i.1uim 1 10. 10th NIvdicail LahoJ:Ltor, Firsi U.S. Am. 141 (>imh, Fr~uicv, 21 .JulY

1V)I11. A\. sot ling 111) 114 IllmhIratohrv tenIt,. BI. ScroI)gy tent.
308 ACTIVITIES OF MEI)ICAL CONSULTANTS

tologic conditions cure and return to (luty was feasible within tile limits of anly

reasonable evacuation policY, such as 30 days. On these p)remises, the decision

was made to supply hospitals being transferred to the Continent with specially

trained medical officers insofar as the nluber of officers permitted. The

remaining officers who would have to care for the severe and disabling derniatologic cases evacuated to hospitals in the United Kingdom were centralized

in hospital groups to permit the optimum care and management of such patients.

Hospitalization and Evacuation

At frequent intervals, Colonel Pillsbury was required to take an active

part, in solving hospitalization and evacuation prob)lems insofar as they concerned patients with diseases of the skin or venereal diseases. In most cases,

the problems were local; that is, their solution rested in the hands of surgeons

on the staffs of subordinate commands. Problems in this area were usuallY

discovered during field trips. In other cases, reports of improper or unsatisfactory treatment revealed that the cause and the cure lay in the establishment

and enforcement of evacuation procedures or hospitalization l)lans.

For example, in late 1944, after the theater had grown tremendously.

there occurred sporadic cases of patients being evacuated during the course of

penicillin treatment for syphilis. This interruption of treatment necessitated

the initiation of another complete series of treatments and was wasteful of

medical facilities, personnel, and supplies, and, in addition, jeopardized the

ultimate cure of the patient. Colonel Pillsbury had to confer with the surgeons

and representatives of commands in which such discrepancies were occurring

in order to fix stringent requirements for the completion of treatment once it

was started.

In another instance, the French had requested help in the treatment of

early or sulfonamide-resistant cases of gonorrhea, which were accumulating

in the French Military Hospital at Val de Grace. Colonel Pillsbury inspected

the hospital and discovered that 30 or 40 patients a nionth were admitted who

required penicillin therapy. Arrangements were mnade to care for these cases

in the 217th General Hospital with the approval of the Surgeon, Seine Bast

Section, in whose area the hospital was located, under conditions satisfactory

to the French and the hosl)ital authorities.

Previously, centralized treatment centers for derniatologic care in the

United Kingdom were mentioned. These had to tbe established because

hospitals arriving front the Zone of Interior were staffed by increasingly less

experienced and less well trained medical officers. On the other hand, the

number of dermnatologic patients in each general hospital was so sniall as to

occupy only a fraction of the time of a specialist.

Obviously, two solutions were possi)le.--....ceitralizatioin of patients or the

use of peripatetic consultants. Both were used, I)ut the fornier proved much

the more effective. In September 1944, such a center was in operation at

the 192d General Hospital of the 15th Hospital Center. Here, there was
EUROPEAN THEATER OF OPERATIONS 30O9

assur niec of accura te (liigliosis anid disposition. Such centraliza tion also

facilitated tile collection of itifornination ais to the incitletice of vairious cotidilions and1( effectiveness of treatnieiit. M\oreover, patients (-ould[ be further

centralizedl onl one or two well-run wardIs with adeqluate fiaciities for special

exallinifltionlianti Sufficient Supp~l)ies of tile collfinilo oinitilents, Solutions, 'Indl

ot her necessai r v itiedicitials. Above allt, speciatlized tiermnat ologic wardis helped

to insure thle interest of wairdlnen and nurses in the care-( of these patients.

Good treatmlent, effected in this mann111er plidt off in thle saving( of hoSpitall-be(

days per patient. The difference in lengthI of hospit alizat ion between --ootl

tlizgiiosis and treatnient and bald was particularly niarked in dermnattologic

cond~it ions.

Classification, Training, aiid Assignment of Personnel

The adequatcy in nunibers andI in training of dermiatologists was thle primiary personnel prolbleni, owing to the ftict, that dliagnosis and treatmient of

(diseases of tilie skini could miot be standlardizedl to thme extent that stanllairdhizalI ion was lpossib~le iii thle venereal thiseaises. Iii addition, soline oldler officers

with Sp~ecial tralining in tiermiatology were so ininiersetl in the specialty aind

so narrowedi in t heir outlook ats to matke thein unadaptable to Arnmy miedical

p~ractice andl to diuty outsidle their particular spec'ialty. On the other hand,

mnedical officers trained1 in (lerniaitologry in the 10 to 15 years lbefore thle wair

in certain civilian gradulate centers provedl extremiely vailuable. It, wa this

smnall group that carried the load( ats regardls thle return to duty' of really difficult cases. The numiber of mnedical officers in the theater with any' tratining

in (lermnatology , including A, B, (C, and D classifications, was 47 als of thle

end of 1944. This nuniber was so fewv that it trained tiermnatologist could not

even lbe assigned to each general hiospital in the theater, although wellconceivedi hospitailizaition policies alleviated this need. However, when the

First U.S. ArinyN iiidicatc- ita need for at terniatologist to be assigned to the

atrmy surgeon's staff, Colonel Kinubrough flatly refused to consider such anl

assigninen t of (lerniatologiStS. 2 8

'The lproblemn of providling adequate service with a limfited numlber of

officers wais inet by initerviewing and assessing the professional qualifications

and1( experience of each dermantologist and assigning hini where lie could be

in ost fruit fully emiploved. Those who were not, full-trained clermiaitologist~s

hut Were filling positions as such were also interviewed to determnine their

ability to carry the load expected of themn amid to hielp thein acquire any*

training or experience that would manke themn more capable. Sonic officers

whose professional qualifications justified their assignmnent ats ward officers

in (lerni atology and syphilology in at general hospital neverthleless required

training, in ni thods particular to thle theater and in mnilitary hospital adininistraition procedures. In Septemiber 1944, all dermiattologists assigned to

28 Nf eniorandum, Lt. Col. 1). 'M. Pillsbury, for Chief, Professional Services Division, offce of the Chief Surgeon,

Hiead'quairters, IETOUSA, 24 Oct. 1944, subject: Report or Visit to F~irst anti Third Armies with Comment No. 2, Col.

J. C. Kimhrough to chief Surgeon, ETOUSA, thereto.
110sf )itlS iill i tlie( ITmite(I( ?Iigoi m (i'C ('h clssified( a " Iit, ledia ( offlicers~ of* top) speciail abilit v, fullyI I(fualifievl to act as' regional ('(ll'til~talit.S ill (erililto~ogy andi~

Veiiei'e(log Y,' and1( 'medicali'l offli'er's xvithI spiecial trlainling, but for v'al'iOiis

r'(llsoiis not (fIllit ISo %velI qua11lified to I() ( its rSegionalI (.olisllltla us. '' ii I )eveii -

her 1944, C oloniel Pillsbur * and MIaj. (hInter Lt. C of.) ( liar1les .1. ( ourlville,

NIC l( ' wo hald funcioned' i ~it' s theW thlea ter' seiiiou. consultant inl (erl lil t olog.v

andi~ syphlilology Cll'l1 oloniel P~ilIlsbury's teliijoi'ull' (lilt V ill tlie( Uinited

States (' laessifiedl all dermaiiutologists~ ill t li thlea ter ats to t heir prlofeQssionaul libtlit ,v.

It W'1i5 noS1110 priul loblemli to kveel traick of (lerlinat oloi'ist s l111ii q din ie

heivght or aict ivit ies ill tilie thlen t r. Eitlivur thle units to which (lerila tologist s

wer'e assigniedl would~ Iev ii 10vQeh or thle I siOjit iilizuit loll resp~onsibili ties of tilie

units wvouhi be cliatig1ed. A hlospitall venter whose ('olisil~tallit in l(l dl-iiu1tOlogy

waIs lissiglied to otie of its ('0ompotien t generall hosit~IalIs wouldl suddh enl fIvli d

it self withlout a conisultanit whnN-i tilie particula ir genieral hiospit at was t ralisf'erred I esew Iiere. A dermaiintologist assigI i1ed to a1 part vileu hospi05)1t al woul1(

sliddveill.v find himiiself trealtilig no skin (diseases and~ performiniug sundiriy otlher

(lti es up101 chlige (fi of th lihlospita l's niission . N Iassg ns * onice t hey hand

beenl pernmitt ed to occur, Were d ifficult to correct , anud exceed ilnglv delicate

i'eahj list liieiits Were somletimnes lie('essar,,v. To effect trlainsfers, C olonel P~illsb~ill'v had1( to obti ll ('lcncrrenices fromi tilie inhdivid uals conicerniedI, fromi tilie

(0M11i lil ildituig officers of gutiliil lug 11( losiiig hiospit als, and1( ofteii f'ront 01We or iiiore

area11 COMllluiids. ( olliliiull~ildiii offijeers of, hiospitalsad antI Surolis of' commliainds.

jen buls of thi p11'jrer-ogat i ve, 0 Itel'I refused to ('011111euta ite t ransf ers of' pel'solii iel

that wel'e (l(esi red b1) te li thlea telr Sell101' conisultan11t ill dermlat ologgy.

The dIirec't justrlul(t iouial 11( ll l'iiiliiiiglact ivitie U'S lig-ed l bN ) ( Coloniel

l~illsbii 1WN, or c'arried oil 01unIder' hiis super'visioni, inicluded tilie followinhg (I) liistI l'l('t ioul to lilvie vaiul offi(ev's ji field iiedli('ul and1( hosp1 ita illuits, reg-arding" thle

dIianguosis and t rea t nelit of comiimlon skill d iseulses thrlouighi lec'tutres lit thle

NIedicl! Field Serv~'ice School aiid thle Eigli thI Air Force Field Servicev School:

(2) cont iniued wh lespread shiowinig of thle NIinlistry' of H ealthl filni onl scabies;

(1i) fprovidhilig ol)1)o1't un it U's fol' inedIi('l offlicer's to ait t ei Iprlofessionial l1vii c ilgs

1111(1 ('on fereulces, such its tlie( niontlitly , v eetinugs of thle sect ion of del'ia t ologv%,

Itoya -l Societ v of NIedicitie ; (4) frequent anid t illelY ar'tic'les ill thle .1lkdicdl

B1il1i in of thle Europeaii t heater'; anld (5) oui-thle-job t mtilling of initerestedl

Moli iedlical off~i(e1s withI sollie t ralillig" ill (lemlliitology or. veilereologv.

'The oii-t lw-job t raining too0k two forlins. One way tws to place potent ia!

spe('ililist s ill (liii u'ge of a. Nvar I anld iav'e t liei i' work frequlen tly suIperv~ised and

l'evimede by V'isit ing ('onsult anlts. Thiese visits wvel'('11d liial t least onice weekly.

Alnothler' mletho 11(1 ws to phlae thle tr1alinve oil teliilrol'l'Y (lilty li til aniistallat ion

whier'e it qfualifiedh liie(Ii('ll officer' wa-s olperlt'lt. itg a lage Ser'vic'e. A typic'al

re'por't of oui-t he-joli trai l ac'com plishied Nv'ithI fouiz' mled ical offieris, Is its

f'ollow~s:

1. The following off~icetrs we-re onl detac~hed servive althi u la'j)ii:1l for I raillingy ill tile

tu'('liquei('of 2(1 tay initenisive arseliothlerap)v fr'omu I 6 April Mitil to 21) April 11.11- * ' *
EUROP)IEAN riiEATER OF OIPERATIO NS 311

2. lin the training of these officers ouir facilities and cases were used to give them experience ill clin ical and ilIabIora tory dIiagntoses of variouis venereal dliseases andt the t echnicjtie of

admiinist rating arsenticals. P~roblemn cases and~ t reatmIent reaction.s were discussed inl group;

mneeting andi ward rounds. lhev leecatne familiar with the admnjiist rat ive (let ails byv prepatring thle recordIs for arhtni-siott andl discharge of pat ients. lit addit ion a discussion oil this

slibject was given by thle registrar of this hosp~it al.

:3. The group as, a whole was enIt husiast ic and cooperative and gave ev'idence that whenl

placedl inl charge of t his tyvpe of patient wouild be aile( to gi\ve a goodl account of t hemselves.

It Ilight be mentioned that nonle of these mlenl have had thle opplort unity of practicing clinical

medc~icinte for approximately two years. 2 9

Visits to Field Installations

Colonlel Pillsbll. irv founid it esseitit l to iiiake frequenit recurrenit visits to

hospitals 1111(1 iistallat ionis ill tilie field. These visits ettabled hiim to have a

g(rasp of the geiieral sit nat ion a~s it really was ait tilie olperat mug level. It also

vttahledl hiiin to check ott thle iiinaiuer ili which prog-raiits atii( dlirect ives were

lbeitig, carriedl ouit, to conisllt oil dhifficult cases, to conlllict. wardl rouniils, autil to

adlvise tilie hosp1 it al, local co11iti inittll or, wheni necessary, thle t heat er hieadlquarters, oit probleuiis lie had( dhiscoveredl (fig. 1 11). ('otinilg ott top) of his ot her

du tites, field t rips took ii cotisidlerah)Ie toil of his timie and( eniergy. Field t rip

dtiuty was hlardl 1uireunit t itig labior, bult essentital work, anid the theater senilor

cons-ult ant hiadl to be du trable.

Soiie visits to ltoshpitals were coniducteti for limnited, specific ptirposes;

ot hers were conicernied with Iimore genieral inaItters. JDuring t.hi period wvhttii

iiany cas;ualties fronii tilie N orthI Africati and( Mediterraneani theaters were

beitig rece ivedl ili ti( l'ieinitedl King~donti, t here occurred frequent cases of all

i'rit at ilig, teriliat it is variously referred to as ''Siciliani itch'' aid ''desert Sores.''

These hiad to be seett byv tlile Europeani t heat er sentior coiiisultatit ill derniatology.

IDuring Coloniel Pillsihuryv"; periodl of temiporary (lutyt ini the Uuite(I St ates,

Major ('otrville siirvey' et arll hospitals inl thle Nortltan(ly ai11( Brittany' Base

Sect ions to evaluatte Services for thle I rentiinent of derniiatologic anil veniereal

(lisease Pitticiits, patrtic'ular'ly withI respect to thle qttalifi'at ioni of nieietlicl officers

assigitedl to thlese t11iti e5. 30 Wheni C(itietml Niorgait visited thle t heat er iii

Mlarchi 1945, ('olontel Pillsbury wats onie of t hose who accoitipaniieh (iemteritl

\lorgmti null ( oloiiel Middhhetonl thIroutghi Various ntletical facilities arld inlstallalotis otl tilie ( oltit iteiit

Research and Development

During the period of 1944-45, which was oectthpied lpritttitrilv with Iiiiedlica~l

support of the Ariiy iii cotii lat , t iinie was nevverthleless found( for act ivitiles inl

alppliedl research, principally dlirect ed to thle soluitioni of probletiis as they arose

itt tilie t heater, for which there was no nuitiiediate available aniswer.

29 Letter, 29Mth General Hfospital, to Chief Surgeon, western Base section, FTO USA, 4 MNay 1944, subject: Training

in Intonsive Arsenotherapy.

10 (ti Letter, Maj. C. J. Courvitte to Surgeon, Normandty Base Section, ETOUSA, 20 Nov. 1044. subject: Faciiities

for Treatmnent or tDermiatoiogic and Venereal D~isease Cases inl Normandy Base Section. (2) Letter, -M ~J. C. J. Courvitle

to Surgeon, Brittany Base Section, ETOUSA, I D~ec. 10J44, subject: Survey of Facilities for Treatnment of Skin and

Venereat Cases in tBrittany Section.
I~rj~ratI~ I lit. iii S~I~e~. H n I IIi Nil I \\ I 1\II 'I I'>

r v '4l'4 1 r ase 1). ii sc It s T 1 "1 -11 i IiI t \ :l 1 '\ l Irk1 \4h I I 1 .1"I"II

1 44?1 I l1 14 1 1 l 11 / 1 1:414 l 1 111 1; t1 1 411 I ( t II

I I I I ~ I ll t I I I it l4j4 1I 1 q1 II'l 4I - 2 1 24 1 41' on 4 III I I I 11I..

r ;I I lI I . I. I i ti

I rr ' 1 , 4 1i ';1 1 1: \N I1 , 1 :I11 . 1 lI11 - t ; tI IIII- It l

r,, I, I I , II f, Ih , IlI I I I I ;I I,, 'I,. II I > I , IIII \i': : ! Il I' t T : I\ I I 1h,, 1,1,.+ , .\

J Ih ... I I ' l , + + , . ~ - : • , l : , + n + _ h , , l ~ , ' : T , + - : ' , l r , ; l . l \ + , i . ( l t . . , 1 l

~ I~e r I..t l In m IIo • ' li, . '',. l ,!tJ~t, +, v ,N . ,,v, : t
EI'I• IPEAN TIIEATERII 0F 0 'ERATIONS 313

BAL for arsenical intoxication.-In late 1943 and early 1944, when the

intensive arsenotherapy of early syphilis was reaching its height, some 1 percent, of those being treated showed severe reactions to the arsenicals used.

Information wits available indicating that BAL wits highly effective in the

treatnient of arspheriamnine dermatitis. Colonel Pillsbury at tempted to obtain

a small supply of the preparation from thie Office of the Surgeon General without

success. Successful arrangements were then made locally in England to obtain

anipules of BAL ointnient (OX.217) from Prof. R. A. Peters, Department of

Biochemistry, Oxford University. Although Colonel Pillsbury thought that

BAL was proving to be of value in treating severe reactions to arsenotherapy,

many factors, such as the limited supply of BAL, mnovements of hospitals, and

treatment with penicillin instead of arsenotherapy, militated against the

setting up of any conclusive test of its worth.31

Penicillin ointment for superficial skin infections.-AMany medical units

throughout the theater devised methods of using penicillin for the external

treatment of superficial infections of the skin. A British proprietary preparation, Lanette Wax SX, was favored initially as an emulsion base. Later,

standard U.S. Army emiulsion bases proved satisfactory. Ordinary lubricating

jelly and Mennen's Brushless Shave cream were also good. The primary problem

was the keeping qualities of the penicillin incorporated into these bases. Here

again, the experiences in the European theater were asked for by The Surgeon

General, and a report wits submittedi. 32

Slow absorption of penicillin.-If there had been some way of administering

a large amount of penicillin so that it could have been absorbed slowly, the

benefit to comabat troops in the treatmlent of gonorrhea would have been treienl(ous (fig. 112). Work was being done on the problem in the Zone of

Interior. Tile Strategic Air Forces in England had attempted a single-injection

treatment of gonorrhea with 100,000 units of penicillin, but the rate of cure

had not been satisfactory. Colonel Pillsbury informed Colonel Middleton that

tile (levelopnient of such an itenl was too great an undertaking for tile theater

at that tiule under conil)at conditions. His judgment. was confirmed when

considerable technical difficulties were encountered in the United States in the

development of penicillin in oil. 33

After Colonel Pillsbury had an opportunity to observe firsthand the

progress that was being made in the United States in developing a slowly absorbed penicillin preparation, attempts were made to produce some of the

material locally in the theater using British sources of supply. When General

Morgan visited the theater in February 1945, lie b)rought samples of a successful

l)reparation with beeswax used as a base and made up in strength of 500,000

units per cubic centimeter.

"31 (I) Memorandum, lProfessional Services Division, for Chief Surgeon, ETOUSA, 29 Feb. 1944, subject: BAL Ointment (OX.217) for Arsenical Intorirction. (2) Memorandum, Professional Services Division, for Col. C. P. Rhoids,

(Ns Casualties Division, Office of the Chief Surgeon, lleadquarters, ETOUSA, 27 July 1944, subject: BAL (OX.217) in

Treatment of Reactions to Mapharsen.

32 IA'tt4,r, Col. i). M. Pillsbury, to Brig. (lon. Hugh J. Morman, Office of the Surgeon General, U.S. Army, 8 Aug. 1944.

33 Memorandum, Col. I). M. Pillsbury, for Col. W. S. Middleton, Chief Consultint in Medicine, Office of the Chief

Surgeon, Headquarters, ETOUSA, 21 Oct. 1944, subject: Technical I)at-& Reports.
311 AC.TIVITI1ES 4)F MEDICiAL C(INSUI.T.\N'1

TABLE

Flivm I 1( I2.-Sland(ard lireparatmiLt o(I peticllw for lvis)4tfflvd M~ar.I ve., isaIddod to) sealed vialis ('Ultiillillg 100(,0O(M xford lunits (of s()(ililtI peticiinitt.

P~rofessionial Activities

Meetings and conferences. rrlie Yewrs of' active warfa-re v no Ietdlowli

IIiI iev iiiiiiilier wIi(I varietv '~ofli ('Cvt ii igs i(I d ci 'Oil ere rie , C olorielPls rr

cirrit lilu(f to at teiill Ht I conf'erenices of, co0111ii1aii1(1lerl-iliatologists hield bv thle

Butisli,1 AuiiivY '111d at olie (A thle coil fere rices, prleselit e'd a I alk Oil th liionlireilch.111i-e of, skil lise Iused III tile 1..S . Ann v1. Tlhe Britishi hadl requei(st ed this

lreseslhit toll l ill i'oiij tillit loll Nit Ii contemiiplatted rev-ision of, th lieionrieniclatilr'e

iisiv I), IV lie Brit ]Is ArI'iii. Adl(resseS were also iuiu (Iebeore t lie SocietY I'fo I lie

(tnd fl Velierval lDiseases; t hie Sect ion of, Iedlicinie, H~o aIl Societ v of. \Iedicii

I ie( Brit isir Associat loln olf ( liniical P~at Iiolo-ists S;aiid t lie I literi-Aflied ( 'oil fere iem-

()Ir Wir MlCdiciuie. M~aj. (biter. It. (Cof.) WXnlifred 1). Killirig'swoii Ii, NW.I('. fouri

liev ( flice (4 tire S11r-eon., I Iidqniarters. Third 'S.5Ar rivl, thIronughialuie

uIIuIts iii.1de lbv ( oloniel IIlsnrv lso gae talk onl penlicillinlieap of,

Venereal; dilseases bef.Iore( a gaillierilig of I tlie la1ter-Allied ( ll'oifelleiw oil NWar

Niedici lie held iul 1 orndoui druirig, late 1944. ( oloriel lPillsbirr'v's mrost illi)oiI a lit

-adl( rss furinini t his peijod was Ilral(' bl'eore thle i ria oi ld' o nel-elwie onI

\erwereal1 I iseases. sponlsor-ed bY thle I.S. Publllic H ealthi Ser-vice arid held aIt St.

Loins. Mo., oni !9 Noveriber' 1944. While oil telnporar *v dirtY iii the Uniited

Stat eý. lie Also) aIttelilenl .1i1d spoke briellY at thre coid'i ferercl IieclcostaIlits field lbv 'I'lie S1urgeon Generial at Ashiford (ierieral Hlosp~ital, White Snillphlrnn
EUROPI\EAN TIIEATER IOF OP'ERATIONS 315

Springs, W. Va., and at tile meeting of service conmnand venereal disease control

officers held at St. Louis on 8 November 1944.

Writing and editing.- Colonel Pillsbury assumed editorship of the

.Mledical Bulletin of the Chief Surgeon's Office, European Theater of Operations,

in August 1944. It was felt that the great a(lvances being made in many fields

of military medicine in the European theater, from the standpoint of b)oth aIdministration and professional care, were not being a(lequately circulated.

As editor of the bulletin, Colonel Pillsbury was specifically responsible for (0)

stimulation of medical officers in all echelons in the writing of papers suitable

for publication, (2) collecting and ab)stracting of material from various meetings,

(3) editorial revision of papers, (4) submission of papers to qualified experts for

review and revision, and (5) recommendation of changes in format of' the

bulletin in conjunction with Col. Howard W. Doan, MC, General Hawley's

executive officer. NMuch emphasis was placed upon the many new (levelopments

in the management of battle casualties in clearing stations and evacuation

hospitals.

As a contributor to the bulletin, Colonel Pillsbury with his subordinate

consultant associates pul)ished papers on the proper handling and shipment of

specimens for serologic examination, on a method for preventing contamination

of spinal fluid, on the in(lications for spinal fluid examination in the management

of syphilis, and on penicillin therapy in gonorrhea.

The following directives emanating from the Office of the Chief Surgeon,

Headquarters, ETOUSA, were drafted1 by Colonel Pillsbury during this period:

Circular Letter No. 31, 10 'March 1944, subject: The Diagnosis and Reporting

of the Venereal Diseases; Circular Letter No. 34,6 ýMarch 1944, subject: Managenient of Simple Skin Diseases; Circular Letter No. 49, 30 March 1944, subject:

Amendment of Circular Letter No. 22 ;" Circular Letter No. 86, 22 June 1944,

subject: Penicillin Therapy for Early Syphilis; Circular Letter No. 103, 9

August 1944, subject: Managenment of Neurosyphilis; and Circular Letter

No. 107, 25 August 1944, subject: Treatment of Gonorrhea and Syphilis with

Penicillin.

SUMMARY IN RETROSPECT

Donald Al. Pillsbury, M.D.

As has been noted elsewhere in this volume, the consultant system instituted

by the Chief Surgeon, ETOUSA, was unique in the Armed Forces of the United

States in 1942. The Office of the Surgeon General, U.S. Army, lacked adequate

consultant representation of the various branches of clinical medicine at the

beginning of the war and never achieved representation conipletely. In the

field of dermatology, for instance, in which great disability was encountered.

Sl)e'cially in tile ,SouthIwest Pacific Area, there was 1o consultant representation

in the Office of the Surgeon General until the war was almost over. The system

8# T'his circular letter first authorized the use of penicillin for the treatment of gonorrhea occurring in combat troops

and! air crews.
316 ACTIVITIES OF MEDICAL ('ONSULTANTS

adopted in the European theater was based upon the "Advisor" scheme of the

Office of the Director General, Royal Army Medical Corps, and the professional

representation was essentially similar.

It, is the firm belief of the writer that the availability of competent consultant service in any large body of troops is essential to a high degree of

professional medical service. On the other hand, the number of consultants

must not be inordinate, to avoid wasting high-grade professional personnel.

The representation among various branches of medicine, surgery, psychiatry.

and the laboratories will vary somewhat depending upon the incidence of

particular diseases and of combat casualties among the body of troops concerned. Obviously, consultants are justified only in large bodies of troops;

for example, in a field army or a higher command.

Certain advantages of the consultant system may be put down, as follows:

1. Provided the consultants concerned are aware of the actual medical

situation on a day-to-day basis, from adequate reports and continuous observation in the field, the origins and growth of important medical problems can

be detected very promptly. An impending situation will frequently be suspected by a competent consultant long before it appears in official reports

through channels in the form of significant disability rates.

2. Provided the distances of travel do not make it impractical, regular

consultant visits to medical installations of all types make possible personal

consultation on large numbers of patients in the light, of the latest information

and the broader experience that a competent consultant may be presumed to

have.

3. A consultant group furnishes a means for exchange of technical information through special channels on an informal basis, and this is very useful.

However, it must be done with the greatest care, in order not. to infringe on

the administrative functions and responsibilities of commanders.

4. The consultant is in a position to alert the surgeon of a command to

the need for the preparation and distribution of technical bulletins or, in some

instances, a need for command directives, particularly in the field of preventive medicine.

5. A respected and acceptable consultant, can be of considerable assistance

in the maintenance of morale and effectiveness among medical officers, particularly those who have been long away from home or who are working in isolated

stations. The reverse effect may, however, result if the consultant is ill

informed, brusque, or personally objectionable.

6. One of the most useful functions of a consultant is the evaluation of

the special and general professional competence of medical officer personnel.

Specialty numbers are frequently an uncertain guide in respect to a medical

officer's true effectiveness; to evaluate an officer properly, personal contact

with him and observation of his work are essential. In such evaluations,

however, the consultant must exercise the utmuost discretion and remain aware

of the responsibilities of command and of personnel officers in this regard.
EiUROIP'EAN TIIEATER OF OPERATIONS 317

In an atmosphere of mutual respect, however, transfers and other changes

essential to good professional care in any unit can ordinarily be effected without

difficulty or friction.

It shouhl be pointed out that. the relatively static conditions obtaining in

tile European theater in tile years 1942 to mid-1944 (with the excel)tion of the

Army Air Forces) permitted the gradual absorption and indoctrination of

consultants. It, seems doubtful that such a condition will exist in any future

war, and p)lanning for such an organization must be made beforehand if it is

ever to l)e effective.

Certain attributes that characterize an effective medical officer apply

equally to consultants, but there are additional stresses and responsibilities

that require a broader professional background and a high degree of diplomacy.

These may be summarizedi as follows:

1. Tlhe professional coml)etence of the consultant must be of a high order;

he cannot (lepend too greatly upon rank and military customs to gain the

true professional respect of his fellow medical officers, however junior. A

consultant who too consistently gets beyond his depth professionally will soon

become ineffective.

2. In a large theater of operations, it is impossible, however, for a chief

consultant to function effectively at too low a rank, particularly in dealing

with commanding officers of hospitals and senior officers in other command

and staff positions. The absence of any approved table of organization for

c'onsultants in ETOUSA was a source of some difficulty in this respect but was

overc(ome to a great extent by tile continuous staunch support and backing of

the Chief Surgeon.

3. A consultant who is not well indoctrinated in Army administrative

pro(cesses will have difficulty in attaining full effectiveness, regardless of his

professional competence, and may encounter repeated official or personal

difficulty because of lack of knowledge of simple rules of procedure. The

experienced( medical officer develops an acute sense of when to p)roceed( through

channels and when to cut, across, when to be official and when to l)e personal.

"This requires many years of experience to realize fully, but the rudiments of

tile game may he learned in a few months of study.

4. The most. useful consultant is one with a real l)rea(lth of professional

vision and willingness. Complete restriction to a narrow specialty is ordinarily

impossible because the consultant is regarded as a representative of the surgeon

and therefore reasonably cognizant of tile nature and scope of the chief problems

being eflcolntered. He may find himself of little usefulness at. times if he

refuses to function outside of some very narrow branch of medicine amid surgery.

Moreover, such an attitude may be destructive to the total effort if it leads to

competition among specialists for increasing recognition of their respective

activities, without. regard for the relative contribution that each may make.

5. Under some circumstances, a medical officer in particular fields must

serve both as a consultant and as an active practitioner in any or all types
318 ACTIVITIES OF MII)ICAL CONSUILTANTS

of medical installations, ranging from a general hospital to a battalion aid

station. Under such circumstances, it is of vital importance that this dual

responsibility be recognized by the commanding officer of the unit concerned.

Although the preceding comments are my considered opinions, they coull,

nonetheless, be illustrated by numerous incidents and personalities which

constitute the historical record.

Part III. Senior Consultant in Neuropsychiatry 5

ARRIVAL AND EVALUATION

The Senior Consultant in Neuropsychiatry, ETOUSA, Col. Lloyd J.

Thompson, NMC (fig. 113), reported for duty on 25 August 1942 to the Office

of the Chief Surgeon, Headquarters, ETOUSA, then located at Cheltenham,

England. He was placed under the overall direction of Colonel M[iddleton,

Chief Consultant in -Medicine, ETOUSA, in keeping with the organizational

plan of General Hawley's office and the precedent established in World War 1.

Colonel Thompson was the second consultant in neuropsychiatry to be

appointed by The Surgeon General during World War II.

Colonel Thompson soon realized that he would be engaged in much staff

work and activities of an operational and planning nature. At the time of his

arrival, the functions of a consultant were as yet unspecified in War Department

doctrine or directives. It was the general understanding that the primary

duty of a consultant was to coordinate and supervise effectively the strictly

p)rofessional aspects of problems involved in providing hospital care to patients.36

Colonel Thompson had to initiate the necessary steps to establish special

facilities for the care of neuropsychiatric patients, evacuation plans an(l policies

with respect to them, and specialized training and educational activities for

those entrusted with their care. In conjunction with the supply service, lie

had to insure that adequate supplies and equipment peculiar to treatment,

of nieiropsychiatric cases were always available. The problems in neuropsychiatry, insofar as Colonel Thompson was concerned, were obviously those

concerned with the development and management of a broad mental health

program.

Colonel Thompson found that there was a definite need for current,

reliable data to serve as a basis for his plans and a need for tangible evidence

to bolster his arguments for their support in discussions with those persons in

a position to approve or disapprove them.

The British, who by this time hall had nearly 3 years of experience in the

war, were very cooperative in providing useful data, information, and coujnsel.

3s (i) The narrative for this section was complied by Maj. James K. Arima, M5SC, The iiistorical Full, V.S. Army

Mediicl Service, in collaboration with L.loyd J. Thompson, M.D., formerly Senior Consultant in Neuroicychi:try,

TO(I'SA. Dr. Thompson contributed the summary In retrospect in May 19.56. (2) tnlessý otherwise noted, this seelion Is hased on the followi ng documents prepared by Colonel Thompson: Annual 'ineprts of Senlor Consultant in N europsychiatry, ETOI'SA, for 1942, 1943, 1944, and 1945 (first half); the official diary of Colonel Thompson; and preliminary

manuscripts submit ted by Coloni Thompson to The Surgeon (Oeneral for the history of neuropsychlatry in World War Ii.

3 Letters, The Surgeon General, to Commanding General, Services of Supply, 28 May 1942 and 23 June 1942, subject:

Coordination and Supervision of Medical Service In Station I lospitals.
Emirop)Ian 1i ent vr. ( Hight, A op) ( )I. iIlo'v (I

Ne(iiopsy~chliat ry. ( tiev of th lI' 'ivf Sizr11. Pa:rson-;, NIC, A ctinag S~enior C'onsuiltanti

inl NE'iii-o)svhiEir r'-, Ofie ofthe' a ChI (Iief

$m-iir-oa, ET1( )1SA: (right, bo01ttom) IA. Col.

JacE(ksonl N1. IThoinsIE NW, C hief. S'choo~l

'--N

I iliriii thle first titoti th of hiis tenuiiire, C oloniel Thioiipsoni speiit coilsilieni ide

tiluec st iidviliig thle tii('IIoisychaiiii INorgalii'ait iolandti~ eXlwriliemS.. of tile Royal1

Ariuiv M edIical C orps altid 11l1e Roya.(11 C.1.d ii iii i M \ e l1e11 CI ( ors. Bi'iznIM 1ie

It. R. Rees, ( oiistiitailit ill P~s*vciiiatiw to tie B~rit ishlAi i*iv lit hiome, anid ( 'oI.

1". 11, \-titi Nost raitd, C oinsultanit iii Ps ciiiatr : v ito lie ( aiiadiaii Arit ' , Were

ext reiiielv hieIpfilI. Ini coiiipaii withI thlese offivers, C oloniel Thiomipsoni visited4

maii gli~~ioms Iainiil lu ict ivities, anid hiospitalis to ol)seve- first han d tlie(

Jpra t ive of psc it llv thle Bri t is i forces. lie aliso at tv(i (lded meetinigs andI

'01fe-euices of t heir. p~sychiatric St affs aii( was late (r to become a1 regular11 parti(ip~illit ill tIteetila~gs of t heir. commtnand coiisiulita iits. Ill order to sihare thiiis
:20 ACTIVITIES 0F MEIlCAT.L ('NSULTANTS

newly found knowledge wit h those who could most, profit by it, Colonel Thompson sent special reports to The Surgeon General on the organization and operations of the British psychiatric services. In particular, Colonel Thompson was

impressed by the efforts of the British to venture be yond tle limits of hospital

practice and to emphasize prevention rather than cure.

The British, on the other hand, revealed that tley -had found much of

value in tihe U.S. Army Medical Department history of neuropsychiatry in

World War I,7 part icularly in coping with t their own early problems concerning

neuropsychiatric activities in World War II. They referred to parts of the work

as a "bible." Colonel Thompson also found it useful as a reference and a

guide in forming policies and organizing units and services.

Current anal*vtical and statistical data for U.S. troops, however, were

lacking. It, was necessary to create, in conjunction withi the Medical Records

Division, Office of tile Chief Surgeon, Headquarters, ETOUSA, special forms

for reporting neuiropsycvhiatric cases. One form was devised for tihe use of

psychiatrists in writing up diagnoses and( dispositions for submission to the

Office of tile Chief Surgeon. Another form was to le made out l'y b)oth the

mfedical oflicer and t lie individual's commanding officer on all patients referred

for psychiatric consultation or treatment. It provided background history

on such matters as convulsive disorders and head injuries and provided special

information desired on flying personnel.

Tle North Ireland Base Section was a closely knit, relatively independent

command. It had an early start in the European theater. Here were marshualed the forces necessary for the invasion of Africa in late 1942. Capt.

(later Lt. Col.) Frederick R. Hanson, MC, working as neuropsychiatric consultant to U.S. Army forces in that command and part-time consultant to

British forces, had coordinated tlie neuropsychiatric services in that area.

established outpatient and consultation services to care for neuropsychiatric

problems outside of hospitals, and was maintaining close liaison with ground

forces in the screening, assignment, and classification of personnel in combat

units and replacement centers. Need for similar services would doubtless arise

in other parts of tile theater. With the invasion of Africa on 8 November 1942,

the exodus of troops from Northern Ireland put an end to most of these particular act ivities.

Hospitals and personnel in 1942.-At tle time of Colonel Thompson's

arrival in the theater, there were 3 general hospitals--2 in England and I in

Northern Ireland-and 2 station hospitals. All the psychiatric wards were

filled to capacity. Each hIospital had one qualified neuropsychiatrist on the

stair, and some had one or two assistants with practically no previous experience

or training in thle specialty. In addition, four partly qualified medical officers

were attendinlg the British School of Neuropsychiatry. There was also one

recently assigned neuropsychiatrist at lleadquarters, Eighthi Air Force, Capt.

17 The Medical Department or the United States Army in the World War. Neuroloychiatry. Washington: U.S.

Government Printingt Ol lier. i929. vol. X.
EURO PEAN THIEATERI OF OP1ERIATIO NS 321I

(later It. Col.) DonaIld W. H astinigs, NMC,3 anl(l onle at tilie headlqiuartenS of the

NorthI Ireland Base Sectionl, Captaint I Ia son. Each hosp~it al hand one ward

for psy* chlit rY, but1 inl Oily.N 01We wa-s there a closedi ward, at mere makeshift.

It wa1s necessaryv to Senld nearly -tll a (list urlbe(l J)s.YliOtiC- patienlts to Brit isil

menta hi losp~itals. T'here were at few nur11ses who hiad had Somie ps~ychuat Vi(

t raininig, blut nione( of tilie wardlmell had hafd aity p~revious experience. PlIans

had alr-eadlv heeul furniishied British cont ractors who were buildling add~itijonal

hospitals for tilie U.S. Arimy~; but for closedl-ward niel'ol)Svchiiatric patients,

these plaits provided for ordvY two small cell-like roomis, designedl withI only onle

small, lbarredl window, near thle ceiling. These roomis were iniconvenientl *N

situlatedl with respect to latrinle andI other ward facilities and the efficient use

of ward attendants.

Ini September 1942, the U.S. Army negotiatedl for thle use of thle Exeter

City Mental Hospital inl Enigland. The hospital was built inl 1885, but, inl

spite of its age, it appeared that it wvouldl prove satisfactory. Onl 23 December

1942, the 1 10th Station Hospital mlovedh into the Exeter H-oslpital. It was

planined to relieve thle 110th Station Hospital with a iueuropsvcbiatric hospital

unit that was expectedl shortly from tile Unlited States.

tpllo review of thle situlation, Colonel Thompson recommendled that all

general hospitals have at ,'ast two separate ps * chnatric wards, one opent and the

other closedh. He supervised preparation of p~laits for the conversion of one

generll11 wardl to a mental wardh inl each general hospital. He was assisted inl this

project by a hospital architect ill thle Hospitalization Division, Office of the

Chief Surgeon, H eadq uart ers, ETOIJSA. Colonel Thompson also submitted

recoinmendhations for the establishment of a neuroses center where treatilentt

condulcive to return of patients to dluty couild lbe rendheredl in anl atmosphere

removedl from the influence of sick, wounded, or psychotic patients.

By- thle end of 1942, two other general hospitals had been estab~lishedl, and

thle 5th General Hlosp~ital had been transferred from Irelandl to England.

Division psychiatrists.-During a visit to the 1st Infantry Division inl

September 1942, Colonel Thompson found that a psyc vhiat rist had lbeen assigned

to the (division surgeon's office a year andl a half before but that the most recent

tables of organization no longer providled for a (division psYchiatrist. Yet there

was evidence of the excellent work (lone 1) *N this psyc vhiatrist inl the 1st Division;

p~laits had even been worked out for his funtctions (luring combat. This sittuation b~roughtt about much discussion b)'y Colonel Thompson wvith other medical

anld line officers onl the needl for a (division lpsy* cliatrist. Ini World W~ar 1, a

similar needl hiad been discovered, and the assignment of one psychiatrist to (eacl

(division was authorized inl early 1918. Although the type of warfare had

changedh, there was ever ' - indhicat ion that a (division psychiatrist would be very

valuiable throughout the long training periodh and that his value inl combat as

well, especiall *y inl thle diagnosis and t reatmeict of fatigue, concussion, andl neurosins cases, seemed unquestionable. Accordingly, Colonel Thompson moit iat ed a

3, Captain hastings waus later teplaced by Capt. (hiter Maj.) Douglag 1). B~ond, NIC. who served until the end of

the war,

56~49l7,41 il -- 23
"322 ACTIVITIES "OF MEI•I'AL ('ONSiIU'ANTS

recommendation to The Surgeon General for reestal)lishiment of tihe position of

division psychiatrist." It was not until considerably later, however, that it

was authorized (p. 344).

This was the first time that Colonel Thompson sub)mitted recomlmenations

for a change in Army organization, but it was not tile last. lie was to finld

that one of his key functions would be the submitting of recommendations for

(he establishment of new tables of organization and changes in existing tables.

Furthermore, the impetus for submitting such recommendations was, eventually, not only to originate from the consultant himself but from other sources

as well.

Summary.-As Colonel Thompson became thoroughly familiar with the

prevailing situation, it was clear that the first and most logical step would be

tile estaablishment of special facilities for the handling of seriously disturbed,

psychotic patients. A more difficult but equally essential project was the

setting up of special wards in all fixed hospitals for both open- and closed-ward

care of neuropsychiatric patients. The most important and apparently insurmountable task was that of providing tihe framework throughout all elements

of the theater to prevent, recognize early, and alleviate the more commonly

occurring neurotic and psychopathic states. In spite of the fact that the

experiences of World War I were fully documented, that the early British

experience in World War II was readily available, and that a working organization had been initiated in Northern Ireland, it was an inescapable conclusion

that the European theater as a whole would be making a completely fresh start.

FROM BUILDUP AND INVASION TO VICTORY

Key Personnel

As the theater expanded and his activities became more diversified, Colonel

Thompson found that lie (ouhl not give all projects the amount of personal

attention they required, particularly special, long-term projects of such a

nature that they could not be established by directive alone and then carried

through solely on the initiative of medical officers in subordinate echelons.

In some cases, the projects required close coordination and supervision by one

centralized authority. In others, one well-qualified individual could carry on

lit project better than many others on a part-time basis. Colonel Thompson

found lie had to rel*y on a few uinusually well qualified and delpendal)le neuropsychiatrists to take tihe onus of carrying through many such projects. As

special requirements arose these few officers were called upon time and again

and were often shifted from one assignment to another as dictated by the

situation.

With few exceptions, these officers condlucted their special project while

still assigned to a hospital unit. In some cases, it was their primary duty; in

others, it was an additional duty; and, in a few cases, the officers were placed

3' Letter, Col. P. R. llawley, MC, Chief Surgeon, ETOUSA, to The Surgeon General, U.S. Army, 3 Nov. 1942.
EUROPEAN TIIEATEIR 1F OPERATIONS 3•23

oil temporary duty with the particular activity they were supporting. it only

two instances were ofticers placed oil duty with the theater headquarters to

augment the professional staff. Maj. (later Lt. Col.) Paul V. Lemkau, MC,

filled in for Colonel Thompson during the latter's temporary dutl' v to the United

States in December 1944 and January 1945. Maj. (later Lt. Col.) Douglas

M. Kelley, MC, in February 1945, was assigned for duty with Colonel Thompson as the consultant in clinical psychology.

In 1942, Colonel Thompson, having in mind one who could be trained in

both neurology and psychiatry, had requested an additional officer to act as

coordinator of hospital neuropsyehiatric activities. Some monthis later, an

officer arrived in the European theater who, alt hough well trained in neurology,

did not have the other necessary requisites for the position. Any further overtures to obtain an assistant were not favorably considered. Colonel Thompson

also suggested the appointment of full-time neuropsychiatric consultants in

base sections to serve in a capacity similar to base section me(lical and surgical

consultants. This recommendation was also not accepte(I.4°

Hospitalization and Evacuation

The policy of providing inpatient, out patient, rehabilitation, anld consultation neuropsychiatric services in all station and general hospitals was adopted

early. It was a policy designed to establish (closer ral)port, between psychiatrists

in hospitals and the general duty medical officer in the unit, thus opening the

door for emphasis on preventive aspects of psychiatry. Sinice the combat

elements did not have neuropsychiatrists as at part of their organization at that

time, this policy served also to take the practice of neuropsychiatry into the

environs where neuropsychiatric problems originated. For Colonel Thonmpson,

the translation of this policy into practice involved frequent visits to hospitals

to make sure that qualified personnel were assigned to neurol)sychiattric positions

an(I that everything was being done, within (lie means available, to provide

adequate facilities, equipment, and service. The most fruitful results, however,

couldt be obtained only through extensive educational and training activities.

Specialized hospitals

The creation of hospitals solely for neuropsychiatric patients was a step

taken with consideral)le reluctance. It was considered extremely iniportant to

keel) neuropsychiatry intimately related to and part of general medicine.

However, the general hospitals and larger station hospitals did not have the

facilities to hold and care for psychotic patients.

Moreover, as tine went on, there wias ever-increasing evidence that, in the

care of neuropsychiatric patients who actually required hospitalization, specialized facilities would have certain distinct advantages over nonspecialized

hospitals. This was particularly true of nonpsychotic patients for whoin there

40 Letter, Lloyd J. Thompson, M.D., to Col. John lloyd Coatles, Jr., MC., I May 1956.
wa a 1 ooti iprmnlgtit)i for! i't-'C()vt.i11d ii et 111,11 1t o useful (Ililt v. t wns2 jm ~i

Il'it :i totilt2 111itiitspiltere t'11)iimdt of ittlticitig, a1 tesire to) retiutrit to (lilt%- Ititt toi bet

ctt'iit t'l ill ortdt'r to) snlvmge Pat itiits Ill t his ('t Iti-wv . II wvits fiit m her a1pparIen It

Ililti ItI orde' ( o'grt'gat (t v mtiii I)5'itt ic1 a111 ni wroi I Ie tI n it'IlelIIvia I m I i v t ii eh pa )ie I Is si

wvell. (wi 'z nt'ie I I Iaw-ltv, t Ie I-(t heatei CI iif u Nigebi.d roon l ti 2ck I I oWldgei t'a IIt lie

Iv for t ht'se I acilit jes 21111 hu it't ilit'l ('outitiiut liing einterst ill their e(stitalsisl36th Station Hospital. Th'lis was.I thle first liteuu'opsYcl it iic Itosjpit iii to be

eist abldishud inlYl( )l. 'SA. ANliei it airrived at Li verpool tat 134 Jimmnnu 1943,.

lie sittinitil wits W1 ItiqIIte ill thlt t is wats i lie oitlv. it(t'iirojisv'huilit rio ltoisliitl aIll

lie theleatoi' ntiI tutiehi latte. ilt thle wall. witeitl uitIs fromt thle N Iedi t errariel ti

let '.were t nillisi 'iiel-rI to ETl( .SA . Tlhle 3Itht Sui tjoit I ltispiit l wats thle

spe('1iI tteuirlolpsVe'li.trii imiit t(lilit 2( Im beeit expect et (1p. :121). It Cn tOIIIlimi itded byIA L. C ol . (Liter Col0.) Erntest 11. 1harsotts, NI d (ig. 11:0, whlo was anl

ex periencedt littit ropsychl 21t ist anit whot liiid lbett Ua Regitlati Anti officer' for' 12

Vi'tii's.

Thit litslitd un itit liati beejilel t ra itit'o itlt ilie Zotte of Init erior it not wals

Ienoldv to fuiriot ioll efficient ly 1pon arlrival. With Iia li611inin1n of stiagung, thei(

lio)sjiitl 211 t')I m-e thtt le I11 t Ii -;tatittion IIosja ti iiat Exet et. Tele (litvs after' its

1ait1%1 vl it the t ltont er, oil 2:4 'Luita i* 1943. thle 36th Ii ttat ioul I lospitali (fig. 114),

ittht1iti t et its first paitiettt, tilt oliotigl t lietir''tit tttitti itsoptig tl

f'ttiu't jtols wils not pubillishitd Ititit 6i (Ilays lat et'. "' 'l'ie tuliit wasIt tesigrun tted its

lt'I liosp)itlkl of (IIOict' fOt' olefittit i e treat utetit of tienrlopsy chltriattt Paltieit s. It

i'eo'e t edjtitit 14 ets ol y1iV f'oii i othIier stlt iol ailt(] get io'ral liospit itis.

All Obvious Proldt'III wa*s presetedt h'I.lowever, inl t Ilint t his tist a1unt1 iou . wit hi

at rattedI :44-bt'd t'2imctitY . wtitilt ntot be tible to iliet't th It' it'tts. of th lt' tli'2t w.

( olotit' I'Thompson iii atle 21 dltt ilt'ie Studyt of prevailit lig jisyt'uiiitri'it raltets 21 ito

thost' of W~or'ld WAr I. FliT'e solut ion tlppt'ai'etld to lit' ill thlit estilbdislintetit of ;I

5t'fmli it e vent eu. for netil totic patIien Is. ( olon el Th'lom ipsoni ni't'soitetl tdint

miit'rotit's who dhidtl itt ret'spondt to I neat iiit'tt illiia short t imeit Shoultd he isdat et I

from thle phusvskitill Ill before s *Viiptonis heemitut toto fixeth. A vt't'tio' for

tlitttflt'Pi pi'lt :Itll( Ilit'at of thlit center' wotultd he ait t'ni itting ('1i ~whetret patit'ii Is

c'tiiltl live a it rul-1 tiiiliti any lift' wit il thrill. lysta t ri-itliittg 1111tl ti, lit' i w.

( 'oitdttl "'l'loitipsoii rt't'tiutivit'tlt'tl t lilt at stilt ioul liospiti211litt Mort'oni I Itilipiuti t with Iit aSiniglt' ovo'rlieatl d1

( itinfrnld I Iawlev sIithit'tl thit i'ecoiliiit'itat iolts t'211 t'fuihlv butt Saw- object iols

to lit' hospit:a1l t \Iorvt'on I lIIIIIpSt ead. "I'hlett wats Somie, tIlt'stloll NvIt't het' it

'1 0irv Ii:r iii L t01r No '211 0 llic, (ift0 Ci c St'iif5ir geon, I Iv;kit (It r I rs. T i~i t'tSA. 2.ý 1:% it. 19 13, su'jtect:I I tostiitaIi:ti Iit Iit'

,,f Nvrirops~veIii~t n I 'Mitits.l

4! 1 othr. Lt. C'ol. L.. J. thrriotiiion ito t'o. I. tC. K imrmririhi. Di.)rector. t'rfvi'Iomil ~'ves. i tititer iif thetiiif ~ur- V I-n livadiqiiiters, E'T't SA, Ii IiFe. tui3. subtject: Ei'Ntimritv of Nvirits for IiiiI ti tm for Nur~itrop hivr'iti c Di

:bit vinETo .
Ic1-:1 1VI1*VAN 'IIVAEA'ItI ViI 4 11VIi'JUAi4 IN.14 ,

Alo t is iiist allatiloll wouldbe I's IN Jiile. awni fii thew :))(;II ýtattioll HolspijtaIl

and~ ( enleral hlawle ' doulbted t hat two4 lI4.pitals tha l*adir ;alir couldll(l eojerat ec elhicienlitv iiiider a siigle (dmlliiit rat ioll. IHe conculrredl III thle Iplali for

C~ll iile~fIacili ties but)11--iU~e-sted thlat anlother 250-lbed hiospit al lbe used l~or

thle liviliroses sect ion.

( oiollel "'Jlioliipsoui bad no ;illeiiaitiveb1)11 to ~zo tot Ihe 8)(th NatiolI Hospital

wil 'ork ouit pialals for thle estabdisliuiient of, a tiaiiliulg1( 1diiie tIli l~Ii~l

BY unlidu-Il~larcl, a t raininig col iipaliv l1.id lbeeli act ivat ed. All A Ir ( orpsca (*;IJ~ IIuI,

whoi( wasi a1 ('onivle's4('it paitientl, was (l'511ig t ciie as it o(l1Iiilailidiil.~ of hicer..

Quart ers were airrauii-ed anld opera ted as ha ru-acks. A rigri , da ily sclledIidev or,

tIuilit ar v act ivitijes was Iitiat ded. Thue progr-aiii also inicludled work details.

occ('lIlaiolai lieraJlv, gr,)i~lJ) (1i541i55i015, iand lill III flrolilat (loll ando edutcationl

activities. 1\~ tlio)It to1(14) hch olifficiili V, .11 atuillosplhiere of1 retlil to) (lit* ~vwas

creat ed ( fig. 11 5). Th'e ret uiru-t o-dultt rat e f'or 11o1l)5.\ychot IC CIaSVS 80(11 rose

1t) oIver 5) per~cent.

In1 Apr)Iil 1943, ( olonie Thiompson50 silb~illi t ed r-evisel est imate s. pi),jvft ed

to *Tatuar ,v 1 944, of I heale ('*Itedos for Iielroj)svchlatriic beds. "'Illese est 111111 ('

('Ii jllihsize(d thle uIeCl f'or a 'larger. bicilit V for uilonsre 5(T015 ol 1 Vlo4t ic cases anud

thle iilliICediatv l' ived for a spec~ial ro'lialilit at 14)1 hosp it al f'-nl ip y1Ujschot ic cases.43

At thle 30 Jjiue 1943 mueet jg 4)1 thle NMedical ( oll"Ill 1ta11 " Subcl)C ml11it lee,

43 ltoter. Lt.Cl.( T.. 1,I. Th iomipson ffo Col. .1. C. Ki:,itr oiiel. Diwetor of Pro~f.-Sioni:11 ývr\ ivvý. Ofltev of lIN, Chiief

Sl~~fevolll' IE'tqj:1 4- l l-jf)U .kO,3 Apr. tl13'ltO iijeet Futurel'( Nvu..s for I Iosp~iluizitioui of Nvmou-r Ncthye i c P:ut fiu t ,lt.
'- -'-.

A

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1tl 144-1)1 I;'1 " II' I 14l ) '1, 41 4c(4Ivll s' :1I II41 ' i 4ll li 4il II I In 1 l I4 ; lIlI ;III (.vl) ' Ifl 'm I I 'lI I s

;n i~ ) v l:el I~h IIii Il cl'l( II :I I : r e•'( k') r I he A s, I I III T r.;I Iit I I,_, ( 'ell I or. I1v
:128 ACTiIVITIE'S OF MEDICrAL CONSULTANTS

(Iirectedl thatt inquliries be iiiat(le iiit() tile 1)ossililit. of' obtatinling huitd ill thle

elivir-olis of tlit( hospital. It wats foundi( thatt grlountid Splice for oultdoor imilitariY

"auth attilletic acetivities wats entirely inaiilequatte 41n1d aidditional grounid couldl

Neuroses center for treatment and rehabilitation

Greneral Haw-ley' haul alwaiys jiiailnttained awt active personail interest ill thet

estalblislilncielt of the neuroses center, anid, onl 2 October 194:3, Colonel Thonipsonl

coniferredl with him oil the( uiiattte~r. ShlortlyN t hereaIfter, it wats sugg'este(1 to

k 'olonel Thomipson thatt at stattion hospital site ait Shughboroulgh Parlk he -oitsidlered for his neuroses center. Onl 23 October 194:3, Colonlel Thom011pson in-_

sjpectedl tile instaldlation ait Shuighorouigh Patrk and round that, there wvere almiost

100 acrles of' lanid thalt. couldl le ilsedl for the. purpose initendle(. Onl 27 October

1943, hie visitedl the( Southern Batse Section andl conferredl with the batse mnedical

conlsult'int anid thle conliiilianling officer of' the 36th Stattion Hospital regar-dinig

p~ersoninel anid other (leftails, anid, onl 8 November- 194:3, lie coumferredl N'ithI chief's

of' various divisionis inl General H-awley's office who wvouldI be concernedl Nvit h

the openling of' thle hospitall.

The pr-oblemns did not end wvith flinding it site, however. Tile 4th Couivatlescenlt Hospital1, which wvas or-1iginlly designaited to be converted into at neuropsychiattric unit and operate the center, wats clatinied for aissiginment to thle

First U.S. Arniv.

312th Station Hospital.-Thiis staition hospitail, at nonspeciailized uinit

which had recently airrived froml tile Zonle of Interior, wats I ele selected to Op)-

cratte the facility ait Sliuigborouigh Patrk. Upoii recoiniinendations iiiit iltet by

Coloniel Thomtpsoni, thle Soutiherri Batse Sectioni trantsferred key iihid viduals",

inicludinig Colonlel Parisonls, from11 the 36thI Stattioni Hospital to thle 3 12thI Stat ion

Hospitail. There wats an adljustiniiet of other personnel so that, eventuatlly,

two neuiropsvchiattric hospitails were iinanied in thle t heater without lbriiigingp

inl alditioniall personnel fromn the United States. The 3121th St ation Hospitail

Wits ofliciaill 'y openied onl 1 Decemnber 194:3, and the first. paitienit wats aldliiit ted

on :3 Deceiiiber 194:3, neairly 10 nuontlis fromt time tinie t hat the estatblisinuenit

of suich ani instaillation wats first recoinitientetide.

The plan of funiction that haid b)een evolved ait the 36th Staitioni Hospitall

wats a1(loptedl. After mlit iall worktip of eatch ciise, with hi ad(ecision ats to type of

trealtielnt, the platieiit. spl~it froni 10 days to 2 wveeks inl the treaitment sectiont.

Following t his, lie wats trantsferred to thle trainiing or rehuialilitaitioii winig, suich

tranisfer beinlg the needled step) between hospitall calre 2111(1 (hlity. Officers of tile

traininiig section were, initiailly, linle officers who iald beenl wouniled l in ction)

inl tile, Nor-thi Africain theaiter. The retuirn-to-duity rate aiveriigedl 80 p~ercenit,

which wats reilnarlkalble sincee tile pat ieiits represeiitetl faliluires received from11

01 her hospi 1,-s.44 Tile, :312thI Staltionl 1IosJit al conitilitied to n11iaintalin t hisrecor-l of per-forriiiinice throuighotit the stilbseqtieiit iionthis of its operattiou5s onl

tilie Conit ineit.

41 Tihompseon, L. J.: Neuropsychiii'iry inl the European Tiheater of Operationls. New Eng. J. MVed. 2.35: 7-11i, 1946.
EUIROIPEAN TIIEATER OF OPERATIONS 329

Holding center for psychoses

96th General Hospital.-To fill the need defined in April 1943 (p. 325)

for a larger facility for the care of more serious psychotic patients, a site neur

Malvern was chosen in August 1943, and the facility was opened by the 56th

General llospital in November 1943; subsequently, in January 1944, it was

oe)crated by the 96th General Hospital. Of particular significance was the

fact that this hosp)ital was organized according to T/O&E 8-550S (Table of

Organization and Equipment) that was proposed by the European theater for

at neuropsychiatric general hospital and approved by the War Department.

As with the 312th Station Hospital, however, the 96th General Hospital, a

nonspecialized general hospital unit arriving from the Zone of Interior, had to

he transformed into a specialized neuropsychiatric unit by exchanging qualified

neuropsychiatric personnel available in the theater for nonneuropsychiatric

Inedical officers arriving with the unit.

The primary mission of this hospital was that of a holding unit. It was

ultimately responsib)le for the care and disposition of nearly all psychotic patients in the theater. The 96th General Hospital was also responsible fo- the

disposition of neuropsychiatric patients determine(l by other hospitals to be

incapable of rehabilitation for duty in the theater. A need for such a unit was

well vindicated following the invasion of the Continent. For example, in Octob)er 1944, the census of the 96th General Hospital was 1,206 with over half of

these patients awaiting evacuation to the Zone of Interior.

Transit hospitals

Forces that invaded the Continent on D-day were provided medical support in the United Kingdom in two phases (fig. 117). First, boat- and airevacuated casualties were receivedt at transit hospitals located along the southern shores or at airfields. Then all casualties were transported by hospital

train or other conveyance to general hospitals in the United Kingdom. In

the early days of the invasion, all casualties, including neuropsychiatric, were

completely intermingled upon arrival at transit hospitals, and the primary

considerations governing their transfer to other hospitals were convenience in

movement and availability of beds.

It was impossible, at this time, to sort patients on the Continent and

evacuate them to designated transit hospitals for further evacuation to a

specialized treatment center, as had been recommended. Triage of neuropsychiatric patients at transit hospitals for transportation to specialized

treatment centers also was recommended but could not be done. Neuropsychiatric patients were surprisingly low in number and their arrival at transit

hospitals so haphazard and sporadic that they could not be grouped together

for a single shipment. The heavy load upon limited transportation facilities

and time necessity of adhering to straightforward transportation schemes did

not permit transfer of small groups of patients from one hospital to another at

crosscurrents to the general flow of traffic. This situation continued for

neuropsych iatric casualties until well into August 1944.
1 II IT TI
I .A

OltIi-i' IS

PI, t 1 .
Trouble~(somelcl('('sequ('ncevs of t his lreyunavoidable sitinat ionl were soonl

to) ailpjeamr 'Ille replacemtent d1epot rep~orted( t hat, betweeni 1)-day andwil 2 fiull '

1 944, m Iore Iatitan 100 neuirojpsvchlat lit patientst 5 in 111 veiell set back to ()dIlt too

SOOti. About half of t hemn iliat been oilne iirolps~ch illt rnc s('rvices ill geiieral

liospit id s, but, app~arenitly thle lpsy'hiiat lists hiad lbeeii too eilt iulsiast ic ill a ppl 'ving their ind(octriniat ion of sendintg pat ients b~ack to (litlY ats sooni as pos'sible.

Th'le remainling haflf Were patients, Who h ad been inlitially v 1 ad n itt ed for at primarlY

(ingliosis othler' t hani I1('irl0 1)5Vhiiult btl~it whose neil rops'.vchiiat rnc symplltomis

ap )lverel ait tihe rep~lacemenet center. C olonel Thlomupsoni had to Visit ats many*

genralVjI hiospit als as,- quickly ats possible iii o)rd er to analyze andl correct thie

sitinati1(11 oil tile sp~ot. C olonel P~arson" was aliso called 111)01 to hll)~.

Th'le general sittnat ionl grew Worse ats tilie tac tical situnat ion grew imore fluid

onl thle C ont inent . By 1-15 Augtust, tw l Thlirdt U.S. Aryhiad joinied the

offenisive, anid tlie first fixed hiospit iils had begunl to est ablishi thiemiselves ill

Normanidy. Before most of thlese hospitails couldl lbegini operatinig efficiently,

they were far out( (list aiiced b~y tilie rap~idly exp~andinjg front. Psych iat ncv

caisilalt ies evftetiatetl froin thle field armies were b~einig shunt ed fromn hiospit ili

to hoslpitaul With Ii 1 t reat ilent excep~t sedlat ion. Evacutatilonl policies t hat

limited holding of patients to not nllore than11 10 (laYs pl'oliihitedl institution of

all.- worthlwhile p)sychiothlerapyV. 'Ilie- First U.S. Army had countered loss of

pernsonniel hby establishiing lprocedlires, onl 10 Juily 1944,' whierehby uieurojpsycllinatric

casilailt l(' could be reassignetl to limiite ml 1tii VWithin th Ile army. H eretofore, a

casmilt Itveit er filld to Ibe ret urned to (hilly WithI his unit or evactiate(1 out, of lthe

arm v. Th'le Third U.S. Army est ablishied p~roceduires for reassignment, of

castadlt hs t~o limnitetl dutty Withliin thle army similar to t hose estalblishied by thle

First U.S. Army. This JpolicY relieved tile situation somewhat but was byV Ito

1VIIeais all answer to tilie greater problem of What to (10 Wvithi those casualties

Whlich tile arm ies the1(mse5lves couldl not1 hiandtle.

Advanved neuropsychiatric units

lit World WVar 1, the Amiericim Expeditionary F~orces hiad found it necessary

to establhishl neuropsychiiatrc mnitls imilnl('iat('v to the( re'ar of the combil't.

ar('a5. IHaving foreseen t he recuirrence of such at situat ion, C olonel Thlomipsoni

had recommended ats earlyI ats ~Januaryv 1944 that a uniit be equipped andI trained'(

to operate as anl adlvancedl unit for rece'ivinig n('irolpsyclintric casiualtihes fronil

at field armiy. At. various t imes( p~rior to thle invasion, lie had rveoinmended

that p~ersonnel1 of the 316th~ Stat ion H ospital, and( litter the :312th~ Station

H osp~ital, he trained( and~ empljloyed for suich at mission."

lit .July 1944, Colonel Th~ompison hield a comiferenice at tended by thle,

( omml~aii(hing Offic(r, ~312th Station Hospital, the D~eputy Chief Surgeon,

ETJOU SA, the Chiief, Planning Branch and the Chief, T 1raining Branch,

"4 (1) l'tter, L.t. C'ol. L. J. Thonip)SOT to ('ol. J. C'. Kinmhrotogh, IDirector, l'rofv.&sional s'rvims D~ivision,, O)flcc of

the ('lii- surgeou,, livaltma~rters. El 0*S A, 26 Apr. 19)43, subiject: P sychiatric Tleamso for Servin Du )ring (Comb at. (2)

li-tter, Senifor ('o,,ulttit in Neuropsychiatry, ElOl SA, to Chiief S:Tzrcvon, ElOUSI.,A, 31 live~. 11)43. m,,hject: I's clilitric

Svrviees in the U.S. Army in N ATIOUSA. (3) Letter, ('ol. L,. J. Tlhomhpson to ('01. Wi.'~ S. I 'i4leton, ('hivf Consultant

in Nlvdiv cine, El' OUS A, ?2 Jan. 1944, sublject: l'syehi, triv Rite srt for Mledicatl Su~i, enimiteev.
EUIROEI'AN TllHEATEII OF OPERATIONS 333

Operations Division, Office of the (Chief Surgeon, Headquarters, ETOUSA.

('olonel Thompson informed the conferees that, from D-day to D-plus-34,

2,012 neuropsychiatric casualties, excluding those with secondary neuropsychiatric conditions, had been evacuated to the United Kingdom. He calhulated that a hospital located just back of the First U.S. Army would receive

some 400 patients weekly. With a 3-week schedule of treatment, 1,200 beds

would be necessary. But such a hospital couhl return to duty nearly 90

percent of the patients admitted-half of them back to combat-thus saving

considerable evacuation to the United Kingdom. In view of these considerations, Colonel Thompson suggested that a 1,000-bed general hospital would

adequately cover personnel needs for the establishment of such a hospital.

The conferees evolved a plan to organize this special neuropsychiatric unit.

This plan was dubbed Colonel Thompson's "triangular plan" by Colonel

Middleton because it involved three hospitals. It consisted of taking a general

hospital arriving from the Zone of Interior in August 1944 and designating

it a neuropsychiatric hospital, filling it with trained personnel from the 312th

Station Hospital, bolstering the remnants of the 312th Station Hospital with

trained personnel from the 36th Station Hospital, and leaving a nonspecialized

station hospital (the 36th) with tile residue of personnel. It was further

planned that the general hospital unit would start staging 1 September 1944,

move to ADSEC (Advance Section), Communications Zone, on 21 September,

and commence to function on 1 October 1944. Tile location was to depend

on the situation, but it was agreed that it should be well forward and easily

accessible from army evacuation points. The scheme was duly presented to

Colonel Kimbrough in a memorandum dated 19 July 1944 and its approval

announced by Colonel Middleton at the next meeting of the Chief Surgeon's

Consultant Committee. The 130th General Hospital was earmarked for this

purpose.

130th General Hospital.-The plan progressed well up to the point where

the 130th General Hospital arrived on the Continent on 4 September 1944

and a choice location had been designated for it at Ciney, Belgium (fig. 118).

A month later, 5 October 1944, Colonel Thompson was obliged to go to Operations Division of General Hawley's office and report that the hospital was

not yet able to operate and that the situation was becoming urgent. The

equipment for the hospital had not arrived.

On 30 October and 1 November 1944, Colonel Thompson again conferred

with Operations Division. While discussing admission andl disposition policies

pertaining to the 130th General Hospital with the chiefs of the Evacuation

Division and Operations Division (chart 3), Colonel Thompson was chagrined

to learn that there was still some question as to how this hospital would function. However, lie did learn, on 2 November 1944 from the Supply Division

of General Hawley's office, that the equipment had been located on I November, was loaded on trucks, and was on the way to the hospital.

While Colonel Thompson was at the hospital on 6 November 1944, the

first truckload of supplies arrived. That very evening, a staff meeting was
IT ACT[\ 441 W II N1L.11 A ,ý 1*.V

i4'ldII4I is pndd id ll I 41dl i f 1111 Ill- 4411414: Iif-I4-. It. 144 4 :1 : l :i \\41 t:4i I 

A14)111 :C u' C iiul I :4 j:II"t~ 114444 11414' 14'.I:Iw ilo ~ ' Ii1.1121

444:4II l a441 hi'' .'14t44II 4lII 11)41 14''441 44I4t'61l!.. T 441)-i l iii I:w4 I 4l4I4rv 

\\I, 14-. (4I:l h il,:1' i''.414 Ii pr )1:41151lo '44~I '44 \\4 14) ,441 \1414 1it 11

( o ma -I 4-'[I4 12M.':4 ~ 'I4 444I t' 44 mil'. I ' Iii )j I~l l he 4 i4I Sii 2 i.-I : '; 14-1,11 :11

-IIi'mi .1: 111114-:1141 nit 1 (11 I'i! m jll 11 ' 1v Im41i S -1411:Il4I 44i 121).I~~ I4I4Ir' 4! 2

,4Iif 'II- ~4IIl 4411 14 11 4 I '-14,11:41414' Il4:4141 . II-I :4 Illi 1114. li 4 *t,1 4l:II 1

\Ivr i it'-.-44 \ f ll 1 1011 ,11 \ 11ý v\dI. 111
EUR0 1'EAN TiI IETER OF ()PERATHI( )S33

CH-.ART3---Flow chart of patienI'v at 1301h General Ilo'Ipilal from adImi.ssion to dis.pamiiion

ADMISSION SECTION TREATMENT SECTION

1. PHYSICAL EXAM. I . CHEMOTHERAPY

2. PSYCHOLOGICAL EXAM. A. NARCOSIS

. PSYCHIATRIC EXAM. 0. INSULIN

4.EVALUATION 0. INGOT

ARMY 0. OTHERS

HOSPIALS I2 . GROUP PSYCHOTHERAPY

HOPIAL 3. INDIVIDUAL PSYCHOTHERAPY

4.OCCUPATIONAL THERAPY

GENERAL HOSPITAL A o SOCIAL THERAPY

I . SURGERY 6S. OTHERS

It. MEDICINE

3. PHYSIOTHERAPY

4. LABORATORY TRIAGE .... ~5. X-RAY 6. LENTm~

DISPOSITION 4-7. DENTAL I . RED CROSS

9. CHAPLAIN I10. SPECIAL SERVICE

I [L LAUNDRY

12I. UNIT SUPPLY

DUTY

EVACUATION DISPOSITION SECTION REHIABILITATION SECTION

I . OFI EALUATON .PHYSICAL RECONDITIONING A. PHYSICAL STATUS Z- . OCCUPATIONAL TRAINING

B. PSYCHIATRIC STATUS 3. ORIENTATION

2. RECOMMENDATION OF 4 . INDOCTRINATION

ASSIGNMENT

Tbe Deput v Chuief Surgeon, (C01. Liston, replied:

We certainly holxe you call. I speak for ailI of xis. These 14 hospitals in UK are

reasonlably up to T/0) strength. I mnight menition that these hospitals are those supposed

to have alrrived1 here ill September anld operating. For reasonls outside our control we

dlon't have themt. If we did have them, certainilv the 130th could operate in the maunler

we in~tenlded it should operate from its inception. The problem is finding enough beds

for the patients we have. As sooti as possible, I hope that we will be able to isolate this

hospital for %%-fat you %%alit to uSe.46

Before the situation could be amended, the Germans struck in their

winter offensive of 1944, known as thle Battle of the Bulge. The hospital

was engulfed iy advancing German forces. Most of the patients and personnel

were evacuiatedl, lbut thle commlandfing officer anl at few volunteers remained

behiind to care for iioit ransportable cases.

According to anl accounit given Colonel Thiompson by Colonel Parsons,

some German officers had( come to the door of the hospital at few days before

Chiristmas. They stated thant thle hiospital wats surrounded and that. the

Germans expected thie commanding officer to take care of German casualties

that mighit be sent there. No German officers were assigned to take over thle

hospital, and Colonel Parsons (lid the b~est hie could and did receive several

German casualties. Onl or about 27 or 28 Dece ' nber 1944, while sitting inl

his office, Colonel Parsons lookedI at his telephone andl dlecided to see if it. wats

still comloected. To ilis surprise, hie was able to get thlrough to somle head46 Minutes of imIeltillg, Chief Surgeon'.4 ConstiltkInt Commiutte, 24 Nov. 1944.
(;i~iIei5iiilA4Ze ti%%.~Is told 14o sit tight I ('Calise Allhied I roop,) woiild s

lbe coniiiig, back t hro4Iiii Hinht awen."

ShIort Iv I I en-hter, 1..troops re-zaiiied (lie area1, andthe lie ospital acted

.I.l a fiid~~ti 14 tdeata hospital o lop11 for tes tllý( mIops iiioiliuitiii t liv

co11 Ite ro IfleIsI, Ve.

On Gu anid 7 Felariar I94, Co~loll Thomponij51 agIin ispected t Ills hiosTpitaI1

.1i14l foundIiIt hat II %%as act ilig, us n statollo hIosplit l for t lie I I 11 RvpIncelliilii

l~eot IIeajaate's.Al sE '.atl ueaihv Ai h~ceiiitalation.Thie venflsI

ws1.2-12 pat Wlelis, of w hich oi[ * v 9 were nivnI Iro psvc~a rl. Oui the afteriiooii

of 7 Fveluiarv the( commiiandinhug oh licer. of thle hospital 11i4d C olone'l Tlhomipsoni

hiell a1 c fl-vi lelce witl Ci(oloniel L~istoni andl 11t Cl( llef, ~visioni. Dici~Iio 

( )lice of tile ( 'hijf ,-;III--oIi, I l-ad'llqaters, ET U SA. Tliv delsire to rtuii

the hospitl: to Its priiiiarv1- fiiuict iol euie to be well ninidertstool, aii1(I coopera*:-

l ion lowarli this 411(1 wa roillisell. B~ill Iwo weeks later, ot her hospitals

Ill close j~oiniVto t l4e 181,)1Iil ( eiieral IHosp~ital er receiuiit I-iuviir

uieiir1opsvYcliat lif patieuits I than I lie 130th Geleniea I lospitl.d Ohli NIl lrcli,

.1 COuifeeli41ce %%-.s hteld wih thile chief of the lvaclatioll D~ivisioni oil this uiiatlter.

Alt hil('tlZi Ilie was alot VeiwoptIiiiisti. ahbollt t lie 1se of t his sjpecialifzed nIIeIiohlsvchl at1 nc hlosplital, owmi lto t raiisjortalt ll dlificiltieis, lie agree-d to issue14

ii3il3.
(: lo 'PI :A 14J I TI 1:I. A U 1'41111 Il

IllrI. II4I~l1,44I 'lllle 4)4I :1S4114'' ii) 44 114'12114 ('IeI:4 I44'-iIll

lI4'~Jil:I. i'2iii11. 1 -\ h:1ll11:14ic -. \)~ '' (rim 4 14 ;41 1114141441 4114 11 14

[Ac p114':Ilql I'.'I mil 1414 1 1:11 d M:4t 41AI4I ['.S.44 : llijllr- 441il 11' h114 ' e.141 'lll I() Ow :11444ll

111:41 :411o thelI4)'~Iill 4 F1:1-14V-ll;. Ar4liI\.Z 441:11 he 11:14' I'i ll'S ;41141 %iIl Ii41111

:4 ilt 4 ' 41 4 11-14 I~iicii- 114414 1114 14 1 44ll 1eled114'l~lo 111114 '4l(I 1 I4 1j1l:I ~ m4 ill. 114

He 4'mmi441 l:i41 th ll 4 Ow i' 44114 1114'11u oŽ i Ii ceI ." t~l~ c :- s' 4'lI. \6 1141 III'4'411 iI't114'41

AD114' 1:44'! I 1iI :iJI :114-'mlis~ 1o c 11:1d II41\ Cm':41444' flu Olff1. I cc4 S 1144' S I):'l:4 ,l .(11

114)j41141 :1141 ll 4'l' l :4r 4 11' 111 a 4'l .l -l e ( ll ' 114':1.11 l all p;I11:41.

f4mi Hit 7'lL 1 .1ec -I( \ )lq l, 1a l lc - ' 11c l h le ];ll e l r
.4* 4

Visi ting thle 81 t h H osp~it al Ceinter, lie founid t here, too, thfat tilie comlmaiildilig. officer, Co0l. R~obert B1. 11 ill, MC, aind hIls evacun t ionl officer wvere ill

compi llet e lý-ei-vInveat withi thle niecessityV of Ira iisferri h ll" 11 iel ro psycl datrnC

pat ient s to tilie 130th Genieral H ospit al. Ill fact, Colonel Hill was anxious,

to etitle , t i iiis ect oio of tilie I30th IiGeneral H ospit al firmly. est ablishied

aind opelat llg So thlit tilie (lint can which hadl hveei designa1.ted for tilie trainliiig

sectijon of thlit hiospi tal wouldl not be lost to tilie M edlical Departmeneit thlroughi

lack of use. Coloiiel l1111I stated liat Ilie had a1 Ilarge bus thlit couldIl e u1sev

fo iusjotii ptjet t leI 0 I 1ue'.1I Hospital. lHe also remarked

that thle I 30thI ( ieiiei'a 1lospi I aI was uisintg. its ownI tranisportationi to take

pat ieiits to tilie rep~lacemienit dlepot nevar I i(~ge dalily, aiid thieie WUas 110 Ieasoli

wi liv t his t ra lisport at loll could iiot be uised( to take iieulrols ('vhintnc p~at ieiits

fromi tilie 81stIil Hospital Center to thle 130th General lHoslitali.

Fiinallv, Coloiiel nloiipsoni visited thle 28th~ aiid 50tht Genieral Hospitals,

Liege, BegirV 11111, a iul t lie 29-St Ii Genieral I hospital. These wvere part of t lie S I St Ii

H ospi tal C'eniter aiid were rece lyingo tilie bulk of iielfrolpsychl atr ie cases ill tilie

ceniter. Thiev dlid lnot have a very* clear pictutre ol tilie relat ionishiip of' tilie 1:30thI

G eiieral I Ilosp)it al to tilie ceiit er. Whien tilie Situta tion was exlpla i iie . t hi~es

fiospit, ;iS promiiisedl t heir. 1,1111cooperat Iion. Durn g Owli course of I hise visits,

it was leariied that tilie 8181t HiIospital Center did( hlot hld pat ieiits over It)

(lays, whlichi was an11 addeI 11-rgulIleiit for thle use of' tilie 130(thl Gciierl. h~ospitall.

These effbnt s by C oloniel Thom psoin brouight iesiilts. For tilie, first t iiiie

siiice tilie hospital lbegai(rl;era o ug ii'iiotse ii c admiission beganl to ex-
ceedl all otherics. Thtis con tin tied fiii rough tilie last week ill M\Iarch a Ill( most. of

A prll 1945 (figs. 124 a id 125). By that t iiie, however, thle IronIlalt hagamin

so far oil t (list allced thle g-etieral liospit als t ha t ordferly evactia tionl to the 13:ithI

( 'enleial H osp~it al was nlot app~ropriatIe ill 111,1a nv cases. At thle samle timhe, the

emphasis ill tilie t heater clialig-edl 110111 fiat of savig- kirld ref aial~itat iii" manlpower' to tha bo(1 k.., elm(1111d e.ciatjug pa Iielit s to thle zonle of* In iterior. as

1*U pidl l as poss5ible. AccOr( Ii ugly, patIillilIs wvere ibei Iig flowni to hi uge ceviters

ill anid abou11t Pa ris (fig. 1 26), hypassiiig ut erveningii h ist ahlalionis (p). 457).

51st Station Hospital.- The( -51st St at ion H ospita~l was a special tieliropsychiaric unt which 1i1(d lbeeui orgatlizedh inl NorthI Afri-ca mid had worked

its Way up I ir-otigli Italy' . It camne Hito thle European t heater inl Novembier

1944 as a hilly equipiJped atid( efhicienity Nvworkingp ulliit with muchl(f eprine

Wbeiie Colonel Tliomipsoni visitedl thle hospital onl 29 Novemiber 1944, it Was

located at Dijoni alild was rece,(ivl~ ingilelrofpsvchiiatrnc patvielits fromi thle SevelithI

I1.5. Arm iiv anld a lim1ited nitini her f'loiii thfe Tfiird U.S. Arnillv. Colonel1 Tlioiiipsoil thiotili t1 it would be f'easible for th fi5.1st Stat ionl H ospi tal to rece.(iN*e iieiiro1-

Jpscfitn pat ieiits (firectilv fromui )0 i, rfiiini ili(I seventhit u.s. Akrmiiis. I,,

that wayv, thle fiospit al cotilid hperf~ol-ii a1 inissiol idueii tical1 to thfat of'I tlie 130th

(;(li(vi'al H osp ital for thfe Fiirst amid NiiithI U.S. Ariiies. The fhospit al, fioweVer~,

WaIS aIlrema , v q litv far '11 th 1le learl.

( ofoiifLeli h'viial, actilug. for Colonlel Tfllioliol )511 (fllnli tilie hitter's Iveli'porar *v (lilt ,v inl thle Uiiited St at es, at temiptedl to iml felielit I his plali on a firmier

basis. The Support of' thle Siurgevon, Soii tfierii Lilies of' ( olli lii llica Iioli , was
:1I) 10'lIT IiES M1., MEIII(A I (I )s. 1t,[1.AN Is

o)Jlainvei. OnI 29) JDecniber 19)44, (t(li 51st St at lol H ospit al was mioved up to)

Ilitit (',-IllIe. Neverthleless, it was5 never. (lose eltotigli to thle arliti1es; it %vas supp~orting, for. (t(l efficietit dischiarge of' Its muissiont. Netirops ,ycitiat tic (astialt ics

(101l1d not he evaictia ted to It Ill Ille mini he1rs plIannued. F'urthlermoire, IS WithI

the ]:)))(t Gi(eneral H ospital, the miission of, tw li 1st Station I losjpital1 was

dvlei(elv al1tereldurn the ( ernialm winiter ofleutisive. Surgical teamis wier

ait taclied, Ulid~ lie hospital's miissioni l)ck;ili(' stirgical.

lII(' est ililishlilig' of, sfpeciniliizedhosp(Jit als hI'm thle care of' lIv~irlopJ), chli1t nc

ta Ilen Iswasa I etuejilois Jojeý(t refurii reat effo)rt l3V all colTIAenicil

11,1cic esta1blished andi~ opera Iitug as I)Jttiellv, 1 liv jestults wvere wel(,l %voit Il tOli

effor)tt iwvl ow%-iu(r to tIlie- tact*ical sitiha t iou, t hey cotlold hot nl wavs be uised

w, tintendoed. lDifficulltieS ('flcoitttel'ed Ill establlishiing t liese SJpecialiil f'.tcIIlItis

WVere litIIst rat ive o' t lie t ype of' pr'obletnIIS ittet ill tIe gettea ra fIopiai

ti(3ii and~ evachiatiloll. Ill addoitioni to specialized f'acilities, Colonel Thompson

waIs IinVolved. Ill planIIining aid( eýst aldishijug- policies Ior evactiatjolt anid liospita;lizat ioul of, netttlopsvchiiati n paitients wit hiiii fieldl tittits, (3;to an fr'omi ot her fixed

hospitalls, and f'ronl thev t heater to the ionvo (3 Interior. The latter wans, at timtes,

a1 part ictII'la- rIdoifficitlt probllemu. ( ertiiili aspects (of' t lie l1iatuling of* neirilopsvchnialtI c pat ictts Il in h Iielhuits duigcombhat arev disculssed l tiider thle hevading that iltillviie(itclv f~ollows.
EUXR I'IEAN THIEATER OF OPERATIONS 341

Neuropsychiatric Services With the Field Armies

It was necessary for Colonel Thompson to have at all times accurate

knowledgge of the state of mental health of all troops in the theater and of what

was being done to maintain mental health, for as an adviser in his speciialty to

General Hawley he had to provide dependable information aii(d to submit

appropriate and timely recommendations, either on his own initiative or in

response to specific direction by his superior officers. As a staff officer in tihe

hea(dquarters of the theater commander, it was also his (lutv to supervise

activities within his special field in all subordinate echelons to insure that

established theater policies, procedures, and (loctrine were being adhered to and

successfully carried out.

In accordance with the general responsibilities and duties of a staff officer,

a consultant did not exercise command. He could not lawfully give direct

orders in his own right to commanders of subordinate units. However, as an

officer on the theater Chief Surgeon's staff-and in exercising staff supervisionhe was bound only to stay within limits of the policies and directives of the

theater comman(ler and the technical (medical) doctrine established by General

Hawley. Inspections and visits enabled him to observe activities in the field

and offer on-the-spot suggestions for correction of any deficiencies observed.

When changes in technical doctrine or establishment of new doctrine were

necessary, lie couil make appropriate recommendations for their adoption to

General Hawley (thirough Colonel Middleton and Colonel Kimbrough). When

it was found necessary to issue orders to commanders of subor(linate echelons,

he could again submit specific recommendations through his imme(diate superior

officers and General Hawley. Upon approval of his recommendation, Colonel

Thompson was usually called upon to prepare for General HaN\ ley or the theater

comman(ler, as appropriate to the case, proper directives implementing their

decisions.

Field Army psychiatrists.-IIn his day-to-day dealings with the Armies,

Colonel Thompson found it expedient to use technical channels. His technical

(hannel of communication with Armies was through the consultant in neuropsychiatry to the Army surgeon. In neuropsychiatric circles, this officer was

commonly referred to as the Army psychiatrist. In a letter, 8 July 1944, to

Col. (later Brig. Gen.) William C. Menninger, MC, Consultant in Neuropsy'chiatry to The Surgeon General, Colonel Thompson described his relationship with the Army psychiatrist as follows:

In one of your recent letters you asked about the Army psychiatrist. I presumed that

you knew about this since they arrived over here already appointed in that position. Ilowever, Lt. Col. Srodes did replace the psychiatrist who originally came with that Army. The

Army ipsyehiatrist is the only position between mine in the Office of the Chief Surgeon and

the division psychiatrist, lie acts as Consultant in the Office of the Army Surgeon, and

s.Upervises the work of the division psychiatrists, as well as the psychiatric services in the

evacu.ation hospitals, and the special N.P. unit. I can report that we have excellent men in

the posit ions.
Ply i~ III -r p .
D IlET-toFME A IIS
344 ACTI\VITI.ES O)F MEDICIAL CONSULTANTS

During the major portion of' ihe fighting iii Europe, the Army psychliatrists were: Colonel Srodes, First U.S. Army; Maj. (later Lt. Col.) Perry %C.

Tralkiimgton, MC, Third U.S. Army; Maj. Alfred 0. Ludwig, MC, Seventh U.S.

Army; Lt. Col. (later Col.) Roscoe W. Cavell. MC, Ninth U.S. Army; and Lt.

Col. (later Col.) Joseph S. Skobba, MC, Fifteentli U.S. Army.

lit lie early (lays of tlie theater, a vigorous program was embarked upon to

carry the principles of preserving mental hiealth to men and officers of the line.

Withi tlie conicurren(ce of tile First U.S. ArImy, Colonel Parsons spent considerab)le time and effort to carry out this program. lie lived withi the units, hell

daily instructional periods, and joined informal conferences among the officers

in tile evenings. The work was carried on later by Colonel Srodes. When

division psychiatrists were appointed in late 1943, much of this activity was

passe(i on to them (p. 321). Guidance of' division psychiatrists and of generaldility medical officers, as well, was effected through the Army psychiatrist and

formal instruction at the school of neuropsychiiatry estab)lished at the 312th

Station Hospital in the United Kingdom.

Tactical organizations and units in North Africa.-Thie inadequacy of

plans and preparations for neuropsychliatric services, partic'ularly in tactical

organizations ani( units, was suhddenly placed in sharp focus when final prepmurations were being inade in October 1942 for the Northi African invasion.

Except for the unofficial and opportune presence of a psychiatrist in the 1st

Infantr Division, it was evident that psychiatry would be represented no

furthier forward than general hospitals. The 400-bed evacuation hospitals

had a table of organization position for a neuropsychiatrist, but no such units

were in tOe theater at that time.

At the suggestion of General Hawley, Colonel Thompson visited Col.

John F. Corby, MC, who had been designated surgeon for U.S. forces involved

in the operation. Colonel Thompson advised him to consider more seriously

lie prol)lem of handling neuropsychiatric casualties and urged that lie take

along a consultant in neuropsychiatry. Colonel Corby did not seem inclined

to accept Colonel Thompson's advice but (lid say that, if the need for a psychiiatrist developed, lie hoped that one could be provided the force. Colonel

Thompson assured him this would be done, and lie discussed this eventuality

with Captain Hanson, Colonel Parsons, and some other psyc'hiatrists, as well

as with Colonel Middleton. There was general agreement that Captain

Hanson, because of his previous experience, would be the logical one to go.48

The invasion of North Africa took place on 8 November 1942. Not

long thereafter, on 21 January 1943, a cablegram was received in the European

theater from tile North African theater, rea(ing: "Select competent psychiatrist

for assignment to ABS." It was brought to Colonel Thionipson's attention a

few days later. Conferring with General Hawley, Colonel Thompson proposed his own name along with that of Captain Hanson. General Hawley

selected Captain Hanson for the assignment. Prior to departing for North

"41 See footnote 40, p. 323.
EVIOWEAN 'I'll 1-:ATI-:I, I)F

-x, -

74,

Fit;( m , 125. If-lw hili;;iIiqm 1::IIll

pil:11. A . if \\:ln k . It. P:11i.-Ill- ill
:1-16 ~~~~~ACTIVITVIiES OF' M EDICAL (4)SLAT

~A

Al .~. I4,

'>4 4

Fi~o 1(1:125. C.:1111-1) C milmic~. 
:1 I .\N NI' I A I I" k\ I I I F l';1:1.\' AT INqt1

r S,

',/1

S!1IL
sub

ýIJop if) raio tl-rpatir.
125.
.'4
EUROPEAN THEATER OF OPERATIONS 351

Africa, Captain Hanson met in conference with Colonel Thompson, Colonel

Parsons, and other neuropsychiatrists. Out of these conferences came a

tentative plan for the organization and operation of neuropsychiatry in the

combat zone, the soundness of which later developments confirmed in many

respects. The plan also contained a proviso that detailed recommendations

of diagnosis, treatment, and disposition would be forwarded to Colonel

Thomnpson after further study under combat conditions.

In November 1943, Colonel Thompson was given permission to visit

the North African theater. He departed on 13 November 1943 and remained

in North Africa until 15 December 1943. There he studied U.S. Army records

and statistics, observed neuropsychiatic cases within a few hours after evacuation, interviewed medical officers, and visited clearing stations, evacuation

hospitals, general hospitals, and a convalescent hospital. He studied Canadian reports and statistics, interviewed several division psychiatrists, and

observed the Canadian 15th General Hospital. He conferred with the British

adviser in psychiatry, interviewed British corps psychiatrists and observed

their corps exhaustion centers, and observed advanced psychiatric wings

of general hospitals, general hospitals, and casualty clearing stations.

Upon his return, Colonel Thompson submitted detailed reports on his

observations of United States, Canadian, and British forces in North Africa

and Italy.49 He also made recommendations dealing with the function and

training of medical officers in line organizations; indoctrination of line officers;

selection, appointment, and training of division psychiatrists; organization,

functions, and training of neuropsychiatric personnel in evacuation hospitals;

establishment and training of a cadre for forward neuropsychiatric hospitals;

hospitalization in specialized facilities in the United Kingdom; and the rehabilitation and return to duty of psychoneurotic casualties. In these recommendations, he stated that such matters as methods of treatment, evacuation

procedures, and diagnostic terminology should be explicitly set forth in directives, but the indoctrination of all personnel in basic tenets had to be

accomplished through formal courses and personal informal contacts.

Colonel Thompson's recommendations were published on 6 January

1944 as Circular Letter No. 2, Office of the Chief Surgeon, Headquarters,

ETOUSA, subject: Early Recognition and Treatment of Neuropsychiatric

Conditions in the Combat Zone. At this stage in the development of the

European theater, the document was most succinct, yet comprehensive, and

remarkably prescient. No need was found to change it during the period of

combat operations in the theater, and much of the material on diagnosis and

treatment was later incorporated in the Manual of Therapy, European Theater

of Operations.

4' (1) Letter, Senior Consultant in Neuropsychiatry, to Chief Surgeon, ETOUSA, 23 Dec. 1943, subject: Canadian

Psychiatric Services in North Africa and Italy. (2) Lctter, Senior Consultant in Neuropsychiatry, to Chief Surgeon,

ETOUSA, 31 Dec. 1943, subject: Psychiatric Services in the U.S. Army in NATOUSA. (3) Letter, Senior Consultant

in Neuropsychiatry, to Chief Surgeon, ETOUSA, 31 Dec. 1943, subject: British Psychiatric Services in Middle East,

North Africa, and Italy.
352ACTIVITIE*S jIF MEDICAL. CONSULTANTS

Exhaustion centers.-However, the most pressing Probldeml'it this titte

was tilie Provisioni for neuirops *vchiatrnc services behlind tilie dlivisionis. IIn

NorthI Africa, two smnail stat ioni 1105fitills were uisedl, wltiilh livid patients for

ziot over 14 (Ilay:s. Thiese hospitals. wvInchl receivedl patienlts (lirectly froml-11

evactiat ionl hos'pitals, 1i0(l ret uniied over* 60 percenlt or* ti hem to ii11Oib~lat (hlity,

inl base sect ionls. witereas ot her fixed hospitals l111d retulrnied Over 60 Percent or

hieir &Ielurol)s "vchiatrie patienits to thle Zonie of' Initerior. Whiei M\ajor Hanisont

visit ed thle Euiropean livthater inl mid-January, 1944, at confeorenice was Iiel(l wvith,

Colonlel SpI'1iit . Ill attendlance were N\11jor Hanson, Colonlel Srodes aiid Colonel

Thiomipsoii. Major flaiison was very inifluenitial inl slIOwiiig tilee need for special

neeuropsyclua tric faicilit ies b~etweeni evacuiation hiospitals amid( genieral hiospitals

inl thle rear. Colontel Thiompson suiggested that Jpersomincl could be trained

atid made availab~le at the three neuropsYchiatric hiospitals inl England and

suchl a special hlospital could be broughlt hito exist eiice when tilie nieed arose.

Colonel Sprulit was cotivi nced that a special forward neurops 'ycliiatriec hospital

was needed, but lie was of thle opinion t hat it should be a field Ilosfpital tlmnder

armym control. At any A rate, thiere was conicurrenice inl thle general Principle,

andl thle way was openled for1 further plannliing.

At this stage, Coloniel Thompson felt that the evacuiation hospital with

its organlie nieuropsvcliiatrnc facilities andl per-soinlie should (d0 all inl its power

to treat and ret urn neuiropsycliiatric casualties to diuttv. The add~itional

hospital thalt hie was proposinig was to take care of' patieiits the evaculation

hioslpitals could not send back to dtity and for whom thiere was good prognosis

for quick recovery. Apparenitly, thle First U.S. Army did not want to chanige

its prevaliling Practices inl thle emlployAmenit of its hospitals, anid thtere were no0

field hospitals available for estalblishiiiig hiolding facilities for exhaustion cases

ts ('omit emjlat ed bY Coloniel Sprulit.

At tile Mledical Coiiisultantts Subcommittee mneeting- of 2 'March 1944,

Colonel Thompson was able to report t hat thle b)asic principles had now receivedl

full support of Genteral Hawley anid that anl apparenitly suitable compromise

measure liadh been readlied. Whlile ('olitinluilig to enitertaimi tilie possillilit * of

usinig at field liosJpit al, thle First U.S. Army hiad decided to make a 250-bed

nieuropsYcina trnc liospi tal b~asedl onl a separate clean nig companly reinforced bY

iieuropsv('luatric personnel from evacuiation hospitals. This meant thlat early

treatment would be carriedh ott inl this special hiospital at approximlat clY tli~e

samne level of evacuiation as thet evacuiation hospital. Theo onily objectionl t hat

Coloniel Thompson saw to this plan was the fact that thle neuiropsvcliiatric

casuialty, would hiave to go thirough the evacuiation hiospital before gettinig to

thle Special nietrops~ychiatric init , and~ lengt heninig, by that much, the chlainl

of evacuiationi mid~ (elayinig earlY treatment.

The First U.S. Armyv made thle invasioni onl 6 June 1944 and two weeks

later had estalblishled two' exhiaust ion centers based oii Colonel Srodes' plant of

reinforced clearing compaiiies. Colonel Thompson 'wrote to Colonel '.\felnihiger on 8 July 1944, as follows:
EURO'PEAN THEATER OF O)PERATIONS 353

I note that the special N.P. unit, which was made up from a clearing company, and

called an "Exhaustion Hospital" is functioning very well with the army. Patients returning

to this area have come back well treated through sedation, and approximately 90 percent

had the term Exhaustion on the E.M.T.

On 3 August 1944, Colonel Thompson wrote:

Bill Srodes, the Army Psychiatrist, is keeping a cool head and is extremely helpful to

the Division Psychiatrist. His arrangement of filling the two exhaustion centers instead of

psychiatric services in Evacuation Hospitals seems to be working well. I should like to see

another good try at the use of Evacuation Hospitals before I would say that Srodes set-up is

better.

When Colonel Menninger visited the theater in September and October of

1944, it was generally agreed that the centralized exhaustion center provided

the best service. Before Colonel Menninger departed, Colonel Thompson

promised to submit detailed recommendations on the organization and equipmeat of an exhaustion center. On 11 November 1944, Colonel Thompson

wrote to Colonel Hanson, as follows:

On the last day of Menninger's visit in this theater, we spent most of the time discussing

the question of the best Army N.P. unit. * * * we carne to the conclusion that the

Field Hospital, with its three platoons, seemed to be the very best arrangement that could be

set up. Colonel Menninger was going to recommend this through his office and I have

already put it in writing for this theater. IIowever, we have not gone into great detail

about Tt() and T/ E, and your information along this line will be greatly appreciated. Eventually, it is hoped that a definite and separate N.P. unit based on these plans may become

a permanent fixture. But, as we all know, this will take a great deal of time.

Since Colonel Srodes had beeni concerned with the planning of these exhaustion centers from the time of their inception in the European theater,

Colonel Thompson visited him on 8 February 1945 and discussed the matter

further with him. Colonel Srodes agreed to submit a detailed table of organization and equipment which the theater believed should be considered a permanen t War Department organization.

In other armies that eventually fought, in the European theater, psychiatric

services behind divisions were variously hanidled in the absence of theater or

War Department specifications. The Third U.S. Army kept its psychiatrists

in evacuation hospitals, as originally suggested by Colonel Thompson, but had,

in addition, a convalescent hospital to take the overflow from the evacuation

hospitals. Colonel Thompson thought that this system worked well for the

type of combat engage( in by this army. The Seventh U.S. Army use(d clearing

companies to set up two exhaustion centers in the same manner as the First

U.S. Army and had indeed used this system in the North African theater even

before its use in the First U.S. Army. The Ninth U.S. Army set up one exhaustion center using a medical gas treatment battalion augmented by psychiatrists from evacuation hospitals. When field hospitals became available, this

army immediately put them into use for the holding and treatment, of neuropsychiatric patients in the army area.

564970'-- 61--25
354 ACTIVITIES OF MEDI~CAL CON'SULTANTS

Rest periods for the combat soldier.-Anothier matter of great moment to

till cofllhat forces ill thle t heater wals the concept of using,' rest periodIs for inidivi-

(duail So1ldiers andt uniits as at motivating faetor ili Preventing loss of manpower

front ps 'vchint rw dIisordecrs. The imipettus for this idlea arose inl a report from

The Surgeon (}enerdal. Ill sober, maltter-of-fact language, the report pressed

honie thle point t litit, unless anl infant ryman is motivated to look forward to

a "blreak,'" lie has nothing to look forward to but, ''death, mutilation, or ps~ychiatric lbreakdlownl." Citing dlata from experiences of the Fifth U.S. Army inl

Italy, the report showed hlow a soldier inl comb~at wore out ''just as anl averagre

truck wears out after a certain number of miles.'' Obviouisly', tile probleml

was how to get this informiation translated into appropriate action. 'Most.

ps 'vehiati'istq or o1ther ifledical personnel realized thlese facts and lhad been trying

w~it It varying degrees of'success to apply tIthem inl their units. The approach now

chosen was most direct and pointed. The Surgeon General's report was

appropriately edited to include only those facts that wvere of immnediate concern

to a commnander of a unit or organization. A terse, forwarding commandi letter,

dattedl 4 October 1944, emanating fromn the theater headquarters readl simnplyi :

" It is (lesire(J that copies of the inclosed extract from at report of the Office of the

Surgeon General be furnished to the commanders of all organizations (do Nn to,

and includin g, regiments andl simiilar unlits.''

As thle st aff officer of thle thlea ter most, (directly concernedl, it remlainedl for

the theater senior consultant inl neurops 'vehiatrv to ob~serve how tile stilted

principles were being carried out, supervise their: imuiplernientitioll where applicab~le, alin t recoiliimenld corrective action whiere indlicatedl. Colonel Thompson

visitet(I the recreation center of the XIX Corps inl Novemb~er 1944. The

center uiseth five smnall hote(ls located in Valkenburg, Net herlandts. Toget her,

they iitconliniotlatel :300 enlistedl nifel tand :34 officers. Men camie for 48 hours

of r:es-t duigwhich they were mlore or less oni their own. Ample opport unityfor recreatilonl as well Its bathlung and~ getting new clothles were provided. Neillutltal (pen tobtirbit al Sodlium) was adiministeredi thle first nlighlt, if indhicat ed,

lbut, otherwise, no nic(lical treatment wats carriedi out. The center was utinder

tilie control of line officers, hut at nIedical officer wias ill at teiilaiice.

I~rgt his samile -visit to units of the( Ninth U.S. Armyv, C'olonel Thompson

Inspected the( recreation ceniter of the 30th InfanitrY Division, which wats

located inl at large mlonlastery' in hKolilschieid, Germany* , and (coul1( house 1 ,000)

to 1,200 iiien ait one timie. -Soldliers ctinie for 48-hour periodIs. At thIns rate.

it wa-Is est iinlt ed that combhat troops could be rotatedI to t his cent en evýry *3 1

weeks. lin fact, ait the tine of C'oloniel Thompson's visit, the( first grouptI

have visitedl thle ceniter had returnedl for its second visit. There were not

enough bedIs for aill of themn, and1( sonie inea had to sleep onl blankets onl tlie(

floor. Inl adlditionl to at mledical officer, there wa-is at denitist., anid I lie Iiienl hadt

ati 01)1014tin it, to talk to at (huilplain , at finance officer, and at represenitat ive of

the judtge adlvocate. The soldiers had at chance to bathle andI get (dry clot lis.

Al Monthly l'roirress Report, Army Service Forees. War lDepa.rtmi~nt, 31 Aug. 11144. Section 7: flua~lth. (C'olonel

T1homipsoniwsas wr rh eeisgie in World W.arlIweedvsoswr eivi in turn (roin trench w~irtrire.)
I1~O AEI I OPElEN'Il RI:ATrIOINS 30")

it (lance b~andl playedC at (mcli nueL. The p~lain '.ms shiiilm- to dunoe emplo-ed

bY ot her divisions in thle XIX C orps.

These and similar visits, plus iniforniat ion fromt other Sources. indicated

t neved for more commonii undi~erst anding of thle p~rinciples involved and a st anda~rdizedl program of rest for infantr *v (divisions througlrourt thle t heater (fig. 127).

Accordinigly, onl 14 November 1944, C oloniel Thomnpson recommended that

'omimand~ act ion b~e takenl to imiiplemen t suich at St and~ a rdized p)rogram. Colonel

K inibrouigh rcoIIMmenided approval of the Phlan to General H awley. But onI

tins atid inumierous ot her occasions, aill Plan sug~gested, collidled irliimedIia tel '

wit It t lie object ionl t hat t here was at serious short age of manpower in tIfle combat

at rells. III his capacity vas thle preventi te nied icinie officer of thle I 2thi Army

Group. (Col. Toni F. Wiiavle, NI( , did everythIing, Possible, ait his level, to

arranige for uinits iln t hat command to have sonme relief fromt thle ardors of

(const ant, ('omiitt. It was an uphTi fight ."'

Special Projects for Nonmmedical Agencies

Behiavioir vairies fromt ''noninal",' well-ititegrat ed adjuistiluent ait, one pole

to thle (disin tegrat ion of thle Psychioti li t thle ot her. It is a1 cont iniuum which

cannot be cuit up1 inito t ight nosolog-i(al groulps. Accordingly, it wa-Is impossible

to draw a1 line whlichi a bsolu tely Separa te C(Iieln rofpsvchlk itrnc cases fromt t he rest.

At broad line of (list inct ion 111(1 toblrbitralrilyv (rawni. The mlore olwions

nell rolpsv(' ll at in' cases wvere funnieled jinto 0ed ical chla I ris anrd camei wvithiml

lie purview of thle M edical lIepart lietit, while nigelicie (ither t han rued ical

oft en inivit ed thle concern of thle theater senlior coiisult ant ill mietropsvchiia try

ill thle mlore bordele]inte cases. The types of cases in volved were inl th lient ure

of men tal def icieincy, inaupt itudl~e, instabililityV, r1ilnor 1)svch 101iei r'o5se, and~

pathIologic persotialit y typies. Manly of thle patients mnanlifestedl no niot iceab~le

org'ali(' or- functional dIisorders,' him r'equiired medical consultatint O to eliminate

this fpossih)Iity. L at er, (cert aitn combait -exliaust ion cases were to fall into t his

borderline ('at egory also.

Replacement depots. Repjnlacerieri (vplets (later caled reimihocenerut

(lepots) ini thIe Eurropeani threatemr ca ine indr~er nimi organiiza tion irimt ially kniowni

as thle Grund For'evs Replaeminerit Svsteini. The suirgeoni of t his corlnlifaiid

was WLt (oh (biter (oh.) G eorge G .IDurst, 1\IC. In add ition to receiving and1(

assigning inidividuials ats replacemienit s, (depots received anird assigned all1 persoifll wo vid hra I been dIischiargedl froniil hiospi tals lifter' assignmrienit to at (let achimeniit (if' pat ients. It wam this bitter function that originially r'esiulhted iin conferences between (woloie Thiompsori adrl ( 'lmrl D~urst . W~opr assignmierit

of rierirop sy('hia trnc pat iernts followinrg rehia I il it ait ion wins a1 crucial fact or ill

their ('0tmplet e recovery. Ats tinlte wenit on], t here wvere tivee s for' psychiiat ric

Services ait repla ceeniti td(epots arisinrg front other Sources, Such ats lair'ge ri ii muhbers of caisuals who oifered physical ('om1plaint s inl a bsenuce of (lerrionist rabl e

orguinnic (hiselis(', riuitrierolis (Iiscliargees arriving fronti (i5('i d li filli ty traininig
* ~ ~ ~ ~ ~ ~ ~ A Tii Iii 'I~Ii'i Ii '
I7 ( 1l 0 A;I. - II(-II * \I.:I ) \. Ii Iv n I par )Iv I tli w. sits->
:158 ACTIVITIF'S OF MEDICAL (CONSULTANTIS

centers in the United States and froin within the theater, and occasional

problems of maldadjustmnent in cadlre personniel.

There wvas no authorization for at neuropsychiatrist in thle table of organization of at rep~lacemient depot.. When thle 33d Station Hospital was brought

in to serve the 10th Replacement Dep~ot in April 194:3, iiii opp~ortunity was

presented to providle p~sychiatric service to that dep~ot , and, although there

was no0 specific position for a1 neuropsyclijatrist Onl thle staff of tile stat ion

hospital, at netiropsYchiatrist was assigned. Once assigned, hie was placed

oil detachedl (lit)- with the depot,. Except for a short. period when Capt.

(later Maj.) Benjamin Colien, NIC, was actually assignedl to the 10th Replacement Depot, this systemn of placingPI officers on dletachied andl/or temporary

(lu1ty with tilte dlepot hiad to be resortedl to. By August 1944, it was neceOssary

to haive two fuill-t ime iieluropsvchiiatrists at tached to t his depot from the

312th St at ion Hospital. This redlucedl the effective mnedical strength of thle

hiospit al, but there was no other satisfactory expedhient.

When the Giroundl Forces Reinforcemmient Commannd was estab~lished on

the Continent, the 19th Reinforcement D~epot wats activated at ttallpes,

France, wvit h functions similar to the l0thI Reinforcement Depot in thle Unitedl

K~ingdlom. Other depots were also estab~lishied, but thle I 9thI Reinforcement

Depot was the key installation in receiving rehiabilitated patients for reassignmacnt to noncomiibat du t ies. Here again, anl officer had to be provided oil

telipjoral 'ry (lilt ty from atilie I 30thI General Hospital. Onl 19 Novemb~er 1944,

while discuss"ing withi Colonel Durst thle reassignment of patients who wvere

beiiig- sent back to duity lby thle I 30thI General Hospital, Colonel Thompson

p~romiised t ha t Captain Colien--*tlien assigliedl to t hat hiosJit al-would be

p~laced Ol on(et achied service at t he 1 9th Reidiom'cemnemit Depot to iniitiat e and

supjervise neuol-Os *vcliiat nc consult ation services, but it wvas not until M\airchi

1945 t ha t he( could be releasedl and1 reassigned to this (hilty.

WithI a small number of nieuropsvchiiatrists b~orrowedl from hospitals, at

great dleal wats (lone if) thle replacement dlepots towardl insuring the suppl 'y

of onlyv mIientall.N and emotionally qualified soldiers to 'ombilat (luties, mnakingr

lie miaximium use for nioncomibat duities of soldiers who were unstable, rehabilit at ing soldiers wh~o were still cap~able of improvement, and elimiinat ing

fromn military*N service soldiers who were grossly unfit. The relationiships

est ablishied ill this waY withI thle replacement systemn also hielped solve problems

of primiiarvY coticerli to thle theater senior conisultant in neuropsvchiatry, as

will be niotedl ini whimit follows.

While Colonel Thompson wats onl temporary (duty in the United States,

hie at tendled thle first comm ferencee of Psychiiat rists in chlarge of consultat ion

services lit replacemien t training ceti ters in thle Zone of Interior. He learned

that herIe wvere 33 such ceniters withi consul tat ion services, includhig, in addition

to tihe psy* chiatrist clnia pscooit anid psychiatric social] workers. At

the t imue Colonel Thompson returnedl to the European theater, manpower

shortages in rombat units were lbecomihing acuite. A plan wats under way to

take thousands of soldiers front Conil) luifnicat ions Zone units 1and( train t helm)iin
EURIOPEAN THIEATIERI OF OPERATIONS 359

four replacement depots for assignment, to combat. duities. In add~ition,

antot her (depot was to be designated ais anl officer candlida te school. III niantv

respects, thle situation wals similarll to that of replacement training centers in

the United States. Colonel Thompson reasoned that an organized conlsultattion service would be most app~ropriate aind recommendedtl~ that af service

Inodeled l fter thlose in thle t~;nite(I States be estab~lishted. The Ground Forces

Reinforcement. Conimiand also requested siniflair services. General H awley

did not concur in the reconmmtendations and request~. lie interpretedl such

work to be concerned withI basic training~an(I statedl that at theater of operations

Nvias no p~lace to emb~ark onl basic training'.

Disciplinary centers.-In forina tion hiad coinec to Colonel Thompson

fronm the British, fromn the experiences of Captain Hanson in Nort hern Ireland,

and froin ot her sources that neuirolsvch illt rc services fittight be requiredl inl

detent ion (,enlters. Onl 5 February 1 94:3, at af coitference of the Chief Surgeon's

Consultant Conmnittee, Colonel Thomipson expressed tilie need for study of

this subject, which arousedI the immnediate concern of General Hawley. Geiteral I iwleY qunoted statistics indIicating thatt less t han 1 percent of offenders

were restoredl to full duty frontl disciplinary barracks andl that only af very low

percent age of thlese ever niadle good aft erwards. He saidl thle staff should

keep iii mindit the possibilityv of detailing a1 man11 permianently on Oltile staff of

tlie disciplinary c-enter for thle p~urpose of stltlyiing offenders, shtouldl tile work

grXIow in suifficiemtt proportions to wvarrant it. InI rel.ly to af quest ion bY General

Hawley, Colonel Thompso i s5 sid t here was anl officer available in thle thIeater

whlo had knowledge and~ experientce in thle field of crilti imall behiavior.

Againt thIe problemi l.Ay it thIe lack of a niteclumaisiui hy whichi a psychiatrist

couldl be assigned and again it was solved by p~lacing iteuropsyclijaltrists Onl

temlitporalry dutty with (It discipl ifilInar ceniters fron;i a miedlical inst allalt ion to whticht

they htad b~een assignedl for this purpose. The first incumbent wais obtauinpv

from thle 3(ithI Stalt, ion IHospital a11id placedl on (lilt *ywith DisciplinaryI Training

Centter Nunmber 1 at. Sitepton Maillet, England. These officers htad to be

Selected wvit h great care b~ecause General Hawley insisted t hat thle neuiropsychtiatrists assignted hald to lbe of t ite highest ordler. ''Those p~eople [tile

iteuiroJ)s ychtiattrists] htave got to be pret t " N solid,"' lite maintained, ''or thtey

[d isciplintary c-enter Personnel] won't, care wltet her thiey have ainy psychiatrist

or- zot.' 52,-

By tlte endl of 1944, stockades of various b~ase sections had1( grown in

numbiher as well as in centsus, antd stockades tit replacemntet (depots were equally

well Jpopuilated. Neuropsychiia trnc service hald b~een well accep~ted by dIiscip~linary t raining centters. Tite intcrease in mnitlefaict ors also resulted it requests

for adit~llional neuropt-ychiuat ris ts to help in discip~linary, rehiabilitat ion training.

It was ito longer feasible, however, to comitie dllC(eprivintg hospitails of trained

neuropsychiiatrists for this duity. InI January 1945, it was necessary to confer

with tilte Office of tlte Provost Marshtal, Headquarters, ETOUSA, and submit

52 Minutes, Chief Surgeon'S Consultant Commnittee meeting, 30 April 1943.
160ACTIVITIES OF' MEDIICAL. (1NSUII'ANTiS

reCOMIl nen(dIat ionis for 1)emi'fiiinet mnodifica tions of tilie t able of orga mizatzionl of at

(lisciJplillilI' t riillhij ('('Iitel' to p)Jrovide( for netlrojpsy(liattr-Y personnel. The

reCOMi llelid~ed chanlges were ap~proved. Qualified psych IIIt li-sts Were found to

fill tile nlewlY (creat ed posit ions.

Althloughi resuilts lit t hese centers wvere niot gratifying In termls Of filet)

return-Ied to ulsefull dulty, thle Work of thle tieuropsvchiatric p~ersonnel was of

Conisiderabi lle valute to thle t heater a 11(1 tlie( Army ats a whole inl maIIIN mIiv as.

Case recordls were workedl ill) oil till individuallts, 1111(1 expert Ofpiliioii alas providled inl uiedicolegall aspects of disciplimlirv- proced tires, thu lisassuring j ust ice

to tilie i nd ividutal prisonier and( broaidenling tilie scope of nli itiil t rv .orrec,(tivel

11iieasuires. Special stud(1ies develop~ed t(chi 0jtiqes inl dealinag with he milit ary

otfliealer a nll a lieoveredl personallityN faictors thlit could( hielp iden t ifY his type inl

hie unlit of' litt all) illIiact eion cent er.

Special training units. III early, 1944, it was realized inl thle ET() that

sp~eciail t rainling unfits would be ne((eded so that l11IIaIuiiII am se, (10ild h~e miade of

mia rginal SoldIiers wh~o ('olildna't alda Jt to iioriiuid nuililitil ,ry assignmen(IIts l1111(I yet

Were no( s~liffcientlY mneitall ,v ill to be admlilt ('( to miedIical treat iiuent facilities.

It wits hoped that cofiisider vI'e Iiuui vh1111ers of phYsically fit Iiieii could be put to

gainlful uise who wer'e othlerwyise Serious liaibilitie's to tilie nililiti arv effort. Thuls,

the project for recoillpinig t his lost nina 1power inivolvedl thle est ablishinien t of at

recovery ('(vliter. ()n 20 February* 1944, Colontel Thiompllson explainiled thle

project to Colonel M enninger, ats follows:

We are just abhout to ope'n aniot her act ivityv called thew recove'ry cent er. This wvill be

under line' officers. and the t rain'ee will be t hose in whom no deftinil m'ent al disorder exis~ts.

but who manifest poor adjustmwent through incorrigib~ility rv.rpeated physical complaints

withlout dlemonst rable basis, and mnwillingtiess to work, or jinap~tituode for ilny special wvork.

The olbj(ct is to fit t lie-su' inu'ui throuigh spec-ialI milita:rY t raining, for assignment to labortinits

or similar orga nizatlions ini this t heat er. All soldiers going to the( recovery center wvill be

scrvenedl t hroigh the 312t1h StatIion Hosp1itali (N. P.).

Onl 61 lebraiar ,% 1944, Colonel Thonmpson wais suaioitioedl to General]

Haiwley'\.s office iand con fer-red With hiIis executitvle offic'er, Colonel IDoaii, onl

correspoli~len('( proposinig thle est alblishlilieiit of tilie rec'overv (''liet er. OnI 9

F'ebruary, Colonel Thiompson50 a(ceolipaiiied Colonel Sprufit to I Ieallquarlters,

Wsern Base Sect ion, ETOUSA, where til hey conlferredl with titlie Stirgeon,

W ester Baise Sectio tll 1(] inispe('ted' t he( proposed site tit Iliydlock Camup,

aplproxiiimttely 20 muiles fromi Liverpool. This etlil) hand it caipacity for 2.50

to :300 mlenl wit hi saiflielit room for expansiont by tentaige. The Western) Base

Sect ion surgeoni expressed it strong de(sire to lhiave at full-t imle medlical officer

aind sofiie enlistedl persolilliel Onl thle table of organization of tihe ('enter b~ecause

at dispensary was olbviously needed. It had 1beeii previously agreedl t hat nio

ps('liiatric personnel wouild lbe required. Conferringii lte tiii tilie daly wit h

('-I (personnel and 11(1iniimist rationi) of WVest emi Base Sect ion, it wvas discovered

~init 110 cadlre per'sonnel had1( been select ed penidiiig receipt of (definite wordl

fromi [Heiadquairters, ETOUSA, to go ahlead with thle p~roject. The ('ouiferees

agreed that it wotld be dlesirable to hatve oii the staiff of the recovery center
EUROPEAN THEATER OF OPERATI()NS 361

one or more line officers who had been incapacitated from frontline service in

the North African theater.

The question of whether trainees should be screened by psychiatric personnel before assignment to the recovery center was raised. Plans called for all

trainees to be screened by the neuroses center at the 312t1h Station Hospital

before assignment to the recovery center. At the Chief Surgeon's Consultant Committee meeting of 25 February 1944, Colonel Kimbrough, however,

stated that he thought this procedure was very cautious and a little bit drastic.

General Hawley replied that all psychiatrists in the theater had to be agreed

on this screening for if they were all allowed to send individuals directly to the

recovery center, there would be no reason to maintain the neuroses center at

the 312th Station Hospital. But when the recovery center was established, tie

96th General Hospital as well as the 312th Station Hospital was authorized to

send patients directly to this center. Eventually, after invasion of the Continent when troops were deployed over a wide geographical area, all general hospitals were permitted to send patients directly to tile recovery center.

Capt. (later Lt. Col.) Robert H. Sipes, Inf., was designated commanding

officer, and the center was officially established on 17 March 1944 as the Services of Supply Recovery Center. 53

Operations at the center proceeded smoothly. Psychiatric consultation

was available from a nearby hospital. Colonel Thompson was required to do

little but check periodically on the type of personnel being sent there an(l advise on training programs. The one problem the center encountered lay in tile

fact that it belonged to no particular service. Although the recovery center

was rehabilitating men, it (lid not come under the Rehabilitation Division,

Office of the Chief Surgeon, Headquarters, ETOUSA, b)ecause it was not,

desirable, psychologically, to have it associated withi the medical service.

A year after the center was estal)lished, it had received a total of 1,278

men for training. Disposition had been made of 996 patients, of which all

except 41 had returned to duty in the theater. Approximately half of those

returned to duty went to general assignments in combat units. The Ground

Forces Reinforcement Command commented very favorably on tie graduates

of the center. Colonel Thompson thought that the unit made good soldiers

out of the majority of the trainees.6 4

Quartermaster work battalions.-The role and importance of a consultant are sometimes more clearly defined when lie is not consulted or when

his advice is not accepted in a matter that concerns him. Instances can be

found in b)oth civil and military administrations. The European theater also

provided an example.

In September 1944, over 4,500 enlisted men and officers, mostly combatexhaustion patients, had been assigned to the detachment of patients of two

general hospitals and subsequently detached to a Quartermaster work battalion. The Quartermaster battalion had placed these men in companies

3 General Orders 37. Western Base Section, Services of Supply, ETOUSA, 17 Mar. 1944, sec. II.

34 See footnote 44, p. 328.
36-2 AC'IIVITIES OF MED:1ICAL CO.NSULTA'NTr,-

Widely vcat tvredi over till of Fraiince. anld tilt, hiospit al, had no0 fuirther cointrol

over t hem. (~oloite rhonipsonl Nva. facedl Nith tilte p~roblIem of screeniling thIese

meI(n and2( of livers if) ordler to make at (lecistiton oiea cl case for defi nit e assignIfleilt or, rehiosptitalizat ion.

Thet situation jlit 11( its birth in the fewv weeks; following D-day when there

Nvas Nitt Wy to dlispose of colibill~t-exhittist jOlt patijent s ('vi (liat eti ouit of the

First U.S. Armvl except to sendi t hem back to thle United Kingdom. ()n 12

July, 1944. Colonel Thlompson1 htad already* conferred wvithI Brig'.. Gien. (la1ter

MaIj.i (;en.) Alhert NV. Kenner. Chief f\ldcl()lie.SpeeIlead(lar21 ercr, Allied Expedit iomtary Force. and t he Surgeon. First U.S. Arm*v, onl t lIe( object ion to

let t ing, ien roipsychltria c patients ecAp&'- to Ling121 nd. Onl thle following, daiy.

plan, had beenl mlade with tilthe chief of mtaxl First UmS Army to establish at anl

earlyv dat e a1 recovery' centeri similar to thle one' in England to liandile ceilaan

patientts veryv carefully screenied b~y thle armly' (xhau e tst ion cenit ers.

()n 23~ JulY 1944, in reply to af proposail t hat coilllbat-'Xiltalstjoii p~atitents

'eScaipimtg" fromtillai armly bte lhanidled ill rejplacenlleit depots, for rehiabilitalt ion

and2( t ra inititg. Colonel Thompson recomnmeinded t hat Such patients reiliill ifiiinder

MedIical ( psychinzit c) care and t reait ment until a definiiite (lecision (c0ul( be~

Mtade ats to returiiii to coililuit, inombmiit ass5ignmenet, or fumrt her evvima t ion.

Het qualified his recommndaictlitions lw Sainimg t ha~t t his dIid not preclude esti2)1-

lisliinent of special labor units omtpose'd of gradutllt e's of re'coveryv ceniter's

similar to thait in thle Untited Kingzdom and reiterated t hat pat ienits Currentlybeing sent t here w.ere not tilie ordlinla' *mitnl of exhaust ion patients but incorrigibIde psycliopati Is andl borderline mental (~lfeti yes.

M\Ieain!while, uniknowii to thle t iea t e senlior consuilt ant in neuropsvcltiatry,

tile Cmi~lla '0) Idi ng General. AD1SEC, had11 beenl direct ed inl no0 uncert ain t ermls 1*v

a let ter from t heat r headquart ers. dait ed 261 JTuly 1944. onl how to dispose of

''calses of Bait tl cWxha tst ion not iimmed iaitel! ve IvI nutible to combat buit whIo

ito long-er requlire medical treatmnent aitd supervisioni * * * , l The

let ter directed t hat Such patienmit s. still caipablIe of Some service ai itd cert ifie(I by,

mted Iical a utholioties as not being retuimilmde to combat for at( least fill ext eitded

period. sliouild be assigned'( to 21 det achlmnett of pat Iient s of a1 ( onlillinlticat ions

Zone' hospi ta2l designitated by thle comtmanmding general of ADISEC and shtould

he formled illtt units for hand.( labor.

Ill a cablelt to thle War D~eparttmeht, permtission w\as then requested to

forum suicht labor units; over and1( ab ove thIe t heat er troops lasis. The cable

ataed that fni Ilitpurposenwas to proidev a situait iontmr nwst uuiomms thbait comnha

inl whiich pyscltia trc casualties could be placed. The Ittat t ei was referred to

The S11 rge zn ( eu eral \\ lit st rnomgly opposedI t lie pilla bevaus-e of its, pui ivti e

impl)1ica itionts. TIhe War D epartmeinemt accepted The Sui-rgeotl CGeueral 's opposition to thle mteasuire andl disapproved thlit reques't .`

Shilsequmendyl, ill iitt'iniilonnlidiliI to G'-I , Ilevadquarters, ETOU.SA. dated(

4 August 1944, ( inemaal I Iawley e'xpressed llhi personal views oii coumbat exm 1eni ititwr. UW AIIzIt C. i''vh jiary ill :i rmiti), I Wiw),). New NYoTk: The NInacM~illan Co.. 194. p. ~ 5
EUROPEAN THEATER OF OP1ERATIONS, 36:3

linust ion. General HawNXley nivainitaiined that psychon11eulrosis was a Cond~it ion,

not a (disealse, t lint its basic caulse wa1s insuifficient courageC, and that feari was,

its 1)inriiii' iiot ivJt jug, factor. Ile ventue litle tlil'OfiiiOi t hat if cowardIs were

stiI i11a16lV executed, thlere would be no0 psychoneurosis, le single u as

tlie great adnlijist rat ive 1111( medical pl'olbeili that group of soldiers who just

lidl not have sufliciel t courage to sustain themselves ill battle. This group,

Gene~ral Hawley wrote, included those who withI only very g reat difficulty couldl

ever be restoredl to comb~at. but who couldl still b~e salivagedl for sonmc useful

service. General Hawley statedl that lie wVas unalterablY opposedl to returning

this group of soldiiers to duty in normnal units, combat or service, because it,

would be ''merely placing rotten apples in b~arrels of sound ones.'' The milder

cases miore appropriately describ~ed by thle term "conilbat exhaust ion "-those

who crack after niiontlis of accept able combat service-' real psvclion euroses,"

and the obviously psychotic, thle General wrote, were b~einig taken care of.

General Hawley suggestedl t hatt, organizedI into special units under specially

selected officers, and noncommuissioned officers and properly adminiimst eredl, some

uiseful work could be had front the problem group. Such units, lie- 'onitinuledl,

iti * * should be wvorked hard. They should lbe quart eredl and fed under no

better condlitions than conibat troops. Thlere should be no attractive considerations to invite soldiers into such units."9

Thle, whole point of General Hawley's memorandum was this. He assertedl

that this probleim soldhier wouldl always exist ats long as lie could escalpe comb~at

by recourse to psychoneurosis, that it. was up to comimand~ to face t his problenm

squarely anld realist ically, and thlat the alternative quest ions facing tile cornniand were: Should this group of problem soldiers be miadle use of or should

ther be dhischiargedl from the service to be rep~laced1 with new dlrafts upon the

po~)tilat ionl?

Over oiie thiouisand~patienits that had accumlulatted inl thle exhaustion centers

of the First U.S. Army were received atit the .5th General Hospital when it

opened Oil tilie C ontiinent onl I August 1944. Withbin :3 or 4 da*vs, 1,360 neuropsychiiatrtic pat ieit s were tuirnedl over to the 90tbI Quart erniaster Bat t allion.

nri(v were screenied in 2 (lilys bv a g-roul) of 9 neuropsvcliiatrists draiwn fromi

ti?I genra tiopi al.ndol 21 patients were bi051 it alizel for hiriim er

treaiiienrt . By umid -Atigist , over two thoulsand patients had becen t uirned over

to tilie 90thI Quart ermiist er Bat thalion while still aissigned to tilie det achiiieiit of

patients, 5tbI General I ospit ii. In late August, adiiitrtieconit ml of thle

labor comipaiiies to whichel t hese pat lent s hand been] senit was trziansferred to tIile

D6tbI Quart ermuast er Bat thalion, mid1( suibsequent aissigninent of incomiing patients

wats to thle (letlachinment of patients, I 9thI General Hlospitald. By tilie end of

Auigust, t he nimmiber of' lpat ients so 50 (ltce micie~nd dislpatchied to work units had

rea(h(le(I over 4,500.

Withi the und~erstandling that the 130th General Hospital (p). .333) was to

Open on) tile Conitinient. onl I September 1944, Colonel Thiomnpson i ad recoinmenided onl 14 August 1944 that. prevailing practices, be allowed to continue,

providled patienits were Sent. to tit(e 90thI Quarterimaster Bat t aiomi only after
364 ACTIVITIES OF MEI)ICAL CONSULTTANTS

proper sorting at army neuropsychiatric units, the 77th Evacuation Hospital,

or general hospitals. He further recommended that screening by psychiatrists

continue at the 90th Quartermaster Battalion and that plans be made for a

more definite assignment of patients placed in service work units.

Following up his recommendations, Colonel Thompson initiated plans for

the screening and disposition of these patients ii, conjunction with the Hospitalization Division, Office of the Chief Surgeon, Headquarters, ETOUSA, and

Colonel Durst of Ground Forces Reinforcement Command. A list of neuropsychiatrists to perform the screening was submitted on 6 September 1944.

Captain Cohen was initially placed in charge.

Meanwhile, the Commanding Officer, 96th Quartermaster Battalion, had

requested that a study be made of the condition of his men, and Maj. Roy L.

Swank, MC, neuropsychiatrist of the 5th General Hospital, made a longitudinal

study of 3 companies over a period of 3 weeks and conducted a cross-sectional,

spot-check study of 13 companies comprising 3,000 men during 1 week. The

study revealed that many of these men still had handicapping symptoms,

many were growing more concerned about their condition, and in quite a few

instances they had been curbed and held under more strict regulations than

others doing similar work.

The screening procedure ran into the same sort of problems that beset

setting up the 130th General Hospital. Almost no screening was done during

September. Colonel Thompson conferred on 5 October 1944 with Colonel

Durst, Maj. (later Lt. Col.) William H. Barnard, MC, of the Hospitalization

Division, and Captain Cohen. He added five more neuropsychiatrists to the

screening team at the 19th General Hospital. Major Barnard and Colonel

Thompson visited the hospital on 13 October 1944 to work out more details as

to the reassignment of men attached to the Quartermaster battalion and found

that only two neuropsychiatrists had arrived and just 208 men had been

screened. The next day, Colonel Thompson checked on the whereabouts of the

psychiatrists ordered to the 19th General Hospital and placed four more on the

list. On 17 October 1944, Colonel Thompson again visited the hospital, this

time with Colonel Menninger, who was visiting the theater. Six psychiatrists

were present, of whom three were recent arrivals. Over 800 patients had been

screened, but it was discovered that most of these were recent arrivals at the

19th General Hospital from other hospitals rather than patients with the 90th

and 96th Quartermaster Battalions. Word had also just been received that

the only noncombat assignment open to those going back to duty would be

as prisoner-of-war guards and military police. Colonel Durst had to be called

upon to rectify this situation.

On 1 November 1944, approximately half of the men had been screened,

but the process was absolutely at a standstill because Normandy Base Section

had not found transportation to get approximately 2,000 men to the hospital.

Nine psychiatrists were present at this time, and their need in hospitals from

which they had been withdrawn was becoming critical. Moreover, half of the

patients screened had to be hospitalized. That afternoon Colonel Thompson
EUI'ROI'EAN TIIIH'ATER 1' OPERATIONS, 365

met with representatives of the Hospitalization Division and the Deputy Chief

Surgeon, ETOUSA, and urged that the screening be expedited. It. was apparent

that the screening was not getting the command support it required. Colonel

Thompson voiced the opinion that the Medical Department was shirking its

responsibility for providing adequate treatment. Following the conference,

Colonel Thompson submitted a memorandum to Colonel Kimbrough on I

November 1944 reviewing the situation from its beginning and including

recommendations and statements made in the conference.

On 3 November 1944, a letter from the theater commander directing the

Commanding General, Normandy Base Section, to expedite the screening

process at the 19th General Hospital was brought to Colonel Thompson's

attention. But one week later, lie discovered that patients were still not being

sent in from Normandy Base Section. During the remainder of the month,

however, patients began arriving at the rate of some 200 per (lay, and the

screening for all intents and purposes was completed as of the end of November.

Isolated groups remained unscreened until V-E Day.

The conclusions of the examining board of psychiatrists that conducted

the screening was that these men were not, significantly helped by 1 to 3 months

of noncombatant work therapy. Of 4,588 enlisted mien examined, 2,503

(55 percent) required hospitalization. Of 51 officers examined, 47 (91 percent)

required hospitalization.5 6

A later sampling of the hospitalized group covering 467 patients revealed

that 41.8 percent were boarded to the Zone of Interior. If this rate was

reliable, the total return-to-duty rate of those who had been in the Quartermiaster battalions would still be less than 60 percent. A still later followup

study of 1,000 cases-500 hospitalized and 500 returned to duty directlyindicated that some 80 percent of the total 1,000 were on duty in the theater.

At the same time (October 1944), the 312th Station Hospital in England

with its mental rehabilitation work had returned 89 percent to duty, and,

significantly, the patients reaching the 312th Station Hospital were those who

had gone through unsuccessful attempts at rehabilitation in all subordinate

echelons of the evac'uation chain for neuropsychiatric casualties.

Following his visit, to the European theater, Colonel Mienninger commented

on the method of handling these cases, as follows:

Many of these had had inadequate treatment, having come directly from Exhaustion

Centers. D)espite this fact, it was reported that these men assigned to work in ordnance

jobs, stretcher bearers in hospitals, and elsewhere had made excellent records. A superficial survey, however, indicated that many were noticeably maladjusted and this fact,

plus the irregular method of carrying them as patients from the 19th General Hospital,

made it necemsary to develop a different plan.

In evaluating the results of the practice, he mentioned the fact that, in

such patients with inadequate treatment, "* * * their guilt reaction, their

feelings of iniadequacy and the atmosphere of impersonalness at replacement

is Letter, Board of Psychiatrists. 19th (Oenral Hospital, to Chiedsurgeon. ETOT'SA, 26 Nov. 1944, subject: Report

on the Mental Status of "Comrhat Exhaustion" lersonnel Attached to the 90th and 96th Quartrmaster Battalions.
366 ACTIVITIES (1F MED)ICAL. CONSULTANTS

(lepots ('an till combine to conltihUe anti] increase te nI ieurot ic dlisabilityv and t hits

convert t ransient ie neroses into permaitnent, p)ensiofl-seeking chronic neu roses."' 5 7

Tile fact remains, neverthleless, t hat, soine of General 1 lawlevys stat citent s

were b)orne out by the experinient, as, reportedi ly the board of Psychiiat rists

who condIuct ed the screening. The more seriously ill mtemblers of the companies

tended t~o ''re-infect'' the others, thums handicapping thle improvelitent of thle

less ill. There was a considIerab~le numbler of ''repeaters''-nien who were

treatedI with apparent success in a forward inedlical echelon, returnted to comblat,

iltid t aei relapsed after a Very short, period of t imeC a111( had to be e'vacuaited at

secotnd or third time,. Finally, ats General Hawley iadl predlicted, thtere coutid

be no doubt that this extra imanpower provided considerable help dutring a most

critical t itne inl gaining" tile init it iVe oilt ilie Continent.

Neitropsycliia tric Education and Training

Education and training were (lav otltinhing requiremient-, in all aspects

of mnedical activities in thle European theater. Ani extensive program was

t'speciailly nleeded inl thle field of neitropsychiatry b~ecause of marked dliffrernces

between practice in anl oversea mihitary theater and civilian practice. Very

few indeed Were the officers inl thle theater who, at the titme of Colonel Thompson's arrival, possessed military experience in this specialt~y. Those who

followed were in many cases equally inexperienced, as wvere ancillary personnelnurses, social workers, clinical psychologists, and attendants. The vast

differences in civilian training and experience also necessitated a training and

indoctrination schteme to establish ordler and understanding; otherwvise, chaos

would have resulted had each been allowed to practice in his own way.

In 1942, U.S. Army medical officers were being sent to a British Army

training center for neuropsychiatrists at Northfield, one of two installations

where neurotics from the British Army were being rehabilitated for useful dutty.

The course was an excellent one. However, it wvas believed that there wouldI

be (listinct adlvantages in having a school mnaintainled by and for the U.S. Army.

First of all, the course at Northfield lasted 3 months, which Colonel Thompson

thought, too long. Furthermore, after completing thle British course, thle

trainee still had nmuchi to learn about tmethIods a111( procedutres used in tile

1'.S. Arnitt. When one considleredl the fact that there hadl beeni more thtan 2-50

neuropsvcltiatrists with the American Expedlit ionary Forces inl November

1918, it was anl ob~vioums imtpossib~ility to ask the British to train that muany or

mtore U.S. Army officers who would make uip the full force in Eutrope inl thle

(lays to coitie.

The UJ.S. Army had established the Mledical Field Service School at

Shmm'iVettltamt, England, andl there was at similar school operat ed by tilie EighthI

Air Force. All t rai iim ig for tied ical elemenetts wals con trolled aitnl Su1pervised

to The .' S1zrgeori (leneral, U.S. Army, 13 Nov. 1944, stihiect: Report of Visit or Coloniel William c. Nienninger, MC, to

hilst.Litlatiois in tile Euroiwan 'rhie:ater of Operations. 7 Sept. to 24 Oct. 1944.
EUROPEAN THEATER OF OPERATIONS 3(67

1w the Operations and Training Division, Office of the Chief Surgeon, Headquarters, ETOUSA, although the Army Air Forces school was relatively indepenlent. However, a course in neuropsychiatry could not. he opened at the

Medical Field Service School because of the lack of qualified instructors and

lack of case work. When the 36th Station Hospital arrived in England, the

facilities and personnel to operate a school of neuropsychiatry became available.

After preliminary discussions with the hospital's commandIing officer, (Colomiel

Parsons, a nmemorandum was submitted by Colonel Thompson on 25 January

1943, proposing the opening of such a school at this hospital. The proposal

was favorably considered and detailed plans were pursued to openi the school.

In agreement with Colonel Parsons, Maj. (later Lt. Col.) Jackson M.

Thomas, MC (fig. 113), 36th Station Hospital, was selected to take charge of

the school. Major Thomas was a well-qualified psychiatrist, a diplomate of

the American Board of Neurology and Psychiatry, and an associate it) psychiatry at the Harvard School of Medicine, Boston, Mass. Others on the hospital

staff were also well qualified to instruct in particular fields.

From the start, it was the aim of the school to make the instruction as

objective and practical as possible. In short, the courses were designed to meet

the needs of the theater. The teaching procedure was explanation, demonstration, application, and examination. There were lectures, clinical conferences,

and ward application under supervision of the clinical staff of the hospital.

Later, demonstration teams were organized with personnel of the hospital

taking roles in depicting battlefield neuropsychiatry in action.

Every opportunity was eagerly grasped to bring those with firsthand experience to the school so that students could learn directly about conditions

under varying types of combat and with different types of troops. Officers

returned from North Africa and other Mediterranean areas, either by rotation

or as casualties, supplied this type of information, and reports from the consultant in neuropsychiatry in the North African theater provided excellent

detail. British neuropsychiatrists, both civilian and military, aided materially.

Before the actual opening of classes, however, many details had to be

ironed out. Complete courses of study had to be presented for approval to

the Training Division, Office of the Chief Surgeon, Headquarters, ETOUSA.

There was a lack of teaching aids, texts, and reference material. Because of

the limited lntuiber of neuropsychiatrists in the theater, Colonel Thomnpson

often had to make arrangements personally with commanding officers of prospective trainees for their at tenidance. This sometimtes involved shifting neuropsychiatrists. temporarily, to cover vacancies resulting from an officer's being

detache(I to the school. The school finally opened in April 1943, the first

medical specialist school to be openeld in the European theater.

The first. course was for 13 netmropsychiat rists from general, station, and

evacuation hospitals to satisfy the immediate needs of the theater, and it

lasted throughout April 1943.

At the ;0 April 1943 meeting of the Chief Surgeon's ('onsult ant Coin mnittee,

Colonel Middletomi iniformed the conferees that the first course had been
368 ACm'rlurESý OF' MEIUICAT. CONSULTANT%%

compllet ed and that 10 nursl-es and 9 en~listed l mcii from genlerall anld station

hospitals, hlad beeni enrolled fcr at course to take place (luring May 194:3. 11 e ailso

rep~orted that Colonel Thompson planned to give four courses, ill JIunc con-is'tuin

of .5. olaYs each for miedical officers fron fieldl units. There w~ere to b~e 1o

zmedical officers ill each course. Inl addition, neluropsNvchiattrists fromt hospital

st airs were to be senit to field medical units for a pe riod of 2 weeks inl order

to gain experience and learn about life in at line unit.

General Hawley commen1 t'lted, ats follows:

I follow with a greait dealt of interest. the training of the generald medical officer and

lIattalioti surgeon) in psyclhiatry. I hope he can be given somlethnl:g. helpful and a little

knowledge won't becom~e it dangerouis thing if we don't give him the ideat that hie is anl expert

jpsYchi:atrist. after at week. I think it. is correct t~o chteck the( scope of the instruction

giveni * * *. I t hink at great deal can be done in couirses like this-not. attempting to

go very deeply into the subject * * * give himt some very practical suggestions). I

think the atssignment of the( officers tit the 3d Stattion Ihospital in the field is at splendid ideat.

It will give thenm very mucwh bitekgrot ind. I think it might well be extended to other people

in the hospitals. The pe'ople in the hospitails like to know how people in the field aire getting

alon1g.

All the courses that had beeni initiated were continued, ats neleede, until thle

end of ~Julv 1943. At about. this time, at majority of thle nielropsvchintrists inl

hospjit ails hlad at tended thle school, and commandl(ers of hospitals arriving inl

the theater found it. dlifficult to release t heir neuropsychiattrists for :30 (lays so

soon following their arrival. The comblat, unlits also had to curtail sending

medlical officers to the short courses, and two groups of flight surgeons had beeni

inst ructedI inl their steadl. Consequently, only one 2-week course for hospital

enlist ed menl was givenl durwing August. 194.3. The time had come for at reexaminiat ion of the( educational andi training needs.

Ill thle meantime, however, ('of. Roy D. Iltlloranl, MC, Chief, Neurops -ychiatry D~ivision, Office of the Surgeon General, U.S. Arily, had written

onl 1 Junle 194:3 to inform Colonel Thmommpson of thle school of nleurops ehiat mw

that had beenl est ablished at.t Lawson General Hiospit al, Atlanta, Ga., umnder

tile dhirection of C~ol. William C. Porter, MIC. as-sisted by IA. (C01. (later ('ol.)

M . Ralph Kaufman, IC". Sometinme latter, Colonel hlahlioran wrote suggesting

that, it would be a goodl ideca to have sonmc neuirol)sycliatrists with experience

inl comb~at, or inl ob~serving and treating combat. nellrol)sychiatriC casualties

relate their experiences at, thle school. Colonel Thompson agreed that it, was

at splendid idea but expressed his apprehension over losing permuanently any

exlperienicedl officers.

Then, onl 20 August 194:3, Colonel Hlalloran wrote to Colonel Thompson

ats follows:

We atre losing the executive officer of the school of militairy neuropsychiat ry anid chief

aissistant to Col. Porter, the D~irector. Lt. Col. Kitufnman is b~eing assigned to foreign (laty'

and therefore, we find it necessary to locate somevone who can teatch mnilit arv nienropsy -

chiatrv front the dynamic standpoint. I am wondering wvhethler wve couild b~orrow the servivee of 'Major .Jacekson Thomaks, wvhom vloi hatve been using in this connect ion in your atrea.

Natittirally we wouild replace him with a nutiropsychiat rist who could be used in it similair

capaicity. I have in mnindl Majtor HIoward Fahibig, who is an excellont neuriologist, ats well
EUROPEAN THEATER OF OPERATIONS 369

as psychiatrist and has been assistant to John Romano at the University of Cincinnati.

In fact, he was formerly with the Cincinnati Unit and is now chief of a section in one of our

large station hospitals. Hie is very anxious to come to your area. Perhaps some such

exchange at this time would prove mutually beneficial.

As you may understand, we are attempting to indoctrinate the large number of neuropsychiatrists that we have on duty at the hospitals of the Ground Forces and Air Forces

and adapt their civilian talents to military problems. We feel it would be valuable if we

could have the services of someone who has been familiar with the active problems in a

theater of operations. If you are unable to send Jackson Thomas, perhaps you could pick

someone else who has teaching experience and whose instruction would be considered fundamentally sound.

The next letter, dated 14 September 1943, received by Colonel Thompson

from Colonel Halloran, stated: "I have heard indirectly that Maj. Jackson

Thomas is to come to us for the purpose of teaching at the School of Military

Neuropsychiatry, which is to be moved to a new unit in New York so that

advantage may be taken of study of casualties newly returned from the various

theaters." The letter confirmed the fact that Maj. (later Lt. Col.) Howard

D. Fabing, MC, was being sent and added that Major Fabing had experience

from service in World War I, had a wide acquaintance in England, and was

very anxious to serve the European tbeater. "I believe that he will make an

excellent teacher and coordinator, especially along the lines of organic neurology," concluded the letter.

As a direct result of losing Major Thomas, formal instruction at the

school of neuropsychiatry remained suspended until Major Fabing arrived in

November 1943. Throughout this whole period beginning in late 1942, General Hawley continued to stress the need for training general medical officers in

field units and the indoctrination of their line officers as well. It was during

this largely unavoidable lull in formal educational and training activities that

the talents of Colonel Parsons were directed to the indoctrination of line officers, as described elsewhere. In cooperation with the Surgeon, V Corps, a

temporary measure was adopted to continue the training of general medical

officers from line units. Major Kelley was obtained from the 30th General

Hospital and conducted a 1-week course using the facilities of three hospitals.

Psychotics were seen at the 36th Station Hospital, combat neuropsychiatric

casualties from North Africa were used in instruction at another hospital, and

neuropsychiatric patients who had been "combed" out of divisions were available at the third.

By the time Major Fabing arrived in the theater, a major change in the

hospitalization of neuropsychiatric patients was being completed. The 36th

Station Hospital was being reserved for psychotic patients while neurotic

patients and most of the staff of the 36th Station Hospital, as well, were being

sent to the newly created 312th Station Hospital. This change also necessitated a relocation of the school of neuropsychiatry. Definite plans had been

announced to commence immediately extensive and concentrated training of

medical officers in line units and mobile hospitals, but instructions had to be

issued to suspend sending trainees to the school until the new facilities were

564970'- 61 -26
:-170 ACTIVIT*IESI* OF M' 3IICAI, l'oNSVI.AN-Ih

ready. C olonel M Iiddlet on andl Coloneitl llThompson0 bo0th gav e consliideralezlh

J)t1'rstlliliI at tent'iotn to he1piin", Ma ;jor Faing andi 11( thle 3 I2th S t atio Ho h5it sp al

prepare'( to reuiililt' 1 list liltt joltill ict ivities. ( olliditera t [oil flow 1ilat to he li'givenl

I1150 to di visioni psvchlzt lists'. fi'st' l ha izit ist, rt't't'lt liet'n altlitorized bY thle

W~ar D~epartmenit.l Th'leir t 'ikiliiliglir I fillt ter of prilnle -olicelii IIInCe niaiiv%

lie Posit ll ion bt whit had no1I ~ realI I tXIpvrlelict ill lieilrops ,vel iat 1W.

As it yevar of colistallit buiildupij with Ii ts at t'ldi~llit probldems drew to it close,

on 28 lDecemiber 1 94:3 at thle Ch'ijef Suirot'oii's (Consultant Commlillit tee Ilii('('ilig,

General 11INAI3IWIt-'V 1 eiZi x pressted bis (conce(rni ani liInterest ill tilit educat'ionaoli

progrll ii, askin' I g r311ictllllrlY a1bouit thle 1i Itict Ii noi ionl of c'omba131t doct1ors ill

com11blting" bat t'e lielirostes. "It trot oflf to) hI sp)lendidt stairt", lit' said(. "Whai3t

is its pre'senlt staite'?" Coloniel lKimibroinzl and ( oloile Thlompson were hothI

Ilwe t.o iniforml Iiii, that thle ilitltict 11 illt ioli of Iinedical officers ill linle unlits

from thle balit talioni level an1 abov li 0~l an titlet trainin il ~of division l)5Vt'lili t rsts

wits to star l lollivi(lt lY. ( ;tlitrlil 131NN1l('V Sitl te progri lii shjould( he plis~leip.

And puishetd Olet irograini Nvas. 'IThe totzii e'ffort WaIs dire'ted lit pt'rsolifiel

inl line units and1( t'vatit'iit oli hiospi tals. Undt er thle tdirection of MIajlor Fl'31II r

700 genieralmd ii catitl tofftt'rs rtctivedt Ilthe sptctiail 1-week- course5t ill iltuloJ)sychi atrie first aiid fromu 27 D~ecemaber 1943 to 15 July 1944. Th'Ie Chief Surgeon11s

O peratIions and Traininii lg IDi vislio re'portet' ttiha t, b v tilie timt' 1)-dav arriveti

1)ra('t i('hYilly31 Illedical offict'rs ill 'oolliblit uniits wiht wouild ctmet ill colit act WithI

bat tle citslailtie h'said been thirouigh this couiise. D~uring tilie Salilt' pelioti-frOmi

the reoen))'inlg of ilistructt ion lit thet 31 2thI Stalt iton Hosp1ital to D-dav---40

evacuatio h01lospital1 liellropsychlit rist 5, 80 e'vacuait ion liospit all IIIIIst', and1( 160

t'vac'uat ioni hospita a11nd1( clearing comipanv enliiste men iil wtere t rainied in courstes

sp)(cihallY dt'sig-lit't for thet'ii. Inlitaddit ion, M ajor Lelinkatiu of thle staff of thlit

31 2thI Stat tio H ospitazl, t rainetd 15 division neit'ropsycliaittlists iln January andit

February 1944 tit thlit school of lieurolpsvcliiltrY~.

While this 1p,)rgil~llii WIIS goinig 011 tit thet school, lpersolinil of general and

stalt ion hiospitails were not ('iti rt'l v i egl ectl ed. As new hiospi ta 31unit s arrivetd

ill tilit thleat er or. Nvt'rt creat etd, lit'l rtips -cli iatrnc personnlt' were gi vell tilit

opport unity to( spendl 2 wveeks lit htspita11, SppejililiZilig ill neuropsycliinttry for

011-tilie-jobý t ra~iliingr jiiitle'i t'Xpetrit'ui't offict'rs, liIrIIses. and1( enliste Iletll'l.

()n 7 Jill ' 1944, alboiit a it moith aifte'r )-tay, v, Colontel Thomnpson wrotte to

IDr. Ed waird A. Strt'cker (fig. 1 2S), who)lii ba vlisited Itlit' theate3 ttr slitwtv lbIefore,

that aill th lit'nivaisioni phills for Ilialilidlig lieliirtilsveliill t lie clis ilalI it's hi11( worketd

oil t silit isfll.t on! vN an litI ilslilt V Illt t'S Were lower tha iilt anl icipatet'd. '"I call hot

but fet'l", said otIlont'I Thlomipsoni, "'t hat part of t his is d(lit' tto our education of

line' officer-, andit dlivision medi IicalI offliters.

Whien C olonel Thiomlpson Whis alellt to visit. more un iit s inl comblat tiat a liltter

date, liialiY Offitce'rs expre'ssted grat itudelt for til lt jiiott rililit ionl the h liit atd It''i

givenl. C ommlienits iui11itlt iuiI ltt'r, tt dated 2 Mlarchi 1945. froml th li'tivision

lieiuropsychllatlist of tilit 6911 IiI flIlit ry I )i%-vi)I~li tto ( 'tloiit' N It'liliiliger ill ipst ra1te

wvell til' St'ntimenets o~f uIiauiv. lie Wvrote:
Fli;vitR 12S.-l)r. Edwaird A. Strecker (second froim riihl. vievilg the moliliieii,

It StoIIelhngIIe, SIisl)irv lPlains, Wiltshire, Eingland, with (left to right) Colonel Thomlpson,

(General lawley, and ('ol. RaYlimoiid E. Duke, M( ', 16 March 19441.

I Zlfl sending herewith the matt'rial used il leht ilres oil ( 'oihi:t l'xhiist ion. We are

iidvlted to t he :312th for :In excellent course and this material was reproduced. Since

Writim-, I obla:iiend their film on Co 'mbnat 'xlmitstion and .lhowvd it to all N(C(O's ald ofliverill tle :l(. 9th Med lin :is wAell as most ()'s in tle det:aichl elis.

We have been ill Combat since the 10th [F'ebr:r.vj :Iiand tOne iidoctriiation is p:ayiii

div'idends.

The filil oil comlbat exhlit lst ion Inentiolled ill the Ipara-..ratph quotedl wa's

p)rodluced at iIl ( 312 l11 S otn4i1 Hosp)ital ill ('oiljlluid ion withi tIhe Ai'liv IPic.torialI

'ver.vi ce of th 1e Si-It i•Il ( 'o l)s. It slhowedl the (work Ieill,- ihm' tIlet e. the specific

trea •ment th...,ixen. lie voi'k of file ii1e1tl-i'ehiu l(ilit(ition nil. h li e tel ,(l'll.ii

Ibeilil- 1i',eli il l, 11vSchool of' liciuropsychiatl'\'. 'l'levre xwei' som~e dlifficulties

with thle sc'elliio andtii podll'u'l ion of' the tfhu Iectllse of its r,,ia.re alih1 sopve.

The tihl, which w•-, in Scenarm'io ill Mahii''ch 1944, wvi.as comipleted in the aututn•nl

of thiat yeali•t.,and was first shown l)tllci\'"v at tilie IEipij'e IlTheater for pei'sollilel

ill (;lene'aI Itial(\ vs office ott 20( Novetihie' 1944 willi Ii 'unininlpui I tile of I hotlu.

ILter, ('(l)ies o4 Ith lielil Nwere duistributel tIolln'oiihotit the Am.\ lv I ii.1viall( (ior'lp

tilu, libraries. ('opies wer'e liesevilled to the Bi'itisli, who had l preivio'isli

pIr'ovided ilie U".S,. Ain"Y %\it- i k gcuiei'otis i11uuinler of' plilits of i lilell oni

combat1 I l vll '(),es'". oI 
,32 A'TIVITIES OF1 MFI)I('AL (ONSULTANTS

Colonel Thompson lectured to almost all classes of miedical officers going

through the .Medical Field Service School at Shrivenhiam. He frequently held

clinics, ward rounds, and lectures at individual hospital installations. Professional meetings of medical officers of the Allied forces also presented

educational opportunities.

In the waning stages of the war and the period immediately following the

cessation of hostilities, the theater senior consultant arranged for participation

by neuropsychiatrists in the broad educational program that was set up in the

European theater. The general scope and intent of this program were described

by Colonel Middleton (p. 253). A school of neuropsychiatry was reest ablished

at the 191st General Hospital, Paris, France, to give a comprehensive review of

neurology and psychiatry while paying considerable attention to recent developments in general medicine. More advanced refresher courses were arranged

for U.S. Army officers at teaching centers and hospitals in England, but

redeployment was so rapid that full advantage could not be taken of the

opportunities that were richly provided.

Visits in the Field

Although Colonel Thompson had to devote a tremendous amount of his

time and energy to staff work at the theater headquarters, he still found or

made time to visit units and installations in the field. There was more than

enough to occupy him at theater headquarters alone. In addition, there were

the obligations of liaison with representatives of the other Allied forces, participation in projects sponsored jointly with British civil and military medical

authorities, and the amenities in conjunction with these. But to sacrifice

visits and inspections in the field to these other activities would have meant

reciprocal loss in consultant effectiveness. Regardless of the thoroughness

of plans, the clarity of announced policies, or the accumulation of large amounts

of data, the proof of their worth could be measured only in terms of their application in the field. The feedback from visits to the field was the servomechanism that directed the proper course of neuropsychiatric activities in the theater.

In broad terms, these visits to the field could be divided into two types,

special and routine. Special visits were necessitated or suggested by some

specific problem or activity. These included such matters as requested consultations, the solution of local personnel problems, inspection of hospital

construction or modification, meeting advance parties of units due to arrive

in the theater, and accompanying visitors to the theater on tours of installations.

The routine visits-although they could hardly be called routine in the

sense that no two visits were exactly alike-were for the most part undertaken

to see what was being done, to make corrections on the spot if necessary, and,

generally, to get the consultant's feet on the ground. They helped him better

to evaluate the capabilities and limitations of personnel and facilities with

respect to the care of neuropsychiatric patients. Bits of infornmation obtained

on visits to individual installations or units eventually fitted together to show
EUROPEAN THEATER OF OPERATIONS 373

definite trends and patterns. On particular occasions, the observations made

were so significant thatl he would ask for a special report on the situation from

the installation or activity visited. These reports, with appropriate comments

by Colonel Thompson, could then be brought to the attention of his superiors

in the Chief Surgeon's Office, as well as in the Office of the Surgeon General.

Thus, he was enabled to keep General Hawley and his staff informed of significant events and problems in the field in a fully documented manner. Again,

these routine visits to the field provided opportunity to answer questions and

establish better rapport and understanding with those who were charged with

actually carrying out the neuropsychiatric policies and procedures of the

theater.

At least half of Colonel Thompson's time was spent in these special or

routine visits in the field.

Personnel Management

Personnel management problems were time consuming and required good

judgment and diplomacy. Many of the problems were obvious but were either

impossib)le of immediate solution or were difficult to solve because many restrictions and concurrences were entailed. Very close liaison was required with the

Personnel Division, Office of the Chief Surgeon, Headquarters, ETOUSA. Colonel Middleton also maintained close supervision over personnel matters, and,

because of their often delicate nature, his arbitration was required in cases of

conflicting interests and to insure the best and proper use of all personnel

specialized in fields that were his concern.

There was first and always the need to know the abilities and location of

neuropsychiatric personnel in the theater. Much of this information could

only be obtained by personal interview and observation of the individual's

work. One of the first things Colonel Thompson did upon his arrival in the

theater, however, was to obtain through Colonel Halloran the complete listing

of psychiatrists and their qualifications as established by the National Research

Council. Although this list did not help him locate individuals, it enabled

him to pick out the qualifications of those he met personally or impersonally

as names in correspondence crossing his desk.

In late 1942 and early 1943, there were many misassignments of neuropsychiatrists. Some were brought to Colonel Thompson's attention directly

from the individuals concerned by letter, word-of-mouth, or during inspections,

and many in letters from Colonel Halloran. As late as July 1944, when the

Third U.S. Army was staging for movement to the Continent, such misassignments could be found. An acquaintance of Colonel Thompson's, and a qualified

neuropsychiatrist, was a general duty medical officer in an armored medical

battalion. Colonel Thompson wrote to this officer, as follows:

I understand that your unit is part of the Third Army and I am writing to Major

Talkington, consultant in psychiatry for that army, so that he may make contact with you

and see whether you can be placed. I shall issue the usual challenge to him that if you are

not needed in the army set-up we have need for psychiatrists elsewhere, but I am sure that

he will find a psychiatric assignment for you.
374 ACTIVITIES OFI. MEDICAL~ ()NSULTXNTS4

m lost imiport ant reasonl for kntolving whio the psvchiu I lists wvere, their

quahificatios a~ltlli t heir locat ion wits to bet ablIe to fill vacancites qutictkly wvit iOil ill t ut er ~Il jilterruthi tag services. Thtis lust wats no smnall task when ie

conlsitlers that, ill spite of existitag- short ages ili thle thleuater anil losses t hroughi

tiorilal attr tii Oll, persoilillel hlad to b~e flouitti to fill the posit ions of evuculat 1011

hiospitali ailld divisioni iletirojps 'chiia I ists as thlese lposit ionls were createdl and1

to fill ucicesill stationl and genleral ho0spitals arrivingl ill tilie theater withIout their full comp~jlemlent.

AnothIer problem inl personnel managemnen wats that of promotions.

First of all, tablles of orgaii iza tiont were oft eiin ext remlely inaldeqjuate or inequitable inl thle ratilk givl-e iieuiropsycl ill t rists wvithI excellenit professiollal t rainling

or those who were requiredi to lialldle a1 greatelr load thanl provided for inl tilie

tables of orgailiza tionl. Alolilg tilie la tter were lielirolpsvch illt rists wit hdrawn

froill evacltui tionl liospitauls, to 11ian1 exiauist ionl ceit eis. Ill tlie( sam~e caitegory

were t hose uissigrietl to small hiospitails for. coiiveii leice and placed On i t v](

with replacement centers, (Iiscilplinulrv barracks, anid ot her tell Iorary-dulty

assigintmeiuts of conlsid era ble i inport a llce.

A solit ionl, atlbeit nlot en firel 'v sat isfactorv, to at problem of this nature

wats that atteiiipted ait tile 36011 Stat olil H ospitatl.

WVit h reference to K * * * 's promnot ion. I atin still wrangling with lesser lights. The

situnat ion is this: We are orga nized tinder a Table of O rganiztiia oln which left no vacanicies

what ever inor opp~ort untit ies for p~romtiton l. Here'~ I havye ptrogressedl to the 1 )oiit oif getting

higher aut horityV to admliit that, mir Talile of Orgaumizalimi imist be zi separalte or .a speciall

TF 0 . o ur bedl captuit v is coitsidlerahl *v greater t hani we figured inl t he States and the( rank

a pproprija te w ill go itt. Inl addt 1iton I. I a itt htoIldin itghat it a 'i who are t rained mit iit ari lv and

p~rofessiontally proficienut to be diilontat es (of Itie Aiterica i Board should htold t ite gra;de of

mtajor. By these deviouis nteaits I hope( to get htimn 11) itt th lie ot too distant fit tire. Hie is

Ithe ntumbetlr onte mtani of t he list 1)1it thet re a re several ot iters * * *. Franitkly th1eare is nio

va lid lieu itetta tt ilt thle o ut fit. Nonte of In' th men are Y ros. Keep your fintgers crossedl while

I make every possible move to sctivezez thIese thlrought."

Two coimmi titleils mnade bY thle Offlice of thle Surgeon Genieral as to personnel wvere rewards, or Coloilel Tholioipsoill's tripj to tile Imlit ed St ates'. It was

agreed that at cert aiii allotmenit of gradiiu tiaes from thle schools of 11(11ropsvchiiiatrY itl tilie zone or Initerior could be senit to thle Eltropeiiil theater up1)01

requtest . Addit ioilaill v, Colonel leilitiloger. p~romiisedl, wh-iellever p~ossible, to

iiiuke knlown, bv niaiii, to ( oloilel ThiollJ)50i1 tIle- officers whlo were beingp~lacedl ill tittits to be activated for. assigniltelilt to tilie Etirolpeail t heater.

Clinical psychologists.- A pvirsomitte 1 problemn of sizable proport 10115

arose ill early 194.3 inl thle coim ilissiotillg of' di ilical psycllolog-ist s (fig. 129).

Etidist e chi i cal psycholo'gist s beg'a 1 a tri~vi ilr ill t lie FEtropeani thIeatiter ill

September 1944 inl hospit als coniling direct fromi thle Zonle of' Ititerior. Ott

2 October 1944, War Depart iniien Circullar No. 3~92 wast- published ailiomincillg,

provisionls for I lie coin inl issiontuug of thlese ('ill ist ('( cliliciaul psychologists. Oil

2 1 D~ecembIeri 1944, at coiimna ilid lettIer wa-Is issuled bY tlie( thleuater lieadquitrters

bs Ivtt,'r, L -t. ('ot. E. 0. Pa~rsons~, NIf , 36th St. tio,, i o,;v.in. toi) Dr. Wbi fr.. Overimltserr 27 J1in. 1943.
1:1J.4TVAN '111FATIA, Ill., I)PIA'ATIOINs,

Ili.: 121). 1-:nlkli-d chim-A 1)-ý ch-d---i-l ww-kin-,- wilh patirio ýo

( 11,1-pilal. C illo-.\ B ,.h-'j1Illl.

proillill-at In-(" jwovisiowý (d, the c't-culat. (It zdl lm't tit Jmiluivv

hw-ý,lfl lo IricIde III wid. III F(dwilan.-I -ronf

df )11(,l I x iliko it III .1-ý n rl 11 (.4 )1 .1111 *111 11(111111 )1)1-ý.\ CI I in I 1*.\

I I if 1-11],-, d, I Irl I'll( )III ps( )I I 's I cill p )1..l n I 111 111 11 lo Zm le 4 )f I III (.1.1( )1., :1 fill I hol I

If )111.1 Till )III )II I I I I orv if,\\ 1"1 ('11 .1 pill Ic.I it I I wns nk() proplod

11.11 1 ho n bo [VI'll It pnict iC11I I I (,I I, well as I it 1111 en W\\ llo

permlaill.\ \\ os Sf) :11111wrl'i III III 1111, spol-I'llized I.\ Ill' of \\ m.k. olld I Ilo 111.1fillel,

ill \\ Illch Ile .1 .1 Ild fiv:111 11 It p.1 I Will \\ .1-ý 4.1*11 H.A.

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Kcilv\ \\.1, .11111111-.116 1111i'd I'm1111-111 it id,1111m) If) \\(.11-1111:1111iod is m .1-ýfwmlv

Illolill wl. 44 flo. Allivi-W.111 .111d \\.I, I tit, .111111ol. (0, 1

(if) Ill, Rof-'rhol-11 Illefilml (01* p-1-1011.1111\ hv j)I,()*4.O-I ke

ill M orch 1!, 1.1. M .1jor IX'v1Ic.\ imidc :I I lim-mi Lrh ý,I fill v ill' I he \\(wi-k hvill'Ll:

dollf. 1)\ ('111114'.11 Ill 114"plink I)II fill, ( mll Ifirill nild n Imillher

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376 ACTIVITIES OF MiEIDI('AL (ONSU'LTANTS

in the work of the neuropsvchiatric section. In more than a few hospitals,

clinical psychologists were being employedI outside the ,,europsychiatric services. In these cases, the commanding officer and psychliatrist did not unlderstand how to make proper use of the clinical psychologist. In most instances

of this nature, it was found that the psychiatrist was totally unfamiliar with

the usual duties of clinical psychologists and consequently had not properly

employed them as full-time assistants.

Since it was obvious that. many clinical psychologists were not being properly employed, steps had to be taken to correct the situation. As a rule, an

explanation of their functions sufficed to convince the commanding officer of

a hospital to reassign them to appropriate duties. Administrative Memoran-

(him No. 17, Office of the Chief Surgeon, Headquarters, ETOUSA, was pul)-

lished on 17 'March 1945, to outline the duties of the clinical psychologist.

A brief article on the same topic was also published in the Medical Bulletin,

Office of the Chief Surgeon, ETOUSA.

In addition, meetings attended by neuropsychiatrists and clinical psychologists were held on the Continent and in the United Kingdom by Colonel

Thompson, Major Kelley, and hospital center neuropsychiatric consultants.

At these meetings, attempts were made to reach a mutual understanding as to

the functions of clinical psychologists and to place the responsibility for their

proper use on the shoulders of the hospital neuropsychiatrists.

Finally, every clinical psychologist who submitted a complaint that he

was being improperly employed was personally interviewed by Colonel Thompson or Major Kelley. The subject was also made a matter of inquiry in routine

hospital visits by the theater senior consultant and hospital center consultants

in neuropsychiatry. In almost all instances, satisfactory adjustments were

ma(de.

A special function was evolved through coordination with the Adjutant

General's Office, Headquarters, ETOUSA, in the use of a team made up of

clinical psychologists and enlisted helpers in screening limit ed-assign men t

personnel who were being discharged from hospitals. Individual classification

records (WD AGO Form 20) were brought up to (late to show the nature of the

patient's limited -assignment requirements, and recommendations were made

as to his future assignments. The service was extended to all categories of

limited-assignment personnel. At one hospital, a team made up of 1 psychologist and 2 assistants, during the period from 14 March 1945 to 25 May 1945,

completed qualification cards and recommended assignments on all discharged

patients-medical and surgical cases as well as psychiatric. A total of 1,190

patients were interviewed, and a followup at the replacement depot showed

that, with only occasional exceptions, the assignment recommended by the

psychologist was followed without change.

The work of clinical psychologists was severely handicapped by the lack

of testing instruments, and efforts to obtain them met with only limited success.

Further plans for group meetings, education, and other activities of clinical

psychologists had to he discontiiued following V-E Day. In all, 608 applica-
EUROPEAN THEATER OF OPERATIONS 377

tions were processed by Colonel Thompson and his associates as of 30 June 1945.

Of this number, 5:13 were rejected. The remaining 75 applications were forwarded to the War Department, which rejected an additional 33, approved 15

for commissioning, with decision still pending on the remaining 27.

Research

Colonel Thompson found it well-nigh impossible to conduct any carefully

controlled, rigidly organized, research projects in the strictest sense of the term

"research." Basic research with the classic design of control and experimental

groups was usually out of the question. Proposals for conducting some wellconceived projects of this nature had to be rejected. On the other liand,certain studies had to be done in order to gain information necessary for the intelligent carrying out of the consultant's mission. The reader should realize that

the basic treatment methods that were taken up and used in the theater--

narcotherapy, insulin therapy, electric shock therapy, diagnosis by electroencepialogramn-were all, to a considerable extent, applied research at that time

(fig. 130). Actually, most of the research accomplished in the theater was of this

same applied type. Since something had to be done, a course of action was

selected using the best information available, and the results were assessed in

any way possible for the purpose of improving techniques. Another type of

research accomplished in the field of neuropsychiatry was in the nature of statistical or questionnaire studies.

Blast syndrome.-One of the problems that defied conclusive results was

that which became known as "blast syndrome." The problem arose in the

first weeks following D-day. On 15 July 1944, Colonel Thompson described it

in a memorandum to Colonel Kimbrough as follows:

The problem of how much symptomatology was due to organic disturbances produced by

blast, and how much was due to emotional factors was brought up at almost every visited

center. Practically nine out of ten of the psychiatric patients gave a history of having been

near exploding shells, and they related this to the onset of their symptomatology, some saying that they were blown out of the foxholes by a shell. In manny there was a statement

that they could not remember what happened for a period of time. It appeared that there

was a danger of attributing too much symptomatology to organic damage, and thereby reverting to the old conception of "shell shock" of the last war. The general opinion was

expressed that unless there was evidence of damage to the central nervous system, as shown

by neurological signs or evidence of blast in other parts of the body, as shown by ruptured

ear drums, hemoptysfi , or other visceral signs, the diagnosis of blast syndrome would not

be made in forward areas. Certain other differential points were discussed such as evaluation of amnesia which in organic conditions is usually retrograde and cannot be fully recovered under Pentothal [Sodium] hypnosis. Further studies of this problem will be carried

out at hospitals at the base in cooperation with the senior consultant in neurosurgery.

When Colonel Thompson was at the Office of the Surgeon General in early

January 1945, the possibility of studying blast conditions with electroencephalograms at the front was discussed. Colonel Thompson suggested to Lt. Col.

William H. Everts, MC, Chief, Neurology Branch, Neuropsychiatry Consultants Division, Office of the Surgeon General, that two electroencephalographiic
378 ACTI VIT I Es M., MEDICAL CWNSULTANTS

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(11-chvlies 1w proviidet for t his Nvoik iwar dw ' rout. 0m ~Ny ould bie ii-ed -,t a

(*lea r-itis. stat iou1 so tha jail recis couldl he st art ed as soonl as p)ossiblde, and( t li

other would be Ilulf her back, perhaps at the I 80tb Gi eneral Hlospit al, where

h1,11lY recordls could hev coui t i tted.

Ini thle iuea uwhil~e, M Iajor Fabiuig (fig. 1:81), who11 had beenthe11 director of

lie school o1, uieliiops ' cliati *~ xWUV's perililittIedl to 'onduclit his ownl st lidVS, oil

b~last svtldroille. leI liil, 1 1d luatll l)Visiill" Pen totha lull80(li ii (t Ii opelitl al sodfiliiii) IliVJui~si adil appJrop)ria te souuui(l effects, a1 patienit who claimiedl to Iliive

beenl reuidlcredi uinconisciouis b'r soliie tlline by a lii'arl-vexplosionl could regain his

nlieiiuor v f'or tw len(lt ire period of' "tlicoisciolliISnss." Whenl t hIls eXpereiew- Iladh

lbeeli re~lvel if) (let ail, ani inject ion of' 10( cc. of' (oraimine (iiikethlaniide) was

"giveui ui)l th li at len eit was awake ill less thalau a uiliui1tit. ltveut naly, thle palien1 'wns able to write his Owni accoun t of, thle episode. BY t is mlethod0(, \ I jor

Fabiuig was able to rettirn 90 p~ercenlt of' hiis (SO cases to d ity.N

Ergotamine tartrate studies. ()if 31 Miay 1944, The Sur-geon General

f'orwarded to thle ('hi je Surgeon, ET( )1SA , two excerpts foii 1)11 p1)1 ica t lolls thlit

(lrauliiaticallv toldl of' the Ilse of, ergotaffiiiue tartrate as a1 reriiedv Iom ''shell

shock ''and ''battle react ion." I fle let ter couicltidedl ''We (10 nlot have anly

experielice what ever. with Ihle Ilse of' t his and kiiow nlotliiug, hfi't her t lain1 what

diese articles slate but votl uiiii- %\-,iit to suggerst the(ir tr-ial I t lelii(ls 11110of soui

competen'ft idividli'il a

After C'olonel Thoipoin lS hiad writ teii to )fill]iiht elegot a iii ne tart rate Was

b~eiiig t ried 0 it ill two W( I 1i5it;.Js, onl 20 fidyv 1944, ( olotiel iiuligr-I-ot % e:
EUROPE'AN TIIEATE31 OF OPERATIONS 381

We want, to think of 1'rgotamine Tartrate as being onl anl investigative level at the present time. Inl other words, we want to be sure that it is very catitiously used and we -want

to get tl he results from its use inl a few places as to its indications, m1aml effects and side effects.

andl results. We doun't propose to issue it except under youir authority * * *

Oin :3 Auigust 1944, Colonel Thompson wrote Colonel Menninger a brief

resiini6 of what wits being (done with the druig.

%Ve have been using ELrgotamine Tart rate under control conditions at the 312th Station

Hospital. This work is being (lone under Major Paul Lemikaui. A return report onl this

sh'" 'd he available b~efore long. 'Major Lemikaui believes- that there is valuie inl the dIrugth;.z equally goodl results are ob~tainled with thle insulin and narcosis therapy. I should add

that a group of 10 control p)at ients inl the same ward b~enefited almost as much onl sugar

capsules and all thle nursing attention that the other patients receivedl, so maybe it is thle

general atmnosphere andl the '"total push'' methods, are the important thing, and at ?Iny

rate it is difficult to judge the value of any type of therapy inl such a setting.

Colonel Thompson forwarded tie( rep~ort onl the use of thle dIrug to Colonel

Mennitiger onl 24 Auigust 1944 with tilte following commient:

I am enclosing a copy of an account of ouir expe'rience with Ergotamine Tartrate as

written uip by the medical officers of the 3112th Station Hospital who did the work. Further

investigation along this linle is being continued anid at the present moment, they are attempting

to combnliie this therapy with modified insuilini so as to give thle gain in weight which seemis

to b~e necessary. The use of this dIrug will be confined to ouir three N. P. hospitals until we

know more abouit it.

These studies were examples of the type of research that cotild not. be

carried onl except in ain active theater. The acuite conditions ob~served in

p~atienlts recently evacuaited front battle were not to ibe founld inl suifficient

nunmlers in the U nited States.

Morale Service opinion survey technique.-On 27 October 1 94:3, Colonel

Hlalloran wrote to Colonel Thomtpson introd''"'ng Dr. Samuel Stautffer and Dr.

Carl Hovland of' thle Morale Service, Ari rmv Service Forces. Colonel Hlalloran

stiltedi thait these were mien of outstanding ability whlo had worked closely

withI thle Office of' the Surgeon General and that Dr. Stauffer wats one of the first

to recognize that lpreventive psychliatry' and~ mInorale were actually the Sam11e

sub~ject anid had1 beeni instrumi en tal in establishing lialisonl bet ween tilie Mforale

Service andl the Netiropsvchiatrie Branch of' tilie Surgeon Genlerall's Office.

Coloinel Halloran added: ''To mimni mindl, the opinion suirvey technique for

studt*ying p~rob~lelms of hnmnian behavior has been at developnient of major imuportaii('e iii this will. It offers perhiaps the miost Promiising appr'oachi of anly to

prohblemis of miilitarty )s *ychuintr 'y. Dr. Stautffer atnd Dr. Carl -IHovlandl are

highly skilledl in the Use of t his technique andi have 11-alreay condtltted suirvevs

of considlerahble value in (his field.''

Onl 24 Mlarch 1944, Dr. Kimball Young, at personal representaltive of

NMaj. Gen. Frederick H. Osborn, Chief, Information andl lduiiction Division,

War Departmient, visited Colonel Thonipson to cement further close working

relationships between the metdical andh morale services.

Front this beginning throtighouti the life of the theater, this close rele tionship wats miaintained. In at waty, it cotuldl be said that the Morale Service
382 ACTIVITIES OF MEI)AI, ('ONSULTANTS

(later known as Research Branch of Information and Education) provided the

means for conducting studies which the neuropsyc'hiatrist wanted (to have done

but for which he had no facilities for accomplishing. Their reports were

read wit h interest from the Chief Surgeon down to medical officers in the lowest

echelons.

Even the facilities of this research organization were not able, however,

to conduct a survey that was particularly desired by Colonel Menninger.

A questionnaire had been used for a cross-section survey of troops in the United

States with valuable and interesting results. Colonel Menninger wanted to

have it applied to from 1,000 to 1,500 normal subjects who had 90 or more

aoggregate combat days on duty with an infantry bat talion in order to (determine

how certain factors considered peculiar to neuropsychiatric patients appear

in normal troopsA9 After many conferences and prelimninary studies, it was

advised by higher officials in the Research Branch of Information and Education

that it might not be worthwhile to start the study at that particular time

(March 1945). It was agreed that it should be held up until there was absolute

certainty that the study could be carried through to completion, either in the

European theater or some other theater.

Other studies.-In addition to the foregoing, some significant followup

studies were completed, requiring the cooperation of field units, the Ground

Forces Reinforcement Command, and the Information and Education Division.

A particularly cogent and interesting study was that of approaching combat

exhaustion on an epideemiologic basis. This study was, to a certain extent,

prompted by the fact that some individuals in the theater thought there

v.oulhl be a sudden drop in neuropsychiatric casualties when soldiers found they

(ould be evacuated for cold injuries. Col. John E. Gordon, MC, Chief, Preventive Medicine Division, Office of the Chief Surgeon, Headquarters,

ETOUSA, had amassed considerable data concerning the epidemiology of

tren'hlfoot, which could be readily related to neuropsychiatric incidence for the

s.iine periods. Like data were available at subordinate comman(ds. The

completed study showed a remarkable similarity of conditions attendant on

(,old injury and tieuroI)sych iatric breakdowns.

Supply

Supply personnel were able to handle problems of procurement, cataloging,

storing, issuing, and the like to a certain p)oint, but when a decision was required

as to exactly what was needed, where it had to be, and in what amounts, the

answer could only come from the using parties. So it was that as early as

October 1942, Colonel Thompson nmade reconnmendations for the amount of

sedative drugs required for every 10,000 men in combat. A later study revealed

a lack of certain items in installations where they would be needed, and revised

recomnmendations were submitted oil 7 December 1942. Periodically thereafter, the Supply Division, Office of the Chief Surgeon, Headquarters, ET'OUSA,

59 LUtter, Col. 1, J. Thompson, to Col. 0. N. solibirt, Chhlf, l•pcial Servicvs Division, ETOUA. II Nov. 1944.
EUROPEAN THEATER OF ()PERATI(ONS 383

would circulate lists of items to be stocked for confirnmation by the respective

consultants. Sometimes substitutions or deletions were suggested. For

example, on 25 April 1944, the Supply Division suggested that Nembutal

(pentobarbital sodium) be substituted for Sodium Amytal (amobarbital

so(dimn). Colonel nonhpson had to disapprove the proposal on the basis

tiht indications differed for the use of the two drugs, and Sodium Arnytal was

t le drug of choice in many psychiatric conditions.

Throughout most of the life of the theater, electrical machines for shock

therapy and for electroenceph alography were in critically short supply.

Initially, three electric-shock machines were borrowed from the British. In

January 1943, Colonel Thompson discovered that the 5th General Hospital

had had ain electroencephalographic machine l)ut was forced to leave it in the

Zone of Interior owing to shipping priorities. It was alleged that lack of

shipping space was also preventing the receipt of electric shock apparatus.

When it was learned that funds were available at the 5th General Hospital for

the purchase of an elect roencephalographic machine, Colonel Thompson

visited the Bruden Neurological Institute at, Bristol, England, and was ultimately able to procure one British-made machine.

Colonel Thompson brought this situation of shortages to Colonel

Menninger's attention by letter on 2 May 1944 "* * * because I thought

that you might. be helpful if the requests ('ome through your office." Colonel

Thompson was astonished at the reply, dated 10 May 1944, which read:

"To my knowledge we haven't had any official request for such and you might

check on that,." By July 1944, tie Supply Division, Office of the Chief Suirgeon, Headquarters, ETOUSA, had informed Colonel Thompson that a "fair

number" of electric-shock machines were on their way. It was not until

Colonel Thompson returned from his temporary duty to the United States

that a specialist in electroencephalographic techniques and electric-shock

treatment from the Surgeon General's Oflice came to the theater and worked

out (letails for supplying such machines and requirements for the personnel to

run them. Finally, an additional supply of electric-shock apparatus arrived

from the Zone of Interior in early 1945.

A request sul)mitted l)y Colonel Thompson in March 1945 for psychologic

tests, answer sheets, and scoring keys also was largely unfulfilled. As ol thie

first of June 1945, the only materials that had arrived were Army General

Classification Tests whiich were already in the theater; 50 sets of Rors-chai.h

cards, which were procured directly from Switzerland; and 25 sets of Thematiic

Apperception Test pictures. More important. tests, such as the WechslerBellevue Intelligence Scale an(d tie IMinnesota Multiphasic Personality Itiventory, were not, forthcoming. Those tests that were made available had to be

provided on a priority basis to units tehe(luled for redeployment to the Pacific

area.

Within the armies, neither the division psychiatrists nor units used as

exhaustion centers had been provided the additional or special equipment

needed to cope with tile number of neuropsychiatric casualities encountered.
3S ATIVITIiES' OF MED IC'AL (i )NSI'L'ANT1S

TPhis wits, part *icuarly t ruie of thle division p)sychint rist lie requiired falcilitieýs

enpa ibie of holdin g and1( cain tg for sonme I 51 calstalties, buIt t iilble5 of orga niza11011 and1( equipmenii't madI~e no0 provision for t his, and1( local 1iil-atrlilgeiieits had1( to

be iliia(e to ob~taint thle eqiplipilvielt Such 11rrange1"ilients wvere best ma11de where

(101iiii11lid( sulrgotis and( 0t1whr stalff officers had Sym11lipthlet ic uinderstanlling, of

thle MINIe for iietir-ojsycliialt li faicilitiles. (Coloniel Thiompson0i devoted mluch

effort t owa rd t his end1( oil his visits to tlie a riii-ies, corp~s, li11( dIivisions. EvenIiiiilly, most division psvchlit lists- were rout inely supp)1liedl with sIiesu essentia l

iieduiall iteiiis ats reflex liiiiiiiiier5, and olpllihililiioscwopes. Thie only ilieans" of

(lefillit clv solving thlese p~rob~lemis, hiowe'ver, wits by niew titlbles of organization

a ind equiiipm ieint or imodi fica tions, of existing talbles.

Professional Puiblica tions, MIeetings, and Societies

Prolessionial literalture was alwayvs in lel demand, part icuihlarly by Colonel

Thompson and the( school. Thiroughi thle courtesy of D~r. C. C . Buirlinga me,

C olonel Thomponil51 Witas ab~le to obtain sufficient copies of ab1st racts p)ublished

by the Intst itutte of Living, 11art ford, ( onti., for his utse 2111(1 for uise inl claisses

tii nietropsY('Iiitry Arquest submitted to C olonel \ lenninger for rep~orts

iii1l1le by the Morle1 service lin1( pub~licaitions of the ,Josiall Ma1cy, Jr., Fouindaitowisequally productive. Event ually, provision wt-malde by The Surgo

Generaul to supply aill (division psychiiatrnists With at full file of rep~orts publlishied

by the MoraleSrv, enftited "Wliat tOe Soldie'r Thiniks."' ]it addIitionl, 21

ba;sic. set of' referenice texts Was' p~rovidled eachl (divisiont jpsvelliia t rist.. Manly

iiid ivid till I officers subscribed to vairiolis professional journals. Somec suibordhinaite consultants in nelirolpsycliat ry ailso procured pumblicat ions for their

c'ommandui( s.

Thel( E~dit orial Board, Office of thle ( Thief Surgeon, I~eadlquitirters, ETOLt'SA,

wats- (established onl 21 October 1944 by Office M eiiiorandluini No. 2:3. C olonel

TIlionijpsonl wits1 appointed its Olies of' its ineiiilers. The board w-its required to

reviewv manuiscripts of' pa2pers to be jpreseiit ed for publ)icat ion or to be re2(ld before

it society Which puildishied such1 papers- iii its journal . As at result, ( olonvie

Thomlpsonl personallyI reald, reviewedl, and commiente ol01 thle many pap1ers

toluchinlg uipon thle subject of' neuiropsvchia t , y t hat were submiiit ted to thle bo0a1rd.

Ill conjulnction Withi thle Public Hvellttionis Oflicer, Office of tw he ier Surgeon,

i Ieitqiiiirt v ers, i;'l'oUSA, C olonel Thompson wits, requiiredl to ad(vise and1( comnilielit onl stoiies b~y report ers in tile thlea ter onl the sub~ject of neuropsychiattry.

Meetings of vaiioiis societies lind( organizations providled olplort tniIt ies to

exchlange inlformat ion and1( iiiet coworkers. They creattedIia general. feeling of

c peOO-)i'2it oll 2111( goodl will ii Iliolig till t hiose itttend1ing.

T1he t heater'I senlior' 'onisultanttt iii neutroIpsychitiitry iand lpsylitiatrists in the

field parlt icipated inl the act ivit ies and( iieet ings of till tie( larger orgainizat ions,

such its thle Inter-Allied ('on ferenee onl Warl ýMedicine the European Theater

Amierican Medical Societyv, and1( the variouis base sect ion medical societies (fig.

1:12). Paipers coneeriling Iieuiropsy('hiat ry p~resenlted by C olonel Thompson tit
LVIZIWFAN TIWATEN 411-' 4 WFUATI, INS

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3186 1'IVITIE.S (OF MEDICI(AL CONSULTANTS

3 months. At. first, Colonel Thompson wits the only U.S. Army rep~resentative

at. its gait herings, but1, in Novembher 1943, till UT.S. Armly adNv ielo~

chialt ists were invitedl to join, )((tieoraizton m(iil ess~witilia, 1 1 p*- ) * 

cimiat tic aissociat ion of t he Allied Armies in Europe. Its meet ings-, whivih were

commonly referredl to its the interservices ineet ing or p~sychliat rists-, were hmeld

lit the Royall Society or Mledivinle inl London. Onle of tile high poinits inl these

gaitherings wits the( session of 25 March 1944 dlevotedl to rehabilitation work.

At. this meveting, C olonel Parsons exp~lainled in (letail the( rehab~ili tat ion program

that wats being carried out ait the 311 2th St at ion I losipitial.

In add~itionl, Colonel ThIompson01 representedtilte U.S. Akrnmv lit tihe special

PsVcilolog-ical and 1Psvchiatrnc Lialisonl C ommiit tee mleet ings- held lit thle offices

of the War ( 'abinet in I ,ondon ; ait conferences or commnan(d p~sychia trists of the

British forces ; tit coniferenices of the British Emergency Mledical -Service psychiiat rists ; and ait meetings, of the Services Subcwominit tee of thle War C abinet 's

Expert, C ommiuttee onl the Work of Psychologists andl Psychiat rists. The(

laitter witas an extremely important associaltion for Colonel Thomlpsonl, since thle

Services Subcomm nitt ee consisted of consuilting psychiiat rists and psychologists

from aill the British services.

Cooperation Front Without the European Theater

This account would be incompjlete if it were limmitedl to deallings, with)

strictly Iiledical elements and individluals wit hin (the theater. The jol) t hat wats

olone, andl coloe with ita consp~icuous dlegree of success, wvouldl never have beeni

po0ssible withbout outside help.

Colonel Thompson wats fortunate in having and mnaint aining frequent.

dlirect contact. wit h thle Netiropsychiat ry Consultants D~ivision, Office of tile

Surgeon General. The beniefits wvere mnutuial and1( extendled into aill spheres of

nilitary neulropsychuiatrnc activities. At first, contact, wats infrequent. and1

relatively formal t hrough approved nmilit ary channels. and b mitary letter,

and these continuied to be us-ed for matters- of inllportlance requiring official

cognizance, particularly policy Iinat ters. However, the wily w~its op~ened for

informal andl personal coimmtunicat ion in niic-l 943.

Onl I June 194:3, Colonel Hlalloran wrote Colonel Thompson ats, follows:

Irmlt ii recemityit wa ncessacry for all cofiittlinicat ions from overseas cotisimitallits to pass~

throtigh official channels. However, we have no0w receivedl informaimti11 t hat overseas

consulltanits5 ill t ie fieldl 5110111( be viicotiraged to coImlimiInicate withI t his office piersoia~l *v itt

least otwei* a ui(lt h. lit this Way we miay he able to familiarize ourselves wit hi maniy p~rob~lems

and receive information which will guide ums inl fortmiumat ug advisorY policies.

In rep)ly to this let ter, Colonel Thompson wrote: ''It, is at great relief to

know t hat, overseas consult ants callm comnmuinicat e personally anld direct ly wit h

your office. lin the past I have hadi~ considlerab~le material whlich I t boughlt

Would he of interest anld vallue to vonl.'
EUROPEAN TIIEATER OF OPERATIONS 38T

When Colonel ' Menninger became Chief, Neuropsychiatry Consultants

Division, Office of the Surgeon General, in December 1943, the relationship

established by his predecessor was continued. On 25 January 1944, Colonel

Menninger wrote Colonel Thompson, as follows:

My stay in this office has been so short that I am still a long way from being oriented.

I do have a very definite impression, however, that the lines of communication between us

here and you over there have been very thin. I would like so much to know the dope from

you and I presume you will be interested in knowing of events which occur around here.

I'm going to try to get out a letter to consultants each two or three weeks just to let you

know what we are doing and what is happening. I know that even in this country I felt

very much isolated from The Surgeon General's Office and we do want to be of as much help

to you as we possibly can.

A few months later, Colonel Menninger was still intent on establishing

personal communications with Colonel Thompson on a sound and continuing

basis, and on 22 .March 1944, he wrote: "I am keen to know what's going on

over there and any suggestions you have for me * * *. So much of our work

is necessarily extremely interlaced with yours and it's a very great handicap

for both of us that we don't know more of the details of each other's planning."

In September 1944, Colonel Menninger visited the European theater. Organizations in the combat zone were the primary goals in his itinerary. Accompanied by Colonel Thomipson, he visited army and division psychiatrists and

inspected evacuation hospitals, field hospitals, exhaustion centers, and clearing

stations of many divisions on the line. Colonel *Menninger then viewed

neuropsychiatric work in fixed hospitals with particular attention to problems

at the 130th General Hospital and the screening of patients from Quartermaster

work units at the 19th General Hospital. Wherever lie went, there were

informal conferences with neuropsychiatrists in the field and direct exchange

of opinions, ideas, and information.

In the United Kingdom, Colonels Menninger and Thompson were escorted

by Brigadier Rees and Lt. (Col. George R. Hargreaves on a grand tour of British

military and civilian neuropsychiatric facilities. Among the installations

visited were the Army Selection Training Unit (Royal Army) at Leeds, England,

the Royal Army NMedical Corps neurosis hospital at Bellsdyke, a primary

training wing in the Scottish Command where the process of testing and placing

recent inductees was observed, and "Gordenburn," the neurosis hospital of

the University of Edinburgh. While in the field commands of the British

Army, the visitors took part in a meeting at York, England, of British Army

regional psychiatrists of the Northern Command. Two of the talks at this

conference were given by the U.S. Army representatives, Colonels Menninger

and Thompson. A meeting sponsored by Dr. David K. Henderson, Professor

of Psychiatry, University of Edinburgh, was held with civilian psychiatrists

in the vicinity of the university. A visit was paid Maj. Gen. J. A. Manifold,

Surgeon, Scottish (Comnmand. Finally, Colonel Menninger attended a series

of conferences arranged by the British in London.
388 ACTIIV ITIES~ OF MElDICAL (ONSVIA'LANTS

1'ponl his return to tile U nitedi Staltes, C'olonlel \enninger wrote it compllete

atcclutnt, of his t rip to te lEuropean~t'it t hieater!"' In this rep~ort lie conliinent ed:

V is its From The' Surgeon, h'nCmrul',v Office

N I' iniprissions ili contacts withi t~lit professionial t'oistiltmaits inl t it( t heater, and1( jnrt ietlarl 'v

With lit-e miedical offcers in t he hospitals, are that. my visit was very mutch appreciated

bect'cist' it iniititat -d anl jintvrest onl tithe part of lThe Stirgeoii G eneral inl t heir situnat ion. I

lwlie've it Was anl jinlivat ionl of I the need for andl valtiet of rat her frequtent contacts betweenl It(l

professional groiip inl The Surgeon (it-neral's Off~ice and the( professional group inl thet field.

Ini December 1944, C'oloniel Thiomipson returnedi to tilie United States for at

period of t etiiporarv- dulty, from 12 D~ecember 1944 to 15 JIaiua ' v 1945. Whltile

ill thle I tilt ('( States, Colonel TIhiompsoni Presenitedl thile major addtress oil millba11t t'xhiuiist lol before( tilie Reseairch Assoviat ion Hi Nervous and M ent al IisClIeSC. Willd acted ats at member of the 'ommtiissiont of the( organizat ion. ( olonlel

rlIThopsoni spetit Somie tinme ait Mason (h'iteral H ospitald onl Lo~ng Island, New

York, wli(rv iletroj)s 'vchiiatrnc calses evacualted front till t heaters wvere to be

seel), wil ti( t t ie( neulrops *vc-lilriat nc onvalescent facvilitY ait. ( amip Uptonl. Ilie

ait telildeu tilie first coniferenc(e of p)svc(.liiat i'ists inl charge of 'onisultat~ion ser-vices

at replacemilent t rainling centers, which wats held ait Aberdeen P~roving Ground.

The're \%aIs nIlcli t'o (Iiscuss, and1( mnyai plains and special arrangemtient s were

ninet(i(at. tie Neuiropsycliiatry Consulftatits Division, Office of The SurIgeonl

(ieneri'l.

There wtere other visits to tie European "'heitter from personnel of the

Sn rgeonl Genlerall's Oflive, relpresentiatives front othbetr War D~epar'tment agreicies, an1d fronm tilie Office of Scientific Research and D~evelopment~ and1 Nattioiial

Itesem cli ( ouncil. All of thlese visits, ('itlier tliret'.Ivy or indirectly, event ually

hadl profound( eff'ect. onl the conduct of neuropsychiatiriec services in the Europeain

The first of these ot her visits wits nuiade in March 1944 by at group headed

by Maj. (Ven. Norman T. Kirk, Tile Surgeon General of tie Army, Ilie was

1ACCOlliaiiied b~y Maij . Gen. D~avid N. Gtrant , the Air Sturgeon, and 6ri. Striecker.

D.r. St recker wats at membher of tile spe('ial war t'onmittee appointed by the(

American sv(iitrcAssociation, thle president. of thle association, andtlia

civiliani consuiltan t inl psych jutrmY to tlie( Secretary of War. lie wats concerneil,

prtimtar'ily, i-it h neuiroses affect ing 'omblat ti('eS Brig. (len. Mfalcolmn C.

Griow, (C01. Elliott, C. C utler, M(C, L4t. (Col. (latter (Col.) Herbert B. Wright,

\1(, (11 RI. 11. Ilill, NUC , and Colonel Thompsoni joined the commission in

its visits to field imustaillalit ions (fig. 133). P~ract ically all general and1 st itt lot

hospitals iii E~ngland serving At'iY Air F~orce unmit~s were v'isited. Dr. St recker

in terviewed( Personally niantY fling pesoninet who were patients. At till thiese

iiistithlat ions, thiere wveme con feretnces withI the psy' chiattrist~s. Of part ivulat'

interest to the visitors was the rehiabilitatiton ceniter of the 307th Station

I lospitall, which was doing anl exceptioinal jolb in returnling wounded airerew
peroiielto (llt *v. and thle 347 th IStat ion Hosp5Jital. which was tine speIral

treatmuient (center for op~erat ionial bit iguie of fbyin hg f('ionfii(l. A 6. 1iiiliidit of

the 101lwas thle visit ibv tlii enitire comm1ission01 to tihe 31 2th Stationi I lospital

where tihe tleatitlitelit .1i1d rehiabilitatlonl of nll)s -vcliot ic patijelits \\'ISs(4111i.

Mied ical offi(ers attend inlg' tihe school of lieu r-opsvchlit uw were em~aeIill

coui fei'etice, andi a comiplete presenitatloln was gienIy tile school's leulliolist railon 1111it of whai~t telivii'ui-ioJ)5*Vlint list mlighit elleoullvite at . a (ivisllt clearingc

station. (Onu 20) March 1 944. 111 evet*ili 1 Itler X\U.S irivellI byN ( 'ol. IjeX 1_

I ivelev. NMI( ', Senior ( 'ouisuult ant inl ( rthIopelvd' Sillgry(Tv. ET( HSA . and C olonel

Thiomlpson for nieulmbers of thle comm~iiissioni and I thir opposite numbe1)(rs Inl ,omisul1tat loll ill oirthop~edics anid psvcliiatr f~ romi t he Brit ishi Services.

Somne t ime after thle visit of thins comumiission, C olonel Thiomnpsoin wrote to

C olonel Nleniiingerv onl 2 NIaY 1 944 a wid expressedI thle hiope thlat D r. -St recker

hiadl bleel able to call on) 11ii11 to tell about thle visit inl the l111opelaii t heater.

"I amt sure,'' ( ololel(I Thlomipsoni Vent uredl to say* ,"t hat lie broluzhit black w\it ii

him considi~erabile first huand iniformat ion that caimiot be exfpresseIi inl writ 1n1r.''

In a reply dated Mt NIay 1 944, C oloniel NIenli liger wrote ill collihiriat loll:

"Ed ;t recker dIidI stop to see uis and1( told is iSll conisliderab le detail about thle

sit unia tlo. Ileollicia I reports comle t Iiroumgi i lmore slowlY.''

Cooe Th111 lomlpsoni had1 to declinle a1 proposal by D~r. St recker for hioldihiui

exa Illiliat iouis of tOli Amijricanl Board of xveilrologv .111 mi V., cl it Ill thle

European theater, desirable as t his wouild hiave beeii. C oloinel Thompson had
indteed receivedl moire thl liazt f(ew a ppl ications Itil (I ueries regardinlg Stiich examinialtiolis but it wouild have bieen too difficult to find the time andiol )ave for

them lit that timle, whenl thle invasion of the C ont inenit was just. I nmonth 01(1.

Brig. (Neli. 11 ugh JT. M organ, C hief C onsult ant inl M edicine to The Surgeon

General, visitedl thle European andio M editerraniean theaters in M arch of 1945).

( Weneral Miorgan was not, interested in neuiropsYchiiat lie activities per se, but.

his broadi interests andl extensive visits to units wit hini eachl of thle field arimi's

in colinbat. brought ouit miany observations and initerviews, with key personnel.

( enerall Morgan wals alble t~o assess keenly the t~ypes of medical uinits beinig

usedI, thle missions they wer~e Performinig. andl t heir capabilit ies aliio limit ations.

lit it ieniorntIduit ill at~ed 19 April 1945, hie rep~orted the resuilts in (letatil to

the C hiief, Operations D~ivision, Office of the Suirgeon General.

C olonel Thompson spent, the entire month of April 1945 with a special

comimiissioni sent to the Euiropean theater to studly psychioiieu rot ics. The

commiiissioni conisist ed of C

1ol. Lucius A. Salisbury, N 1(, 101): C ol. Peter

Sehiiiick, (iS(: Lc.. (Col. Herbert. 0. Peet , 101); Colonel EiVerts; and I't'. C

1ol.

W~alter 0. Klingmian, NMC. lin the lat ter pairt. of 1944, at commissI5~io made

up1 of Colonel Salisbury aind four civilinil lpsYchl ntrists had conduhlctedl it studhy

of thle treatmieiit. of psvchioneurot ics b~eing carried out. inl the Zonle of Interior.

As at resuilt , thle Secret ar *v of Will- asked thle Inspector General for at report, oii

the samne topic fromt the theaters. Onle commiission wats Seiit to thle Pacific

area, and this oiie had( 'onic to Europo and wats to proceed litter to the NMediterrainean theater.

Tw~o days wvere spent, in orienting the group and1( planning thie itinlerary.

The first daiy of thle t our wats spent, in long conferences withI General Kenner

ait Stipreiue 1 leaolquart ers, Allied Expedit ioniary Force, and with Col. (later

M aj. G en.) Alvini L. (Gorby, N IC, and Colonel Whiayne, bot h of thle 1 2thI Armiy

G rouip. Front there, each armny in comibit. wats visited; thatt is, Oie First,,

Tlhiird, 'Sev'enthi, and Ninth lIT.S. Armies. Ini each arni', medical ats wvell ats

ot her p~ersonniel were int~erviewed ait. till echelons front armny anid corps lieanl-

(j muzirt ers dowin to units wvit'lhin die1( divisions. tIn this way, opinions were o1)-

lainmed fromt commiandlers of miajor organizat ionus, various st aff sec(t ions, anid

iiiedical officers. Ever~y t~vlpe of niedical treatmwent, facilit~y in uise wats observed

froml dhivision clearing stations b~ack to exhiauist ion centers supp~ort ing evateuattioti hospitals. Early in the tour, the 51st. Staition H ospital, which wats at

specialized unit, supp~ort ing Third and Sevent h (U.S. Armies, wats inspect ed

thioroughily. After thle t~our t liroughi tlie( armiies, it simiilar t horough st udy

was miade of the modt General IHospit al anid its rehiablilit at ion cent er, which

%\it tlie( t erininus of neuropsychiatric evacuiat ion front First, and NinthI U.S.

Armiies.

F'acilitfies and medical staffs of Eighth and Ninth Air Forces wvere allso

visited, including thle rest, lioiies of Eighthi Air F~orce in t lie Unit edi IKingdlom

til(]I It( l oie h)11er fieldl tit Polehbrook. While in t lie Ili-t isli Isles, t lie group) miiade

acit J'11)lete st ii(y of t reatmulent of neuroses ats conui~uct.el at.t thle 31 I2thI St ation
EUROPEAN THEATER OF OPERATIONS 391

Hospital-the "last ditch" rehabilitation center for neurotic patients in the

theater. The 96th General Hospital, the holding center for psychotic patients,

was also observed.

The work by this group during April 1945 was the most comprehensive

on-the-spot assessment possible at that time. It included all facets of the

whole problem--command and medical--as it pertained to psychoneurosis in

the European theater. The seriousness and interest with which the members

of the group proceeded about their work proved to be a real stimulus wherever

they went. The following excerpt from a letter written on 25 April 1945 by

Maj. Alfred 0. Ludwig, MC, Consultant in Neuropsychiatry, Seventh U.S.

Army, to Colonel Menninger, shortly after the visit of this group to his area,

illustrates this feeling:

I had the pleasure of meeting Lt. Col. Everts when he visited us with the most recent

of the many investigating committees that have "looked into" our affairs in the past two

years. He, of course, was thoroughly familiar with what we have been trying to do, as well

-is with the various circumstances that influence the NP rates over here, but it was with

very considerable satisfaction that I expounded some of our ideas to the other non-medical

gentlemen. We tried to give them a very frank opinion, backed with facts and figures,

as to the reasons for the situation, and emphasized particularly some of the things over

which the medical department has no control.

On 21 April 1945, another commission arrived in the European theater

from the Zone of Interior, made up of civilian consultants in neuropsychiatry

to The Surgeon General. Its overall mission was to study the psychodynamics

of combat exhaustion. The commission was composed of Drs. Leo H. Bartemeier, chairman, and John Romano, Karl Menninger, John C. Whitehorn, and

Lawrence S. , Its raison d'etre was the fact that the clinical manifestations of ps.ychioueurosis in combat differed considerably from typical psychoneurotic re.,tions, and, as the clinical picture changed more or less rapidly as

the pttient was evacuated to the rear, reliable information was needed for

correlating psychopathology in forward areas with subsequent treatment

methods. It was assumed that psychiatrists in the Army, and particularly

the group ati the lower echelons, did not have time and might not be professionally equipped to undertake such research. The contemplated project had

the complete approval of the Office of Scientific Research and Development

and was strongly endorsed by Brig. Gen. William A. Borden, New Developments, War Department. Earlier during the year, when The Surgeon General

approached General Hawley on the feasibility of the project, an invitation was

extended by General Hawley for a commission of this nature to be sent to the

European theater.

The commission had intended to proceed in pairs or individually to different active fronts. However, the collapse of German resistance in many areas

militated against such a plan. Colonel Thompson advised the members of the

group to travel together. Because he was engaged in touring with the group

headed by Colonel Salisbury, Colonel Thompson obtained the services of

Colonel Parsons to escort them. The civilian commission covered practically
:192 ACTIVITIES OF MEDI)ICAL CONSIL'LTANTS

the same ground as the earlier conmnission, t)ut its menibers were able to spend

much more time at tile 130th General Hospital and with British neuropsychiatrists. Unfortunately for the commission, there were alnost no new battle

casualties.

A comnplete report was malde 1)v the commnission upon its return, in which

it noted the peculiar advantage it had in dealing with i military neuropsyehiatric

patients."

Being civilians facilitated the obtaining of information from some patients. It also

enabled us to identify ourselves very readily with either privates or officers . . . because

we were not, in fact, in any one of these positions ourselves . . . We were not under any

compulsion or obligation to find ways of getting men back to duty. It was our function

only to study the conditions without the necessity of serving any utilitarian purpose by

which Army doctors are always bound and constrained.

If any one individual outside the European theater left a permanent

mark upon the theater's neuropsychiatric activities, that person was Colonel

Hanson, Consultant in Neuropsychiatry, NATOUSA (MTOUSA). Even

b)efore Colonel Thompson's arrival in the theater, when Colonel Hanson had

been assigned to the North Ireland Base Section, ETOUSA, he had written a

letter to the Chief Surgeon, ETOUSA, on 10 August 1942 citing the need for a

much better organized, equipped, and extensive neuropsychiatric service in

the European theater. The letter so impressed General Hawley that he had

used it as the basis for requesting a full-time neuropsychiatric consultant of

suitable high caliber to organize and operate such a program as proposed by

then Captain Hanson.6

It has been mentioned previously that, before departing for the North

African theater, Colonel Hanson, with Colonel Thompson, had worked out a

plan to be used in combat that was amazing in its foresight. When the European theater was in the process of making firm plans for mounting the invasion

of the European Continent, Colonel Hanson had accompanied Colonel Thompson back to Europe from North Africa and helped sell the basic system, which

was ultimately used in all field armies in Europe. At the same time, lie gave

lectures to students at the school of neuropsychiatry that were most acute and

timely. His reports, verbal and written, were the basis for a significant part,

of the indoctrination of line medical officers and neuropsychiatrists in mobile

hospital units at the school of neiiropsychiatry.

When Colonel Menninger visited the theater, Colonel Hanson was able to

join him with Colonel Thompson and make the visit more fruitful, both in

terms of what Colonel Menninger was able to find out on his trip and the immediate benefit of the trip to neuropsvchiatrists in field units with whom conferences were held. Forms devised by Colonel Hanson were used with but

V. Report of Psychiatric Mission, Office of Scientific Research and Development, European Theater of OpeMrations,

16 April 1945-16 July 1945.

13 Letter. Col. Paul It. Ilawley. Chief Surpeon, E'I'OUSA, to Surgeon (leneral, '.s. Army, 15 Aum. 1942. , uhjeet:

Neuropsychiatric Treatment iri the Theater of Operations.
EURO PEAN THEATER OF OPERATIONS 393

slight modifications in the European theater. When Colonel Thompson was

asked to recommend tables of organization and equipment. for division psy.

chiatrists, hospitals to be used as exhaustion centers, and special general

hospitals for neuropsychiiatrists, lie found it good practice to ask for Colonel

Hanson's advice with respect, to these matters.

An indication of the regard which Colonel Thompson had for Colonel

Hanson may be found in the following letter which Colonel Thompson wrote

to Colonel Hanson on 24 February 1944, after Colonel Hanson's first return

visit to the European theater:

I should have written to you before this time to thank you for all the help which you

gave psychiatry in this theater. The men at our N.P. hospitals are still talking about your

visit and the good your talks did for the personnel. You certainly did help getting things

over to Colonel Spruit, and the plans which we made with him are going forward in spite of

the fact that he recently moved on to another assignment.

Following Colonel Hanson's second visit to the European theater, Colonel

Thompson wrote, on II November 1944: "Once more let. me say that your

visit it this theater was extremely helpful and stimulating. We all look to

you as tile pioneer ill things that we are now trying to (0o."

In concluding this section, the aid given by the British forces, the Morale

Services of Ariy Service Forces, and the Adjutant Gineral's Office should hIe

mentioned. Their contributions have been described in other l)arts of this

survey. Colonel Thompson, in turn, found occasion to give advice and c(ounsel

to consultants in neurot)sychiatry from the other Allied nations. The London

office of the Rockefeller Foundation always maintained an enlightened and

active interest in neuropvsychiatric educational activities of the theater. The

Josiah Nlacy, Jr., Foundation and the Institute of Living were always helpful

in 1)roviding mulch needed literature.

Finally, another passage from the report of the commission headed by

Doctor Barteineier may be quoted here, for it suinniarizes the singular effectiveness of tire arduous task of saving ||anpower and relieving neuropsychiatrii c

losses as it was carried out in ETOUSA. 4 The report reads:

Among the most recent statistics which the commission have were those presented by

Col. Lloyd J. Thompson, and Col. W. S. Middleton, at a meeting with Maj. Gen. Paul i.

Hawley, the Chief Surgeon, and his consultants in Paris on 24 -May 1945. The colmmission

•attended this meeting and learned that 17 percent of those casualties in the ET() who were

returned to the Zone of Interior were suffering from neuropsychiatric disabilities. (This is

in contrast to figures of 42 percent said to have been reported from other theaters.) The

commission also learned that 80) percent of all N.P. cases in ETOUSA have been returned

to various kinds of military duty. Perhaps even more dramatic was the report, from one

of the special U.S. military hospitals to the effect that 5,000 men were returned to some

kind of military duty from this inst allation during the period of one year. If these thousands had not been treate(d they would have presu|miably been lost to the theater and would

have returned home chronically ill. It is the opinion of the commission that this report is

a high tribute to the effective work of army psychiatrists.

64 See I tinofe tP2, ). 392.
34At'11'VrIIES itIP M1EDIC(AL ('ONSV1IA''AN'T'

SU NINI AlY IN mETIIOsvi,,EcT

I,1lnvdj.. fIllv)If ol/ -Wl 1.D.

P~erha1ps tilit Senlior (Consuiltantt ill Nt'Iroj)sycliit IT, F..l( )SA, shold~l~

hiave' hel(tl tit cie conlsu~ltanit oil at level withI thle Ch'i etf Cotsili anit s inl Ni edici tie

an 11( llt tg('tr, E'l'()1 8. Sulch l ar 1tranIgemlenit wvould have bleen ill keepji ng

wvith tilte situatztion t hat existed ini (tle(- )flice of tilie Sii rgoeoll Genl 1-l. 1 lowevvr.,

ait no titme tlur1itig liy 3 years in the Europeani theater was, t here tiny difficulty

in working '' under'" C oloniel MIidd(let on. Ill fact , on ti eou occasions, thI ere

were (listitict 21(1va nt ages, 211(1 always I 1121( thle feeling or workiiigr -'wit It'

(C'lotiel M ~ iddleon. With IOther persotudi ties this iii ighit not h avye bteen t rue.

I wvant to express again liy great appreciattion of thle gener-ols help and

loyal1 coop~era2tion genby Brigadlier Rees of thle Royal Armyi MIedlical C orps,

Colonel vati N ost rIali of tilie Royal Ca'inadiaini Armyi NIedic'al C orps, 21nd by

their fellow officers thIirouglhout t le wari in Europe. Iit lily f irst cotntact wvithI

(Adoonvl NI id lt on I suggested that psycliillt rvshould 1be conicernedl withI prvvenltiou 21 td tilit earliest possible t rea~tmeitn t and should not waint for psychiiatit c

cllsil~lltivs to be admiit ted to general hOWptls I soon found that thle Etiglisli

and Canadlian~il p~sychiazt rists hIad lbeenl app)jlyinig" t his idea'2 since' thle beginning of

the wvar.

mI n 21pj~''imatiml or th litloyni and1( prod igiolls alssist anlce given by thle lint ii er

Ois 0'15 leil0lSyclialt lists ill our own ariiy was5 explre'ssed( verblmly and i lldi vid tllally

long" ago but shlouldI be' recorded here.

Th~e first great siurp~rise a11 itchai~llenge thallt* ca iiu after re'port ing for' (lilt y in

Augu st 1 942 'NV-l5 thle dliscovery thIiat tilie positioll of dlivisionl psychia1trtist hiad

beeni dropped't fronti tilie table of organlizaion 101 omelit yealrs p~rev~iou1sly. Hlaviing

kinowni several of t(le dIivision psychialt rist s of World WXar I 21d hal111ving hieard'(

their a1ccoutslli, it. seemed'( t ha~t t his posit ion would~ still be( it key oilie, althloulgh

lthe type1 of wa rfare i' id cha~ngedh. LoMokinhg Iback oii subsequni t experienices,

I feel certait 21it t each d'i('itivisioni couild have lt' 115ed t wo psychtia21trist"s to great I

nd(vnnintlgp. of couirse, t here was5 not th liquan11t it y of tWWtI(l peirmllu'l to Ilel'-

nit. tvvti a1n exlqertilet hin t his direct oll

O riginlally it w~it" thlouighit thaiit Nvileil liveessil IT, dIivisi~on lit'itl'oI)sychinticitn

('2ti5l2litivs woiiid be e'vaculatetdt frotii tilit c'lea2ring' sta21t ions to eva1cua2t ion h os'pnt~i15. Apparet'ltly, t his was5 st andtard o~peralt ing priocedurei'(. IHowetver, lit t his

level it grea2lt deal1 of e'xperimeiintitn g wts donle. 'lT'e First, 17.S. Aklrly 1 pi('erelle

(ott tilie baisis of exp~erienlce ill NorthtI Africa 2111( Itally) ill t'stabldishiing exhiauist ionl

ceii t ers lu1 itit'd miost ly by psvchiiatrtist s fronti tilit ('v2c1121ti h~llospital1s. In

contitrast , th lT'hllird U..S. Armyv kept, p~sychia~trtic stetvictes ill its ev21('i21 1(11

htospi tails, butt est abllished'( ill onle contvaklescenit htospita 21t h1lolditng and1( t liit iniittt

ventIer for ltitrllopsyclitria c pa1t ietstt. Thertet werev still other mtodIificait ions (of

service lit t his leve'l atid arlgiuiment s conicerniing tilit best pla1n miay still be goinhg

on1. At til lit'ed Of til ~2l', Wlt it HIa Il n'21'( tdin1t th lT' Ihiirid U.S . Artinypiv 1)2 aid beein

best folr its parttviclarl type of comibat iniits swt''p from Normandylu into Ge,(rmany l.

lIt thlit First. 1' . At'tiv, zis well as ill lt' oth li'i nlti i(' whierte e'xhaust ion ('(elterls
EI'IR)EAN TIII.'iATER, OF ()1'ERATIO3NS ;)5

were estalblished, their p)lai worked equally well and seemed suited to their

functions.

The establishnent of the specialized neuropsy(chiatric hospitals just back of

army areas, with their emphasis on rehabilitation, certainly had strong support

from General Hawley regardless of opposition from other sources. Tihe plan

to have such a rehabilitation center just back of the First and Ninth U.,S.

Armies and another just back of the Third and Seventh U.S. Armies seemed

logical. Because of delay iii establishing these centers and because of their use

for other purposes, the plan never caime to full fruition. On the other hand,

the specialized neuropsychiatric hospitals in England fulfilled their functions

beyond expectation. While speaking of these neuropsychiatric hospitals, the

brave action of (Colonel Parsons, commanding officer of the 130th General

Hospital, during the Battle of the Bulge should be recorded again and again.

lie remained behind as the only medical officer with patients who could not.

be evacuated while the German Army swept by and beyond his hospital.

Having these separate neuropsychiatric units-exhaustion cienters within

the armies, rehabilitation hospitals just back of army areas as well as in England,

and at the saimie time, adequate psychiatric services in evacuation, general, and

even station hospitals-may have seemied like "having your cake and eating it,

too." Considering the magnitude of the psychiatric problems as well as the

results obtained, this apparent overlapping seems to have been necessary.

Psychiatric participation in organizations outside of .Medical Department.

activities, such as replacement depots, and disciplinary centers was a 0uih

needed function that was fulfilled in a somewhat makeshift manner. Most of

these functions had to be "sold" and when "bought'" the lack of psychiatric

personnel as well as of command backing often produced embarrassing situations.

The formation of units for hard labor came as a surprise to psychiatrists

and perhaps to the majority of medical officers. Who was to decide just which

combat-exhaust ion soldiers should be assigned to labor battalions and which

should be treated as casualties and receive psychiatric care remained an open

question. This unanswered question is of tremendous importance in all branches

of the services andi at all times. The answer lies not only in the imoral fiber

of the individual but in the atmosphere of morale, leadership, and motivation

that surrounds the individual from the time of induction until signs of breakdown appear. In respect to this question, psychiatrists were often considered

as being too soft. At times and under certain individual circumstances, such

may have l)een tlie case. Generally speaking, however, we attempted to steer

a coiln]1On-sense ni(ddle course.

The part played by the theater school of neuropsychiatry and other

educational efforts is worthy of further comnmendation. The numerous division

psychiatrists, frontline medical officers, and many others who received indoctrination at the school were responsible for enhancing the success of the neuropsychiatric program. The accomplishennts of Major Thomas and later

Major Fabing in carrying out the mission of the school were far beyond expect a-
:1)(6 ACTIVITIES OF MEI)ICAL CONSULTANTS

tions. They were ably assisted by other psychiatrists, but I shall not list

their nanies for fear of slighting someone by an inadvertent omission.

It remains my conviction that an assistant in the office of the theater

senior consultant in neuropsychiatry could have been used to great advantage.

An assistant in neurology was asked for, anticipating that this might be a

neuropsychiatrist who would have adequate knowledge about neurology,

elet roencep)halogratphy, hospital organization, physical therai)ies, and even

clinical psychology. Such an assistant could have carried on many functions

while the senior consultant was out, of the office.

My visits to North Africa, from 13 November to 21 December 1943, and

to the United States, from 12 December 1944 to 15 January 1945, were surely

essential. Visitors coming into the theater contributed immeasurably to the

ncuropsychiatric and other programs, but, it is to be recognized, without detracting fronm their valued assistance, that time had to be spent with them.

The Surgeon General of the Army and the Air Surgeon, accompanied by

Dr. Strecker, were present during March 1944. Colonel Menninger arrived in

September 1944 for a tour of duty lasting about 6 weeks. His visit gave

impetus to many sagging operations and started new ones. A group of visiting officers under Colonel Salisbury came early in April 1945 to study the

uinctions of neuropsychiatry in the European theater. Their thorough investigations were extremely helpful. Before these visitors had departed, another group of civilian psychiatrists under Dr. Leo Bartemeier came for further

studies. The latter group remained until 4 July 1945. Later, they produced

a very valuable and well documented report on many aspects of neuropsychiatry

in the European theater.

The foregoing account concerning visits and visitors has been given mainly to record the great value received from those who came and stayed to help,

its they (lid, but the account seenis to indicate also that the senior consultant

needed an assistant in his office.

Acknowledging the betterment of neuropsychiatric services during the

war in Korea but hoping that another war will never occur, wherein our exampl)es will again have to be referred to, I want to close this brief personal

sumnmary by expressing thanks to and admiration for my inimmediate superior

officers, Colonel Middleton, Colonel Kiinbrough, and General Hawley.

Part IV. Senior Consultants in Infectious Diseases and

Tuberculosis, and Medical Consultation in Subordinate

Commands "

The preceding parts of this chapter first reviewed the overall medical

coitsultant system in the European theater and continued with detailed dis-

"l The narral ire for this part was conmplhed by M aj. James K. Arima, M SC, The II btori(ctl Unit, ['.S.Army Medica I

Servi e,, in collaboration with Yale Kneeland, Jr., M.1)., and Theodore L. Badger, Mi.)., former Senior Consultants in

Inf(ctious Diseases and Tuberculosis, ETOUSA, respectively. Drs. Kneeland and Badger contributed summaries In

n rerspect Inn id-1956.
V iti \sljtj:us3 . Colll~lte 41 Iý 'if] til-d s'ttl. I uiiisIl-jti tsst B lsss. 1.1.i Iid. ( 'us . )Iss

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398 ACTIVITIES OF MEDICAL CONSULTANTS

consultants, who, for a major part of the active life of the theater, were also

tile t heater senior consultants in their specialties.

Finally, there were many medical officers with unusual talents assigned

to sl)ecific projects or studies in conjunction with the solving of theater tIedical

problems. Their participation in the theater's consultant activities imust be

nientioned to round out this account.

Accordingly, this final section of the history of medical consultants in the

European theater will discuss the more significant medical problems in the

context in which they occurred, except for those special fields already covered,

in an endeavor to indicate the contribution or' each consultant to the solution

of1 a particular problem and to show in proper perspective the integrated fulctioning of the consultant system as a whole.

BUILDUP IN THE UNITED KINGDOM

Atypical Pneumonia

One of the first medical problems to strike the fledgling European theater

was an increasing numl)er of cases of atypical pneumonia in the early fall of

1942. At that time, the specific characteristics of the disease were far from

common knowledge among members of the medical profession ati large. It

was only in the mid and late 1930's that atypical pneumonia had been recognized as a (distinct entity with an unknown causative agent, which was definitelynot a pneumococcus. In both England and the United States, the resistance

of some pneumonias to sulfonamide therapy had emphasized this (list int ion.

The Secretary of War, upon recommendation by The Surgeon General, had

appointedi a small civilian commission to study an epidemic of pneumonia at

('amp ('laibourne, La., in the summer of 1941. The commission concluded

that the epidemic was one of atypical pneumonia. Following recomnmendations by this commission, The Surgeon General established the Commission

on Acute Respiratory Diseases. As a result of preliminary studies by these

bodies, the classification "Primary Atypical Pneumonia, Etiology Unknown"

was added, for the first time in 'March 1942, to the list of diseases reportable

on the weekly statistical health report.

In the fall of 1942, the disease was appearing in ever-increasing numbers

in the European theater. Cases occurring at this time were often mild, and

symptoms varied considerably. There were no specific diagnostic manifestations to make identification simple. In spite of the usually benign course of

the disease, convalescence was relatively long, frequently requiring hospitalization for a month or more. Little was known of the residual effects of atypical pneumonia, and there was the possibility that some soldiels were being

returned to duty without sufficient rehabilitation.

On 20 October 1942, Colonel Middleton wrote to Air Commodore Alan

F. Rook, RAF, asking for information on British experience with the disease.

On 22 October 1942, Colonel M[iddleton wrote to each of the medical officers
EIR)IPEAN TIHEATER OF l'IERATI(MNS 399

who were concerned with the diagnosis and treatment of atypical pneumonia

in the theater's three general and two station hospitals. 66 He informed them

of tile incidence of atypical pneumonia in the five hospitals; told them of a

survey being (lone by the Preventive Medicine Division with participation by

tile Professional Services Division, both in the Office of the ('hief Surgeon,

Headquarters, ETOUSA, and the assistance of the 3d Station Hospital; and

concluded with the following:

Clinical, X-ray and laboratory observations must be accurately recorded to capitalize

upon the current experience in the interests of better service to the soldiers. In the light

of certain observations, it is suggested that X-rays of the chests of soldiers suffering from

app)larently nild respiratory infections be taken, particularly when they report from units

in which atypical pneumonia has occurred. There is reason to believe that an appreciable

percentage of these patients will show pneumonitis to the X-ray. This office will serve as

a clearing house for such clinical experiences as you may wish to report.

By November 1942, the incidence of atypical pneumonia seemed to be

reaching its peak. Medical officers at the hospitals continued to submit

reports in reply to Colonel Middleton's letter of 22 October. On 21 November

1942, in a memorandum to General Hawley, Colonel \Middleton recommended

that a committee he appointed to coor(dinate and pursue the study of atypical

pneumonia from its epidemiologic, clinical, and laboratory aspects, and suggested as members Colonel Kneeland, Colonel Gordon, and Major Muckenfuss.

Colonel Kneeland was Chief, Medical Services, 2d General Hospital, and had

been one of the members of the Secretary of War's special commission which

had made the preliminary investigations at Camp Claibourne, La., in 1941.

Colonel Gordon was Chief, Preventive 'Medicine Division, Office of the Chief

Surgeon, Headquarters, ETOUSA, and Major Muckenfuss, an experienced

virologist, wias Commanding Officer, General Medical Laboratory A.

General Hawley quickly approved the proposal, and Special Order No. 23

establishing the committee was published by the Office of the Chief Surgeon,

Headquarters, ETOUSA, on 23 November 1942.

With Colonel Kneeland serving as president and chairman, Major Muckenfuss as the recorder, and Colonel Gordon as the third member, the committee

met at General Medical Laboratory A on 12-13 December 1942. First, the

committee decided that a circular letter should be prepared embodying material

recently published in War Mledicine 17 and directing that undue incidence

should be reported directly to General Hawley's office. This directive was

to be prepared by Colonel Gordon and to be published by General Hawley.

Next, the committee considered the possibility of there being a change in

clinical character of this disease and a greater influence of secondary infection

in the days to come. Colonel Kneeland agreed to discuss with the necessary

individuals the need to observe cases closely for such changes. Finally, it

44 Letter, Lt. Col. Wm. S. Mlddleton, to Lft. Col. Yale Kneeland, 2d (eneral Hlospital, Lt. Col. T. I1. Badger, 5th

(eneral lhospItal, l.t. Col. (Ooidon E. Hein, 30th General Ilospital, Maj. James R. May, 3d Station llospital, and Capt.

Sidney G. Page, Jr., 151st Station Il ospital, 22 Oct. 1942, subject: Incidence of Atypical Pneumonia.

67 Moore, (0. B., Jr., Tannenbaum, A. J., i.nd Smaha, T. (.: Atypical Pneumonia in an Army Camp. War Med.

2: 615, 1942.
400 AC'TIVITIES~ 0FI 1MEIPItAL ('(iNSiiTANTl'

,%als resolvedl thlt Ilhlitiorn(v ilivest iglt ions- dIirect ed towirls-- avlentifiviat ionl of

tlit( et iologic aigent should he goivernied Ilv tilie generiall priticiple of doing" onlyi

those thlinigs ti lint could lie calrrievl out to aoldviiii t age ill a1 theaiter of operalt iiils,

a voi(Iitig tilie int ensive INvpe of in vest igat loll t li1i1t Wotildl (I uplicat e sitidies

und~er wayliy 1) the I 5pe('iliI commnission in~ tilie Zone (of lnterioir. D~irect ion (if

lalioraltory itivest i(itt ioii oil th li'(isense ill t he EuAropvtin theatter wals tilie

provwince of NI ijol' NIuck('ifliss.

CThe cir-cular letter onl atlvjN-iciad poiewnllonia "was complet ed ill lDeceniber.

fnd~ plublishied liY tilie Ollice of tilie (Chief Surgeon, I lvadqluatt eris, ETOUSA,

onl 7 *TaniarvY 1943, as ( ircula- L ettIer No. 2. It gave at brief hiistorv of thle

(Iisetse ; noite ('1prevatililiig epideleniologic fatctors: discussedl clinlicall fealt tires,

(liflrelietiall doliagnosis, ma a11iagement, of Ilospitil dcase's, plat hologic studi1 es. ittio

rehlatd virus infectil- ,u : land closedl with I11 para-lgralph Onl speciail report in

procedIutres. The mle(Iical officer responisible for tilie iiied icil service of' at

con' pa ny, or at (letiachilen t of sini ilar size, wasll ord ered II oreport (Iirect lv to(

( lie Office of thle (ChIief Sturgeonl, I lemilultiarters. ETI( USA, liv t elephione thle

(iccurrence of thlree 01' 1ii0ire CaIs O'of lirulllary fit viiicall ipieuimoll inl witIi in I

week inl thle companly or- (ettaclimlett concerned. Likewise, whenevver at lio'slpitall nlmdlitteol three oiM' mor01 calses inl any , onle week fromn at company or (letmaclt

mnetit, tile hiosJpitil commlildvi.er Wais Aireete(l toi repo(rt, the( fact liv N telejiloite

(hil*'ect lv to tilie Office of thle C hief Surgeonl, Heali(ulqti-ers-, ETOUSA.

In; th liletmeanwhile, L4t. C ol. .Josep')li (C. Turner, NI( , 2d1 General IlosIpittad,

hiaI bveen iissigrieo to M\ edicall General Labhoratory A to~ condutct latboratto -iv

sttudies onl titl N-icti piieunoniat. By mid-Februatry 1943, lie 11ad ma11de at

oliscoverv tllint aipjellred to thlrow light, oil thle immunlllologyv of thle (hisealse.

Onl 16 Febrirtary 194:3, C oloniel Kneelaind w~rot~e to C olonel Gordon ats follows:

Th'lanaks ever so nuich for your let t.r repiort ing oill Atypical Pnieumonoiia. I'll(, disease

seemis to have dried upl hevre except for one very seriotisly ill officer-which is rather had

luck, for .104 Tuirner has jiist got hold of n serologictl c~iniagv whichi, if it t airis upl inl othler

cases of the dIisea'se, nii hglt he 1'very Iinteresting indleed. lie's going over to the( 2d1 Evac.

tomorrow to get blood from t heir ne.w ca1ses, .1nd if the thljing looks piromhisinig he'll lbevr

ainxious for more tnat.'rial. TIhe.refore, do you suipipose youi couIld let nit, know of mny new

cases \oil heair of, inrt icailarlv sev(ere' one's?

In rep~ly, C oloniel Gordon wats aible to provide C olonel lKneeilnnd imlniediat ely with Ii'what is essentially at complete list of attypicall pneumilonlia caisessinice Febi. 1st.''

By the end of Aprili 194:3, C olonel Turner hald gtlihea'ed enlough daltat to

slio~ cousi(Iealliy wit rlailt ht t there wats ail incriealse inl cold aiggilttitilinls

(tillt olliemaggl tit ill inls) inl pattients conivilescetit from primaitry ait picall puieuimlownil. The mniiutes oif tile :30 April 1943 meeting of thie (Chlief Surgeon's

( onlsulti ant C ommit tee, record C olonel Niddloletoin repoirt ing ats follows: ''it,

fias been shown ti hat t here is at development of cold aigglutainiuis afte oet'(lO week

of illness, with at building-uip atild then subhsequtenit faliling-oil'. The p~roc'ess Is

found inl at fewv ot her ('oiilhitiotis andl( maiy halve wider. ram11ificaltionls land conltriliute to our knowledge of imiiuuiology.'' Colonel Turner wats aible to pubillishi
E1U'R(OPEAN THEATER OF OPERATIONS 401

his findings in a British publication 68 at about the same time that the results

of independent studies onl tile phenomenon were published in the United

St at es.69

The studies conducted in ETOUSA demonstrated again the place of

research in a theater of operations during wartime. Soon after the results

hadl been obtained, the technique of a coll-agglutinin test as a promising aid

in the differential diagnosis of pneumonia was promulgated in the European

theater.'0 Had this preliminary work not been done, months might have

elapsed before the theater could have put the test to practical use, and, by

that time, tie invasion of the European Continent would have precluded any

efficient trial of the method.

Prior to publication of the technique, the atypical pneumonia committee

had met at the 1st Medical General Laboratory (fig. 135) on 19 Septellber 1943

to consider the accumulated d(ata on atypical pneumonia and to plan further

studies, with Colonel Turner attending by invitation. The committee agreed

to arrange for the collection of a large aniount of' data on the incidence of cases

showing a rise in titer of cold agglutinins during the disease. The purpose

was to obtain additional information as to the clinical value of the tests and

also to accumulate records that might be used later in determining the incidence

of second attacks. It was realized that there were no existing data on the

question of immunity conferred by one attack of the disease. The conferees

also suggested that another way to study active immunity would be to have

medical officers make a special effort, in cases of atypical pneumonia, to determine I)y careful history taking whether the patient had ever had a previous

attack. Finally, the committee suggested that the chiefs of medical services of

hospitals be urged to keep the bacterial flora of the sputum from patients with

atypical pneumonia under as close scrutiny as the hospital laboratory facilities

would permit. It was considered important to bear constantly in mind the

possibility of secondary bacterial infection and, in particular, to note any

preponderant micro-organism.

In the spring of 1944, there wias a sharp rise in the incidence of both atypical

and lobar pneumonia without the rise in the common respiratory diseases or

influenza such as conimnonly precedes an increased incidence of primary bacterial

pneumonia. It was believed that much of the reported incidence of lobar

pneumonia was due to a misdiagnosis of cases of primary atypical pneumonia.

During March and April of 1944, the incidence of primary atypical pneumonia

reached mild epidemic proportions but (lid not reach the peak of 1942. The

(lisease always remained an important consideration in medical planning,

however, because it did not have a seasonal distribution.

is Turner. J. C.: Development of Cold Agglutinins in Atypical Pneumonia. Nature, London 151:419, 1943.

"i Peterson, 0. L., 11am, T. If., and Finlard, M.: Cold Agglutinins (Autohemagglutinins) In Primary Atypical

Pneumonias.. Science 97: 1t17, 1943.

70 Letter, Office of the Chief Surgeon, Headquarters, ETOUSA, to surgeons of all base sections and commanding

officers of all U.S. Army hospitals, 24 Nov. 1943, subject: Technique of Cold Agglutinin Test for Use in D)ifferentlai l)iagnosis of Pneumonia.

5649701- 61--28
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IE:UROPEAN THIEATER OF OPERATIONS 403

in the European theater indicated that only 51 percent of recruits called to

indluction stations before March 1941 had been examined by X-ray and that

large unubers had not been done up to January 1942. It was not until after

Mobilization Regulations 1-9, dated 15 March 1942, were put into effect that

routine roentgenograins were made of tile chest Of all inductees.72

There was clearly need for an early assessment of the tuberculosis problem

in the European theater. Accepting the recommendations of Colonel Middletoti, General Hawley, on 2 January 1943, appointed Colonel Badger, Chief,

NMedical Service, 5th General Hospital, as Senior Consultant in Tuberculosis,

ETIOUSA.

Colonel Badger appraised the tuberculosis situation and, in a letter to

Colonel Middleton on 8 February 1943, reported that tile British Army was

not using preenlistinent X-ray screening. During the first 2 years of war,

Colonel Badger found that 86 percent of tuberculosis in the British Army had

appeared within the first year and 41 percent during the first month of active

training. The British had considered using mobile X-ray units, but nothing

had been (done to implement their use as of February 1943, except in tile Royval

Air Force, which was screening all enlistments with 35-mni. fluorographic units.

Wing Comdr. R. R. r'rail, RAF, insisted that the procedure be supervised and

run by medical officers with wide experience in clinical chest disease; there was

also a radiologic adviser to each X-ray unit. Two very significant facts

learned also by Colonel Badger were these: (1) Fresh milk in the United

Kingdom was not being pasteurized, and 11 to 20 percent of fluid milk contained viable tubercle bacilli; and (2) manpower problems required the Royal

Army to sort cases with very minimal lung lesions into those unfit for service,

those fit for light work, and those fit for only sedentary jobs.

Colonel Badger reported that the Canadian Army, on the other hand,

was examining all candidates by X-ray and was rejecting approximately 1

percent. A report by at Canadian Army medical officer in 1942 showed that,

of 104 cases of tuberculosis which developed in personnel while they were

in the Army, 92 percent occurreld in soldiers with a negative preenlistment

X-ray. The ('anadians had attempted no mass X-ray surveys after original

preenlistment screening, but contacts of open cases were being examine(d

by X-ray, and active cases were being boarded back to Canada. Like the

British, the Canadian Army studied small lesions at their general hospital

in the United Kingdom and, wherever possible, reclassified for duty patients

with such lesions.

In his report, Colonel Badger estimated that the tuberculosis hazards

for U.S. Army troops would be as follows: (1) Early exacerbation of subclinical

cases admitted to service without X-ray of the lungs; (2) association with

unscreened British troops and civilians; (3) drinking of infected milk; (4)

the effects of combat such as excessive fatigue, changes of nutrition with

72 (I) Long, E. R.: War and Tuberculosis. Am. Rev. Tubere. 45: 616, 1942. (2) Long, E. R., and Jahlon, S.: Tuberculoqis in the Army of the United Slates in World War 11-An Epidemiologlcal Study with an Evaluation of X-ray

Screening. Wa.hington: U.S. G•overnment Printing Otlhee, 1955.
404 MA VITIVIll:S OF M)l.'I):1CAL CONSULTANTS

marked loss of weight, and malnutrition; and (5) the yev undetermined effects

or intercurrent resl)iratorv infection.

Colonel Ba(iger reported these facts at the ('hiicf Surgeon's Consultant

('ommittee meeting of 5 February 1943. In a(dlition, he reported a reverwsal

in the ratio of pleurisy withi effusion to parenchyitial involvement, as comp)ared

withi the usual ratio found in civilians. Reliable data could only be obtained

by spot surveys with fixed equipment, already in medical installations. Ile

indicated that surveys of field units that had been in the theater 1 year or

more and of units tlat had only been in Europe 6 months would be desirable.

('olonel Badger estimated that these surveys would involve 2,000 or more

chest films.

When asked whether the use of microfilms was feasible, Colonel Badger

replied that they were less accurate than full-sized filns. General Ilawley

said that getting 2,000 or more peol)le into a hospital for X-ray examination

would dislocate training and other hospital activities, lie agreed to the survey

only if it could be (lone by going into camps withi a mobile apparatus and using

it, perhaps after supper, without causing any dislocation of the work and

routine of troops. He suggested that thie developing could be (lone at the

nearest hospital during tile (lay. ('olonel Kinibrough, ('hief, Professional

Services Division in General Hawley's office, said that Lt. Col. (later Col.)

Kenneth D. A. Allen, Nit', Senior Consultant in Radiology, ETOUSA, and

the Operations and Training Division, Office of tile Chief Surgeon, Headquarters, ETOUSA, could work out a suitable portal)Ie apparatus. Colonel

Cutler, the theater chief consultant in surgery, asked if a survey of hospital

personnel would suffice, and Colonel Badger replied that he thought not; he

himself, had in mind a survey of the 29th Infantry Division. General Hawley

agreend that it would be profitable to screen such men as the labor troops and the

engineers who had been working in the mud. Colonel Badger then specifically

asked General Hawley if he (Colonel Badger) had the authority of General

Hawley to obtain a portable apparatus and embark on the survey. General

Hlawley assented but said that before Colonel Badger went into any divisions,

lie (General Hawley) would first like to write to the division surgeons for

concurrence.

Colonel Badger then raised the question of milk and food being provided

U.S. troops by American Red Cross canteens, saying he had observed fresh

cow's milk being served to troops (fig. 136). He reconlmen(led inspection

of premises and employees wherever U.S. soldiers were served food. General Hawley said that lie would take up the matter with the American Red

('ross commissioner in Great Britain and would ask for somle sort of sanitary

control over the milk, foodhandlers, and sanitation in American Red Cross

establishments.

There remained two problems to be settled before Colonel Badger could

embark on his spot survey. One was the matter of obtaining permission

to enter a unit to conduct the survey, and the second was the creation of a
EUROPEAN THIEATlERI OF OPERAT IONS 405

Fi;nk;t 1i 36.-Thie Washington Club, premier A~merican Red Cross club, London,

.July 1942.

miobile X-ray unit. Regarding the former,(Colonel Middleton conferred

Furl her w~ithI Col. Oraniel H. Stanley, MIC, Depuity Surgeon, Headquarters,

Services of' Supply, ETOUSA, who thouight it would be desirable to avoid1

official (hiatifels of communication on such at matter. In order to proceedl

with the survey, it wats agreed that Colonel Badger should write to tite surgeon

of at nmajor conmmiandl or thle commnandIing officer of at smaller unit, ats approp~riaite to the case, andl request permission to take chest X-rays for at tubercullosis survey which hadl beenl authorized by General Hawley. Colonel Staniley

believed that General Hawley would approve this procedure, and General

Hawley did approve it ait a latter (late.

Colonel Middlleton also asked Colonel Allen for guidance in assemblling

at portab~le X-ray unit and for advice in the technical aspects of taking, deCvelopiing, and interpreting roentgenogramis. Colonel Allen wats more than

willing to help since lie( hoped, in the future, to establish mnobile field X-ray

units biniseif. C olonel Badger embarked onl the p)rogram in late February

194:3. He met only the most cordlial acceptance of his proposals for making
406• ACTI\VITrIES, OF, MIIE'.\IA CO•NSUL'T.ANTS,,

tuberculosis survevs ill units. Fill exai phe, (C'ol ('. VW. Brentn, MCI(', Sm'•gon,

V ('orps, wrole to ('oloniel Badger on 22 Fel,1ruary 1943, as follows:

1. The (Chief of StaIT, V ('orps liitif.) has gratited at1thoritv for you to lI'rsonalyl

contact commanlding officers of units where you wvish to make X-ray and/or otIhcr surveys,

and to make sich arraungemenlts as niay he tII1ttilly accept:dIe.

2. It is suggested that, you premsent. a copy of this letter whnvn first contactjing a1 iiliit

COml 11 ia tidI'r.

hie mobile X-raiv unit wits quickly assembled using eqtuimllent and personnel available at the 5th General Ilosl)ital (fig. 137). ('apt. (later ILt. ('ot.)

Magin s !. Siiiedal, NI( ', ('hIief, X-ray Service, )tlh (Getierl Hlosp)ital, took an

active inter'est ill Setting ti1) this equiplielnl, and his help liter ill reading the

X-rayss was l111 indispensalle contribution. The coilmI ilantldi ng oflicei, ('olonel

Keeler, gave tile project his wholetrieiited support.

As eventtilly constitutedl at ithe .5th (Ieneral Hlospital, the mobile X-ray

unit, which was c'omp)osedl of 31 stanlidard Picker portabllhe X-ray unit and a

dairk-field tent, wits transported ill a I .2 toil tri'ck and set 1t p ill a3 vaciCnt Nissen

hlt lit the unitni Imveve I. The elquilpmenl, wlhen packed, measured 671I4 culic

feet 3a1d weighled 1,663 pounds. ()ne clarryvll w\is used to Itranisport the I ,: ll

of I oflicer zind 7 enlisted men. Of thlie latter, I w\-t1ill liiX-l'Iv op~ertlt or: 2

were darkroom workeris and plate chnlingers; I futict totied 315 tile rilillel', vasset te carrier, and tr uick driver; I prepared number st rips ; I positioned markers;

Iln(d I wits it noncolmmliissioned ofticer who maintainted recorlds.

The unit wis c'ustoalialily set ill) and working within ii hour after arrival.

Chest films, 14 x 17 iniches, were taken lit thle averawge rate of 90 lilt hour, illcludingl a 10-mninut e stop elichi hour to rest ile telaiii. The Iliiximuilml l nuiiihber

of X-rays taken per hour wits 137. Ih'e teali wits carefully trained in tile

technique of ralid lIliss production nilld worked with great eficiency. All

ro'il genograins were develolped lt the 5th General Ilospital and 1 were interpreted tIhere by ( 'olonel ]1dilger 11nd(1 (1ltai S .73li

During tile imonthis of lebl-tirry and . larch 1943, a total of 2,5342 persons

wits exainiiied. Troops froni fixed an1(d fiehl Inedita1l uillits, co(alilit enlginleet's

and the infantry Iiide pll) the sample. li a h ltter dated 27 April 19413 to

Colonel Middleton, Colonel Badger reported on the results of the survey and

noted, 31s follows:

* * * The itideflet of re-inlfction tuhercillosis of W.9 percent is not bad. 1, of course,

do not have lie clitic'd chec'k-uI) of all these cases, htit repeated X-rays of not, less than a1

month apalrt show itiher no changed p)tret-hylitinl provesses or by stereoscopic vision (the

lesions arir revealed', its d(ense fihro-calhitic affairs.

SOIllt' of those alotit whiichi I feel sonmewhatt colncertned I have carefully avoided callitlg

" healed" h-sions. I hltve rvlniestehd lt re-X-ray of llt,, douhtful (lols agalil ill two 1110i1ths,

and met 1with only tillh greatest co-opration a(nd interest. My itljression il regard to

this prob : 11m 1it, Ifnvole Itt. has n1ot ch11ged from tlihe recommendations which were sill)-

llitted at the last tleeting. If ithere is any (Ihtestion of moIvement, in the 29th Division it

mtay Ie wise to 0(-tll in two of their tien from stretmious field ditty.

": Lelter. Sellor ('Ctmlt l~ll In T'iwrculth•IsJ, o ('lhlef Nfdlic:a Conlomllt, '(11 I'tati SA, 17 D)ec. 1943, SIjhiecl: Anllli

Rlelrort of i (iof "I'lml ,re hejl,.
:till I ii 4' llllu I44115Ill: 144 4441144 :11 1ti4 111:l 1:I 1 4 411 illlit' I I l rl i4'III4-iw,.ý '-t:11-4) f 1,j

fliill..%. 111 '4 Ili- 4 4 14'41i4-i.. I) 1-4 :I'\'I 14 111 144 Y(4. Ili)II

)('.\ I''' :1, rffqwf4' it)4Y11 :1(14141 Il ( 1:1 4 44 :1 :1 )~II441 lil I 11'1''11I I:-4' (44:11-Hll

1114dil4 e '\44 -will1 I 4I w1 I [*.I12144 ill) ¶ letI cr:.;I~ )1 lit, 1 sliY 12 ' 114 ;4'r;Im

II4.Jl l:4 it 1 N I 444c l B1)1 :141 H l. wil 1141 lv 14114 I-) 4lI i' 11', 11411 rv.2 14411 I i I': i ~i i i I Y \ ,I4'4 I~llI

iIllI- 1ý1. vi t d !414II c -wýill' 1 44-jcit:II- I)4:I~li-4 ' (1 Ic list)l Ii-1kcd il l4 ntI 4'. 4I'Av Y i 4 ll 1144 n I 11

444414 M e i':1iuI''i'i 1 41 )4444 I\ -sil\4 M ice I () *s- I1 11e ( Alef 4 Ii I tI t 441 . I 4 1 itII )1

14 4111 fri 14 ) 4 2 11 vi i it i , r4)1 14 j 4 4) !~ I AI ) '\. I I i o 2( A 1: I 4 rv I v41 J18 ilIIl :(111' ( 1i4 141 14'
4108 ACTlIVITIES (1F MEDIC~AL CO)NSUJL'.NTIS

gronij. Fiirtherniorv, the c'ondit ionsi sirromiiiliuig thi t'lotI Statiion Hlospitail nutrsinig pvrsontiiit are larp-ly diiplict ed ill thle 5th1 ( 4-neral inursing gronp.

For thleste tilvioiis reaisonsan zititi hevesitty~i of keeping t his oiriginazl sp)ot survey wit hin

reaonable' litnits, t he project to X-ray the .17 nutrses of t he l~thI Sta~t ion Il spita is1 d5tisapjprovedi.

As the lprobllemu is evolved( oti tlivi compileltioni of the initialI sp&l nrvv'ý, Ow over-ill

policy for lit- Theaiter will bv ev-olved, Sii OMhn no group ill Wn miele('iet K in thlog ruin.

O)n 8 3i te 1 943, ( olotie Blid ger aloitrri Tigeti With HIV i N ltI icall lRcOr( s

D)iv ision in ( ueienl I nwleviv's oflice to olt am iniformaiontoi its to fitnil d ilgi tosis

of hospJita adm issIions511 ill thle Et"irlojpeiii t heateri ilitia mv *t dii ii~m '~e' as pleu'trisy,

I hlbteticlosis, lietilotyij"Vss anti spoli t involis plittielt initho-iaX. C olontel Bati4get'

jprepiul't'tI it list of itill pati enits oil w¶hol0i lie wiiiitetl thle iuiformat ion, givin g the

111ni1ies of1 ('lili t heir diiagniosis, andi( th hi'losp~Iitals toI which I heY hald beeni

Wlieiitill t hicse adititOionall dat it Nvei' issenilbledt and 11tliialgaiiiatedl NithI thle

origiluid I tinti, thle t tt dl S saliipie of oflivers, ii tirses, anti enlistv eI meti examiiiie I

r*oeii t geiiogi'ii j)lli -icllý a1nioutiieti to 3,031 cases (fig. I 3S). O f thlesv, 2, 1431

(atpproximiatIely 71I percent ) hadtt c it irl~vl liegiut ti e X-raly films. (O)nly 35 case's

of reinifet'ttion ttlubvrctilosis wevre founid (I.I percen lt of thlit totall). In April

1 943 uwhn ( Aolotil Btldger tiatit' Ids rejport to ('011( W ivMiddletont, t lie followtilp

of thetse' 3.5 lesiotis of 1rt inifectioti wits still b eing cii rrieti out, and1( fiinalre lt

werev peniding X-raiy examtiinttion of units thlit Iliid beenl oil thle mlove. Oni I

of tblese 3.5 cases was clWsiie its minimiiial active lit'rctlosis, h"t it hadl not

bee't'ii nevcssilry to 1-i't'itvt ially inidivid tual froinitiiuty V 1)calist' of X-ra1N f inidinigs.

Ill addition to Captjtaini SnvielalI, (Capt. (lItter Nlaj.) Sanlita'l 1). Asper:. .Jr., Mc( ,

5th Gi(eneratl H1ospiutal, had lit'llt'( ('ollidittl'ibly ini this piSl~ls( tof thlit tuiberctilosis

stuivey. A comipletet mudiiasis of thbest' dilil %\-wassubm1iiit tetd in ll)t ii11ttlvi-ili repo~trt

by' ( olonitl Baldgtre to C olonel Nliddlvttoii wh.Io, ill tun t ii~i ad th ltvrpor-t forwarlded to 'lT'e Stiigeoii (;tli'rild.

At t lit' int''tiing of t lit NI'lvicitl C onisult alits Suibcomimit tee hetltd onl 25

~June' 1943, ( loloia'l MIitdlettoin rteporte~d thlit C olonitl Badger hald fotunid lit

t'v'it vtiict of a live tt forit a nuiss snilvt'y ait t Iiis t iiiit Ibuti tbad i''couil iudeii (lttimt

a notheri' sp)ot stur-vt' be valriitt otit ill S',pt euii er oir Oc)t oberi 1943. Spteciftic

reCoiii1(14IllndI itons rtegardiiig at nalss stirvey wvouild l)( w~ililleli uintil iiftt'r thlit

lnext. Spot suruvey 'wh ichi iii iglt lenad to Ilit' est 111)1iSlitiileit tof anl tovtrli Il~l poicy

for' th lt' eateliitr. Also tit th lit' metlug. C olontel Midtletton stiggtestted t a1t it

s('~l-itrte projectt colisist ing of X-ray" exami nat*ioti of soldIieris ii lt'e 29th Ii iifit iiC oh. Esnioiid It. L ong, C onuiilltanit in 'I'll IWrctdlosis to Thel'i Stzrgt'oii (itiitral,

onl 1I Atigust 1943, hin acknowltedgiiig retceipt of C olonel Batlg'r's initerimn repot'IO

notm t'ltlint:

* * * Iii the' 3,0)31 petrsonis e'xamnediit, 1.1 pterenut hatd evidvevut of re-infect itou type

tuihercuultsis iii their X-ray iv I:ns. It is gratlifyinig to iiote thIatl 901 jxreeuut of (lit' east's dliscoive'redI were in iil tm inimail sI zige, unut tlintt of the entire group of 3.5 cases, only five were

conisidered to b)e clinica'zlly ignifivenit.
t,11 the tI 1 h I 4 II ( llliiI I 51h > ;boh Ii I I I Sha ihoi- hlrY i pl hirl. , II iiIiiu

4.11:1 ~ ~ 414 I!V:44 ~ I1Ii441141i. h Nc 01:11 lil- nrrvi . li 1 pi:Il111 l vi-l4lx 41'I4:1 (b) j wx lx :411

\\ il l lIlj4 44144114 .1 4I r rIi:. -lL~4im: 4 prm.1 X drd jIiji. * v1 ill) imi~lI 5I11i141 I-i c l

ill 14:111- i fit il :1111 l d Ilx 11.. :11 I- : \ j1: l 4 1- 44 41 : .- 14h 0 llijIllId 1).\u I~i- 4 :41. 11114 lt'4 i ilIil iINl Iic~lll4 4 4~l4.j I4-j-I:444. :14 ~ lo 14111,11 144 l .1j\ p.11~jl W ll, \ 1 IiIIMtIII

4:10* IS4 I I c (I b .ý IIo )th oIIv q rm ,: l w tIIo )IIl
410 ACTIVITIES OF MEDICAL CONSULTANTS

Final decision had to await the results of the second spot survey, planned

for September or October 1943. ihe survey was carried out as scheduled in

generally tile same manner as tile first, except that it concentrated upon elmedical and infantry troops- -tie 49th and 168th Station Hospitals and the 5th

Infantry Division-recently arrived in the United Kingdom after consi(deral)le

service in Iceland. In addition, considerable numbers of personnel from units

in the Eighth Air Force were also examined by X-ray. Total examinations

amounted to 3,634 roentgenograms of the chest. The results again indicated

that there was no significant incidence of unrecognized tul)erculosis among U.S.

troops, that a mass survey was not indicated at that time, and that periodic

spot surveys were the most appropriate means of determining whether any

significant changes in the incidence of tuberculosis had occurred.7 4

In this second survey, X-ray examination of the personnel of the 49th

Station Hospital in Scotland was conducted by that hospital, and the plates

were then forwarded to Colonel Badger and Major Smedal for reading. Another

innovation concerned the field trial of an experimental auxiliary X-ray unit

estat)lished by Colonel Allen. Sometime before the survey was begun, Colonel

Middleton also wrote, in his letter of 25 August 1943 to Colonel Badger, as

follows:

I am pleased that you are affording Colonel Allen an opportunity of testing his field unit

at the time of your next survey. From the personal conversations, I realize that he is loath

to make such requests, in fear that you may think that he wishes to encroach upon your

provinces. I know that he has no such design but isualizes this is the only project in which

he can test his field unit to a useful end without setting up an artificial program.

On 21 September 1943 in a formal letter from the Office of the Chief

Surgeon, Headquarters, ETOUSA, to the Surgeon, Southern Base Section,

it was requested that Colonel Badger give an experimental auxiliary X-ray

unit at 30-day field test and report on the adequacy of the equipment and the

quality of the technical work performed. Unfortunately, Colonel Allen was

on temporary duty in the North African theater during the latter part of September and the first half of October 1943; thus, when the auxiliary X-ray unit

(fig. 139) was turned over to Colonel Badger, equipment difficulties had not

yet been satisfactorily resolved, and the three enlisted technicians were not

yet adequately trained. As a result, no field trials were conducted, but Colonel

Badger was able to experiment further with the equipment, train the enlisted

nien and make recommendations for modification.75

During the period of this second survey, the 35 individuals with parenchymal lesions previously discovered were followed up through Colonel Long,

who was able to trace 13 preinduction X-rays and to reinterpret t heni in the

light of subsequent findings in the European theater. No significant differ-

(nces were noted, and there were only minor variations of interpretation, owing

to poo10 X-ray filns. Thlis small study confirmed the accuracy of procedures

being used in the European theater and showed that very little of importance

74 See !rmt note 73, 1). 4W.

73 Eventually, 12 auxiliary X-ray units were employed during combat in the European theater.
EVIi0i)Ii:AN 'I'll:EATRi 4W ()iI:ILRAHNs 411

I'1~U (1- IM4I.- (ol. kiiiut 1i). A..Allens mobile :tixiliary X-rayv imtit -et IiJ) in the flu d.

had~ I )emi pelillit t"!( to vmIU t~1he induvtl nt scl(reenl ing. Those who~m had escapJedl

(letectlion presented foQl r th lie o par)1j) t old fib rot ic. ai~pparently heat(ledleinNN-lnlini(I hal ot lhro)keh) (loN-II ill .11, 0o4eISea t heat er .7,

WithIini less t hani I Year'. conside(rablle da~ta hid lbeehi as-setllibed Iiotiili te

tw Sp51ot sutrvey-s an th1 I e (colla teral stutdies'. Ini alddi tionl a spjc~iail series of1

578 (ch est filins had b~een tinade Oil jersotllnel of t lhe 1WOiel('IIs, Artmny ( orp ill

Euilglanid. The tot al number of individuals, exa minedI by X-ray a moumnte(dl to

714A; The (seilior 'on~su~lt anlt lI in l )ercllloss v011( flow, withI assit ni lice. Sill)-

tnit recomliiiienidationousfor the est abldishituiett of theater p)olicy Onl the dlispositijotn

orI twhl )ecuilou. patilentIs. This lie (lid onl 12 November 1943, in a letter to Co'lonel M 4iddletoun, who conureurted ini all buIt one (let ail ; niatU('1V, I le place of gast nc

wash intg, ill thle (ltgliosis of1 1 1ihercilos. '' If wve are to take thle posit ion thlat

;ny eliv ('~'i i al eleitient ill Ilaborator d1(iagniosis is a1 ' b)Irdletll',' Colonel MIiddlet on

wvrot e to C oloniel Badlger, Onl 1.5 Novemb er 1943, ''we c'lose our dloor's to cert aini

inivalutable aids5."

( )it 2S, D ecem iber 1943. ( oe B1ad( W(ger n S~lniittIing md to ( 'line NI i hqlll O

r'evisedI recommuenedat ions in which tw liult imiate decision for d1isposition was,

plIa'edl oti thle itidividtial examuiner, wvrote the following:

No fixed s.('Iit'iR (f clasiIficattjion far disposititont of I intlrcifihsis cover., every eas~e of

disasets. Therefore Ithe followimg criteria for disposit ion dixverge fromt Mi 1 - 1) out tite baisi

76()Svf,t ftote 73, 1p. P6lK. (2) Lettecr, Senior (Coisinlt jit in Tobe.rciulosi'. ETOF) S A. to ()imj of inw St'c iriuon

Gow l :Itii: 4 lijf of Di%) sioni of tiii~l.j~ (Thur : 4 tiiec of the ('iicif ,imn~won, Iv1i-I.j:i~ irtcrs, ETOUSA), 14 Nov.

1913. shubet: V riy of Soldiers hi E.) Kt Comjpire( With1 Itiaurprct~uinoin of Induct ion X-as
412 ACTIVITIFS O1F MEIDICAL CONSULTANTS

of experience gained in the E.T.O. They are presented to serve as an objective basis on

which the examiner may make his decis.ion of dlisposition in an active theater of operations.

Certain of the lesions described present a precatrious prognosis unless followed carefully

over a period of months by clinical and X-ray observation. Under battle coniditions in this

theater such follow-up would be difficult if not entirely impossible and the evaluation of

parenchyrnal lesions must be carried out to the N)(At of the ability and wisdomi of the examiner

at a single hospital period of observation.

In addition, Colonel Badger gave detailed recommendations for (1) eases

to be boarded to the Zone of Interior, (2) cases to be returned to full duty. (3)

cases to be returned to noncombat duty, (4) a yardstick to determine activity

in small lesions of doubtful stability, and (5) procedures for the follow up under

battle conditions of individuals with small tuberculous lesions.

The revised recomnmendations were approved by Colonel Middleton on

9 January 1944. The salient points were published on 22 February 1944 in

Administrative Memorandum No. 22, the Office of the Chief Surgeon, lheadquarters, ETO)USA, to surgeons of all base sections and commanding officers

of all U.S. Army hospitals. The yardstick for determination of activity in

small lesions of doubtful stability, published as paragraph 6 of the directive,

was as follows:

* * * The clinical, laboratory and X-ray study necessary to clarify the status of the

small parenchymal lesion, thought to be tuberculosis, should fulfill the following minimal

standards:

a. Hospitalization for at least a week, with limited ward activity.

b. Complete history and physical examination with special reference to tuberculosis or

other pulmonary background.

c. Four hourly temperature, pulse and respiration, which will be charted for clearer

detection of elevations.

d. X-ray and fluoroscopic study of the lungs on the 1st and 7th day of admission.

e. Complete blood and urine examination.

f. Sputum examination daily for tubercle bacilli, except where sputum is scanty,

repeated 3-day concentrated specimens will be used.

In addition, sedimentation rate, aspiration of gastric contents only with

guinea-pig inoculation, and the tuberculin test were listed as additional proce(dures, not necessary routine. The directive concluded with the following

paragraph:

X-ray and clinical follow-up of individuals with small tuberculous lesions in this theater.

Battle conditions in this theater do not permit of clinical and X-ray observation for follow-up.

The proper evaluation of these parenchymal lesions depends upon the abilit v and wisdom of

examiner during a single hospital period of observation using paragraph 6 as the basic yardstick for evaltuation of these lesions not proven to be active tuberculosis. Individuals presenting an undue risk of reactivation or who may become a source of tuberculous infection

will be evacuated to ZI.

In addition to the directive, Colonel Badger prepared an article for the

Mfedical Bulletin, European Theater of Operations. This article explained

the underlying considerations for the decisions that had been nade and elaborated on sonic of the finer points of the directive.
EURi OPEAN THIEl\ATEIR (OF OPERATI( ONS 413

Allergy

Oil 12 July 1943, a letter from the Office of the Chief Surgeon, Headquarters,

ETOUSA, instructed commanding officers of all A.r. Amy hospitals and general

dispensaries to send to the 298th General Hospital all allergic patients under

their care who required grreater diagnostic and therapeutic facilities, making

the necessary arrangemlnen ts in advance with the Commanding Officer, 298th

Generald hlospitial.

The 298th General Hospital was an affiliated unit from the University of

Michigan. IA. Col. (later Col.) John McF. Sheldon, MC, Chief, Medical

Service, 298th General Hospital, had brought with him a small but representative selection of testing extracts as well as some therapeutic material from the

allergy clinic of the University of Michigan Hospital. Previous to the designation of this hospital as the allergy center, a number of allergic inpatients and

outpatients had been seen by Colonel Sheldon. When it became apparent that

allergic manifestations would present an increasing iedical problen, more

material for skin testing and desensitization had been acquired from the Universitv of Michigan Hospital, and Colonel Sheldon was also able to obtain

additional diagnostic British grass pollen front Dr. David A. Williams, Llandough

Hospital, Cardiff, South Wdles..7 Thus, the opportune combination of tihe

foresightedness and initiative of an individual medical officer and the affiliation

of the unit with a university hospital had made possible a specialized allergy

center.

In evaluating the lay fever problem, Colonel Sheldon said, at the second

conference of the chiefs of medical services held on 30 July 1943:

It, is a seasonal disease, particularly in reference to pollinosis. It is only within the

past year that I)r. Williams, University of South Wales, has carried out adequate observations

throughout a large portion of the country. His information is not published. He has showti

me his data. Particularly the grass family and specifically those closely pathologically

related to Timothy produce pollens for a rather short season, ap)proximately 6 weeks. Our

experience this year has followed this pattern. We had rather a high rise in late June, which

dropped in July. Timothy, plantain and the orchard grass group seemed to he the predominant offenders. * * * We do not expect to have any important seasonal pollinosis,

with the exception of that occasional case of hay sensitivity. We do not expect any of those

patients who had difficulty with the raggweed family at home to have any trouble here.

(Grass sensitive people have just as severe symptoms here as in the States. I do not believe

that it is a great problem. There is also a questian of sensitivity to that unknown factor

that occ;irs in old houses. These patients respond markedly to dust extracts.

Following Colonel Sheldon's remarks, Colonel Middleton commented:

"We have not enough men or materials to duplicate the study of sensitivity

in many centers. For thie time being those patients who do not respond to

ordinary lmeasures should be sent. to the 298th General Hospital."

During the first 6 months that the allergy clinic was operating at this

hospital, 293 consultations were held, and 98 cases of bronchial asthma were

evwcuate(I to the Zone of Interior. In 1944, the 298th General Hospital planned

77 Annual Report, 298th (General I lospital, European Theatcr of Or rations, United States Army, 1943.
414 ACTIVITIES 01F MEICI('AL ('0NS'ULTANTS

to have a separate ward for allergy and bronchial asthma patients. Tile

anticipated greater need for diagnostic and treatment materials precluded

continuation of the formner informal means of obtailning thein: requisitions

were made through regular medical supply channels instead. Preparations for

the invasion of tihe Continent and a change in mission for the hospital, however,

prevented carrying through niany aspects of these plans.78

Influenza

At a meeting of the Inter-Allied Conferences on War Medicine, Colonel

Middleton reported the following: "In November 1943, an olninous situation

confronted us in an explosive epidemic of virus A influenza. Fortunately it

was an inter-pandenic episode, free from complications and mortality. Had

it been the first wave of a true pandemic, the invasion of the Continent would

have been handicapped by the second and complicated sequence."7 9

Epidemic influenza in England had been appearing in the o(l(i-nunbered

years with a larger wave every fourth year. According to this schedule, a

moderate outbreak should have occurred in January 1943 and a severe out break

in January 1945. Had this expected influenza visitation of January 1945

actually come about, its effects would have been severely felt by the U.S. Army

whose hospitals, at that time, were filled to capacity with surgical and cold

injury cases.8a

As it was, the Committee on Infectious Diseases composed of Colonels

Kneeland, Gordon, and Muckenfuss, at its meeting of 19 September 1943

(p. 401), had already made preliminary plans in anticipation of the occurrence of

influenza. The committee had suggested the following:

In view of the fact that influenza may at any time l)ecome an important cause of disability (and with the experience of the last war in mind), it is considered wise to keep a

close watch on influenza-like conditions under treatment in hospitals. Here one is confronted with a disease where definition is extremely difficult, and in which routine reports

may give a thoroughly misleading picture. As the appraisal of influenza requires a uniform

critique it was suggested that the consultant make periodic visits to station hospitals in

order to keep abreast of the situation.81

As with atypical pneumonia, the committee thought that, under the

direction of Colonel Kneeland, it would be wise to collect limited aniountts of

sera for antibody determination. Lnimited-scale virus studies could then be

made by ('apt. (later Lt. Col.) Joseph E. Smadel, MC, at the 1st. Medical

General Laboratory.

Just as tile committee had anticipated, indications of influenza appeared

first in the fixed hospitals of the theater. The 108th, 32d, and 5th General

71 Annual RelMrts, 298th (General Ilospital, 1943 and 1944.

19 Inter-Allied Conferences on War Medicine. Progress in War Medicine Since 1939, •ec. XIII. Edited by II. L.

Tidy. London: Staples l'req. 1943.

"0 The full Implications of what would have occurred and observations on what actually transpired have been

described by Colonel Kneeland in the chapter on respiratory (itsea.es In "Medical Department, United States Army,

Internal Medicine in World Wa II. Volume II. Infectious M)lses,,s." [In preparation.]

l Letter, 1.t. Col. Yale Kneeland, Senior Consultant in Infectious IMseavs., to Col. William S. Middleton, Chief

Consultant in Medicine, ETO USA, 27 Oct. 1943. subject: Meeting of the Atypical Pneumonia Board.
EUROFPEAN THEATER OF OPERATIONS 415

Hospitals and the 130th Station Hospital reported almost simultaneously a

significant change in the clinical expression of respiratory diseases during the

first week in November. Major Sma(lel estal)lished marked increase in tile

titer of antibodies to virus A in typical subjects of the epidemic disease.82

Colonel Kneeland, attending the Chief Surgeon's Consultant Committee

meeting of 22 November 1943, commented on tile spread of influenza in tlie

U.S. and British Armies in the theater, where it. had aroused a great deal of

interest and some alarmi. He assure(l the conferees that, there was no reason

to regard this epidemic as anything like that of 1918. He said that a brief note

was being published in the Medical Bulletin of the European theater and that a

directive was being promulgated.

The directive, he said, would first cover clinical aspects of the disease, pointing out that it is mild and almost invariably uncomplicated. Medical officers

would be exhorted to give the term "influenza" a fairly limited and precise

significance, applying the diagnosis on epidemiologic grounds to an explosive

disease of the clinical character described, occurring in groups and not in isolated cases. The (lirective would emphasize that the precise identification of

the etiologic agent could only be made by at study of antibo(ly titers in convalescents as opposed to acute symptoms in the clinical case. Because only a

limited number of these examitnations could be made at the 1st Medical General

Laboratory, it was urged that serum specimens be sent through channels,

while the 1st, Medical General Laboratory should be consulted as to the desirability of submitting samples from various types of cases. Finally, Colonel

Kneeland reported, the directive would cover treatment by the statement that

it is systematic. It. would note that sulfonamides are contraindicated as being

of no benefit, except in complications, and these almost never occur.

The meeting later turned into an open discussion of the epidemiology of

influenza and the possibilitv of identifying factors that made tile current. epidemic skip a year and occur so late in season. The theme underlying this

discussion was, of course, an attempt. to determine whether it would be possible

to predict the future occurrence of an epidemic of influenza.

The outbreak of upper respiratory disease continued throughout November.

For the week ending on 26 November 1943, there were 11,300 cases of acute

respiratory infection among United States elements in the theater. Some 600

of this number were reported as influenza, although it seemed likely that much

more than this was true epidemic influenza. The peak incidence of these tipper

respiratory infections was reached during this week, but the peak in the curve

of reporte(l influenza (lid not, occur until the week ending on 3 December 1943.

After that date, there was a steady decline which paralleled the decline for all

respiratory (tisease.83 Influenza was never again a problem. Many theories

were later proposed explaining the occurrence of influenza at this time which, as

if by fate, coincided with that period of the European theater when it could

best cope with tile prob)lem.

"12 Annual Report, Chief Consultant In Medicine, ETOfl4A, 1943.

,3 Es.,.enthtl TechniCal MeIc(la Data, Iheatlquariers. ETO'SA, for months of Novemlber and December 1943.
416 ACTIVITIES OF MED)ICAL CO +NSULTANTS

Malaria

Tile 1st Infantry Division was inoved from Sicily to the United King(oni

in the first part of November 1943. Within a month, the division reported

over 200 cases of malaria in hospitals or on quarters. At about, the same timie,

27 cases of mialaria occurred in a bomber group which had recently arrived in

the United Kingdom via the southern ferry route. There was ever., indication

that the nunl)er of cases would increase with the shift of more troops to England fronm the Mediterranean theater.s4

Colonel MXliddleton obtained data as to the actual incidence of clinical

malaria from hospitals where cases were appearing. Two lengthy directives

(Circular Letter No. 117 dated 12 August 1943, and Circular Letter No. 142

dated 17 September 1943) had been published by the Office of the Chief Surgeon,

Headquarters, ETOUSA, with respect to the management of mnalarious patients,

but these were generally a mere restatement of opinions received froom the Office

of the Surgeon General. The imnmiiediate need was for more specific instructions

to meet the sudden rising incidence of malaria in the theater. Accordingly,

fromn the (lata at hand, the Office of the Chief Surgeon, Headquarters. ETOUSA,

on 16 February 1944, published Circular Letter No. 24 on the management of

the convalescence of malaria. Tile circular let~ter emphasized dietary, therapeutic, and psychologic means of insuring early convalescence and rehabilitation

of debilitated and depressed nialarious patients while avoiding serious relapses

or postponement of complete con valescenrice.

Colonel Mliddleton was aware, however, that there were many unanswered

questions as to the course of tertian malaria and the efficacy of various regimens

of treatment. In a letter to Colonel Middleton, General Morgan in the Surgeon

General's Office, suggested approaches to the study and solution of some of the

most pressing questions. Colonel Middleton called upon Colonel Muckenfuss

and Maj. (later ILt. Col.) Henry P. Colnore, MC, to meet with him as an informal inalaria committee. Major Colnore, who was then assigned to the 2(1

General Hospital, was undoul)tedly the best qualified officer in the theater in

the field of tropical diseases. Among other positions, lie had recently been an

associate on the staff of the School of Tropical Medicine, San Juan, P.R.

The immalaria committee met at the 1st Medical General Laboratory on

10 March 1944 and made plans for a controlled study of benign tertian malaria.

Tile study envisaged a pursuit of two problems: (1) Would the natural course

of the disease lead to a spontaneous "l)urning out"? (2) What were tile effects

in various dosages of certain agents suchd as quinine, Atabrine (quinacrine

hyd(rochloride) and Plasimochin Naplithoate (pamnaquine naphthoate)? It was

proposed that subjects for the study couhl be obtained fromn volunteers

suffering relapses of nalaria. It was agreed that Major Colniore should be

placed on temtporary duty at the 1st Medical General Laboratory to conduct

these studies. The plan was submitted to General Hawley for approval the

"04 EKential Technical Medical Data, Headquarter-, ETOUSA, for November 1943.
EUROPEAN THEATER OF OPERATIONS 417

following day. General Haleiy initially disapproved the study but uponl

further' considera tion reversedl his dlecision.",

Major Coiriore wats able to begin the iatlatriat study onl 14 April 1 944."

At the outset, at problem appeared which prevailed throughout tile study.

The first 16 soldiers quer'iedl refused to volunteer for the experiment lbecauise

of thieir desire to rejoin their organizations and buddies. As the Invasion fever

reatched it higher pitch, this desire Onl the Part of indivi(Iualls to ret urnr to t heir'

unlits increased1. There were also those who refused to cooperate b~ecause of

past experiences withI thle dhisease. During thle 1/12-nointli periodl of the study,

ord , 24 volunt eer's were 01)1atined. Among thle voluntet ers, t here were ext reiiiel y

few catses that mnet the criteria r'equiredl for at study of spontaneous r'emrissiori;

that is, chronic recrudlescenit uncomplicated benign tell ial ilatlan'ia. Accordingly, thler'apy wats withlheld froni 110 indhividulas. Ini ord(er to dleterlminie

whlet her the small number of chronic recrudescenices wits nmerelY at chaince finding in the smaill group of 24 volunteers, Major Colmiore questioned patients at

lie 3d Stat ion Hospital and examiinedl the files of thle Surgeon, 2d Armored

D~ivisioni, where t here wats at recordI of 2,454 individuals withi one or miore at tacks

of Iiialar'ia. Ilie dletermniredl t hat the recurrence rate for' b~enign tert ian malaria

was riot at problem aind thlat it compared favorably wit Ii figures quoted for

civilians living under less rigorous (condit ions. The interviews and exaimi nation of records also revealed t hat t here wats a sudd~eni increase iii thle inc(idence'(

of rinalariat in Mairci, April, aind i\Iay, which wits at tributalble to tilie 0hIara'llct erist re late relapse of benlign tertiain infection raither t han to thle chronically

reemridlescen t tyVpe.

Furt ierniore, thle st itid y of tlie( relative effectivenless of anlt irmialarial thIerapy,

includinrg at comparison of Atabririe and quinine, with tithe necessar-Y followup

procedulues, wais precluded by tlie( imipending invasion. Accor-dingly, M\Iajor.

(1olnrore spent a1 considlerab~le Period of tile minalarial st i~ld inl devising at codle

foi' t ie classifica tion of (hiffer-ent pat terns of' rela pses and recurring mairlairia and

a nrly3Zedl tilie reCcords of pat ienits using t his c'ode.

Ackcept inig M\ ajor Colmiore's recommniend~at ions, Colonel M\Iiddletoni dIiscon tinued1 thle st udy iii late M atY 1944. Partly ats at result of M\Iakjor- ('ohnone's

st in lies, hoe ' ws -itpossible to plan for tit(e expected i rcic leice of in 11a lana

ill Ilie comning Invasion . Plans for' tilie recep~tion and~ trevatienti of' casuail ties

wit il r'elaps) ing anrd r-ecrurdescerit innalaria w~ere miadhe bY Colonel Midd 11let on wvitin

C

1oloniel Krneeland~~, ac'tinig iii his caipacity as Conisuiltanit in \ledicinie, Solitilrei'ii

Base Sectioni, a nid wit Ii It. ('ol. (haten' Col .) Neil 1. ( 'onie, NIC( , ( onisnil t ant ill

M ed icine, Fir-st U7.S. krm irv. ( )it IS M Iay 1944, C olonrel N Iidldlet oni con lei'i'c

wit Ii Gerien'a hlznwle v anid C olonrel G ordlon as to tilie imissionis andri~l fnct ions oh

pl-ev'ertit e riredicirie per-sonnirlv vis-a-vis .agencies fon. tIre ('lric.iJ treatilirenit of

mnraai'a (nirirgt( lc (omniig- opc tm'a ois. ( )ii 20) Mlay 1 944, all I lie pi'evioiis

'4 Iotf-,r \h~j. it. I'.C('Int rv. k %qi aIInj, .iE r:tr.lE('if 'tol,: in N1,'Iicitt. Ot E 'tiv o ti. ('116-1
418 ACTIVITIES OF MEDICAL (4)NSILTANTS,

h~eater dlirectives on the treatment and mnanaigemnent of mtalaria were rescinded

an~d replaced b~y on~e comtprehiensive and~ pertinent directive, Circular Letter

No. 73, Office of the Chiief Surgeoni, Hleadquarters, ETOUSA.

Other Activities

Atmong othier activities enigaiged inlb iw medical consultants in the Europeani

hieat er, tlie( following aire wortiliv of nienit ion ill conlcludinig t hiese parlagralphs

onl thle buildup of U.S. Armiy forces iii the Uii itedl Kiingdloi preparatory to

O le in vasioni of cont iental Europe.

Typhus commission.-Colontel Knieeland wats at niemiber of at three-miiiii

tvfpliuts coiiiimiiission froin thte European t heater whichl visitedl the Near East

11i1d the North African theater in February anid Mairch of 1944. Ot lieri'titeiibers

were [t. Col. (litter Col.) Emiory C. Cushinilg, IMC, an1 epidefiliologist represent -

MI( tgI ie Prevemitt we Medhcinie Division, Office of the Chiief Surgeoni, Hleadquart ers,

ETOUSA, and M ajor Sinaidel. The commulissionl iiia1le a teaml approachl to

ItIe si uidl of tvjpillis anld Stiillhiit ted its finidiiigs, 1)V ,ett l i9 dW ated 2 M archi 1944,

f'roit Headhquarters, First 'Medlical Geiieral Laboratory, to thle Chlief Surgeonl,

ETOUSA, subject: Report of Missioni onl Typhuls, ETO. A coiiplete (hisctissioni of t 'yphus fever in World War 11 cain be found inl othier volumlles of thlis

hlistor-y.

Recommendations concerning heart diseases.-Coloniel HWill called aittenilion) to tite possibility of traumlatic hieart diseases whiichi could( easily Ibe overlooked. Onet( possible source of hleart danilage was low oxygenl pressures ait

h1igh altitudes; ano1thler wats accidenits, its whlen a. hieavy object falls up1)01 tilie

soldier. Elect rocardhiogratpliic equipmlenit was Placed inl all genleral ho0spitials

an11d provedl very useful ill Iiiikinig r'eliab~le (lecisions for the( dispositionl of'

patienits. P'llceineiit of elect rocardliogratpliic equiflmienit, aiid( basail niieta holisni apparatus ats well, inl cercii a staltionl hospitalls wats Onl several occasionls

recoiii mnenmledl to Genteral hlawley, hbut hle remlainled opposed to t(lie ext (1151011

of these fu~ct ionls to st ationl hospit mils. Courses inl tlite utse of elect rocardhio-

?grap~hiic equipmient were giveni at thie European thteater M\edical Field Service

Schiool. As at result. of recoitiiiendat ionls onl art erial hvypert elisionl ma1de b.%

Colonlel I leinl, it, becamle acceptablie lpolic *y to retami tin t lie thevater those indiviflualls whlose only abnormal1111ity wats ati) elevat loll inl b)100( pressure.",

Penicillin study.-Coloniel Knteelaind onl I .1une 1944, stibjiiit ted at rep~ort

to Colonlel ýMiddletonl onl at st udy of nearly all calses (except venereal (lisealseS)

treat ed withil penlicillin Onl thle mledical services. of U.S. Armly liospitails in) thte

tinitedl Kinigdomi over th~e preceding 8 itmont s. Owinig to shlort ages of penlicillinl, its ulse ill ulielical cases wAsN-it- ii ited to t hose inl wh icl it wats thloughi

essenitial to recovery. Ini only at few cases of lobar pmieuiiioiiia aimdonieof niieiiiiigitis wits it. used deliberatel Iy for experinien~t ail purposes ats the only tihera1-

petit ic agenit.. It wivas imlpossiIble to (draw limly conlclusiojis froml man11Y Cases ill

whlichl it hIad been used in conijunctioni wit hi ot her agents; other pattiemits were

57 N if lvii I 1ý of Hhv'4't ini, Nlef I i~i odCUSivitnS' ýUhICOnIIi Ito tip, 24 Jan. 1944.
EURO)PEAN THEATEIR ()F (PE'RATI( NS 419

first. treated with penicillin when obviouisly moribund. There were, nevertheless, somec cases in which thle diagnosis wits unequiivocal, and the effect of

p~enicillin ('0111( be clearly dliscernled.

Limuitedl as lie wats by the type of daitat available an1d( considlering the

short age of penicillin, Colonel Kneeliand ventutred to saty that the pauicity of

catses for stuldy in itself indhicatedl thalt, a~part from veniereall (isealse, there wvere

coiipatrat ivel : few nlledlical caises5 ill Arniy hospit alls t hat albsolu t clv req izired

this anlt iliOt ic. Suist ainiwng previously known fact, there was evidence that

penicillin wa1s th leizost efiect ive agent aivalilalble ait thle tulne against getieral

infect ions (inc to StaIph' lvOoc('Us. It also ap~peared to lbe highly effective

,ag'ainst tilie nienlingococcls iti~l tilie pl)etliiilocoeccus, alt hoigli its siuperioritY to

sullfona~iiiides in) thlese fields wats not uinequivocably demionstrated. Neverthleless, Colonel Kneeland t bough t that its tise wa-is ind~icat ed ats anl adjunlct to

suilfonlamlide t herapyW inl overwhzelning in fect ions (tin to eit her of these btc--

terial. Lalstl lV, Colonel Kiieelaiid stat ed t ha t, when penicillin wats empilloved in

mixed in fect ions, thle restil ts were likely' to lbe dlisapploiniting".

This pen icillini st uidl conci(ded by Colonel K~neelandl, limited as it wit- In

1111M.aillws, Wits neverIthleless of considera ble impiJortance ini making l)Iinis for

the iiext phase of operations inl the t heater.

NORMANDY INVASION AND CAMIPAIGNS IN NORTHERN

FRANCE

First and foremost in the minds of aill stationed in the United Kingdom

wits anl evenitual assauilt onl the Continient. As the buildupj in England and1(

Northbern Ireland continued mntil it, seemned ats if the United Kingdom were

comiplet ely saturatedl with thle tremlenldouls concentration of ciil and miateriel,

excitement over lie invasion rose to fever pitch. However, the sober pictulre

of I hoiosanlds of b~attIle casuallties 11nd soldiers b~ecomiing seriouisly ill unlder tilie

primitive coindit ions of land wvarfare Servedl to templer, for tlie iIlledicall officer,

exciteiment over thle p~rospect of comning to grip~s with the enemy onl his owni

ground. To insuire the UT.S. soldier Prompt mnedicnl at teiition regardlless of

how or when thle need for it arose, phl~las that were flexible, practical, anld always

cuirrent. were requidred. To t his end, eachl (livisioli of General fHawley's Office

main tainedl a poiis-n-rceue loilillent for 111011 ntiiig tilie opera tion.

Colonel Mlidd~leton, liveordhiigly, cold riblutedl to tliepoiesadrcdus

(loctillwielt of thle Professioiial Services Division, Office of the Chief Suirgeon,

hleadquatrters, ETOUSA.8 81

Preparatory Measures

Regardless of hlow wiorthIy at plan might appear oil paper, it couild never be

miore effect ive t haii thle means aivailable to imuplemenmt it. The primary' problem wats oiie of personnel. There shouild have been qualified medical officers

-M emorandutm. Cief consni itant In NMed icie, for Chief surgeoun, ETOU( ISA, 5 Apr. 19444, ;1jbj(Tt: Medical 5.0. P.

for Fvacuation front "Overlord."
420 ACTIVITIES OF MEDICAL CONSULTANTS

in all echelons of evacuation and in all installations where casualties from the

operations could be expected, but this was not the case. The problem has

been discussed elsewhere (p. 248), but it is worthy of note here that, as early as

February 1944, Colonel Middleton had surveyed the fixed hospitals of the

theater and had compiled a list of 89 officers who could be used to strengthen

units arriving from the Zone of Interior or transferred elsewhere as required.8 9

Even at a time when the invasion was imminent, a survey of key fixed hospitals revealed the need to replace the chiefs of medicine in two general hospitals.

Forward medical echelons were provided with large amounts of diphtheria

antitoxin, and niotion-sickness preventives were issued on the basis of 10 capsules per individual. In addition, a 2 weeks' supply of Atabrine was provided

each soldier with a previous history of malaria. The U.S. Army in the

European theater was dependent upon British sources for many items of supply, among which were respirators. Through the auspices of the Medical

Subcommittee, Army Medical Consultants, Committee of the Royal Army,

Colonel Middleton was able to obtain a promise for 18 respirators to be used

in the amphibious operation.90

Colonel Middleton and his subordinate consultants in the base sections

insisted in all their contacts with hospitals that the medical service must be

prepared to function under the central leadership of the commanding officer to

insure teamwork under stress. In order to achieve this flexibility, 4 officers

from the medical service were trained to head shock teams working under the

direction of the chief of surgical service, and 2 officers from the medical service

were trained in anesthesia. These arrangements applied to all 750-bed station

and 1,000-bed general hospitals, with a proportionate ratio of officers to be

trained for these functions in the medical services of smaller hospitals (fig.

140).91

Initially, it was thought that triage of patients according to their diagnoses

would be possible at the hards where patients were to be unloaded following

evacuation across the Channel by ship. Accordingly, Colonel Middleton and

('olonel Kneeland, the latter in his capacity as the medical consultant for the

Soutlhern Base Section, selected and designated a well-trained clinician for ea(h

point of triage. Specific plans were also made by Colonels Mid(leton and

Kneeland for the evacuation of patients with conmtunicable diseases and all

those who were seriously ill to designated hospitals.9 2

After the transit hospitals were designated (p. 329), Colonel Middleton made

a totir through eacih of them to give personal instruction in certain basic principles of reception and evacuation of medical casualties. In addition, field

liospitals were to be set tip in close vicinity to tile bards as holding units to

"N If,.irtioni . I'rofvssion:i service, I) ivisio•, for Chief Siirgeon. ETOIVSA, 24 Feb. 1941. s NIijet Medical I iflc•,rs

Av:iihbhl ftor "l'ratsfer to Ulnits. ". Mentnor;iltirn, I'rofessionail services Divisiion. for Chivf Sulrgion Eon, T 1 .A, loi Mar. 1911., •bjvet: Medical Siuho Iniiit, Arryv .ei. i, Co•sll tants,' conmititiv.

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EUROPEAN THEATER OF OPERATIONS 423

Obviously, the wounded will constitute the overwhelming majority of early casualties.

This predominance will probably amount to 80 percent of the total for the first 24 hours.

For the first week it is estimated that the total load will be 60 percent surgical, and 40 percent

medical. After the first week a fair estimate will reverse this figure. On this basis, 400

medical patients may be anticipated out of each 1,000 evacuees to the near shore. For the

first week of such an operation, a fair estimate would give an overall figure of 25 percent

neuropsychiatric casualties. Hence, 250 of the 400 medical patients would be neuropsychiatric, and 150 sick. On the basis of available data, 100 of these medical patients would

be seriously ill and 50 would have lesser ailments. After the first week it is predicted that

the figures for neuropsychiatric and medical patients will be reversed.)

The Invasion and Its Aftermath

On 4 June 1944, just 2 days before the invasion, all consultants in the Office

of the Chief Surgeon, Headquarters, ETOUSA, received the following directive

from Colonel Kimbrough:

In the continental liberation, the members of the consultant group will carry out their

duties as consultants in the transit hospitals and other hospitals it, echelons in the rear of the

transit hospitals.

The consultants' activities in echelons forward of the transit hospitals will be carried

[out] at the direction of the Chief Surgeon, ETOUSA, and the surgeons of such echelons.

These restrictions were no hardship to the theater chief consultant in

medicine since he had, from the beginning, planned to operate in this manner.

On D-day, 6 June 1944, Colonel Middleton by chance had arranged for

a field trip to three transit hospitals, the 38th Station Hospital and the 48th

and 158th General Hospitals at Stockbridge, Hantshire, and Odstock, respectively. The units had received orders to evacuate all transportable patients,

and Colonel Middleton observed that they carried out this mission with great

facility and complete lack of confusion. Refraining from further movement in

the area of transit hospitals, Colonel Middleton, for a period of about 3 weeks,

confined his activities to fixed hospitals of the rear echelon of the Communications Zone. His observations, made during June 1944, were as follows:

The expeditious, thoughtful and adequate reception of hospital trains and convoys. This

circumstance applied almost universally and was most conspicuous in new and untried units.

Their pride in accomplishment was only equalled by the Chief Consultant's appreciation of

the strides in organization made under pressure (fig. 142)

Condition of patients. As a clinician, one could not escape the impression of the uniformly good physical status of all patients. Hundreds of temperature charts were reviewed,

with fever as the rare exception, a circumstance in startling contrast to the experience of

World War I.

Special problems. Isolated instances of hemothorax and pneumothorax led to the early

suggestion of the assignment of an officer from the Medical Service to each surgical ward

receiving such patients. This opportunity for co-ordinated effort has been early implemented

to the advantage of the wounded soldier.

Minor casualties. In the original medical S.O.P., attention was called to the desirability

of diverting "wet" soldiers from lines of evacuation. An oversight of this principle led to

the occasional movement of valuable personnel well to the rear, into fixed hospitals, when

a change of clothing might have returned them to active duty from shipboard or at the hards

9$ See footnote 88. p. 419.
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l h -If i 1 i 2 I h''• I • - ' l l I I, i II l t•l • I III" , -i l ' ' i -i In II" 1 1. 4 1 1 -'Ii I I• I l:l ;Y II I I h vi t~ I• I \1 \11

I• I• I • ml IrI I1'-4 1 > 11 iii I • l'I f. In li II I I il• III-I- h Il :• 1 4 : kI ý I I I h l iI II iI I II f: i 2 1 1 1i 11 11 1

I• • i- in Ih i 1 1 II. i • i•, • I" lin I Ii','- , : I I-. I I I- I I i (':] I II ictr• If II" I•lF i A'- I .\'n .••
2-

A r'

.It is tIIe cusImll.i1ii ,N ate o4 prv'dticimlls 11,1 )w * vIIS ))ls b IiOlmlif'ied tI lhe

ligltof (dsilb4sv(Ileilt evenits, .11id phlifls based 1t)(IjlIi he itl Iist also) e(i~ iUved

Folo ( '(d(l(lel \Iiddl4et(im, t Ie( (hiiiline a~i 11bvoialde otie. Thie Ii-lit loadi(I*o

miedhical evaclives ga1ve limii ani varly ()u 1ortlijt v 14) stiVVte I'inedieiil sit Ila~-

Itill III I lhe Fir'st U'.S. ArIiiv. r1 '

1 i I( h1,1id irzo E1T( )1'S;A, .11141 rzeii

FlI'st I .S. Armiv, 1)4t11i apl-lw)-ed anl efarlY v-isit bY C( Oltel \hid~lt'tlmi to) lev

VOiih4;It '/.Ol (fig.- 1-15). 1fm t1l1v period Il'roii 29 .Jtire to 2 fJill*v 19144,

( l((imeI Middllmleton s jWOvi(1e4 ever* b'IcIhit : v I'm thle ll Wiev~Il ( st ild ,

(III lliehi('aI 4perat ions oil tw lie( 011ilielt. I1pill1Ills ret01it,1 1t) Englandc, lie

stililtitat',zed4 his fiitnhiiigs as blos

JOjshI,111( ml 4 4 ,, f4 rtsialf. III Il h p'' wi d frmn 1; 23~ .June. ap i44)t4\i(Ii:4i4'Iv 2,661- inedieciI

:lppI'aPxitI:hII(Iv 11 p4('I'i'4 ofI (If th l 1ati40:11 cn av ti . In tI) I, ~I u'm peri4ad. 2,011174 '( S p ive tI

t14'il' 4Jv1' ii:4 Sle ije('ts hav4e bevtI :l(IIiljI ted. 'I'ii v'amiujitie titilre 4f 1 7 p-cI((t((ttlepe

Iuspeiell himpilillf~wltu 'tnh'' s Pvrrl. Ow ('tIIletitali theet:4nildingieit :4(1 ixolt ill. the4(iit

Iim(i. ti gi: l ofI. fl 4 h s e i1 ~ (d 11 4 1 e l1 1,f- n l - ilv l f m l i

I x11i4(11 4( (IifII IIf:lI't4 I l441s1 1 (i tI I( I In 11f. l til/al' "J4(i :4of III,1 ti' ' I 1t ll4\' t44'('t4 lit ' 4'- p:4i I :1 fi 'it I - - caf uu n' u:I 
1-1,It'I WEiAN T FTE1441V I I tl'ICH.XItNS 1 I 427

Tie, irok. Vitd tilt, I l e s-tIirI of (om ;i t condili as. all1 ninaiks and1( arad1s of thle

Mcqlj(:l ( ICrJIs lI:IvI 1)1111 WNi-i~i-i into1 an1 elfcti ve lIimijhin for- I lic cane o)f the sick tidiu

\-IIII ,if -- 1.si,, P:11- 1 015a . 1111 ijial hf- qim ~lis (111 th l~alembelp (If tilt Ann X. Nul-sv Colo'itl a nd o

Pf tll -lcd \ii ni par-oi:I J dillies aIii being v~iulvelfl Ii(III. adcmecil lfil

thatJi~lll~tli. c -110111m It (tilicatim 'I-I') li IIII,.lrll filt- Medlicolo News -l~al o atiili f Sigo the 

lif tit, F2 . IA111v :1d e- ola )te e.v a lia voc son
42S ACTIVITIE'SI: 41V MED:ICAL~I t1iNNUI:IANTI',

li()Sjii1 aII ill I Iu'( uxruiieu n Zolne.17

ýli' Imiidl~ing52 of veiiereul dlit'seas, and livit'iirtpsVt'Iintric prac'tice('S NIhIliih have

As ()f' ili end () Jl' 1 v 1944, t lie mnedical loadt in thle field and ill fixed IbM)-

lpitaHIM ill 11liv I lleat(l' coniitiiiuetl bo e -i-pi'ing-lyZI lighit. No coibfimmit'ab)Ie

111 a mwi'ey of 15 gent'iit 'Ilimlpit als \j wil respect'(' Ito I)(e'o~lltI p~roflessional

qiiah1ifict'lioiis, it wasI himind litat ()r' 2-IS iiit'tic~il (4f ice('i' 71 hath limd (iillv 9I

J"iis)i () tf inlte'rnsip~i. "'liii detficie'ncies ill sjpt'(iol skill, 1i.td to) be tmiinpt'iisaite

As of thle endo of Anginst 1944, Owli mediceal lomid of' thi'Ileu thent'. iiollcldtile.

withI i'tlai lsiuilZ iiial1ii'ii th olt *vclit iuini ng, 1)i'Ohbh'ii of' anly lp'On)I'I bus. Tll

iiobilit 'v of lie ari'uies (fig. 146fi) andthetlt jtIml'v ohI' kt'e g owmt() mld

hdlimol iuiited t'oitact't w~ithI civilianls antI foretstalled thii anit iti)cipa I iincurease inl

conn lln ii'alit'disease, inci'ldint gi &oiiorl-I'hea andI Syphiilis.

I-Ow , 91 p.1211.
't''11i Il ( % , Ih , 1 -I i )* -l. I.'

144 \) il '111441 1444114144 fil I- 11 1411'14(11.1 'r.c s 1

MIalaria

TI'Iw m4444'1 411 4'4' 441. Il* II41;Irki dlI11iII I Ill-" I44'14,41 I4''I.S ll4'4I ti'441 I ~ 4 cm)I(idif4I

p I 1' I~ - . ~ . I 114.11 II .11 (:1 1., v Ilý : .
430 ACTIVITIES OF' MEI)IlAL C(ONSILTANT.

adrenalin by the emergency mechanism of Cannon) nIay have been factors in

precipitating attacks.

Colonel Crone, of the First U.S. Army, divided patients manifesting

clinical malaria into complicated and uncomplicated cases. Complicated cases

were defined as those having more than three relapses with one or more of the

following conditions: Splenoniegaly, anemia, or continued debility. Patients

with these conditions were discharged from the Army. The uncomplicated

cases were the objects of concern as to possible saving in manpower. These

patients were initially treated in mobile hospitals of the army for a period of

time necessary to fit them for ambulatory treatment in the 4th Convalescent

Hospital assigned to the First U.S. Army. Colonel Crone estimated that for

75 percent of the patients the period spent at the convalescent hospital was 5

days. This policy effectively and noticeably reduced evacuation of malaria

casualties to the United Kingdom, while at the same time the use of the convalescent hospital as a holding facility kept these patients from overburdening

and clogging the main lines of evacuation. 100

By the end of July, the medical service in the First U.S. Army had done

all it could to control the malaria sit uation and to advise commanders of necessary corrective measures. However, there was no abatement, of the incidence

of clinical malaria. The 91st Gas Treatment Battalion hiad been brought in

to care for the increased load and was caring for some 400 malarious patients

at this time. By all criteria, the supply and the dosage of Atabrine had been

adequate to meet the needs for the affected individuals of the four divisions

known to contain all of the potential mualarious subjects. On 29 August 1944,

Colonel Middleton was obliged to advise General Hawley concerning nalaria

control, as follows:

Obviously, the problem has continued beyond reasonable limits for causes that are now

controllable. Atabrine in full doses for suppressive purposes 0.1 grain daily will prevent

the clinical manifestations of malaria in an overwhelming majority of instances. The

attrition in manpower from this cause has not been disabling, but the Command responsibility for the active administration of the drug should be reiterated in the interest of more

effective control.

Tuberculosis

At a meeting of tie Medical Consultants, Subcommittee held in January

1944, Colonel Badger mentioned his concern over a certain lack of consideration

for the individual tuberculous patient in his processing and evacuation to tihe

Zone of Interior. Colonel Middleton asked him to look into the matter and

submit recommendations at a later (late. The impending invasion of the

Continent and the dissolution of specialized treatment facilities supplied urgency.

Heretofore, tuberculous patients to be evacuated to the Zone of Interior had

b)een transferred to the 298th General Hospital for care and therapy until

transportation became available.

100 ,me r(K)tnohts 91, p. 420, and 98, p. 428.
EUROPEAN THIEATERI OF OPERATIONS 431

The( day after the invasion took place, 7 June 1944, Colonel Badger

hastened to submilit his recommendIii~at ions to Coloniel M iddlet on concerning thle

treattment and evacuiation of t ulbercuiloiis patients. lie uirged t~hat~ pneuniothorax treatmient Ile usedI onl *y for thle einergeiicv yease of tuberculosis or whien

(delay wouild lie injurious to tilie patient b~ecause of hienmorrhage or thle progressive

natutre of the disease. Ilie pointedl out that collapse therapy wats best initiated

anld carried onl when the course of treat inent. would not be initerrulptedI ly

frequent transfer of thre 1)ait elt froin one operattor to another and, uisually.

when preceded by at month to 6 weeks of absolut~e bed rest with good (diet anld

nursing Care. Colonel Baidger notedl:

The ne(cessity for frequent refills iii the( early stages of pneumothorax treatment, andl the,

compjlications associated with the in~terrupJtion of treatment ini the course of t ransp~ort,

entail hazards for the pat ient which will cit her cause delay in transfer to the Zone of Interior,

or necessitate conduct of the (-:se- 1w numIerouis medical officers of varying ideas and experience

in collaI5e therapy. D elays in refills and comjilicationsmasociated with early pneumot borax

treatmrent huave been proveni unavoidable during the numerous evacuiation episodes that

mark the course of every transportation to the Zone of Interior.

InI addlit ion, Colonel Baidger uirged that boarding and evacuation procedhures be materially Speeded uip in patients admitt~ed to general hosp)itals

with 21 adefinlite (lialgilosis of tublercuilosis. He not~ed also thre p~ract ice of allowing patients withI serotibrinlotis pleurisy, whose t~emperature 1111(1 returnied to

noritia1111(an whose fltuid 1had( been ab~sorbed, to ret~urn to tire Zone of Inuterior

Its akitlbulatory cases.' 0' Ile strongly recommended that, aill p~atienlts with

atctive ttiherettlosis lbe returnedl to absolute bed rest, for tile entire trip.

All of C olonel Badger's recoinmendlat ions were amplified land incorporatted

into at direct ive wvhich wats isstued front the Office of thre Chief Surgeon, Ileiidquairters, ETOI'SA, ats ( ircuilar Letter No. 100, dat~ed 25 July 1944. This

circtilair concludled wit Ii the statement.: ''Recommnendatfions for treat muent, itt

at)sohiite b~ed rest for the entire trip will be entered on the pattient's mnedical

recordl byv t ie iiiedical officer inl (bar11ge.''

[It the mieanwhile, C olonel Badger had lbeen transferred to thie Office of tilie

Surgeon, Forward Echelon, C ommumnications Zone, andl subsequently to thre

15;th Hosp151ital (Center, while still retaining his position its thle Senior- C onsuilt ant

in Tuberculosis, ETOUSA. Shortly aifter D-day, C olonel Badger conduicted

at field tripl thirotighi staltion land~ general hospitazls in t~he W~estern Base Sect ion

to (use155 1111( evahtiitte ttubercullosis probilemns. He had also requested at repiort,

froim the( chief inirse of thre European theater, showing cases of tuberculosis and

.erofibrinlous p~leuirisy aniong inurses who hand bieen evacuiated to thle Zone (if

lInterior. His surlVey ('ontirmnled the fact thiat, tuberculosis wats atit its lowest ebb

11111 (hit niot, const it ute at seriotus probilemn." 12 The report onl the incidlence of

tuberculosis inl nurses, alt hough not equated for differences in thie numbers of

FIM litter, Lt. Coi. T. 1, MidgIer, to Col. E. R. Lon1g, Chief, I)ivLni,,; of TuI',itwrcosbi, Olice oft the Surgeom (ienera,ui

I Jtizi 1944.

i',z Letter, Lt. Col. T. L. Bauiger, to Surgeom, W"-stern Mist* Section, E'roUSA, 2 July 1944, subject: Report or the

S.,, ir ('onstltanrt in Inim hrelosils.
432 ACTIVITIES O~F MED)ICAL CONSULTANTS

nur11ses, nevertheless seemed to inidicate at considIerab~le increase inl thle secolld

year of thle theater's activities.

In it letter to General Hawley on 14 August, 1944, Colonel Badger recoinmended at spot survey by X-ray for tuberculosis in nurses in 2 general andI 2

station hospitals, whinch had been in thle theater front IS to 24 mionths, and inl

2 general and 2 station hospitals,,. which had been in thle theater 3 to 6 nionthis.

fie assured General Hawley hie would impress each hospital that these X-rays

were to be taken at their convenienceI and when their workload wats slack.

C olone Allen, the theater consultant in radiology, app~rove([ thle use of X-ray

films to condluct this spot, survey involvintg 584 nurses, and both C olonels

SIi(Idlet on andl Kinibrough recomnmended approval. General Hawley, however, replied to Professional Services Division ats follows: '' 1im 111Sorry b)ut we

are fighting at very rapidl war at this moment and such surveys will have to

Wait until this thming slows (town at lit.''

And ind~eedI, the fighting wats tunn norpid pursuit. The Allies,

halving enie-r~ed fromi thle hedgerows of Normandy, appeared to be on the verge

of anl unimipedIed onslaught to the Rhine andl into the Lowland1s.

FINAL OPERATIONS

By thle end of September 1944, most of the theater headquarters had

IMovedl to France, includling General Hlawley's office. In its wake, at sep~arate

commndu i~ under C oln ill imications Zonle headIquart ers h~ad b~eeni established in

Enmgland effective ats of 10 Septeumber 1 944,I"~ and designated thle t'nuted King'-

(1011 Base Section. Its surgeon wats Colonel -Spruit, formerly the theat~er

deputy chief surgeon. Colonel Kneeland wats niamed ats his 'onisult ant. inl

Ille(Ii(inle. Onl the Continent, the Communications Zone had b~een solidIly estab~lishmed withI six base sections and time Advance Section, ComniuniCal ions

Zone. Tirty general hospitals had been moved to thle Continent, of which

eighteen were operating. At, the front,, thle Third U.S. Army had entered

Comtbat onl I August and was now assaulting the Siegfried Line. onl the central

front sout It of time First U.S. Army. The Ninth U.S. Army had entered comuhbat,

in early September during tlie siege of Brest and1 other French ports, imiid thle

Seventh ItU.S. Army, after landing in southern France onl 15 August 1944, had

adlvanced northlward and (luring Sept ember cainle under the operational conltrol

of tilie European theater commnander. The battle for Germany itself had just

lbeguln.

Thi's sp)lit timng of medlical resources between the Unitedi Kingdom and1( the

(Cont inment placedI C olonel Kneeland in at unique posit ion allnomig thle mnedical

('onsult ants sublordinlate to thle (chief consultant. in medlicine. First. of all, thle

eva('liation p~olicy Oil t W(ltileCninenit wits 30 days, wh~ile for the theater ats at

whole it. was 180 days. TUhis nmeant. that the grevater part, of definitive treat.-

ilmemit wats being carried out in thle Unlited Kingdom . C olonel Kneeland '-

dluties, ats a1 memeber of thle Professional Services Division, Office of the Surgeon,

101 G eneral O rdier No. 3.5, I iea loitart ers. C'om uic~aiit ions Zone, ET ) USA, 15 Ang. 1044.
EICUtIuIEAN I'l IEATE'R~ 0 F ( IEI(A'l'l NS 433.,

U nit ed Kinigdiom Base, were to (1) review t retmn ent. procedurIes, (2) select

Iindlividutals for p~rofessionail trani ntg, (31) Su perv~ise rest'ieali in lli military n licti ii i(,

(4) contrto~l act ivitites of 1i051it ill centet m'*iiledical conisultanuts, litit (5) inspect

andi( evaltiatt' profess5ionial carte inl thle Unitedi Kingdomi.'"" C oloniel Middietoni,

etigageti across, tie (- 'linitIel, hiatd to (delegate uiianvY of his ownt Supe~rvisorv

fit net ioiis, Jpikl teiduardv ill research act iv~itie's, to C olonel Kneeland. lie Ia iitoItt

dlelegate to himui also 11i1anV of hIls (lose associations with Brit ishi meiienleili ol'hot

civiliant anti mii jtary, Which lilt([ p~rovedl so profit aide ill thle paist. For exampl 1 e,

C olonels Kit ib rough , C ut ler, antd MIiddl~et on, ats chief of professioiiall services

aknd( chiief conlsuilt anits5 ill surgery an lt tetlici lit' re'spectiey formerly rt'i)Its('lt eti Getit'rnl H awley ait mieet ings of tilie Penicillin Trials ( ouliinIIt t (' of liet

Brittisli Natitonal Research (Couincil. Thius futnct ion had to be delegaited to Ii ie

suirgical an tid nethical cotisult ants of Un'iitetd Kitigtlouu Base.

'it'll first prtblemti It) het tiiseuissedt ill thins periodi origiitateti inl thite Unit ed

Kiiigdoiti.

Sil fadiazine Prophyilaxis

The Arntiv Air Forces ili Briitain requ't iestetd pertm ission tof tilie Ch'Iief Mi rg('tli

to uise sill fa Id li DV Iteas at I)rt0)llhvlatXis agtillist respi rat orv*N inifect tiois litti preseted It'

intformat ion from i tlit'- Air -Strgeoit ats to its eflicatvy. Tlhiere wtere tertaiii cionilit ions inl thle thlenatetr, however, thlit miiii tialted againist allt uncrtl titical appro)t)vali

of tilie proposedI prtoject.t The l'eo-plest. wa-Is rteferred for considertiont u to thei t

( ollnltinIt ep onilt Intfectious Diseastes which was to niiiett on 28 Stept eutber 1 944.

L a ter', tilie comi til tete coor-di [liat t'd its detlibheratijolts with Co( tlonetl Gordon, who

''Fli' commiiiitttee detfinied limiitedi indictije onts for tilit use of stillfat~ilazi ntias at

lprolpi~l *lXis. Two such limiit at ions Werte wheltu pivotail i nti vid uIiils mid( to be~

maintaiintd'l int state of excellent lit'alth Ii nd whlt eui t'i'tid colin ritiunitnlbe thisellsts Ii at r'tI it'le d Specifhied critic'al levtels. FlThe ctomminitteet recommiiiti ende it

p~eriodt of 4 weetks ats sufficitetnt tott prot ect igignilst risks of liajot' epidiemiics andt

potin tetd ou t Spec'tific contitrols that, shiouldl he' observedli a ad ill i initer1ing tlit'-

tiru1g. 'lThe commiiit te tco tntludtetd its cmili uiitnt s. ats follows:

Th'lis Commnit te a''gre'es t hat tllt' results oif snilfaliaziie p~ro)phlax~is may~l we'll prove to)

be s sal isfacinpr y ms h'Ihlie Air Stirgeo'ois imemorarniu(II wE)iji(I jilI(4lcte. it still, howe'ver,

is opposed toaIlne idvn of (list rilbnl lur :I 1owe-rftul drug onl a very large S"enI1v as :1 ennlunllndhf

fmictim loll enfss co)nside4rat ions oIf importarnuce' ill regard to t114' waIr effortr warrano Si sch (listril~iution11. It is for this reason thlank I he('Cnommiitee has tanken its pa-illol tha Iilt line idivatitons fo r suilfadiaiiunt prop~hylax is are st rattegic'.

Suulfadiauzine( p~rophylaxis nalfiiltf'(lI dones not1 cowrluur) virs dkjemv'N inciniuitig iullie-iuzn,

and it is nton sI rikiuiglY elhicaviotis .'gauiust seconnuilarY baicterial jinteclloins of a miixedl ehnracier,

juuclminudg I)4livilnWovccatI jiufecliouns. Ill tlt-~ past tw Yea vrs, meneijuigiti wiS 114 s1 rvpt0V0n'c:kI

iinfect ills, whic4hi are' mo4st flvorhlll*Iv laff~ecedlhYm stilfanlia.iune iurolplYhlxis, notV4 lI b len

i-pinlvinic ilii ihis Theate-r. Thus whe'n t 114' quiestioni is cohnsidered inl relation to StOS t roops)

illI nitd Ic Kuudouun, the4 C onmmuittee is oppoen'n to suulfadiauziunn prophnylaxi' tiiulvsý 1114.

pal lerul of epidem'Iic diseanse is unnkeriallY altered.l"'l

4 .'.nnnn:it Itiwiir I'nlivd. Kingdom'nn l~ase. 11141.

EýWll'Inn linnule Mo'icinu I )atau, Il,:nmhinn:rt-ir's IE'II SA,., tiw ,'vwlumnI.r 1!1I 1.

-)649u741 f ;l 30~4
4134 ACTIVITIES OF'" MEI)ICAL C(O)NSULTANTS

The committee voiced no objection against trial use of the drug by the

Army Air Forces. It also recommended that a small controlled experiment

on the prophylactic use of sulfadiazine he carried out in one or more hospital

units of the theater.

(0ol. Joseph C. Turner, Chief, Medical Services, 154th General Hospital,

near Wroughton, England, was selected to conduct the limited study recoinmended by the committee. He divided half of the hospital's enlisted complemient into two experimental groups- -one receiving 0.5 gin. of sulfadiazine

daily and the other receiving 1.0 gmi. daily. The other half served as controls.

The Eighth Air Force in England conducted a clinical trial in the prophylactic

use of sulfadiazine in four stations of its Air Service Command. There were

a few toxic reactions, none severe. However, several Air Force patients who

were adinitted to hospitals for diseases other than upper respiratory infection

became toxic from the additional therapeutic administrations of the drug.

Colonel Spruit had to notify all hospitals to ask Air Force patients if they had

had experimental doses of sulfadiazine prior to initiation of sulfonamide

therapy.106

The drug trials at the 154th General Hospital and in the Eighth Air Force

Air Service Command were continued throughout the winter of 1944-45. In

the meantime, TB MED (War Department Technical Bulletin) 112, issued 1 November 1944, authorized the prophvlactic use of sulfadiazine at. the discretion

of the theater commander, under circumstances and by methods practically

identical with those previously recomumended by the Committee on Infectious

Diseases. As a result, sulfadiazine was used prophylactically in other isolated

instances with varying results.

In his final report on his experiments, Colonel Turner noted that the results of such tests hinged to a considerable extent on the pattern of disease that

chanced to unfold. In this case, the winter proved noteworthy for the rarity

of severe diseases of the respiratory tract, and hemolytic streptococcal infection

was seldom seen.

"Thus the epidemiological conditions developing in this experiment were

not strictly ('v1comparable to those obtaining for most groups reported on by

others," wrote Colonel Turner. "They set, rather, the question of how sulfa-

(liazine prophylaxis will influence upper respiratory tract disease which is mild

and mixed and non-streptococcal in character."

After almost 5 months of trial, Colonel Turner found the answer to this

question. He reported: "The incidence of mild upper respiratory infection was

about the same for hoth treated and control groups. Sulfadiazine did not appear to influence the occurrence of colds or of chronic upper respiratory infection." 107

The Air Force study, on the other hand, indicated t~he following results

froni use of prophylactic sulfadiazine: (1) A reduction in the noneffective rate

due to respiratory disease (patients admitted to hospitals and quarters) as well

I" Se e footnote 1(4, p. 433.

10" Essential Technical .Medioil Data, Ih adquwrtero, ETOISA. for April 1945.
EUROPEAN THEATER (IF OIPERATI(ONS 435

as for those treated on a duty status, (2) a similar reduction ill the incidence of

gonorrhea, and (3) a reduction in the number of individuals that. would probalbly have been affected by a diarrheal outbreak in which the etiologic agent

could not be definitely identified. 'Thlie results were, however, inconclusive with

respect to the pneumonias.'/°

Diphtheria

As the concentrated attacks on the defenses of the German homeland grew

in intensity, miore anid more prisoners were captured. Together with the increased influx of German prisoners, the first sporadic cases of diphtheria were

seen. This had been expected, and the supply of antitoxin was adequate. By

inid-October 1944, when Colonels Middleton and Pillsbury Iiad(e a tour through

the medical installations of First and Third U.S. Armies, diphtheria was occurring in increasing numbers among prisoners of war, and cases had appeared in

U.S. troops. It was observed t hat penicillin was proving to be remarkably efficacious in the treatment of diphtheria. To date, it had been used primarily in

patients sensitive to foreign serum or in the few instances where antitoxin was

not immediately available. Colonel Middleton advised extending the use of

penicillin to patients with grave toxemia, for whom the combined adniinistration of diphtheria antitoxin and penicillin might offer a better prospect than

antitoxin alone. Colonel Middleton also considered the possibility of penicillin

application to the carrier state.

It was necessary first to gather data on the actual efficacy of penicillin in

the treatment of diphtheria while discouraging its injincdiate acceptance as a

substitute for antitoxin. To facilitate obtaining this data, the Office of the

('hief Surgeon, Headquarters, ETOUSA, issued Administrative Memoraniduni

No. 151, dated 27 November 1944, which furnished adivice on tihe consolidation

of information gained from treated cases and which reconmumended the dosage

to be followed. The fornula advised was 25,000 units every 2 hours (300,000

units a day) for 7 days. The directive also required prompt reports on cases

thus treated.

Next, since early results as to treating diphtheria carriers with penicillin in

the foregoing schedule were indetenninate, at imore positive and directed study

was obviously necessary. Prof. Sir Alexander Fleming of the Penicillin Clinicaal Trials Comminittee, British Medical Research Council, advised substituting

topical applications for intramuscular injections. He suggested using a suspension of 500 units penicillin per cubic centimeter of normal saline solution

or oil as a nebulizer for the nose and throat. In addition, it, was proposed that

troches containing 500 units of penicillin and capable of solution in the 111outh

in from 15 to 20 miinutes be used.

Lt. Col. (later Col.) Rudolph A. Kocher, MC, Chief, Medical Service,

203d General Hospital, Garches, France, used lhe spray aind troche treatment.

on 22 diphtheria carriers (all German prisoners of war). During the course of

to. Report, Eighth Air Force, (Jfiee of the Surgeon, 27 Mar. 1945. subject: Prophyla:tie Use of suifadiazine on Eighth

Air Force IPersonnel.
4316 AC"I'IIE 0P~.: U MEDICAL C 'NSLIA'AWT$

I lie st 11(1* , lie foiund it expedlienit to dlouble the st rengtli of peinicillin. ThiPspray

Wits Used every *2.- hours und thle lozenige every hour (durinig thle day. The

( rynenbacteriu iin(phth~eriae disappearedl comiplete ' v from thie cullt ures of t he

nose and t hroatt of 14 of the 22 c'arriers. The re IIit'll)1*ing eight had badi v (iseasedl ('rVt ic t oiisils, 101( therewa WiSolly ilegulir, if any, cont rol of thle noiouils

flora withI penicillin. Toniisllect omiy effected at relief of thle cairier st-ate ill all

eigh~t of t hese subljec(ts.,')

Th'le prioblIemf of (hiplithleria amiong, U.S. troop~s was never great inl terms of

its incidlence, but, many (leat hs from (liphi thleria conitinuedl to occur duringii trhe

renia inlder of tlie( war. 1 tý appeared t hat, a conid~~erab~le numb~er of thiese

hat alit ies could1( have beeii avoided. Thle dhisease flow occiiri'ed so infrequentl 'V

iii thle U nited'( St ates thiat, a if(e%%- gener'at ion of (clinician h1 Iad arisen who had had

no oppoi't u1iiitvY to becomie familiar withl its Val rious cl InIical ma11 niifestatt ions. There

wa-is also blind dependence onl lahoralt or * 'onifir'mat ion of thle (diagnosis, Whicihl

(oo frequen'ttl I (le, 've(I its recognition and~, for 1111111Y reas'iIons, wa-Is itself not

a lwa ,Ns jnlfillil)le. Finally, Th'le Surgeon General sent. a spec'ial 'ommlission to

SItidy diphi thleiia. inl thle European t heat er. F~urt her dliscussionl of the (disease'

miust be reserved( for' that portion of this narrative pertaining to the p~osthost ilit i('S Period, whenl (hiJpit hieria blecamfe a inatter of relatively greater concern.

Cold Injury

Ini mid-Sept ember 1944, the Allies 1111( at temp 1 ted to outflanuk the Siegfried illne ait its northlerni term intis using two UT.S. fil(] one( British airb~ornie

dlivisionitas thle primary assault, elements. The massive airborne operation

wa-Is executiedl lpreciselY, but., dlespite t'ilie heroic effort s of thle Brit ishi 1st Airborne D~ivision to hold a bridgehiead across thle Neder Rhline Iin thle vicinityi% of

Arnhiem, Gecrmana d(efenses were equal to thle occasion. Tlhe Siegfried L ille

('0111(1 not. be turn'Iedl, and the Allied armies along the entire West erii Fronit had

to at tac'k tile enemy fronitally. There was fierce fighitinig, and proguress wa-Is

slow. Behind tile lines, t here had to be a t remenidouis logistical bulild hi) of

suifficient prop~ort ions to siist aml a march to aind beyond tilie Rhine.

Meanwhile, the weather tuirnied coldl and wet, p)resaging tilie coldlest w~inter inl Euirope inl a number of years (fig. 147). Thiere wats a (listinct risiing truend(

inl the incidhence of up~per respiratory infections amounting to fromn 60 to 70 per-

(-(elit of total hospital admissions. 110 For thle first, tuime siiice 1)-day, tlie( a rniies

weueV nlow having at priepoiiderance of mnediciil over smiigical pait ients.*iI Ill

November, the evactiat ion and hiospitail iza tion situation became criticall. Oni

two) oc'casionis, there was no evac'uat ioni from nin ' V~u a reas for' al IS i- to 24-lion

periodl becaiuse of it hick of hiospitial t rainis land Ih ospi tal 1bedIs oil tilie Cont inent.

On)u four differenit occasions dIuiriiig tilie mionith, thler'e waIs no0 evacua tion froni

Ihle ouiti iien t to tlie( U nit ed Kingdom, eithler' by sea oi- air. Onl 24 November

11 i'ii1:1T401cii1I', Nt'(11 I Dai, )ica I iivai-lijimrters ET!'I(*SA, for i',l~r~ir 1911!.
c()Id 4: \,191 111d .5

144,1Iii'i at I~(IaIhe ]-Ii 'i iien It' o 4)1 t'\;I wni iaIjld iiiir ve i( 1)i I a - bioilli. w ih I e

liospitill. Tie (it'n~ de s aile fo hetr F141-' V.(4 A1iivt v' 12.lt'1to be dtrelL tlI ta to expethl.

4'h ..r.nlcl -ý Ir. om,144.r-4 I d uii v 4I11rovv vi; en (4 Ils'l- .4 .1 A444(4*1 I'- hospj li'l r.1*, \\,I-4.

dv.h, I'' :(o .111 Ihe cOlclal..l efo t. F rt e..'.Sd~~s 'N ve b r
438 ACTIVITIES OF MEI)ICAL CONSULTANTS

In the European theater, it was primarily the number of surgical casualties

that naturally diverted this charge to the medical services." 4 For example, the

100th General Hospital, Paris, France, during 1944 admitted 1,101 trenchfoot, 20 immersion foot, and 314 frostbite cases to the surgical service, but all

except those requiring amputation were cared for by the medical service. 1

•

The 7th General Hospital, lterts, England, in an attempt to equalize the voltume of work between medicine and surgery, admitted nearly all cold injury

cases to the medical service. These patients were not transferred to the surgical wards excel)t in the event of some complication requiring surgery. In

this waxY, the hospital rcplorted, surgical officers were relieved of a great amount

of administrative work and could devote more time to the treatment of battle

casualties.

in looking back on this situation, Colonel Kneeland, the United Kingdom

Base medical consultant, noted as follows:

In nearlv all hospitals within the United Kingdom, trenchfoot was regarded asa Inedical prol)lem, except in the small percentage of cases with extensive gangrene. With a b)ed

occupancy well al)ove the normal capacity, the problent of treatment and disposition of

these cases was a very pressing one. Most of our medical officers wN-ere wholly inexperieniced in this condition and much of the available technical data dealt with more severe

types of cold injury than were occurring on the Western front. Broadly speaking, the

majority of cases were relatively mild. Only about 10 percent had gangrene and most of

the gangrene was in the form of superficial skin necrosis. In 90 percent of the cases, therefore, one was dealing with soldiers whose skin was intact, who had comparatively few

objective signs of cold iniury, hut who had varying degrees of subjective discomfort.

With a demand for hospital beds on the one hand and a pressing need for infantry

riflemen on the other, the disposition of these cases became of the utmost importanc:s.

Because of our lack of experience, the medical consultant felt on very insecure ground in

giving advice to chiefs of services and it was his duty to obtain experience and create a

working hypothesis as rapidly as possible. This was essential for the following reasonsif men were unnecessarily boarded [to the Zone of Interior), loss in manpower would be

very serious to the fighting forces, as the great majority of cases occurred in the Infantry;

on the other hand, if men were kept in the hospital who could not be returned to duty within

the evacuation policy of the theater, the congestion of hospital beds might prove disastrous.

It was the duty of the medical consultant, therefore, to frame some sort of coherent policy

which could be disseminated to all the hospitals.116

Colonel Middleton was particularly concerned over the lack of information on which to base a theaterwide policy. Speaking about trenchfoot at

the 24 November 1944 meeting of the Chief Surgeon's Consultant Committee,

he said: "As you all know, not only is this an important problem, the most.

important single problem in the theater at the present time, but we have no

measurements of either injury or of convalescence." At the 30 December

1944 meeting of the connmittee, Colonel Middleton remarked on the prevailing

idea that, 50 percent of cold injury cases entering army mobile hospitals were

being evacuated to Conminunications Zone hospitals. Of this 50 percent,

anywhere front 5 to 35 percent were being returned to duty. Said Colonel

'If Essenth:i Technical Medical Data, Ifleadquarters, ETOUSA, for December 1944.

- Aunual Report, 100th (leneral I ospital , 1944.

116 Anniwal Report, 'nilted Kingdom Base. I Jn. 19451-30 June 1945.
Milddletoni: "'It is elitirely too Nvde. variaficv of the ab~ility o*. O of the opinili'

44 1Ihe sil('oii :I- to) the albilit ,v to reibabl~itIate. Ilii conid~lering thle wor)ik ill

ti s part ieiilai11 field, I thlik it would be very de~siiahle to gZet smilie crleria o)f

inifl ry anad ieCi.' oloniel Cutiler, Iw the hater clivii consuilt ant ill slilgv r\.

-4~iel I don't tiljk we have riiizcli to ,.ay ablloit it yet ."

tinlder 11l1e overall gulidanice of C'oloniel Kiieelai1d, C apt. (later Lt. 04o.)

R~obert A. l'.ivinid ,v, NI(. 1 25th (jenierl H ospital, IDor-seshirie. igli(

p~lacedu on eIvIllmiar ,v (hiit ,v at t he 7t hi ienieral I los-pital to coniduct st (Idies tIer

1ili4he!. 1hle supervision of Lt. C oh. (Liter (Col.) Lan11-irete B. EHlis. MC(. ('aptnalit

h4,eiiiied v had l1aid (oiisidlerabiv4 eXperleiice ill treating&Z coldl inijury(oil Att li atid

hadl devised a1 respirator for tihe t real iieit of cold iiijuirvcases ( fig. 14S). ( ohoiel

ElAlis was an1 experieniced physiologrist and t horoniglly a nIa jint ed ~ithI w experimienital echli aiqties ill physiology.

Thei basici prinipiJle of ( apht ail Knl~eiii'ds procedure was, to cause hiyperventl iat ionl I hirotighi legiat ive pressiirv app~lied to thle th loax eiieisedh ill .1ii

niI imimiiiii jacket . 11 is hivJ)otliesis was t hat such iieg-it ivi.pe l si'455ii Iraiisiiiit I ci

to t ie t lraici4( cavity, , would~ tvend to iimpr~iove veiioiis aniid pro1hablly Ivitphlia;

flow fhoiii thle ext reilifiies. Th'lis, ill t(urn, would impr~iove th li )Xvgeui sliplylI

to tille (ia111iaiged twn is 4e 16I i feet as Mvel as dhiuiniisht thle edeleii of thlese Imlsa1.

Suipply dillicuilties. pari'tiluih1iiIy ill olitailiiiiii I lie exact tvhte of respir-ator.

prievenitedl experimienitation i l as wenxeisive a1 Scale as wmoild hae eeii desintbivd. Neverthleless. vail v resuil1ts wvere favorable. 11141 paliielis treated ill

lie repl45 -iat('liii himpovmed at a linore rapid~~ rate 4 otii subject ively awl1 (Ithjl.etvejlv bthim pat jetits treated bY other tuet ilmls. t

hivsioloir.ic Studhies of the
440) A('TI VI'I' OF1 MED.IC'iflAL ' 1NSU 1111A NS

cireciniola 11 of Pat iets linider I eivitilelt wer~e illit illted to obtain itiformijalionl

oil thle tInecaltaisiti of the re IpiI'Utor'5 21('tiollIid1( OIl tile patthologic physiology

of lie inji urv it self.\ Mleasureiien s of thle femtot'ii venous prlessure shiowed

11lt imiiledlialt ani td sigiiificlult drlop t%-jjiqj tlie lpIt a uswas ill ac(t ionl.11 I nit et'

filItI dilIIgS were an inI te(resti Igo comltie II itarV I I1)011 the dieeier order. of te IIvplt Iliologic

elm li1ges. Reil psesce 0(Ii 1-red I I cn ('il~' e5(ci It pi t iet Its, at ( lpattlel It' 5wit Ii (Ieejver

cold( 13 injres exp~erienlced 'on~siderable Patin1 w~hien thle 'eslpiri'toI' was usewd."

The st iIld'v wats coiit itlied tiut ii April 1945. It, wats compl)et ed under thli

dIirect ion o* (i pt. (litter' Malzj.) M a rk Aistier., N\I ( , who hald prey iousl , atssist C(

Cl'apta inl KennledY . Ill generall, thle ('olcisi(~oli wits I hat this Iv pe of' aippara-ltius

wa1S of' Vadlue Inl re(11~ii('igI lie( edeleiali(1an sYnipt onis of' patient (tIs ili thle ailit e

stage.( of. ('01( Iinjury , especlia ly wit hini thle first 2 or :1 weekis a ft ci developiniie i

of, triei (li 10(11. Thie liosilit al slav. of' pa1tijen ts ill tIilis ('atvgOl'v so t reaitllv was

(lefillitelv shiortenied, aind at hirgeri 11iunihe(r of'* tlvien l'eut~lued t (1%0 dbyullt. ill

gi'o(ss ijititihet's. the nIet hod could niot lhe ('ollsidered as, ha1viig. bveen of, jinpol'-

tallice('l' duing thle trieiiclif'oot elpid(leliii. Fiii' iei'more, patients w%[ith ptire Frost -

bitv eillid t hose sevei'e caises not trlelite( mit il uither Itle thlird or fburthI week

showed little or' no0 peri'uiviatlit re(spolise. V1lii1i Ide ilif'oriiiat1 loll w%-,s obtinled

-is to ltill (offec(t5 of' thle t rent ielit oil lperi'iliend~ ('irl'(tlittiollki 11( its uiselulmi('ss

An othei~r st ti l beguitin in N ovembher 1944 wa-is to ha ye mUore( inmie lint e

efl('(t inl t lie trlea t illent of, ('oji i nj tirv. At t lhe 11I01 Ii St ait jolt I lospit all. Lt. ( ol.

(1lit el ( Ao.) TIheodore ( o1 Ieui %I( ' , tihogll ilt 11. lizi it(, he were to take~ a1 grlonllp of

25 pat jliens ainl exercise t henm as sooii als possiblle, ie((11v1cul ri'elibililitiate thlenil

faIst en. lHe l'ouuild tIin it .5 weeks a fter' exposu511re alil 25 paktients 'ouild act iv ev* 

(qltrnj~lt' ill sollie wvork ar1oundi~ thle ltoslitil mtid 12 of' th ri-'goulp ul('liet

a ;-mIle - 1re1i. ( 'olol1ie~ Niddletonl reported thIese eolicoliraging riidlzsa

Ie It(, I0 )veeliier 1944 mneet ilig of' lie( ( 'Ii ief' Suurlzeoli's ( olis~tilt aint ( 'ollinlit teey.

( eiiernt I a 1xi hv wa lit e to kntow how seriouls thle 113 urv was. ( 'olonel Kneelan1d exphulinied thalt, oil t he whole, he woulid sat*y thle iijtill' "Is wa of' solliewhiut

mlore lIm l111avei'age sei'ioisiiess. "Ilivre vei'e severall pat iei its wit t iligrle

filt n1ow all W(V' Wallking". ( olozil ( uler ill ('O~l fii'uii t ion, made~j( I lie followvi h

lll(r 4s(opi('lettm wtilhthe ('111 il' :din:,, h of d tllllI'111114 dc ilhie ' 1) Cooe 1 Middletofn04 rIlo:t 'Il

I 10tl11, 11111' vt'')' il$li I 1114-'1-1- I'$ lr :Ivi g o s s n h I eskill 1.11:11 whiu(1 ito' b 1 4'ftit'i (1:lll , N' WOS10 i to'iv

l':lJittmliI'. nis$ is ill iie iti' Wil tItl' st ildil's 1) 'vCoI(lonel Goden' :1141 his group :11 to' I loiith

As i1 rei'('1t of' Ithese lind( othler' siliihil.tl st 11(1ies",SIN it soolt 1)e('ul~le ob~viouts

t hat mlost cold( inji'V- calses ('0111( be retuir'ned to dIutY' withIini fr'ont 6 to 8 weeks

It' A.iiiiil Rvpi'llf . 7th Gvniril Il4llos iI:4i. W4itI.

(I) s.lilun:111Alo iviti.rr . 7111 I *UI-rd~ 1ll'",i':tj, I l m.n. :WI." 1 1111vu 191.1. (21 S5,', ftm~in'til H64, 1). 43"ý.
EUROPEAN THEATER OF OPERATIO4 NS 441

if proper physical training wits started early enough. Such treatment became.

routine. Thle. 188th General Hospital in Gloucestersh ire, Englandi, reported

that, after suich a period of observation and rehabilitation, 90 percent of thle

patients suffering from trenchifoot, frostbite, and exposure were retutrned1 to

either full or limited duty."' lIn summary, Colonel Kneeland wrote:

Material aid1 was given by Lt. Col. Theodore Golden of thle 110th Station Hospital,

Lt. Col. Laurence B. Ellis of the 7th General Hospital, and Lt. Col. Samutel M illinan of the

188th General Hospital. These three officers conducted active programs of jinvest igat ion

antd treatment inl connection wit~h trenchifoot and, ats a resuilt, of their exp)erienice, the ('oilsult ant. inl Medicinle was ab~le to say, with solute assurance, that the majorit V of t reiichfoot

cases could he returned to some formi of duty inl the theater, provided that active iniiusciilar

rehabilitation was started as early' as possible. This point of view wvas disseminated to the(

various hospitals through the hospital center consult ants in miedicinie and it. waus believed

worthwhile and1( untdoubtedly responsible for thle conservation of manpower. More, this

active programn resulted iii a (limint it ion iii the (disability of those who could not be retuirned

to duty. Trenchifoot. was far and away the most important medlical problem of the winter.

Wheni General 'Morgan visited the theater in February 1945, hie broutght

it Plan for tile study of hleparin ill Pitkin menstruuim in the treatmetnt of' t renchiloot. A tentative platn wats established to tt'elt 50 patients with thIirdI-degree

chaiinges. These pittietnts were to be select ed fr'oml three (differenlt airillies.

H~owe'ver, at sudden change inl the weather loweredI the incidence of (c01( intjury'

before that treatment plain could he effected.

Although thle load of' col(1 iinjul'v cases recedledl dramattically with the

adIvenit or' spring, ptoblemus concerning patients wvith ('01(1 injuryv (Iid iot stop

t here. Thetre wats the (lerniatologic problem of thle sublsequtent fate ofr ('01(1

hijitry patients Which Colonel Pillsbury, thle thleuter sentor consiultanit inl

(letmatologY, found reason to be concerned about. He felt that t hese soldiers

hlad alteredl skin, were sub~ject to macerated states, and were miore suscep~t ible

to ti'icltophytosis. Thlere were also those so1ldiers who continuedI to uise tile

sequelae of ('01(1 injury ats lil illegitimate baisis for release from forward (lilt 'v.

Finally, there wats the smaller numbler of cases resulting from some soldiers'

neglect of their (cold injury (luring thle past winter. TIhese were stout, soldliers

who had1 resistedl evacuiation dluring the strenuous fighting of the Bulge but

whose painful feet hadt( flinally ledl them to seek medlical attention. IlieY

shiowe(d extreme vascular (changes and, usually, had ('old, clammly, blute feet

with or. withlout, (denfla.122

Homologous Serum Jaundice

In late auitunin or 1944, Capt. (later Maj.) Hlarold S. Ginsberg, MIC, 7t h

Genetral H-ospital, called Colonel Kneeland's attention to 14 jaundic'e cases

oc'curring at that, hospital. Each patient htad re(ceivedl l)lasllal sonlic motit hs

prior to tile (Ievelopinent, of jaundice, iitid somle had r'ceived whole blood ats

well. Since tile incidece' of infectious hepatitis wats low litt thle tunle, Captain

121 Annual Riepnrt, 198th ( Penral I iosp~ital, I Jan. 194.5-31 MaY 1945.

E2sFsential Technical Medical Data, Ileadlquarters E'ro USA, for Apirl 1945.
442 ACTIVITIES OF MEI)ICAL CO( NSULTANTS

Ginsberg suggested that thle condhition under scrutinyv might. b~e homologous

serumi jautndice. Accordingly, Colonel Kneeland requestetd t hat thet hosiOit al

c-enter consultants collect (lilta concerning jaitndhice cases in the United King(,-

(10,11.121

At the :30 December 1944 meeting of the Chief Surgeon's Consultant Colnmiittee, ( 1ololiel Kneeland rep~ortedl there hiad been nine cases of severe hepatit is at the 3i16OthI Station Ho0spital- Four of tile patients lilt([ died. All tile

patients had received plasma, anid seven of them~i hiad rece~ived( blood

transfusions.

Lt. C ol. .John B. McKee, MIC, the Ninth UT.S. -rmy medical consultant.

at at meeting of the Medical Subcommiittee held onl 21 IFe1)ruiry 194.5, exp~ressedl

lie op~inion t hat transfusion react ions were imiore common I han wats suipp1osed.

He the olght that riot a1ll calses were being reported, particularly t hose occurring

in, fiehi iosjpit als. There wits growinig Suspicion that t iese t ransfusion rem.-

tiotis tendled to occur when thle blood used wats over 14 days old. Colonel

McKee said that invest igation wats cont inuing.

By~ I Nliirchi 1945, 49 hospitals had rep~ortedl to Colonel Kneeland. 'Ninle

liosfitlds reported no cases, the reliaining hospitals reported at totall of 281

cases of jaunldice. These cases were surgical patients in whoni tilie jaundiced

con11dit ion had developed from 45 to 100 days after t hey had received blood or

plasmia. Twenty-one of thlese p~at ients lii~l died. I'llfort rmnt elyl.tO there wereý

comp jlet e recordhs onl only 146 of t hese 281 cases. Ani analysis of thlese 146 revealed t hatt 14 had (lied, at Mortality of about 10 percent. Fatall calses invariab~ly had

at d urat ion of' only from 4 to 10 days alfter onset. The (hit a strongly uindicat ed

that plasmal wats the source of in fect ion. Accordhingly, C olonel Kneelandl (oiliferredi wit i, c olonel NIuckenfuss andl~ Doctor Bradley, Brit ishMi nIist ry of

H ealthI and at mieniber. of thle Jaun11dice (Commiit tee of thle Medicall Research

C ouncil.

D~octor Bradley 1)roughlt forthI stat istics onl thle occurrence of hiomtologouls

sern111 jiii audice inl British troops confhirming C olonel Kneelandl's finding's which

iplicat ed Jplasitia its tile( carrier of thle icteir()(-(lic aigent . Both Ci(olonel

NIuckenfuss and D)octor Bradley hbelieve(I that (let alile( studhy of tile p)robleml

requnired t racing tilie plasmia to its source. Adhmlit tedlv, thins wats an1 lmnpossibilityv in ETIO1 SA. The only recourse wats to contninue to gathe le' ore datia

so thiat. the facts, could niot be questionied.

When General N orgain visited the theater in February and Mtarch 194-5.

lie wits appjrisedh of thle sit uat ion. The (iiselise suggest e(l at serious pr-oblem for

the Zonle of I it erior hiospit als inl view of thle excessively long incuibation period.

Thie timedicah offic'ers who were conicernedI ill thle invest igaltion of hloiiologous1

serim jaituldice in tilie European theater t bought thaiit tile subseqluientI recoga itionl of the (his'eas-e in Zone of Inuterior hiospit als and thle studies ma11de there

%%(Ir due ill part to t heir early identit ficat ion of tilie widIespreadl inicidence of

It( li isellse.

O'M (I lii i'r. mlm~ of Iw 4 It# irgeon. n, t'lt,' Kingdomj ThLsC to Chief I5ur914n. FTO US A. I Apr. 1945, subject: St~udy

oIf II I.Kio(l4)gi((i Senityil Jun' ilee. (2; S fow5 1101w 119 (1 1). 440 mi, I II 16, p43s.
EUROPEAN THEATER OF OPERATIONS 443

At about this time, there was a precipitous rise in the incidence of infectious

hepatitis. Approximately 1,000 cases occurred in February. For tile weeks

ending on 23 and 30 March, there were 952 and 892 cases, respectively. In

the first two weeks of April, 965 cases occurred tile first week and 979 cases

occurred the secold. 124 Some medical officers thought there was a direct relationship between presumptive homologous serumn jaundice and naturally

occurring infectious hepatitis. These officers pointed to the closely corresponding curves of incidence. Colonel Kneeland found that not only the curve of

incidence hut the gravity of jaundice among wounded patients was much

greater than for any other group.' 25

Tuberculosis

Throughout most of the period of continuous heavy fighting, the incidence

of tuberculosis in the U.S. Army in Europe continued to remain low. Hospital

admission rates for tuberculosis for all troops were, in fact, at their lowest since

the activation of tile theater, although the incidence of tuberculosis among

nurses showed a persistent increase. In the last months of the war, however,

this picture was to change dramatically.

Colonel Badger had an opportunity to confer with Col. Esmond R. Long

at the Office of the Surgeon General in October 1944 on policies of the European

theater as expressed in Administrative Memorandum No. 22 and Circular

Letter No. 100, pertaining to the evacuation of tuberculosis patients from tile

European theater to the Zone of Interior (pp. 412 and 431). Colonel Long considered these directives well adapted to the needs of the European theater and

thought that, through them, diagnosis, treatment, disposition, and evacuation

were both siniplified and expeditedh.' 6

In addition, Colonel Badger looked into the possibility of obtaining mobile

miniature X-ray units for use in the theater. After conferences with X-ray

and sulpply personnel in the Office of the Surgeon General, it was apparent that

these units were iml)ractical for use in tile United Kingdom or on tile Continent

for a variet v of reasons. The British 35-mam. mobile unit was, by comparison,

a more workable outfit with value in si)ot-survey work as contemplated for

the European theater. 127

Just previous to Colonel Badger's departure for temporary duty in the

Zone of I nterior, there came to light eight cases of active pulmonary tuberculosis

in the 56th Fighter Group, Eighth Air Force, between August 1943 and Septenmber 1944. There was also one acute case in the 78th Fighter Group,

Eighth Air Force. This brought the suggestion from Colonel Badger that all

per-sonnel of these and associated units be examined by X-ray. This suggestion

wis executed by ('olonel Kneeland in Colonel Badger's absence by auithority

of ('ol. Joseph 11. McNinch, MC, Deputy Surgeon, United Kingdom Base.

124 S.,e footnote lt. p. 441.

l12 E.ss4entlal Technical Medical Data, Headquarters, ETOUSA, for March 1945.

126 Annual Report, Senior Consultant in TuberculosLs, ETOI'SA, 1944.

127 Ibid.

I., Letter, Office of the Surgeon, Hleadquarters. Unitled Kingdom iRaie, toComnmandingOIflcer, 163d General Hospital,

6 Oct. 1944, subject: Survey of Tuberculosi:s In the Eighth Air Force.
444 ACTIVITIES OF MEI)ICAL ('ONSULTANTS

The chest X-ray surveys of the 78th and 56th Fighter Groups were carried

out at the 163d General Hospital near Cambridge, England. 121 In the survey

of the 78th Fighter Group conducted by Capt. (later Lt. Col.) James S.

Mansfield, MC, with Capt. (later Maj.) James P. Palmer, MC, seven cases of

active tuberculosis were discovered and boarded for return to the Zone of

Interior. Captain Mansfield and Capt. (later Lt. Col.) Peter Zanca, MC,

carried out the survey of the 56th Fighter Group, and found one case of active

tuberculosis with positive sputum. Over 3,600 chest films were taken and read

at the 163d General Hospital during October and November 1944.

It was concluded from these two surveys by Captain Mansfield and his

associates, that no common source of infection could be found for the total of

17 cases of pulmonary tuberculosis discovered in these two fighter groups,

9 cases prior to the surveys and 8 cases as a result of the surveys. All of the

cases were regarded as reactivation of previously existing pulmonary

tuberculosis. 130

Shortly after his return to the theater, Colonel Badger was assigned as

Consultant in Medicine, Normandy Base Section, while still retaining his

position as theater senior consultant in tuberculosis. In February 1945, he

submitted, for study by the Chief Surgeon's staff, recommendations for a

tuberculosis survey at the end of hostilities of all personnel who had been in the

theater for longer than 8 months. Next, he prepared a circular letter to

formalize procedures for the followup of contacts with active cases of

tuberculosis.

This circular letter was published on 8 April 1945 by the Office of the Chief

Surgeon, Headquarters, ETOUSA, as Circular Letter No. 38. It required the

first hospital in the chain of evacuation making the diagnosis of tuberculosis

to notify both the patient's unit and the Chief Surgeon, ETOUSA, of the fact.

The European theater Follow-up Card (medical) (p. 251) was to be used for this

purpose. The tactical situation permitting, the circular letter required examinations of all contacts, that is, persons who had been in frequent close association

with the afflicted individual. This circular letter assured proper followup

examination and provided a simple and efficient method of noting cases and

trends of active pulmonary tuberculosis as they occurred.

Recovered Soviet prisoners of war.-Meanwhile, the Third U.S. Army had

recovered a group of Soviet prisoners of war at Sarreguemines in December

1944 (fig. 149). These Soviet soldiers had been captured by the Germans

between May 1941 and May 1943 in the Black Sea area and in the Ukraine.

After being shifted around from camp to camp in Germany as labor battalions,

they had finally been sent to the mines in the Metz, Bitche, and Sarreguemines

areas. Here, they had worked 12 or more hours daily with 1 day off a month

when the coal-mining quota was filled. The men had been worked to the point

12 (I) Report, I63d Generai IIospital, 22 Oct. 1944, subject: Trutmrculosbs Survey of 78th Fighter (roup. 8th Air Force,

and Attached Units. (2) Re1port, 1t01l General Ilospitlal, 16 Nov. 1944, subject: Tuberculosis Survey of the 56th Fighter

Group, 8th Air Force, and Attached U'nlts.

13 Letter, T. L. Badger, to Col. J. D. Coates, Jr., 8July 1956, subject: Corrections and Additions to Manuscript.
lt I 'l 1I4.:\N 'lll:414 \T-Il.14I 1 111l." G I'I. I .\T l II : I•. 114 • |14;":+.I'4:lu 

(Ii 44I1lj-4 I14. i I~ '(1111)-'4 II I :1.\ 4 I I ii -T I4'1 4 I- AIII\ 14441 Il I i

•~ fe

\,() 11 : I- 4:I I I:4 k'I f ;41 I 14 *11 

41441~ 4I 4-hjli ro'114I 411 1 41 :11 1I 1I 1': W l'l I II I' I 11'

"I I' +. 14 tl I ,,X I\ 11.141 i, " 111 ',' 11 . r i,, 11 ,I 1 " \Il -- \ 11 4; I I' lI I*Ti 114'I II I I., '1 14 4)1 1 'h:1 , l I I \ r. r- : ,

A'T . ++ I"' ';lti~ +' II'+_ ll lll •l+ ll I• h , ll l~ r 1 l 1',l,, t'Jl r• .• l' Jll' '-. "':ir ,.,r ,.r l~ i1._Itl r1 
446 ACTIVITIES OF MEI)ICAL CONSULTANTS

was generalized edema, and, in many, starvation bellies. Of the total 325,

there were 136 who were diagnosed as having terminal pulmonary tuberculosis

with severe malnutrition and marked avitaminosis; 78 had far-advanced

pulmonary tuberculosis with severe malnutrition; 40 had minimal, moderately

advanced and extrapulmonary tuberculosis, malnutrition, and avitami nosis;

and 71 had injuries and diseases other than tuberculosis with malnutrition and

avit amninosis.132

[he hospital initiated immediate measures to save life. Copious amounts

of blood, plasma, glucose, and saline solutions were given. There were 170

pneumothorax treatments in 25 cases with hemoptysis, and there were 34

thoracenteces with aspiration in 15 cases with empyema or effusion. In

spite of these measures, 28 patients died within a week after arrival, and 4

had expired en route to the hospital.

Most of these patients remained at the 50th General Hospital throughout

the first half of 1945. This was an isolated incident which was not to be

repeated for another 3 months but which remained a local problem until

Mfarch 1945. These Soviet prisoners had been recovered in a precariously

held bridgehead across the Saar at. the very apex of the Third U.S. Army's

advance. While they were being evacuated to the 50th General Hospital,

the main effort of the German winter offensive had struck some 100 miles to

the northwest, stopping further advance by the Allies in this area during most

of the approaching winter. Had the German counteroffensive struck a few

days earlier, these prisoners might not have been recoveredt at this time. This

unique problem which presented itself at the 50th General Hospital was greatly

overshadowed by the more pressing medical problems of the winter.

In i\Iarch, however, when the Allies were once again sending the reeling

German Army behind the protective banks of the Rhine, there was a sudden

influx of recovered Allied military personnel and displaced persons (fig. 150).

The brunt of the evacuation fell on the 28th and 57th Field Hospitals and the

1S0th and 35th Station Hospitals, mostly in the Continental Advance Section

and Oise Base Section of the Communications Zone. Col. Richard M. McKean, MC, medical consultant for Oise Base Section, reported that the 35th

Station Hospital had found 123 cases of active tuberculosis and 80 suspects in

373 (dislocated nationals.'" The immediate concern was for the protection of

American personnel in the receiving hospitals. Colonel Badger thought that

the European theater Medical Bulletin. would be the most appropriate medium

to warn the greatest number of medical personnel of the existing dangers.

His article, published in the April 1945 edition, read in part, as follows:

German prisoners of war, allied nationals, especially the Russians subjected to years of

forced labor, are coming to us as patients with advanced tuberculosis presenting very

strongly positive sputa. These individuals are significant sources of contagion and all

hospital personnel having responsibility for their care need adequate protection from these

virilent forms of tuberculosis.

"I" Sev fool notv 131, p. 445.

13 Minutes, Chief Surgeon's Consultant Comninittee Meting, 22 Mar. 1945.
117

7

f

7

Fi(o fit: pvrýomicl 11 \ill,-, Ow Trivolm. :1ý (1i'llwills of U.S.

ArIllY pn-pnn- 1114,111 fill. 1.4,1111,11 lo Fr;lllve.

It is fill- t:iýk of v\ ,I-%- mcdiv:il 40fic"I. :ill([ 11111-4. 1,) 11-:I\ I. Ili) ýlmle 11111 Ill-11i'd ill 4,fl*,)I.I- I's

control I Ilk-l-vuhl-i.S. Spr,-:ld if I lit- diýcnýc 1) v :lit-howilf. rolill.- ns %No-11 ;1ý h v collt:11*1 -I -

the pal 1,1-11 of cmll rol. Sin-1.1 ' v If() ofil, \\ wild dr ' v-s\%c,.p ill' 111i'l :1 floor \\ Ili -n . I

b:Icilli \\.tit illip:11 it-Ill IY 141 1w ýprl.aif :11-ollild. N o oflP \iollld ý1ý-oci:tlv it. it if I Iw I 11114-f-culo-ip;il if-iit wit hout cloýin!ý, off 1 Iw \vrY som-ci, it( infoct im, itý,-lf hY n iwisk it) linflit. t ho linuillijNo one would Ili, -;4f, C:Iýwd ns tit itifevi arcaý of a ward wit 11 ohjocl, collInfililml, , I

fl-mll contact \\-it If 1114-4, No 1111it Illellic:11 (Olicl-r wolild \\ i-II I -o

1-f-III:iiII ill i'-m orniler (if I tilw rcul o-i, I he lifiv of ex :1(.Il:ll ioll ill ont. of lliý Illf-:1 :

fill. w il v 1) v lJolifiv.11jol) of sill-h is Ili- :114,11 1,411 11) 1111, ýJw cini fill- 1114, pI-f)ltcli.)Il

i if i I I it Irs. lint icio ý not I m ine(I ill i liv :ort of ol Ill.(.d illilm -1 rilm l iw l ill

till. I vvIlflif 1111'. 'I'lle 1,1111cm im i of tit(, m ho-rculosis ifi(IM 1111:111 collcol-Ilill-'. Ill.- fintlirc (it' Ili11:111Y. The I(-(, of tll(ý I I I(qjiva I of licer ill it -ývnrl.v d in,_,tio-is :fill I pre\cii I iwi

)It I N la rch 1945, ordens were reveived it the 461h Gielivrol Hospilol,

Besancon, France, ft) 1() admit 1,200 newl , X. fiberalvil Sovivt Imlicids.

w1m wvn. If) arrive at Ille raiv of mw Inlin load pel. da v I'm- 4 da vs. No Wher

infol-111.111011 W.IS ;lVollable cxcvpI that Ihe ' v wen. to bv prvdollmm ill IY Inedic,11

Thv 461h Gvnend 1h)splial (fig. 151) s1111111mrizvd It., vXpvr'vflc(- With

p'l(itints ill its 11111(fal report for I Januarv 1hrough 30 June 1945, as,

Tllv Imlivill's arrived bv 11-:6111wids, nlid it wn- di-cox-f-red 01:11 Own. wclv llot onk

-111dif-I.- .1lid ckili:111- bill per-1111111.1 froill 111f)-l lit' Ow ei'llfill-if.- tit' Fur''pl.

Akio, Ow v:ifIl,.frlIIl :111 pýlrtýldltml coulli I.Y.. Al"'cim,
J |,•,~~~A .\ -I'lIV .. •I"E 41 . l E .M lM .\. AL 44'1J\. I.T' kI'.\ 's.

I.N

. . .. .
4,1 LA
450 ACTIVITIES OF MEI)I('AL CONSULTANTS

and Stalingrad: the Ural Mountains, Turkestan: Siber;a: and even Mongolia * * *. All

these had to be helped and treated without the medium of language. Signs were the only

help, and in many instances these were misunderstood.

During the months of March and April, 2,472 Russians, 41 Poles, and 128 Yugoslavs were

admitted * * * Of ) the civilians, som(e were boys of 15 and ol hers were old men of 65 * *

The H ospital Staff was aghast at the terrible physical condition of these people.

Because a great number of these patients had infectious diseases, it was necessary to

practice isolalion t echniques and maintain proper sanitary conditions in the area. This was

a problem equalling or surpassing that of language. ()ur conceptions of modern sanitation

were unknown to them * * *. Then, because of their starvation experiences, the patients

would hoard any food they could lay hands on * * *

The majority of these patients arrived with either no medical records or with records so

incomplete as to be practically valueless. (One complete train arrived with E.M.T.'s marked

F.17.0. in all cases.) Names had to be spelled phonetically, and on 16 March, with the

last trainload, rosters of patients who had been sent to this unit before arrived. Since the

patients had been previously reported under the name listed on the roster, it was felt that our

records should be brought into agreement. This required hours of careful checking and

correcting of records.

With the arrival of the 78th Russian Citizen Regroupment Center (18 officers and 43

enlisted men) every effort was made to work through them * * *. Patients ready for duty

were evacuated weekly through the Provost Marshal or G-5 channels. On 5 June, two U.S.

Hospital Trains evacuated over 500 long-term hospitalization cases.

Hundreds of lives have been saved by the care given them: many have doubled their

weight, and have changed from listless hungry animals to almost child-like, playful human

beings. Discipline, which was such a great problem at first because of the restrictions necessary for their proper care, is greatly improved because of understanding through constant

education. It is felt that as these patients leave the 46th General Hospital and return to

their native land, there will go with them a spirit of thankfulness and appreciation for the

work done for them.

By the end of March 1945, Colonel Badger had inspected the 57th Field

Hospital and the 46t h and 50th General Hospitals, and had made reconunendations concerning changes in treatment and tightening up of general control

measures. He conmmended the 50th General Hospital for its excellent handling

of a very difficult and dangerous situation and noted particularly the good progress which had been made at this hospital in the treatment of recovered Soviet

prisoners of war.'3 4

The patients at the 46th General Hospital had only recently arrived an(d

that hospital was still in the throes of establishing routine measures for handling

the problem (fig. 152) when, in addition to the treatment and control measures

described elsewhere, Colonel Badger also made the following specific recoinniendlations for contacts:

1. It is felt that the seriousness of contact with this group of cases of far advanced

tuberculosis is such that personnel of the hospitals who have been associated with their

evacuation to the 46th General Hospital should be X-rayed at the present time and reX-rayed every three months a year.

2. Personnel of the 46th General Hospital have all been X-rayed and it is recommended

that they should be re-X-rayed on a three-monthly basis as a routine or more often if they

present signs or symptoms suggestive of underlying tuberculous pathology.

114 Letter, Senior Consultant in Tuberculoss, ETOUSA, to Office of the Chief Surgeon, Headquarters, ETOUSA,

attention: Chief Medical Consultant, 3 Apr. 1945, subject: Tuberculosis Among Russian RAMP's at 50th General

II nsrItn i.
1-:11"H II:.\N '1 FV1:Z I F I 1PII 'I*~~\'IIIlli

)-i; u-152 Apr I ti ¶145. e Ith ctte l reI4 att Wtiit I;t-fliea l~ttlo t'ita t thepter. ývl t Iil

It 3.ii ( - nette it lospittl ot 1 eve 1 (: v illl11. l95. 11l--:knw t tee to ihN lOjit- di il 5. Wini e the-po

,If fit' f)c;,it Itits 111-c Itli ~ll ' vI'Ittmtlau-iIloI pati~ent s. ttti ('Neefti lot- tll hos f %%'ill Ill)-

t(C tttitO'tIOl \11 lit, itte sie 1'iitg i- et Inded111 v iooth hte' tt lho~trl~isl. :tltltoltlet

diIjtl\i0te hlrtil pi'el'tIv e pr 111 ldeiat I lie 4it Itof ietterlol It lopthir ia 1ip~/ill 3

lti tter ( :1.x Seior ('illllitlotl Nintuwit 1,irotiios.IleA wlrt Iilfllc Af tllit. ('ilkIf til itt.e thaatiirl. n-li iTO

1111tvhei t -ell: i ble\t dti fill. 1 tatitt 1c 'iu011iol 4#S pIlijil R1(1iltoort 4t reity pl it itr l autu ttoo a ctilit *.ilucrti ittt 1

itia nis Fit A prtl 1945,t ( 'tijet n eqtii Longiitatt in M- ay ittiS I ll Iiihel E Sliriy it Hll(i.t I A NVi III
452 ACTI V ITI ES OF MEI)ICAL CON SULTANTS

Soon, a similar problem of equal proportions canie to light. In early

April, the Third U.S. Arnty uncovered a inotorious concentration camp, Buchenwal(I. This was only the first of such camps the Third U.S. Army was to uncover

in rapid succession during its dash across central Germany into Austria and

Czechoslovakia. Approximately 21,000 persons were in the camp when it

was overrun. They were living under most horril)le conditions, and it was

estimated that the ill numbered 5,000. The 120th Evacuation Hospital,

newly arrived in the army area, was dispatched on 15 April to provide medical

service for them. This unit, plus a clearing platoon, operated for about 10

days until relieved by units of the First U.S. AriyN.a 3T7

Tile 45th Evacuation Hospital, under command of Col. Abner Zelim,

MC, took over where the 628th Clearing Company and the 120th Evacuation

Hospital were forced to leave off. Under tihe able direction of its commanding

officer, this hospital rapidly estaablished aseptic techniques for processing

large numbers of tuberculous patients that would have been a credit to any

sanatorium in the United States. 3

" Neither the limitations of space nor

the scope of this chapter permit, a discussion of the appalling conditions that

were found at this and other concentration camps, nor would a few words

do justice to the exemplary manner in which the problem was managed (fig.

153). Suffice it to say that, from the administrative point of view, it was

initially a job for the armies, then a charge to the forward echelons of the

Communications Zone, and later a longer term responsibility of military

government. In tile final analysis, it was a problem for the German people

themselves who had permitted the situation to exist and to whom rightfully

belonged the obligation to rectify this affront to civilization and humanity.

Although it was a great problem in its early stages to the medical service of

tie U.S. Army, every effort was made to have German facilities accept this

obligation alt the earliest opportunity.

Recovered United States prisoners of war.-To complicate further the

patient-load problems that beset each army on the front as a result of great

numbers of prisoners of war, recovere(d Allied personnel, displaced persons,

and refugees suddenly beconming their wards, there was also the happy reunion

of advalncinig U.S. forces with their fellow soldiers who had been held captive by

the Germans (fig. 154). As the Allies struck deeper into Germany, U.S. prisoners of war were recovered, sometimes by the thousands. Most of them were

eventually evacuated through the Normandy Base Section. This base section

hiad (esignated Camp Lucky Strike as the reception center for these returned

prisoners. Here, the 77th Field Hospital was opened on 8 April 1945 with an

initial 350-bed capacity. Patients camie in such great numbers, however,

that its capacity had to be enlarged to 1,000 beds by augmenting the 77th

Field lHospital with tihe :30thi General Hospital (operating during this period

V' Annual Report, Third U.S. Army, I .lrm. 1945.30.1).it' 11145.

13' (1) See f(oonott 1t 6, 1).451. (2) Thile Animal Report. 45thi Evacuation IHosp~itall, I Jan. 1945-301June 1945. containls ;a

fuill tttli dltailed description of the unit's activities at 1ltrchenwi ad calnh).
liI)ernltim1r forces. BI. ( )n of the pu of dead watjgcrvilinttiont fouind tipos si ibst.taim (isif

Blicltsiewaid.
ACT I VITI V" V Al I: I I -A I.

fk

Ailloric:111 :111d Brili-11 pris"11cf-S brick faclor.\.

A. FAWHIW (d B. IJ\ ifl-" c0fldiliollý-.
:Is : c ix:ilIv'..Iti nI1ile). App)rIfxtini;IIlY IS p)Cvow itof' thle Nirst 12.000~t vcI I 1 'l p r miii II l t ((alr iv ei a I lii I o ui v t pi i' (1,11 W ll ) I It t~II IN i eles11s. I lie hlo p p ed;

h(lol.Il~i Ile v.II-iit -'iojlps of x re I I I'ill il', wa 11 1)ii 111e Iit loll, ii0L, Ci~s~ lah .-

Rot li~.liiiliea ri'il I frI o r Ill i1(1 wert iie Illmi t (h)Ill\-I llh C:Is W s ii; rx S tI ie iaI

>111 ii I ea ldIe~Id 1111,11all ('i Iion idenc uiiu of l boilu I xloix \\.Is ne ol Stlil m 1a,1 f oi i

1*i.'.. Ii,. II'iI I iel'( iA t lore 1 loiltd i di il1--ols of~ II Ilblh;I fSii iii hliI ihui-i,.

ill hccma rol ( 'il .S. (ml-isox] 44111 \\:I.eC~~I I be ii I'm(ild iIi~ li l~t u 'xa

Boduvr.II 72 .t:Ill f . It. ll. wi Ij0(i.n \l Xlt iidii. II\-tm-jf d~ imindl it
Ii~iii I~)d--MAliiiitiit int ai 3 rec(1verted Allivd 3sohlicr.

commiioni tvdelle*cv to luse iuiiildequaite s~lipplivs of pliismiii. Hie ailso no~ted tihe

C51()itl , v of jutVavt'iiolis jproticm sol utionis. Ini fact, C oloniel Baidger. Stat ed, lit

the \ 1wi uiet ing of thle Chlief Siurgeon's C onisul~tanit C ommniitteec, t hut thle 60

bot tle oC f it) t I'll veflOUs proteini ill his possession repriesenite 11 tl Ihere wals ill thle

fliu t er. Circular L et ter No. :36, dhated 19 April 1945, Offlice of Ow li h(Iiif

Suin-v~on, "levid(juiurter's, FYI(U SA, outlined thle pr*ogi-11m for thle nutrit ionazl

1na1nM ;i geim ci of ii lii11liouiislied recovered Allied mii iit a r per'soinnel andl provid(edl

for t lie nilt raveiiouis a~ldiniist rutionl of 4 units of plasma and -500 ce. of whole

biloodi ill 24 houirs to patients withI edeuiii who couldl not tolerate food 1) *v Imiotit hi.

W~heii tw lifirst g'roulps of recoveredl U.S. prisoners of war caline iiito 0 (13111

L u cky St nike, t heir tiill t I-it ionall iii an -ilgeuen t was alreadyN wevllplainned. The ragMA, d.~ishievelled , an:d niii ca tv Ilel me resp~ond~ed wvell to t ca tin en t. SeverelyV ill

patI'iet s uaii iiv( to take iioulishmeiii t 1)' uiouithI showed renilarkable response to

slowly i iicreasi n qu (111iilit 's of plasmna m(imiiiist r('re in traivenously. Ihie very

slow adiiniiist rat ion 1y te li cotist 3ilit dr~ip techlinuiui of ak high-pr-otein (diet inl

liqulid foruil by nasall cathieter t hirou&ll huIle ;Iolll~lcl.i also gave excellent results.
EURI )PEAN TIIHEATEI.R O F OIER MTO NS 4577

The proportion of primary nutritional deficiencies was greatly diminished in

those arriving during May 1945, and respiratory infections and minor injuries

predomninated as causes for admission.'42

FROM V-E DAY TO V-J DAY

The war in Europe ended when etitissaries of the German High Command

signed a document of unconditional surrender in the early morning hours of 8 Mlay 1945. in anticipation of this |enorable event, a number of changes had

taken place as regards inedicine. General Hawley's office announced, in late

April, that, effective 1 May 1945, the evacuation policy for the European

theater would be 60 days. Imniediately after V-E Day, evacuation from the

Continent to the United Kingdom was curtailed. The plan called for the evacuation out. of Europe of all patients requiring over 60 days of hospitalization

by the end of July 1945.143 Staging of units for conibat liad halted, and

planning and organizing units for redeployment to other active theaters

had begun. So rapid was the closing out of activities in the United Kingdom

that the occupied beds in hospitals fell from 129,289 on 90 days before V-E

Day to 28,153 by the end of May and to a mere 8,664 on 30 June 1945.1'

The activity that now dentanded by far the greatest attention from tie

theater chief consultant in medicine down to regional consultants in hospital

centers was the formation of units for direct redeployment to other still active

theaters. At least the following variables had to be considered for each individual before he could be assigned to a unit scheduled for redeployment:

His adjusted service rating;145 physical profile; specialty, if any; professional

competence; age; and grade. These factors then had to be considered in

relation to requirements of the table-of-organization position to which tile individual was being assigned; that is, grade, military occupational specialty

numnber, and index of professional competence. Above and beyond the need

to weigh these specific items, there was always the desire to form compatible

groups of medical officers who could work together and who, collectively,

could supplement each other to provide the wide range of skills called for by

the table of organization. The magnitude and complexity of the problem

caused considerable confusion and many a headache. As stated earlier, many

questions resolved themnselves into a matter of supply and demand (p. 278).

The medical problem still outstanding at this time was the question of a

mass radiographic survey for tuberculosis proposed in the earliest (lays of the

theater. It had been deferred on numerous occasions as a result of Colonel

Badger's spot surveys which indicated that there was no dangerous increase

in tile incidence of tuberculosis. The X-ray examination of all inductees commencimig in early 194:3 further mitigated the need for a mass survey. On the

142 See footnhole 139, p.455

'is Essential Technical Medical Data. Ileadquarters, ETOU'SA, for May 1945.

144 See footnote 116, p.43S.

143 The adjusted service rat ing was an arbitrary criterion for retention in service edculated on the basis of number

of dependeunts and service In the Zone' of Interior, overseas. and In combat.
458 ACTI'iVITIES OF MlIC! OSLAT

othler' hand1(, certain dlesiredl riadiograiphlic survey' s, -ouldl not be en irried out dlurnig

the p~eak of hostilities. Nowv there wvere moe i0 1*1* livillale ts Ut r'esult. of thle

Air Force survey* sand o1ther limited survey* scarriedl out. inl processing officer

cU nlidaidies Uaid recovered1 prisoners of wvar. 'Mlore recent lY, there was thie

1111portilant fact or of greatl ly inicreased opplort unities for contaUct with t uberculosis

lby vli~tiliy plt'rsoliliel ill tilie inannge1(riliett of lirge numbiilers of prisoners of wvar,

(Iisfplicedl personis, and~ refugees. Althlouglh p siciYdC~ examinalit ions were' Ieiig.

coii1duct ed Uit. nssenibly Uireas ili conijuncetioni withI thle physical profiling of troops

to be redele)o ' vl , t lie p)ossib~ilityV was remote thatt tilly signifihcant niumbers of

tublercuilosis ('Use(s NVOiild he uticloveredl bv this Imethlod.

All these factors, talkeit collect ivelv,' iiidicaltedl t hal iU reevaluaft-ionl of the

problem NvUs iecevssar *v. I'ort~uniitelY, Coloniel LonIg -%%its iii thec Europetin

then t er Uit this I inie. I us counlsel ai ~vice nd1 wvere miost welcome. The prob~leml

iiar1rowedl down to one sallient fact(- The ilmuiedlintIe needh wvas to (let ect and screen

out1. cases of t uberculosis from tinnits being rvephj~oYevl to 01ther thlen ters. Eiicl

such case Ira nisferred to anmot her theater present ed it serious la lhilit y involving~

fu turie hiospitilliza 1 ion a 11(1t rainsportat ion inl adldit ion to jeopairdizing thle inldividuail's life. If 110 screening by X-ray wvas conducted, it, was esti imat~e(1

that, some 20(0 cises of pot1ential or aictive t~uberculosis wouldl be re(1ellovedl.141

Ill couistiltaltio0H With Ci(oloniel Long *111( in) coordhiintition withI Colonel Allen,

tile t heater seti ior couisuilt uuuit. iii radliologýv, Colonel Badlger formulated a plan11

t~o effrect this screenling with die equiipmuent. available mid( Iund~er exp~ectedI as,-

seiiblv airea conditions. Furthermore, ill order to save time and X-ray filmn,

it. was t hought (lesiralble to limlit tilie screening to those amnong w-hom thle probab~ility of t uberculosis wa*is the greatest. AccordiuiglY, thle consuiltanits dlecided

uiponl screeniing aill personnel who hand beenl ill thle theater Over 1IS llouit lis and1

all mediivil Department, personinel regardlless of length of service inl thle Europeaui tIvhater. X-ray' examitiatioii was to be carriedl out, 1)y field units of hlospitalls locilted lit tit lie ssemlbly a 1rea s. The( plan was simple and~ yet, (leemed

aihequa te to mieet tilie ctiuieuit. neiees. Moreover, t here was a surplus of some

1 ,700,000) sheets of X-raY filmn, 14 x 17 inches, inl depot stocks, ailt bough it. wass

reillizedl thalt there wats anl overall shortage of X-ray filnm worldwide. This

inventi 01 ' of lia iilae X-ray1N film excluded those liti hospitat i st ocks. The

number oif personnel tilld the criteria for redeployment, indicated thitt there

would be 1no mlore thanl 50,000) personls to be thus examined (fig. 1,56).",~

The plan wats (juicklY approved withinu the( theater headquarters, i1. radhio

linesstige was (hisj)Utchied fronm E'lOUSA onl 29 May 1945 to the War D~epartiiieit , and( it re)i 'v was received oii : 1 M ay 1945. The plan was not favorably

conisidheredl beca use of the( worldwide short age of X-ray filni.

Genleral I la"vwle' , however, hleeded thle oft-repeatedl remonstriinces of Colonel Badger lind( lipproved the X-raY exitmina t ion of aill nurs-es to be dhirectly

-M (1) Let i'r, C'ol. F. it. L~ong. to P 1w Srgi'or I Iewnerl 'I. NI May 1945. sazhject: VtsIl of Tuhercuilo~s Consuhltant In

ti'tri,;wmi Tliemv itw f 01wprathmos. U'n ited, StAt e Army . 21Sev foot note 144), 1)455. (3) EA~wtsei l T'chbnical Aledical

D~ata,. I Ivai'Itimirters. FTI tISA. for htim- 1915'. datedI Atittw t 1945.

14 IIbI].
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(Circilar Lettecr No. GOt, ()fhice of thle (Chief Siir-zeoiU.. Forces, Fitlopeali Thfeater, 2 Auguist I1945, sectioli III, stibJect :( liest SuIVey- o)f lDirectlv

RedleJplo iii Pl-cisoiiel, was~ p)Ioiiiiilga'ted aflter ( 'olotiel BahliIel'5 dI'l)Uituli'

f-i'iii thei I fii';t(r. It re(IIIrIlle .11i X-ray o' ()I* t the ciesI for all meicai'lI offlicvrTN

liiii'5(C'. O1(1 liO)Sf)it dl aid~iilei ;issi~u:iiedl to warlid (ift v who) wVere schledulled for

iIilIi'ct r-edelh)l*ovIl(Iict to ;iuiot her I heateci of 0lperatit 101 A Sju11jhi1r reqpliireelit

plm i54'i~-lii iji thiau ol 111la ls ~iih to be;i' lilte) Vci pe by t(lc~ihe' hr (iltlt relic-ms

(fl, Ilie re'ml'5oibilv hiospjital w~ithI pli aper li1101mail of Owli result., oi t1lie persouzilel

141011l. o)f thle indi -(lilis ('olvilellel. Im iiielliieitatMili of thle pI.i1i at thle

hw(;iIl level was iiiade a1 responisib~ilityv of the base sect iOu siir"Zcoui ill the areas-

-Ifeci edf

oimil alfter tw ple l w)asi~V placed Inito lill effec't, the \s5elibii'lv Area ( olililiiiild(

jpl'lt e~stci that thle 10111 I(lpmiornipli of dlireclyt I V pi'cil e p~O rl l~i'i'()I i was

(liila ~Iri " h le iil-iveiiii (f Some iulit. Al'cordiuighV, Ow';llro)'~t secti lo

of ( ii'euilr Letter No. 61) was rescinided b) v Circuilair Let ter' No. W1, Office of

lhe ( hijef ur, ii U'ý.SFocs Euiiopaui 'I'liater, s Awui.st 1945. section I,
EUROPErfAN THEIIATIER OIF OI'EHATI( NS 461

sub1ject: Chest, Survey of Directly Redeployed Personnel; section 1I, sublject:

( 'iest survey of Redeployedt Nurses. Only the requirement t hat a1 (lest

surlvey b e compl)etedl onl all dlirectly redleplo~yed nurses wits conitinuedl. Thme

'Ta pUhi0Se capit11ulat ion followed soonl t hereaftIer with titlie resultant curalamimnet.

of (direct redeplo ' yment. This automatically endled thle last of Colonel Badger's

wartimle tulberculosis p)rojects ili tilie European theatter.

As C ol. O)sceola C. Mckwen, MC , assumied the position of theater chief

conisultant ill mie(Iicimie, to help guide thle transit ion of t he U.S. Arm 'y inl Europe' fromi at wartinme to occupation stat us, tilie incidence of respira tory and1(

in fect ious diseases was- V'ery low. The hepatitis epidemic had well pas-sed

its peak. There wats only one significant, prob~lemu, (liplithleria. To ( olonel

M\ rFweni it. appearedI inevitable t hat withl tilie high incidlence of lipl)ithIeria

among11 Germian civilianls and tilie iticreasilig fraternization bletween Amiericanis

and thle Germian populationi, there would he a (list inct increase inl tilie disease

amiong Amierican troops (luring thle coming wimhit er. F'urt hermnore, (lealthls fromi

liplhithIeria conit inuedl to occur, an1d patients appeared inl hospit als withI obvious

coinpllicat ions of diplit heria inl whoml thle diagniosis hald not p~reviously beeii

niade. Colonel M\cEwen enlisted the help of the War Departmient investigaltors

of thle dlisease, Lt. Col. Aimis C. M\cGuinness, 'MC, and~ Dr. H~owardl J. MuI eller,

ili tilie preparat ion of at (direct ive. The directive wits pub~lishedl onl 28 Septemiiher 1945 ats section 1, Circular Letter No. 69, Office of the ChIief Surgeon,

U. S. Forces, European Theater. It wats at comiprehensive sumuniary11- of g-enerall

principles to be followed inl the (diagnosis, treatment, and conitrol of di pithteVitt,

wit h parlticular refereiice to condlitions p)revailing, inl thle t heauter.

By the t imne V-J D~ay wats celebrated, tilie wvartinme t heat er chief consult -

anit inl m~edicinle, ( olonlel M Iiddleton, an1d his coimplete staff of senlior. constilt ants had returnedh to the U nited Sitaites, their talsk comiipleted.

SUMMARY IN RETROSPECT

Yale Kneeland, Jr., MV.D.

Thle wvriter wats consultant inl medicine for 6 monthis inl at base sect ion

inl the European theater from wvhich at very lar]IIge am 1piliibiols operatlion was

launched. Following t his, his sphere of activities wats elialargedl to include

waN11t had1( originauly ' V een two add~it ional blase sections, 11i1d, at, onle tunle, tlie(

hospital bed occupancy of the areai wats over 129,000. Ile served in this,

cap~acity for 10 monthis.

D~uring each periodI, the office of professional services consistedl of two

inmlividluils - thle wvriter and1( his colleague ili surgery. They were uii(ler tilie

(comm nand of, and1( resp~onsib~le to, thle base sur'geon ; but there wats an add~it ional

resjpotisihbilitv, of at professional chiaract er, to tilie Ch'lief C onsultanits inl M edwinhe iaid Surgery* , Office of thle C hiief Surgeon, Hlead~quarters,, ETOUSA.

This idea of it (11111 allegiance is contrar *y to the traditional Armiy hieor~y of

coilinlan11ll. Thius, their relationship to the theater chief consult ants, although

initimtat e, wats illiia senise un mofficial. Thle batse suirgeonis, to their great credit,
462 m-iv'1'i''Is OF' MEDICI(AL CONSULTANTS

(lid not aippear' to ob)ject to this type or short circuit iii sp~ite of' its untconvenitional cin ract ci'.

lit anyv compillex sit natio, the mnit at the top) pitches tilie key, so to speak;

his myr i~ad Sublordiniates t rv (withI varying su ccess) to sin itune.Bei-ai

lialt General Hawley, Ch'ijef Surgeon, ETOUSA, was oni thle side oA the angels.

Ilie wanltedl the Amnericani soldiers to have the lbest p)ossible niedical c-are. lIfe

lbelievedl thlit lprofesmionia services iilda~i great deal to( offer toward this olbjecfive. lie resp~ected his conisuiltanits anid lent t Iheir op~inionis a1 critical, but

invariably court eons, ear. Ile often imnplemieinted their advice against tile

wvishes of' his adhliniastrative Sulhor 'Autes. The prestige thle consultants niltinniately ob~tainedI was iii large mueasure due to hi influence. But for him, the

whole of professional serviceS niglit have been redlucedI to im poten'lce.

Roughly, the first 6 niont hs of the writer's service was wilat a bacteriologist

might call the ''phase of logarit hiiic growthI.'' At its beginninig, before thle

invasion, tilie niumbler of hospit als in the base section wa-is siiiall. lit tilie course

of 13 mont hs, new general hospitals arrived by the scor'e. The seconi.~ period

was it plateau phase, where the volume of professional work was very great

buit tilie situnatio ll regard to hospital units anld lpersonIiie, fairly st able. Thetwo periods also dliffered ini thlit, (Idnrlg the first, the writer had free and ready

access to thle t heater chie&f conisultanit and could~ submiit his dlecisionis for

app~roval- During thle second, thle theater cduer consultanit was oti a, separate

continent, andl conimunicat ion was infrequent andl difficult.

To begin with, the base sectlion consultant round himiself on a nieilical

staff lhat was unused to thle luxury- of professional services and somewhat

ssusp~iciouis at first of the innovation. It, was necessary for him to gain the

conifidlence of his chief and his colleagues in ot her sectioiis. It was also liecessnrv for hdim to orient hiiiiself in a 1)ewddering ne'w worldl. Ilie had to visit

thle hospitals alreadIy set, 1ll) and~ working, mieet and1( appraise thliru medical

ipeisonniei, ingratiate himself (if' possib~le) with tilte conimanding officers, and~

prepare lists of qualified indhividluals who Iniigit be used later Oil to h)olstervl tilie

weaker units ats they arrived. Many of tile ''01(1' units wer'e affiliatedl withI

anmd hind been derived fronti teachiing hospitals. These un~its were staffedl by

outst aniding mumeii

The consultant, had very little tinlie to achieve orientation b~efore thle iiew

units begati ariiviii( and lie experienced at sense of bewvildermient wviich never

quite left huimi. Here, if ever, was the mnioiient. whele one niededlelta ordlerly

mind, at long meniory, and at flair for indices 1111( files. Not, all the good iiien

were in tilie affiliated units. They turned uip in field hospitals 1111( were often

tutcked off it, very o(dd corners. This paurticuilar consultanit has at had mnemory

anid at disordherly mind1(. Much of' the t inie lie felt, as if lie wvere looking in to at

kaleidoscope. Ile struggled anid tr'ied to overcomle his dleficienicies. The work

had to lbe (lone 111( (lone r'apidhly. The new units arrivedl pehhiiuell. t umbled

into staging areas, and thlen p~roceedled to hiospitali sites t hat miighit or uiiiglit

not be comnpl~ete. These new units wer'e delib~erately sent, out front the Zone

of Interior Iniunus miost of fthe pivotal prIofessiolnal nlien ; t hat is, tilie chiefs of
EIUROPEIAN THEATER OF OPEERATIONS 463

services and sections. Occupants for these positions were to l)e provided after

the unit had arrived. It was the jot) of the consultant to determine the needs

of units and then try to supply them.

Thus, tile newly arrived hospital units had to be "vetted" as soon as

possible. In a 10-minute conversation, the consultant was supposed to determine each officer's educational accomplishments, experience, and character.

It required considerable effrontery to (1o this, or to do it with any sense of

infallibility. The consultant was aware of the superficiality of his judgments,

but, there was no time for more searching investigation.

One fell back, inevitably, upon tile record of formal education, together

with hospital and teaching appointments, and it was remarkable how accurate

these indices were, within obvious limits. Almost invariably, the man with

the best education turned in a good performance. It was true, of course,

that some individuals were much better than their rather mediocre background

wouhl suggest. To somne of these, injustice may have been done. But in

general the modern system of internships, residencies, and board certification

mnade a quick appraisal far easier and more accurate than it would have been

in the past.

At. first, an attempt was made to strengthen these new hospitals in all

positions. Soon, however, it became apparent that the supply of qualified

men in tile theater would run out unless this strengthening were kept at a

bare minimunm. On the medical service, there had to be a really first-rate

chief of service, one other really good younger muan, a qualified neuropsychiatrist, and, if possible, someone with a working knowledge of communicable

disease. (Fortunately there were a good many certified pediatricians available

for this purpose.) It was desirable that one of the two internists be familiar

with electrocardiographic interpretation. Also, an endeavor was imade to provide someone with at least Army experience in dermatology. It was impossible

to supply each hospital with a qualified dermatologist, and the deficiency was

cared for by the establishment of a local consulting system in this specialty.

The rest of the service could be made up of general duty officers. No attempt

was made to provide an allergist or a gastroenterologist. (In an oversea

theater, allergic disorders can be appraised by an internist; it is impractical

to attempt any special studies. As to gastroenterologists, the average general hospital gets on better without one. The soldier with organic disease of

the gut goes hoine; the soldier with functional dyspepsia is better off without

too much study and treatment.)

Thus, the bare minimum wits bare indeed, and yet it became increasingly

difficult, to satisfy. One did not want to reduce the affiliated units to mnediocrity by too heavy withdrawals from their personnel, and yet they had to be tile

principal source. The consultant's dilemnia 'was increased by tile fact that

many of the incoming hospitals had on their rosters professionally inadequate

men of higher military rank than those whom one proposed to send in to be

chiefs of services. Moreover, once tile necessary shifts of personnel had been

decided oil, it was the duty of the consultant to coordinate the transfers.
46;4 AC'riVITIES OF M31-)CA1. CONSULT1ANTS

This requiredl conivinc(ing, a given indlividull~a that lie wanitedl to leave his Unlit

for at mlore resp~onib~lle post, Persuainilug his coin inaliliding officer to let him go,

allid inllicilig thle new commaiiinding officer to accep~t hiiii. A considierable

alnoulint of tact wats nlecessary, anid althbough it wits always possible to inivoke tile

auithorit v of the b~ase surgeoni and~ ordler thle transfers to Ile effected, thle velvet

glove wvas greatlyN preferabl)e to the iron hand withini it. Thus, (.oordliliatili(?

took t ime its well ats patience, and it added to thle, existing congestion of a1 badly

overworkedl lollg-(histaiice t elephonie svst eml.

Once thle new itien hiad ibeenl installed l in hospital, it, wats necesSary * to

visit thIemn inl order to find out howv thlings were working out if' t hey had, ill

fact , beeni givenl tilie jobs5 for Which the were sent, 2111(1 what prob~lem~s ill geiterall

conf ron tedl thleni. With t hese inemi, who had beenl assignied to at jolb onl thle

consultant's recommndnelationi, the consultant, thereafter enjoyed at rat her

special relat ion. Ill a senlse hie stoodI inl loco parenitis to t hiem, and1( they tendled,

for thle most part, to conisult. him Wvhien (ifficuilties arose. It wats a happy

arlranlgemlent.

All this activity inl regardl to personnel occupied the greater p~art of the

consuiltantt's waking hours (luring thle first period of' his service. Neverthleless,

he had ot her occuPitt ions. Ile felt it incumllbent Oil hiimself to brief* hospitall

lInedicail services oil thle mnedicad problems of the invasion --or ait least onl what

lie thought. the medical problenis wvere likely* t o le. Ilie discussed the iiiaiiageumient of' the( valriouis infectious dliseases, the( function of the disposition hoard,

and~ inl general attenipted to impart, what, knowledge lie 1111( gainied inl nearly

two years overseas. Furthermore, lie served as a channel by, which in formnat ion

ill the( Possession of tile chief conlsultanlts might be (directed to its dlestiniationi.

L astly, ie( (hid a1 certain amtount of' actual consultation where timie and1( (distance

p~ermit ted. It is possib~le that somie of these consuiltations were of' value, if not

to the( patient, at.t least, to his pht'ysician. Always, they were of value to the

conisultant. ` and lie learned from them. Occasionally, frantic calls for inforniationl cainle inl by telephione, usuiall *y onl such subljects ats viper b~ites, woodl alcohiol

Poisoning, or l)otlulismnl w~ith wi~hich tit- consultant' had the barest niodd~ing

acmuaiintaince. Onl the whole, howvever, lie did not regrardl seeing cases during

hlis hospital visits ats time ill spent. If nothing else, it gave medical officers

it chaince to p~resent. t~heir choicest, wares, wvhichm wats alwvays at source of pleasure.

nihere wuits routine office wvork, too. Disposition board procTeedings wvere

reviewedl until their volume became so great, that it had to lbe abandoned.

Reconmmendat ions for promnot ion of' miedical officers wvere also passedl onl, a funictionl that gave thle consultanit somei opp)ortuniity, tit least inl 21 niegaltive senlse,

to see t hat credhit went where credlit, w~its (due. Lastl.y, there were monients

whlen his opinion wats sought by Other sections of the office. Altogether, (durinig

this Period, lie wats not idhle a111(, throughout it, received l miost valuable advice

and~ cooperat ion fromi thle t heat er chief conisuilta21nt, ii imedicinie.

The ]list 10 mionthis of his service ats at consultant formied the second or

hplateall Pha~se. The gr'oundwork hiad~ beenl (bile, tile hospitauls wvere set lip

anid wvorking, and1( it now remained for t hemii to give the very best care inl t heir
ECUROPJ~EAN TH'1EATIERI OF OPIERIATIO N S 465

power to thle vast thlrong of sick; aitd woundedl which passed t hrough I hemi.

Fortheconultntit wits a periodofines nrstalhug1oeilwic

lie fel t (list ressi ugly reit ote front Ithle losp~Iital wa rds. His iiPeti had1( beeni Initt w

enlalrged, thle 11051 itatls were nmi erouis, and~ tilie ituitler of puItWilýits ast roitoitica-,l.

Hie asforced to inist it ute at S-Nsteit of local medical consultinug b~asedl Oil htospit al

group)s. (By I his t inte, the hiospit als had beein divided inito seveit groups.

each with ata centier hlead~quatrters.) With ione excep~tiont, eachi of' tilie grouip

contsultanits inl nwitvicitt WiS as lso chlief or thle ittetold service Iin a iemrl hospi t al

withinii the group. iThey (l thIeir consult at ion in addition to ot her (ltit es, antd

very- valuiable service t hey rend~eredl. Che consultanit at. bWe lteadqutairters

worked thtrought these inen antd woutld have been quite helpless without titeiti.

This Nvas ia pertiod when thle need fotr hospit al beds becamne pvessi hg. P~olicies int rear todsoiion were constantly changing, and thlese chtaniges Itat

to lbe itilpleittieited. At tjules, the adiviinistraitors plalcedl (iflereilt voitstruictioil

on vaiious directives fromt what was int entded. Tite coitsultantt, thIrought his

local con sul tantts, worked for uiiiiformiityv in policy anid harintony inl thle vairious

agentcies. Onte prob~lemt which cani he taken ats at coincrete exampl Ile is trteinchfoot. Whet her the highi coninttitdl~ expectedl at w~inter camp)aignl is irtelevan tt

to t his (lisciissioil. (1 ertaiidv, thle tnedlical coitstitant 1111( tot , and his knowledige of ('0o(1 iiijuries was very slight. Moreover, tilie available circuila rs Oil thIe

subject left, to Ilis lnindl, niluci to lhe desired, dlealintg, ats t hey did, with Ii amtore

severe varietyv of' iitjutry. Many thiousands-(I of calses were seeni, but t hey were

Ittild. Only I inl 10 hi11( ally lesion of t he sAin. The specific pt'oblenis t hat

facedl thle ward officer were tnot answ~eredl in thle circuilars w~hat to (10 wit thi Ile

90 percent m tild in]juries? The indviua soldier lay onl his back withI 10 toes

p)ointinlg heavenward, and, ill general, they were pretty 1Ilori11al toes. flow to

treat hull? flow long will lie be laid up? 'Should he( be boarded Itoite unillediat clv for Itis bed wats needed badly-- -or kept onl the chtance of' tis beingr

aible to perfortt useful dlutty again in thIis t heat er? These wvere imlportantil

q nestjolts for several reasons: H osput al beds werev short, manipower wns shtort

(I hise pat ilts wer'e imostly combat troops) and t he ilutnlbrs intvolvedh were

equil valnt to several divisols. The wardl suirgeonls claniored for ad(1vice.

Whatt wvits the mledical coitsutltant to tell then)?

1-i-iort 111T t ('v, lhe Ailn 't kcnow, bitt in thle shortest, space of t inie it wits

lweve~ssar to find~ out . This is not thle p~lace for a (letatiledl discuissioin of t ren~chfoot. Let it suffice to say thtat niany w-illing- workers helped the imedlical

consilitant. They set upl I rench foot wards witere p~racticail clinlical researichi

wats carried out . Wit hill a fewv weeks, it b~ecame clear that pattien ts in wltNi101

active itt iscular rellalhititt iOil was st un enl ti-: did better t han thiose wito were

p~ermiit ted to remlauin idle. iThe sooner at mtan wats ntade to Walk, the better.

The resu lt s of syimpathetdic block and t he like wevre equtivocail, but the result s

oif til earniest prograi li of phiysicatl reb h ilit ation were dcIi r. (T'rt t ini (T rit(ia

wvere (establishted by whticht tie( iiiiiteditite progiiosis for return11 to limlitedl (lity,

at heamt, inigli be gumessedl atl. (The( nitdierhcl consultatnit (lidl iot kno1w wh~a t tile

ultimate prognlosis was.) In anty cas~e, sottie order A as5 develop~ed out of tile
466 ACTLVI'fIES OF MED)ICAL CONSULTANTS

original chiaos in his mind, and thereupon lie couild proceedl-tentativel. , andl~

with Iio itiassiveý assurance-to dissemuina te at programn onl t rencli foot.

There wats ainot her general category of affairs that occupied tile considtant.

The( country in which his base wats located happened to be thlit of a1 very highly

civilized MI-allndf~ con t ainedl nainn learned men in manV fieldls, who had Much o;f

great valuie to impart to tlie( Amierican i ndical officer. lin fact, t here wats much

of valuie to bothi sides in the( muttual exchange of information. Thus, vatrious

meetings were lrrangedl, and, in thle arrangement for suich programs, the -onlsultant found himself aicting ats at sort of liaison officer. Moreover, lie had

access to aill the newest medical informat ion in thle hiands of his ally; lie wits

gralcioulsly invited to atttend till relevanlt commiiit tee Ilnk'tiflgs 2and, itS 21 ColisVquence, acquiredl a larger stock of knowledge to disseminate duiring his visits

to the hospitails. Eminent medical tourists fromt the United S'tates usually

p~aidl a ceremloniall call ait his office, andlihe endleavoredl on such occasions to pick

their brains. Altogether, the office took onl the chatracter of at nerve c-enter annd,

had thle medical consultant himself been of greater intellectual capacity, this

function would1( no dloubt have been better performed.

The consult ant frequently found himself engaiged with problems inhtma

relations, a1rising fromt the fact tha~t most civiliain doctors are not happy in

miilit ary service, particularly overseas. It lilts already been remarked t hat

relations- between thle civilians andl thle regiiluirs were not easy. Thel( typical

p~roduict of the university clinic is idlealist ic, sensitive, and ver~y individualistic.

Ofteni, he felt himself to be operatin~g in anl unfriendly, almost at hostile, atniosspliere. One such remarkedl to the wvriter: ''We aill felt like June brides when

we joined thle Army, hut I never expectedl the groom would turn ouit to he at

gorilla.'' Strong wvords, no dloub~t, but exp~ressive of at point of viewv. Often.

the professional man in the hospitals felt lonely and forlorn. Frequently, he(

wats conscious of hostility, real or inmagined, on the part of tile adlministration,

usuially in the( person of his commanding officer.

The liospitail commanders, generally, were not (drawvn fromt thle top of the

b)asket , p~rofessionally speaking. Some were regulairs. Mainy were reservists

who practiced generall medicine in p~rivate life. Some were excellent. Some

were inot . For the( perfect hospital coimmiander, many qualities tire necessary.

Ile should have, to beginl Avit il, at firs-thand acquaint ance withI goodl medicinie.

Hle should be at first -rate soldier. Add to these qualities the guile of the serpent,

the soft ness of' tile dlove, and at working knowledge of electricity, plumbing,

landscape archiit ect tire, andlo international relations. Ahove till, lie must be at

housekeeper and at leader of menl. To say thlat some hiospita c1 (ommaiuinders fell

short of tilis ideal is tin utndersta2t ement.

Even withI good commiianding officers-, thle p~rofessional men cou~ld become

restless and1( unhappy. The( (oilstilt anlt was thle one individuall who w-its in at

posit ion to applyll~ some1( 1)111 to t heir Woundls. lie Stoo0(, ats hals beenl said, in

loco par-en tis to miany of' tlie( professional mien. They hiad (direct access to him.

They felt hiim to be oil their side. At the sainme time, it little of the reflected
EUROPEAN TIHEATER OF OOPERATIONS 46(7

glory of headquarters hung al)out him, andl he had, therefore, some influence

with some commanding officers. The consultant's position was thus unique;

lihe could, and possibly did, bring a little light into the gloom of some. provincial

hospitals. At any rate, he tried.

It was also possible for the consultant to interest himself in research, not

fundamental research, but clinical investigation of the journeyman type.

Under con(ditions of an active military compaign, definitive studies were very

difficult to accomplish, but some useful infornmation could be compiled. In

this particular base, the consultant aided in the inauguration of certain

studies. Specifically, these were homologous serum jaundice (in the wounded

after D-day), sonic physiologic aspects of trenchfoot, sulfadiazine prophylaxis

of conmnon diseases of the upper respiratory tract, the local use of penicillin in

infections of the mouth and throat, and antibody formation in nephritis aniongst

Germans.

At the end of his tour of duty, with victory in that theater won, the consultant wias faced with the task of redeployment. The writer prefers to touch

on this unhappy subject very lightly. It, is not for him to criticize the basic

theory of redeployment or to suggest that planning was insufficiently far

advanced when the cease-fire sounded. The personnel problems of redeployment were uppermost in his mind, and there was little he could (1o al)out them.

Many factors were involved, such as theater needs, about which the consultant

knew nothing. All lie knew was that his advice was sought in regard to personnel changes in the redeploying hospitals. The game had to be played

according to a set of rules that lie had no part in creating. There were tables

of organization calling for certain specialty ratings (of which he did not approve),

there was the adjusted service rating score, and there were physical profiles.

All of these played a part in determining the immediate future of tile individual

officer. The consultant endeavored to temper justice with niercy but to little

avail. He is not proud of his role during redeployment, andl he gladly relinquished his post to his unfortunate successor when the moment camie for him

to return home.

The other hat which lie wore during this whole period was labeled "senior

consultant in infectious diseases." He has very little comment to make on

this subject for the reason that infectious diseases never presented a major

problem. There was no situation comparable to malaria in the Pacific or the

unfamiliar and often exotic diseases encountered in tropical areas generally.

The incidence of streptococcal, meningococcal, and pneumococcal infections

was lower than in the Zone of Interior. Gastrointestinal infections were infrequent, and the incidence of childhood communicable diseases is always low

in seasoned troops. The epidlemic of influenza A in the late autumn of 1943

was the only major respiratory outbreak, and it presented no special problems.

So it is that as this particular consultant looks back on the war years, it

is his experience as a base section consultant that overshadows all other activities.
468 ACTrIVITlIES 0P MEIW!. INSUT I1ANTS'

SUMMARY IN RETROSPECT

Themdore L. BadgJer. M.D,

Reviewing7, someU 12 to 15 vniIs, lat er, the World Wart 1I experiences or

thle writer as chief of tile mnedical service of the 5th General Hospital, senlior

consult ant inl t uberculosis or tilie European theater, and medical conisult ant to

thle Normandyv Base Sect ion arter the invasion, there lire several events thatt

have ellnerge(I fr'om tilie chaos of war experiences that aire exciting and importalit anid evenl glamlorouls. The "'F'ifth Iieneral,'' firs-t genlerl21 hospitalI of thle U.S. ivm to arrive in

Europe (lur-ing World Wait 11, landed inl Nort herni Ireland inl Ma\it% of 1942.

I rovi'callI enough-I for at groulp of Harvard lileli, it wats hioused l in rat her gloomyi

inst iituttion for dlelinqluent lbovs ill Balitoral, Belfast.

'Fie hospital arrivedI inl Ireland iii the same convoy wit h tilie crack 1st

Armored D~ivision, at former cavalr *y division convertedl to armor andl( tauiks.

This prouid offenisive fightinig uinit of tile UT.S. Armyv wats so riddled with hiiomologrous serum11 hiepat it is from yellow fever vaccinat ions, that if it haldenad

immlediately' ill conlibait its, effectiveniess would have beenl seriously iliupiiredl.

Up, to 6j00 jaundl~i.edI l)jat ic1tS Were Onl thle wardls of tile 5th (ieuieral lHosp~ital

ait one t ille, and( at totali of' some 1,600 patients withi hepatitis was adm~iit ted ill

at period of 4 moniths. Colonel Gordon latter traced this jaundice to its associaltion withi certalin Specific lot niumbers of (con taminated yellow fever vaccine.

'The 5th~ General Hospital statff, particularly Maj. (later U. C ol.) C harles 1).

May, MIC, Maj. (later L4t. (101.) Charles P. Emerson, ,Jr., MC, and Mlaj.

(later Lt. ('ol.) Richard V. E~bert, 'MC, handled thle medIical casuiallties of this

epidemic uint il later aided by, the arrival of the 2d General Hospital, tilie Presbyterianl Hospital unlit from 'New York, with mnedical Services und~er tilie dlirectioni

of C olonel Kneelandl.

Thel( e'pidemlic of jaunldice wats hardly over whleni the first waive of primlatry

at~ypical pneumnonia struck inl August, 1942. Twvo hundlred aiid twentyv carefully~ st udiedI and1( (documenCted cases, wvithi it total of (lose to five h11un(Ire(I adflhls'suiis, shiowedl clearly- its nionfaital course inl this age grolip~ of youing soldiers

ats wvell ats tile inleffectivenless of peuiicilliii anid Sill fadiazinle Onl (t(li course of evenl

thle most severe miliary formis of thle disealse. It was ait this time thalt at chest

X-ray surveyv of the entire .5th Genleral H ospital per'sonnlel revealedl miore thalat

.50 instances of amllbulatory ''atvjpical' pnetnmonitis similar to that seeii inl those

hospitalized for ''typical'' ait v pical pliellimloiia.

It was iipproxiiniitel ,v Jiiie 1942, at mnonthi after arrival of tihe 5thI General

H-ospital, whileli lie( Writer mlet C olonels MIiddlet on, ( Ut ler. and Gordon. This

wals thle beginninug of t (close assocliat ion withi till thriee of thiese nIeui hut esJpeciall1Y wit hi Colonel MIiddleton, since tilie writer wats soon to ble appIoinited ats his

senlior coui1sult alit inl t uberculosis for tlie( remainider of the war "'ili add it ion to

his Ot her dlut ies."

lIn December 1942, thle 5thi General H ospital wats transferred fromn Belfast,

Ireland, to Salishury, Wiltslu ire, ill sou thern Englarid(. The person rwl and'
EURO( PEAN TH'1EATER OF OPE4rIRATIOn NS 46;9

snaill equipmnent wveit by plane inl tile couirse of at day whiile vehicles aiill heavy

eqtiipmleiit Weldt by mnotor. and~ boat.

It wits (luring this SOjourn-1 il souliherii Eiliganld t hat tilie InOIbile X-ray

tiiit was or1aimizedl. Thtis tmitij, with the (

4Uicielit mfedlical aidlifeli of tile 5th

('emierall H ospital a11d Colonlel Smledall, tile roeimtelimologist, proved to be a1 most

11hi2jptable outfit. It prodlucedl excellenit chles't roenitgrenlogram1s withI ralpidl

efliciemiicy inl survey work mnd maide it possible to keel) track of' thle siut tition in

tublercuilosis wvithI lit tle or nto (hislOcatioli of trainling sch edlules.

It was also during" this long- period ill Eng-land, from December of 1942 to

lie invasion ill Julie 1944-at periodl of relative inactivity v while wvaiting for thle

ra -1iicllnel crossiiig-tiliat thle bajsjic edilial progriaml for h naso a

t tredl. New mfedhical uniits tiot illdoctrimiited( inl the needs of an active theater

of' war anld variably equipped in medical tailenit swairnedl into Britain. I t wits

inl t is period thlat. Colonlels Middletonl anld Cutler built tip tile conlsultaltionl

services of h le t heate ad mi iniitiated tihe reassignmiient of mnedical personnel fromt

01We liii it to aiio0thIei ini stichli av whay it ealch g-eneral anld stat ionl hospital had

chiefs of, services of suifilcienit abilitý andl( eXlperiencee to ajssure UT.S. troops tilie

b~est mledical anld surgical care. At first, many, thle writer inceluded, ob~jected

to being" 'rob~bedl' of1 some of t heir best medhical talent. But it soon became

liplalreiit that t his (list rilbut ion of medical officers withI real professional abilit 'y

was niot oiil.% asstraiice for maintaining thle highest st andards of' medicinev, but

it was also an1 opportunlity for Promotiiig younger officers of atccomiplishimentt.

('ohouii4 Middletonl ill medicine and ( oloniel Cutler in surgery performed ain

ext raordliar ,v service ill tilie equitab~le dlistrib~ution of mfedhical care to U. S.

soldiers inl the Eturopeaii theater.

It is to C olonel NMiddletonl's credlit. that, lie encoturaged (deviations from thle

routitine in (liniical investigiation, teachiiig, and research ats long as this (lid

not up~set the miilitary uiiission of building uip for winning the vair.

Genleral hlawley 's mieet ings of thle professional Consulting staff at t be

thieat er headquarters will alwvays reniain miemorabhle ats ain exhiblition of the

p~ower of persualsion When actunal hbeiiefits to til lielheath of thle military Commniiid

could be shiown. General Hawley wats at hard lbargatiner but, gaive wiuse and~

jud~icial council in dlecisions concerning thle military and the niedicall, and lie

required ats niuch of his subordinates. It, wats at trutly superb) miedical service

that wats establishied in thle Europeatn theater. Ini retrospect, it still appears

liat top muilitairy atithiorities failed to give full credlit to the t heater chief conuitltaiiits in Iliedhicitle and~ surgery in tinuely promnotionis and ap~propriate raiik.

For example, the theatter chief consultants were frequently, if iiot alwauys, of

iniferior raink ats comiplaredl to tilie corresponding British coiistiltaiits. The C hiief

Suirgeon, ETrOLSA, likewise, wits late in receiving the rank of major general,

long overdule for tile service and (luty lie wats reiideriiig his cotuit ry in thle uiiedical

operatIions of the t heater.

The special problems of thle theat er seiiior constult ant ili tutberculosis have

beeui Well dhocumientedl in tilie body of t his report, but two or' thiree th lugs miay

lbe addled. The British coiisultants wvere seriously bothered that no0 one ini the
470 ACTIVITIES OF MEDIICAL. ('4NSULTANTS

U.S.. Arniv wat- allowed to touch any B~rit ish milk prodlucts liecaiise of -onlailinlat ion withI tiliercitlosis. At tilie IA)nidon C ounty C ouncil inl 1943. it wvas

revealled that . while Only 30 p~erceint of Brit isli milik wit iinfest ed with tiIubercle

b~acillus, milk iil~l Iodoll Wits fet to lbe 1011 pe'rcen't ('Out aliniialted. It was

collected'( ealch tin lv I train ill huge conltaziners int o whicb tilie milk supply fromi

eliCli station wvas dumpedi onl its- way to tile b~ig e'ity. hitis, b~oth, cilean anld

dityl m ilik were well minxed. Fuirt hermlore, it wats believed by man11y emiulient

English physicians that this cond~it ion might be bieneficial ill building up mndividIilil ilmnimlmity to thle (hisea-se it sell. P~aste(urizati oln, if lise liat all. wats (tone

by tile filash mietlhod, which wits known to lie ilmiperfect being inl inexperienced

hiands1 as at result of thle war's drain onl skilled mlanpiower.

Most remarkable, however, was thle p)light of thle Soviet pirisoners of wair

evacumat ed to( the 46thtI Generadl I os-pit al. These starvedt etialcialte(I imet present ed tulbercullos'is inl its miost acuite and fuilmiinat ing forms. Rarelyv wats at

piroblemi inl prevenition and isolaition of tulbercullosis nIore dtifficult t .han inl thlese

mieni withI little or no0 kniowledge of miodlern vehicles of hygiene aind sanlitat ion

and withi whoml t here wats at compllet e language barrier. Fuirt hermuore. t heir

pirimiitive practices of hlygienle and Sanitation had further degenierated under

years of bestial t reatmnent by t heir German capitors. Protect ion of U.S. nurses

and~ mledical adnielle was- thle mat ter of greate(st concern. To imake mat ters

iiiore difficult , at Soviet medical delegat ion, senit ostensib~ly to help. disagrvee(

withI Ani('rican nmethlodis of t rent ing t uberculosis and did its best to aissuinie

contrmol of all1 planls for t reatnment. It quickly became apparent. to thle senior

conlsult ant inl tub~erculosis that thle sooner thle Soviet. Comiandit sent at train to

evaciat e t hese paitients to their own ''bheaut iful saintoria'' inl thle mount ains

near thle Black seal, the bet ter it, wouldt be for international relations, if not for

thle t uberculous patients.

Mhost dlisappjointing wats thle refusal by the WVar Departmnent of the requIest

for permission to survey by chest filmns allf military personnel to be redeplo~yed

to the Fill- East theaters. When the request wats finially ap~provedl. it wits too

late to b~e of inuchi use. nhe uilt imat e. altiboughi late, aiccept allice of thle planl by

tie War D~epart ment wits (tile to thle strcong sup~port givenl by General I Iawlev

ai11( Colonel M Iidd~let on.

th'le adldit ioiall assignment of t(be writer ats miedlical consult ant to Normnandy

Base Sectioni dt(s-erves two comlmients5.

First was thle enlliormos aimiount (if (c01( injury or renclifoot t hat wits seeii

ili thle winteri of 1 944-45. Ilii Decemnber 1942, the Brit islh invited representiatives fromn thle U.S. Armiy to at conlfereiiCe Oil Cold( iiij Ill' ill lA)ii1tOll. There.

they (tiscliss-ed t he types an1d Variet ies of clothlung thlit widle exper'ience hadl

taught thleiii were goodt ill tilie prevenlt ion of colt injiury. D~uring thle wvinter of

1944-45, the British inl the Europeanl theater lost only a1 handful of menl fromt

trenichmfoot and1( o1tier coldt injuiry Its- cointpilredl to U..losses (tii( to coldt injury.

U.S. troop~s were ill equipped, having imiproper footgear amid socks for useME i

cold weat her. Whethter it, wats iniproper logistics or unlwilhimigness to accept
EURO( PEAN THIEATERI OF OPERIATIO NS 471

the experience of o1thers is not, cleair, )ut , in retrospect, it wats anl error, not

only of judgment. but. of imp~roper clothling land shoes.

'ni secon(l itein to he notedi concernis recovered p..lrisoner,; of wilr.

April 1945, with dite endl of thle wair in sighit. lrotiglt iti thanI iusanil recovered

American prisoners of' wair to ( 'amip Luicky strilie in the Nornmandl Baise Seeclion. These rec'overedl prisoners, swarmliedl into the camp fair in excess, of its

melitdcal findl nulit alr resources. The( eairly eniergency care of thlese enuiaciated

mnen wats, ait first, an explloraition into the( conservaltive renovaltionl of these

releaised prisoners who were stairvedl fr'onti a diet deficient in proteins, vitantins,

aind total cailories. Too entluisiaist ic feedIings precip~itat ed aicute landl seriouis

aivitaiminosis. Too raipid use of int raivenouis 1)lismai in those una11ble to ealt

b~rought lactate lpulmionairY M~enial land circulatory collapse. Earl-ier, in the

Nornmandy camipatign, the vailue land eaise of t rauisnalsall gaistric feedings of

high-proteinl content in those depletedl by injuiry andi infect ion had~ been lemrnedi.

A high negaitive nitrogen lbailance could be realdily remedied by this mleanls, at

lesson learned fromt thle C'Oooanutlt Grove Disaister st udies in Boston."' 4 This

technhiqute aigaini prioved1 useful ait (

1 amp Lucky Strmike in the cauitious, selective

feeding of t hese stairve l andl inji ured prisoners of walr.

Colonel Long, the consultaint, in tuliberculosis in the Office of the Su~rgeon

Generail, visitedl the Euiropeain theaiter onl 19 April 1945. It. wats tile writer's

privilege to review withI him the principal problems of interest in tuberculosis

control land (disposition throuighout, the theaiter. The (hiagnosis mnd treatmient

of thie recoveredI Soviet. p~risoners, of wair atit Besancon, Fraince, find of tile Amiericans atit Clamp Lucky Strike in Normandy conistittuted the maijor lacuate problemis

of epidlemnic tub~erculosis. To these situa11tions, Colonel LonIg Co1trilbUted

greatly from his long experience in tulberculosis work and with his clalm wisdom

in evaluating what wats best. for thle tuberculous soldier land most expedlient for

the Armied Forces. He had at forceful but. pleatsant. land friendly waty of getting

things, (lone, land it, wats helpful to the Eulropealn theatter senior consuiltaint. in

t~uberculosis to have his blacking front at higher echelon in problems vital] to

hiealth but (hifficuilt of execution in the excitemenit of the lalst. months of thle war.

The laist. dayti of the wart wats memoramble to thle writer along with i a smlaill

pairty of mnedicalf officers aind nurses who had gone onl 7 Mayv 1945 with Colonel

Long by amnbulance tratin front St rasslmurg to Mannheimn, Germainy. to pick

uip at traiinload of woundled soldiers.

Shortly aifter atrriving ait the Mi\nnlieim railroaid staition, the miorning of

8 Mi\ y 194.5, whistles aind sirens land lair nianeuivers ainiotncedl the endl of tilie

European war. Colonel Lonig aissemmbled thle smallll group Onl thle baittered p~latforni of (the almiost destroy* ed st ation of that wair-ralvagedl city land with implressivye dignity land sincerity of feeling palid deep tribute to thalt solenuin mtomienit

when the hostilities were over ait last.

141 The Ccoan~uit (Irove, it nightclub in Boston. Mas~s., Heile by a crowdi of some on- t houisand licisons celebrmt tg

a college footballI victory, was swept by fire at apprtoximately 2015~ hours on Sattird:,y, 2$ Nmernher 11942. Bly Shortly

after midnbight, v let Iots oft the holociuist had been evacuiate- Ito Bost on c it y I I ospit :1ansi Nlasýachtset ts G enera II IW I )IP Itat.

The official count onf 6 December 1942 showedl 4t1$ dead. Source: A ItIre Iinmilary Report on thte Cocoanut Orove D isaster,

'Massachusetts General Hospital, 6, Dee. 19.42.
472) A("IVIi'IES OF MEDIC(AL C('ENSI'I.TAN'TS

No recon striuct ion of th lie edical! work in the 1%u ropca n t I ia ter ill AWorld

War 11 is possible withiouit an expression of tBanks to thle anut hidikjiduals of

every rankl! inl tilie )\ edical Decpartmiient who hirougli1 t heir Iov~ ty an d111(evot ion

cont Irib ilted to tilie ext rlaOrdil iair reccord( of Illedlical calre thaiit was pract iced

throug-hout the( theater. Aiiioiii. the niurses, tlie( Iiiedical oflicers, and aidiiicn

are tilie records of untisng. heroism i, whethe iriii thle comibat or (Comutniticatlions

Zonie. ( )ne( looks back yem arshterm withI sonlic nostalgia for tilie experiences ini thle

Caire of thle sick and1( woundi~ed. Med c~icahlly tilie widle varietyv of diseases 111( tilie

vast iinumbier of cases was unpi larahllele ill ci vilianl pract ice. P~reven tive In edicinie ws as import a lt as curai ive t rent tivtit. 'Ilie soiiewhiat liarassihg brushes,

withI A rmyi pr'oceduires were temiiporarilyV fi'ist-1rat ing, but they niever hinlitlled tilie

ext raordiniary iiehicah experiences of tlie War.

It was at privilege to hav ye M n ie th Ile coilsilt ing service of tilie M\ edical

De)pa rtmenilt of thle U..S. Arlin : wit I a chief surgeon who combiniied thle underst andinjg. anid ironl det eriltlinat ionl t hat waIs G'eneral Ii awlev VS ' und( il(er a1 chief

medicahczl coinsult anit Nvith Iit Inle tsighit., brilliant leadership, and friendliness of

Colotiel -Mliddletoti. (Cotnsidering thle writer's 3~9 mtonithis in the Europeanl

theat er, ats long as t his hand to be spent ini tudi ar it ty away from hoiote andl thle

pracicek of inudkici the * vc coihId iardy havye been richer ill tiie(ical experiemice

lthoutghoiut thle whole couirse of thle war.

Tittie heals miiall ills ats Well ats the personality pr'obletis that arise front

the close atnd uniatuiral t associa tions of warm, perhaps becauise it is Itiore pleasatit

to remembtiler tilie brighter experiences or ipvrhas because (listatnce leinds enchiant -

men t and thle rough places look imore stiioothi. P~erhiaps, it is julst (hle mInellowi ng'

lmroces of age that tinakes th lebst stanid out( in silhoioet te-thle writer cannuot

say. litt it is to be hoped that tilie lessons, ot her than miedical, learned frontt

W~orld Wvar 11 wvill ualke it iuninecessairy for tlie( risitig, genierat ion to repeat tilie

expenieice of aiot her sintilar or p~rohbably tiore (devast atinig war somet ime in tile

f utit itv.
CHAPTER V

Southwest Pacific Area

Henry It. Thomas, Jr., M.D.

Part I. Administrative Considerations

The medical history of thie SWPA (Southwest Pacific Area) and the part

played in it by the medical consultants must be viewed in the light of conditions

as they existed in this area. These conditions included warfare in tile tropical

jungle; amphibious island hopping; stupendous engineering feats by which

jungle was cleared and a whole series of isolated bases built, complete with

airstrips, roads, docks, and supply dumps; and the conduct of a war 7,000 miles

from the United States, with relatively little manpower and relatively little

materiel of any kind.

The best of planning could not have prepared for the unique developments

in Australia, New Guinea, and the Philippine Islands. No one could have

foreseen that hospital personnel would have to build their own hospitals, sometimes even clearing the jungle, grading and draining the area, and installing

plumbing and electricity. No one could have anticipated that shipping and

air transportation would be so scarce and over such great distances that equipnient which was usually considered essential, as well as key personnel, would

sometimes be left beihind to make room for amuwunition and minimum food

allowances. No one could have planned for the evacuation of casualties with

even minor wounds 500 to 1,000 miles by water or air. No one could have

anticipated that there would be a constant struggle to provide enough hospital

beds for patients who constituted what proved to be a low sick and wounded

rate. Yet all of these things caine to pass, and as a result attention was focused,

first of all, upon the procurement of basic essentials.

ORGANIZATION OF THE MEDICAL DEPARTMENT

The medical organization in the SWPA, which eventually grew to considerable size, began as USAFIA (U.S. Army Forces in Australia), with only

a few officers. Early in 1942, Col. (later Brig. Gen.) Percy ,J. Carroll, M('.,

who was on dutv in the Philippines when the war began in December 1941,

collected a group of patients just before the fall of Manila and evacuated them

on the small U.S.A.H.S. Mactan (fig. 158). When he arrived in Australia. he

was made responsible, as ranking medical officer in the area, for Medical

Department activities of USAFIA.

On 28 Februar% 1942, the 4th General Hospital and a number of casual

medical officers arrived and set tip in Melbourne, Australia. In April, the ist

and 10th Evacuation Hospitals landed, together with several small station

473
J~;iii.).~.- .S.A.H.lI .11tcitýl(a upon~i he'r hi lirt to Manila. ' ihippijojit, IslmiiioJl,,Jijo i

hlsiOfit ;is. fit ('ii , v .Tiine, .1 nIilumer of Oilher stationl hospilals I ddillNId

Ikoil-le. oil thle U.S.S. ll,(.St Iho;11f. whliic alIso brl"ihZ1t fhlri'i alliliatedl losplia~ls.

TIliSe werie thle I,00(t-hedl 105t hi Gen'erail I lospit al. tihe .500-bed I 1StlIt Gener-al

H ospita;l, anld thle 500-bed 42d (vicned H ospitali. Fromi I his time, wint i

Il1oe t han a *veal, lalter, mIik a fewv caIslal Medical C orps offiicer, ahnd a few

Ilotia juilia ted staition hospi tals Wevre seat to SW P A. It, is s11all wvonder, that.

(I111i111g. thle variiv d(a *vs, it '(eeled to 11111 ,v miedlic-.1 oh beers in this arcai t hat

11wlv laid bleen 1(,ft to strilhrgle ailong, as biest 'I", tI ev couhld . sliliie I 11ey hadl -eIlalivelY fiftice help ili tie formt of cit her mat wrend or. persotinel.

I )iiuigi 1943 and 1 944, cert am pecuiai~i1ntles, of lhe collml.i lid on~alli;1izion Illi SW PA, whIic WIIsicce('(edl ISA F'IA onl I S Apriil 1942. expla ited cert ai n

)II(Ide'd~ (liffliillties Ill this iirev, illcldi~llg. the limiitationi of the conisulitants,

aIctivities.

1'11v C~ ommande( 1r ill C h ief of th e Allied Forces, S'W PA, Gen). Dotiglas

NIma Arthlii, had its his sitaf Owt i person iicl assignred to Genlera IIlea dq iiaIi es.

Undri Gv(;e~iwral IHeadquarlit ers (chiart 4) were lie UnIt ed State. andii~ Auistrailiain

Forces. ()n tie U.S. side, directlY nn1der Genevral I elqlltrwere thle U.S.

Na' v% anrd I5A FFE (U.S. .Arim ]-'lorces it) thle Far East ). 0[n thle Iiext. level

julder1 FISA FF'E wccthle followiiaz complonlents:

1. ( ronll 111Frcs onsist il. 11)1111 oarl-f thle Si xth UiI.S. A.Armv. This armuy.

with Ii ts predecessor. comimaiids, the Alam~o Force (Uniiit ed Stat es) 11( 111 leNew" 

(iiiuen Force (Aluist aliati ). did all1 the Jandlfgtn ill New Gnirliva. The

La.~i -Iti U.S. Arliv was onlaaiiz~ed l i thle course of tble New (ninea cilupaiglin
SOUTIIWEST PACIFIC AREA 475

CH!ART-4.-Simplified organizetion chart, SIPPA, 19.-/

SGeneral Headquarters, SWPA Combined Advisory

Committee on Tropical

Medicine, Hygiene and

Sanitation

Australian Forces USAFFE I I U.S. Navy

Army NayAir

Service Forces Air Fore l Gound Forces

(USASOS) (Sxh U.S. Army)

it saw major action in the southern Philippines but played a smaller role than

the Sixth U.S. Army on both Leyte and Luzon. Both the Sixth and Eighth

U.S. Armies had been assigned roles in the invasion of Japan.

2. The Fifth Air Force, later the Far East Air Forces.

3. USASOS (U.S. Army, Services of Supply).

When Col. (later Brig. Gen.) George W. Rice, MC, arrived in Australia

and became Surgeon on the staff at General Headquarters, SWPA, his position

was entirely advisory, and he had no office personnel. There was no actual

theater surgeon, although the Chief Surgeon, USASOS, ostensibly filled the

position. All operational activity was centered in his office, but there was

little if any collaboration between it and the Office of the Surgeon at General

Headquarters, SWPA.

USAFFE, which was intermediate between these two headquarters, was

a small headquarters in which the surgeon's office consisted only of one lieutenant colonel and one or two secretaries. This headquarters coordinated the

activities of the various forces but did not initiate polices.

Minor changes in this organizational structure were introduced from time

to time, but it was not until the end of the war, when the Surgeon's Office in

Headquarters, USAFPAC (U.S. Army Forces, Pacific) was placed on the General Headquarters level and was given a sizable table of organization, that the

theater surgeon's office achieved a position from which it could function

effectively.
476 ACTIVITIES OF MEI)ICAL CONSULTANTS

During the period of reorganization in the Pacific in the spring of 1945,

General Headquarters, SWPA, and USAFFE were coml)ined to form Allied

Forces Pacific, and SWPA was changed to U.S. Army Forces, Western Pacific.

Professional Services Division

In February 1943, Col. Maurice C. Pincoffs, MC, Commanding Officer.

42d General Hospital (fig. 159), was moved to the Office of the Chief Surgeon.

Headquarters, USAFFE, to serve as Chief, Professional Services. By this

time, Colonel Carroll had been transferred from his position as Chief Surgeon,

USASOS, to the position of Chief Surgeon, USAFFE, where he was to remain

until his return to the Services of Supply Headquarters in September 1943.

Colonel Pincoffs, by both background and experience, was admirably

suited for his new position. In World War I, he had served with troops in an

aid station and had been awarded the Distinguished Service Cross for bravery.

Between the World Wars, his position as professor of medicine at the University

of Maryland Medical School, Baltimore, Md., had given him heavy teaching

and administrative responsibilities. When World War II began, he organized

a 1,000-bed getieral hospital, recruited from the staff of the University of Maryland. When it became apparent that a unit of such size would have a long

wait for oversea duty, he persuaded The Surgeon General to divide it into two

500-bed hospitals and to send them overseas promptly. His training was

rounded off by firsthand experience with the problems of his own hospital after

it arrived in Australia, where he had some contact with casualties returning

from New Guinea.

Almost overnight, Colonel Pincoffs became director of all phases of

professional medical operations in the Office of the Chief Surgeon, Headquarters,

USAFFE. lie performed many of the duties of consultant in medicine until

the arrival of Col. Henry M. Thomas, Jr., MC (fig. 159), in October 1943.

('olonel Pincoffs represented the Chief Surgeon on all professional matters,

particularly those that required cooperation with other headquarters or otlher

branches of USASOS. With Col. Howard F. Smith, U.S. Public Health Service, he also represented the Chief Surgeon on the Combined Advisory Committee

on Tropical Medicine, Hygiene, and Sanitation. This committee, which was

attached to General Headquarters, SWPA, and reported directly to General

MacArthur (chart 4), was composed of representatives of the armies, navies,

and( air forces of the United States and Australian commands. Its chairman

was Brigaldier N. Hamilton Fairley of the Royal Australian Army Medical

C(orps, an international authorit v on tropical disease.

Colonel Pincoffs edited technical 1)tidletins. He reviewed all reports,

including those from various research projects. He handled arrangements for

the United States of America Typhus Commission (p. 526). He directed tile

policies and activities of tile Preventive Medicine Section, wvhich consisted of a

sinle health officer, with almost no army experience, a situation which could

niot h)e corrected because of lack of contact withi tile Office of the Surgeon General. Colonel Pincoffs also afdvise(l with the surgical and iieuropychiiatric
8411-i1iiWis'i PAI P114, ARE:A -.77

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US.11141 SeWI'A.
478 AUriVITIITIS OF MEDI)ICAL (ONSI'LTANTS

consultants; reports from the Dental, Veterinary, and Nursing Sections passed

over his desk.

Colonel lPincofis continued to performi these responsible and onerous (diltties

in Iead(ljllarters, USAFFE, until June 1945 except for the period between I

October 1943 and 21 January 1944, when lie served in the same capacity in

lHeadquarters, USASOS.

In the early days, when SWPA was in the formative stage, it was both

necessary and practical for this widespread diversity of duties to 1)e handled

by oneil person. As time passed and complex problems began to develop ill

rapid succession, each dluty grew larger, and bottlenecks developed and persisted. There was no one to rearrange duties and delegate anthoritv. for the

Chief Surgeon, the Deputy Surgeon, and the Executive Officer were all fully

occupied with necessary planning and operations in their office.

In January 1944, when Brig. Gen. (later Maj. Gen.) Guy B. Denit (fig. 160)

was appointed ('hief Surgeon, USASOS, and also designated Chief Surgeon.

USAFFE, it had seemeed that a step was being taken toward coordination of

tile various units of the theater medical service. Only in the Oflice of the

Chief Surgeon, IHeadquarters, USASOS, however, was there adequate personnel

for operational functions, and the general status of the medical service therefore remained substantiallYv unchanged.

In January 1944, when Colonel Pincoffs returned to USAFFE, the various

consultants were instructed to report directly to the Chief Surgeon, USASOS

(fig. 161). This change in organization, which was designed to give the consultants greater scope in their activities, did not materially alter their duty

functioning, but it added so greatly to the Chief Surgeon's routine duties that

the consultants, with the rest o1 the office staff, were placed under the direction

of the Deputy Surgeon. His duties left him no time for professional matters,

and the situation was as unsatisfactory as it had been before General Denit's

appointment.

Growth of the Consultant System

From time to time in the early dlays of the war in the Pacific, Colonel

Carroll transferred officers from hospital units to duty in his office at USASOS

or used them to form base surgeon's staffs when bases were formed throughout

Australia and later in New Guinea.

In June 1942, Lt. Col. (later Col.) William B. Parsons, MC, and Lt. Col.

(later Col.) Samuel A. Challnan, MC, were sent from the United States and

assigned to USASOS, Colonel Parsons as consultant in surgery and Colonel

Chialhman as consultant, in neuropsychiatry.

A month later the young, inexperienced captain in the Medical Reserve

Corps who had been sent from Washington, D.C., to act as consultant in

medicine, USASOS, was replaced by Lt. Col. (later Col.) Joseph M. Hayman,

Jr., MC, Chief, Medical Service, 4th General Hospital, who acted in this position until 11 October 1943. On that date, Colonel Thomas, formerly consultant in medicine, Fourth Service Command, reported to General Headquarters,
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SOUTHWEST PACIFIC AREA. 481

Consultant system, Sixth and Eighth U.S. Armies.-In the SWPA,

b)ecause of the commland organization (p). 475), the Chief Surgeon, USASOS,

was oil the level of the Surgeons of tile Sixth U.S. Army and the Air Forces.

Each new task force was largely staffed by the Sixth U.S. Army, accompanied

by Navy groups and the Fifth Air Force. Each task force functioned directly

under General Headquarters, SWPA, without control froom USAFFE or

USASOS.

This arrangement miade for innumerable difficulties and effectively prevented tile consultants from having any contact with the army surgeons.

All reports, requisitions, and requests from the Surgeon, Sixth U.S. Army,

weit directly to General Headquarters. There was no routine communication

i)etween what was supposed to be the theater surgeon's office (Chief Surgeon,

USASOS) and the surgeon of the combat troops (Surgeon, Sixth U.S. Army).

The theater consultants' activities were therefore strictly confined to units

under USASOS control unless specific requests for assistance were received

from the Surgeon, Sixth U.S. Army.

On tile surface, it would seem that these difficulties could readily have

been resolved if the appropriate officer from the Office of the Chief Surgeon,

Headquarters, USASOS, had visited forward headquarters (Sixth U.S. Army)

with instructions to cooperate in every way possible with respect to the medical

needs of the combat troops. If General Denit's trip to New Guinea had not

been cut short by a severe attack of dengue, which required his return to Australia for convalescence, it is quite possibhi that the situation, which had developed b)efore fie was assigned to SWPA, would have been altered.

By July 1943, when the need for a medical consultant in the Sixth U.S.

Army had become apparent, Col. (latter Brig. Gen.) William A. llagins, MC,

assigned to this position Lt. Col. (later Col.) Garfield G. Duncan, MC, Chief

of Medicine, 52d Evacuation Hospital, an affiliated unit then assigned to the

Sixth U.S. Army. Colonel Duncan was later decorated with the Legion of

Merit by the Sixth U.S. Army comm ander, particularly for his fiel denionstration of tihe efficacy of Atlabriie (iihydrochiloride (quinacrine hydrochloride)

in suppressing malaria and for his educational and supervisory activities

conceTrning its use in co(01bat troops.

When the Eighth U.S. Army was forming, while it was still a skeleton

organization, Lt. Col. (later Col.) Worth1 B. Daniels, MC, was sent from tile

Zone of Interior to serve as meldical consultant to the Army Surgeon. By

virtue of his backgroumid in imternal medicine and his accom plishnients as

Chief, 'Medical Service, Station Hospital, Fort Bragg, N.C., he was unusually

well fitted professionally for consultant duties in a conibat arnmy. The closest

an1( imiost profitable kind of cooperation grew up b)etween him and Colonel

Thomas as the result of nutmerous ('omlferemmces anid long discussions.

In January 1945, when vacamicies for mliedical conlsultants existed in both

the Sixthi and tihe Eighthi U.S. Armyv, Col. Bruce P. Webster, MC, and Colonel

Eppinger were requested for this purpose. Colonel Eppinger at that thime was

assigned to tile Office of tile Chief Surgeon, Ileadquarters, USASOS, as assistant

564970"- 61---- 3:1
48:2 ACTIVI%,riEs m. m1'~ m (lI)CA. I)Nsuur.''NTrs

to the Chief, Professional Service, an(d 1)oth he( and Colonel Webster were

(leclaired indi~isp~ensable by thle Chief Surgeon. After at laipse of several mionthus,

two excellent young lieuitenanllt colonels were assignedl fromi the Zonle of In! erior1

onl thle recommiienidat ion of Brig. Geni. HIugh ~J. Morga ii, (ilief Consult ant ill

M edlicinie to The Surgeon General.

FUNCTIONS OF THlE MEDICAL CONSULTANT

Before discussing thle functions of consultants inl the SIVI"A, it mnigh t he

well to mnent ion brieflY thle p~lighit inl which the Medical Corps found itself Inl

lie early-N daiys, of thle war, when it wits ob~ligedl to care for the livallth bi oth oilo

ati~l off thie bat tlef ieldl, of solni 10 million citizens who hild~ lbeeli sudd~enlyl

called away from their civilian pursuits and made inito soldIier,,. WithI very

little help from line officers, who had aill that they could (10 inl their own fields.

the Medical Corps of the Regular Army found itself dlirecting the military,'

Iraining and functioning of the civilian physicians who had enteredl the service

andl who were to providle most, of the specialized care which soldiers required.

These civilian physicians, by virtue of t heir professional stat us, had beeil

accuistonmed to giving ordlers, not. taking thleni. They (lid not take kindly to

dlisciplinie. They disliked redtape. They were usually oblivious, b~ecauise of

t~heir training, to everything but the welfare of the sick and wounded. Maknof thein were slow to learn that, wars, tire not won by sick and1( woundled. The(

business of keeping fighting soldiers inl condition to fight wats at new p~oinit of

view for tiem. They complrehended only vaguely the ii orale-build ing vailue

of preventitive and supportive medical service. They had suddlenly been t rainsp~ortedl into anl exacting new environnient, in which they were requiredl to

perform unifornily as well ats efficiently. Left to thleniselves, nllialnv of t heim

would never have learned how to find( t'he sick and wounded, how to transport

and house andl feed thlenm, anld what to (10 withI theml after t~heir lmedical treat -

mient had beeni completed. Ini short, theY had1( no idlea how niuich they di(1 not

know or what they had to learn about. military organlizat~ion.

For their part, the Regular Arniy miedhical officers were faced wvith serious

prob~lemsi. It wats these officers who, often withlout firsthand experience, had~

to comnmtand hospitals, a lposit ion which evenl thle best of thle affiliatedl units

oftenl had( (iflictillty* inl filling satisfactorily froiii t heir own personnel.

l~tnder- t lhe circumrstanices, misuinderst andings were inevit abl)e, and unilimiitedl

patience, tact , anid effort were needed to resolve themn. Consult ants couild

havye servedl profit abi on Olite t st aff's of commiand surgeons, filling th liemnportanit

professiotnil gapl bet ween thle surgeon of thle commluandl and newly' inducted

ined Iica I offi cers. It is uniifortuni at e t hat tiall consul tan fts were not a ppoinltedl

eiarl Ier at lid I Iiti t he1 ir fit tIcI! ion s were not miore clIearly ii undlerstood(.

The consult attis thiemiselvyes, however, were in at rat her diffiuch positlonl.

Trhey had1( 111 Ihad any p~reviouis experience inl their (ltittes, and1( t hey had1( no

exp~erienice ill overall IlidlitarlY orgainiza tion amid( operation. There was n o

po~sitioni for thiemi Iil thle t able of orgalniza Iionl 11a ld thle Ch'lief Surgeoni, IISAS( S,
SOUTHIWEST PACIFIC AREA 483

actinglas theater surgeonl, wit-, allowed only ablouit at third of the officerpjersOniiel

Ilie needed in hlis office, lie thlerefore gave tilie consultan lt s assignied to it 11i.aiiY

1111(1various(lit ies. Tile%- were given var~ious rout ince (lilt les, Including chieckinig

(disposit ion board p~roceedings for pliYsicail dIisabIility examnniat ions for call-

(litates. The surgical consultaniit wa-is given) thle taisk of organizing tlie( writing

of thle medical histor, a task which wa1s later taken over bY at lieutenant in the

IMedical Admiinist rat ive Corps sent front Washington. Until after thle visit

in N~lay 194:3 of Brig. Gen. Charles C. Hilhnaln, Chief, Professional Services,

Office of the Surgeon General, thle consuiltanlts; could not, leave tilie office to

visit hospitads.

There vais constant pressure front higher headq uatuers to I inlit tile table

of organiza tion. To coimpJly with this p)ressure, t lie consultants were phiaced

onl the rosters of vatrious hospitail un~its in which p~osition Vacancies existedl anld

were b~roughlt in~to the Office of the Chief Surgeon, Ileadlquiar-ter's, USASOS,

01) tenmporitry dhuty. This was not it desirablel arrangemuent , for at nliumber of

r'easonis. It eliminated chances for promotion of medical officers in thle hlospit als

to which thle consultants were assigned. Because t hey were not onl tilie hIeadlquarters tabl)e of organization, thle Consuultanits Were not aldequmatel.A p~rovidedl

with office space or secretarial service. As a result , each conisultanit functioned

ilidivihuiahlv~. When, after General Hillnman's visit, tilie conisultanit was givenl

somle freedomi of movement, lie spen~t pairt of his time traveling around tilie

areat to ob~tain) informnat ion and give instruct ion anid part atit headquarters, where,

almost singlelia lidedly, lie p~repared report-, and reconunenda t olls and ait,-

tem~pted to accomplish "'conipleted staff action.'' Often onl his return hie found

onl his dlesk for such action thle very reports which lie had hiimself madle (durinig

his tour.

In .January 1945, in an~ informald report, Colonel Thiomias outlinied his

imlpressions of thle functijon of at consultant ini Iluedicille, lbasedl up1)1 hli's own

15.-nilontli experience in t his position, as- follows:

Improvement in the care of the patient and th(e conduct of the hospital can he attained

by the consultant's precept and example, 1wy his supervis4ionb his explanation of the

Principles laid down in the technical memoraiidimis circulated by headquarters, by disclissiotis of the medical literatutre, by the awakeninig of interest inl the studIy and treatment

of disease, and by the proper handling of the soldier patient so as to improve his morale and(

prevent thew conidit ion known as hospitalitis.

The chance to discuss their observations and ideas with more experieniced medical mnen

is welcomeiid with real etit husiasm by the few well-t rniined clinicians in small hospita:ls. For

less well trained medical officers, the opport unit v to %vileii their knowledge is of the ut~most

impiort ance hin their pre'seiit and fufture careers in the practice of medicine.

The work of the whole service in a hospital is raised to the level of efficiency of the

hiiiividiial chief of service when he realized that ani import ant part of his duities is, careful

b~edside slipervisiori, in order to provide for goodl ease( histories, thorough phvsival examiniatios. aippro~priate* laboratory tests, stiitaible therapeutic measures, and, finall 'y. promipt andl

correct disposit ion of pat ieiits. Wort hwhile clinical experience then can hw obtainled by all

muembers of t he service.

Colonel Thiomias coinmen ted, ait thle enid of t his report, that, ait present,

mlost chiefs of medical services were well-t rained mniei, whose onlyN lacks were
484 ACTriVITIIS 01P MEDICIAL ('4INSIi.TANTS

exjieriencve ill t eaelling aind ii ll I.111in litg service. Th Iese thIinigs t hey coulid

ler.i, tlie( few%% lntwistilis il ii %iicli viiiers of serviet had14 insufiienejt prolessiowlial trainling, alde(Ilate repllaeviliewits coiuld be provided.

Redistribution of medical officer personnel.- (n t ilie whiole, well-t riwiled

prwofvssiowlill persowiwiel weite s('iirce ill SAITA aint ewer c,1ieflY coicewit ralted Ill

lie gi'oiw I of g(weriild liospiit iils atflifiililte w~"i thI wwleielc scihools (liii i'valrdi, *Jo~l is

I Iopliwils, I'lliiversit N.Io arllv~la m, C ollege of NIed ical Elvangielist s). Eatch

of, the(se. hiosIpitils hladl aiwiorig it-, Jersowwiiel hlighlY q ual1ified swirlgeowis atl

iwnternwists who were filly, coniiietviit to) ferrorwii as chiiefs of services Ilit whlo

WeiP aissigiwed Itas cilivifs of sections or, ill souw we inst aiit'e', ats walrt officerls.

Ill addit l~oll, of-casioiial staltiowi ando evacuw.111 ionl hiospit ils hald aui11lowi thevir

persoliwlvie severa I1 officers cowmp fete('wt to serve its chiief., of services. Inl cowi Iralst

to t his plet horn1 of skilledl ntid well-t rainied iwiediciwl oficeviA, 111111v Shtiat lowi ad

eva cwwui t j owl hiospi tials Were cow nplet el.N flicking ill coni ipent ewi su wgowis a utd

Ill Sept euii er a ind O ct oberI 1944, ( olowiel lEppintger. whio wits thlen serviwig

its als-istnalit cowlisuwit a it lit iiiedwcwnle. I leadqilla Ht ers, wats dIirect ed by, thle ( 'ijer

Stwrgeoll wiISAN )0S, ill vt'tilbahow'it iou withI othe c1towisuillt lit5tOiti to 11111O uikt' 

of exist iwii uitsi(wiwiewt s awi(I to iatiake weeowiiwiewiditt lows for' reiisswgni li('wt or

ilvii iiiall offilcers t hi nulitlotwt tIlie t l'ient er'. ''ie object i% v'Of tit Sle su vva %'' wit

relvist riIailt olow of lpersowlwiel was- to strwewigthIeni thli weak uit wits with ou t wvenikewiiwig

I t(,e 51.1)11g.

I it N ovembiier 1944, oil orolet's froi ii thle C hi ef Sn r-g'owl , I SAS( S, wiiore thlii

100) iit'tlicill officeris were t wilre onw asg ?a i ei . ''w ec olls to4

I IesA' t 'Asfl(iSft'5 we aied lrt . N atwiy offivers were give Vt iopport uiiit ies to 2issillne(

posit iowis; coin i.Ii iwsluira t eý withI t heir albali ties' ulinl were pluit iwi liwie for pwomuot ions.

O t hers wer'e foalIit to be separiated frownl their'i utilts. St ill othiers, tiwi fort 1w11i11elvI.

becakiwie dispilaced p~ersonis, losiwng both Ii thir lposit ionls 1awid t heir senliority.

BY 194-5, thle affiliated unitis hadk~ beeni so reduced inl key persowiwiel1 t fiat

S o1V f thleuii hald difficulty iwl fliwict iowiiwig efficiewit "lV. wI t ilie othler han11d.

lie( excellewit perfor Iilialive of (t( li iecoist itwilteid unwit s, du1iwig thle w'inainiiwlig.

fightiwng iwi New 611inviet awitl tlie cawi ipaigwis ill t(le Phl~lippiwies jus"tified lie

dira1st iv reshli iflliwig of of ficew'~s.

I powi thle colitipletionl of t his sti rvev . Co'lowiel Eppaigvel visit v'd aill thle New

( uwiwit'u bases. uildvisiwig \\itIil thle disposit iowi boards of thle hospitals land( r'esp~ltwliwig t) re~llestIs to) fiwiet ionl as iiit'iilcl cowisuilltiwit.

Simmary mwid Atialvsis

Iwi wet rospect, thle following" poiwnts iiiipr-ss()It oietas explatiwiiwg 111.wiy of tii'e

fprofessionllk dilifctillt es ewicoiiwitt'retl bY cowuswltawilt s ill t lie SWPA liwi tilie perflowiiiawice or thIeiwr dliitns:

'. l'lv type. of wil rfawe wiecessikrv iwli tlie jilwigle 11wi4h tilil, lowii" wa1ter ow' atir

(iat'lwte hweewi biuses liwit rodlic(I iwiwisiwal1 problemiis ohf ow'giliizit ioul, cowistriuiclion, liEslpitiliztilloll, evuiclatiliowi, 1ilid siippiv.
SOUTHWEST PACIFIC AREA 485

2. General Headquarters, SWPA, dlid not. concerni itself to any greait

extent. with medical p~roblem~s.

:i. There wats 110 antuhoritattive surgeon ait ti( liie iheter level, a1nd (cOiiI[1iia1id

Organization ledI to indlirect. indl conflictinlg relations b~etween thle Iledlicld

braniches of USASOS andi~ t1w Sixth an td Eighth U.S. Armies and tile Fiftl I

anid mhirteenthI Air Forces.

4. lIn tilie Oflice of Oie Chilef Surgeon0i, hleadquarters, USASOS, miost profes5sionai1 prob)lemsii Were directed by at single officer, it st ate of maiifiiis wIiici

persisted eveti after tile theater had grown large.

.N ledicill officers, inl tile area dIutring its formative days were iiiexjerieiice(I

inl adiliiiist rative (duties.

6;. The functions or consultants as' at groupj were poorl-y undi~erst ood by '1ll

(oiiceriie(I. Regular Armiy mnedical officers were iniclinied to t hinik of t hei i

chiiefly Its insp ect ors, anid t hey were lusmally Iihtreate its sulch 1)*y thle comin tint mu hg

Officers of the( tililts that Were visit ed. Ilie11 I)IrOfeSSiOiial s;taff Were more1 illclitied to coulsider thlemili as Professional conisult ants, ats inl civilianl life, allid to

accep~t t Iieiii as ilist ret ()rs 1111( adlvisers. instructilonl 2nid ixa- ice were ire-

(Iluelt ly uiee(led by tilie chiefs of service inl resp~ect to supervision of thle lprofessmonall activities of their Officers, p)ersonneitl p)roblemis, lind( supplyv problemis.

Ani tidi(titonal (ilifcult v wats that. I le conisult ants inl thle viurioums sp~ecialt ies

arrivedl in the SWPA ait different tinlies, withI differenit, concepts of t heir own

and each other's functions. [lie admhiniist rative (difficultijes under which they

labored midl thle widle areas that separakte~ themi (luirilig 111ost Of t heir duties

dlelayedI their learning to function cooperatively, andI there wats no One to give

them tile assistaiice they needed. Owing to lack of (lefinition, t heir efforts ait

cooperaltioni with various sections of tile (Chief Surgeon's, Office were often

inleffectuial.

7. Thie SAVPA, not, without reason, camtte to lbelieve that, miedical care

had1( to b~e p~rovidhed in anl area in which iieit her materiel nor personnlu( would

b~e adequate uint il Germianiy had been (defeated. General Morgan visitedl the

hbeater in thle very early (lays of thle war, but. lie had so mulch ground to cover.

t hat, lie wats unlable to clarify many of t-he p~rob~lemis which thlen existedl. A

secondI visit fromi him ait. at laiter (liate would have been very useful. Whien

tlie C onsultanit ill Suirgery, Office of thle Surgeoni General, visited the -SWPA

in 1944, thme circumistanices or hiis visit. preveit e(l hiis sp)eniinhfg niuch t imie onl

(hese mat ters. There were ot her occaisionall visitors, but. t hey did iiot Stay

long enlough to find out. Whly tilie policies mnid pro'edlures they crit icizedh were

being empi~loyedl, 1111d1 t heir visits were too short to be really hielpfuil.

Ini spite of these d iflicullt ies anld serious hilandicalps. however, tilie Mledical.

Depart ment in SWPA performied couiraigeously and to good effect,.

ACTIVITIES OF THlE MEDICAL CONSULTANT

C olonel Thomas' first week ait fleam~hiartt ers, USA-SOS, after his appoint -

mient inl October 194:3, left hi~mm with it somiewhat confused pictutre of the war in
486 ACT2IIVITI'ES O F MEDICJ(AL CO(NSU'LTANTS

SWP... Brisbanle, it lplea~ints , milddle-sizedl Aiist raliain city, lmd~ ik (liliat e nlot

unlike Malt inore, Mdl. M\ost, of thle ranking officers, in addition to General

N lacArt litir, were b~illetedl at thie single nmoern. hotel, I~ennows. 'Fie two

genlerall hospit ills nearby hald at few int erest ing catses, but their p~ersonnfel were

ra1thter biored iby nothling, but, routine du~ties, farl frontl thle colibliat Zone, anld were

inlchled to he (Tit icall of (bVticullati pol )licies, ('specitilIV those for neuropsychialt ncjpat ient s.

All healdqaillrt ers wvere tche lo(21t ml ill Brisblae excep~t t hose of thle SixthI

U,'.. Arnivl, which hald moved to Goodenough Island. One wits dlepressed by

Ihe reellitg of isolatioln from Walshing~ton aind the Armiy in the rest of thle world,

l111( byv tilie indirect relaitionlship between tile Office of thle Ch'ijef Surgeon,

H eadquiart ers, USASOS, and thle miedical services of thle fighting forces. It

"wats stated thalt. since General II illinan's visit to th lie rea in Maty 1943, the -otiSul a 1iiis hald been aillowed more freedion of movement., but, it, wats still evident

I 11t. their functions and1 possible usefulness were not well understood.

First tour of New Guinea hospitals.-When Colonel Thomats wvas about. to

set out onl his first, tour of New Guinea liospi tials, t Ilie p~rob~lem of t ran11sport at ion

wa-ls Suimplifiedl ly tile arlrivall of the tecan from the United Stattes of Americat

Tryphus (commission, whiche 1111( beein sent, out, to studi~y tsuitsugniuislii fever

(scrub typhus) and wats about, to be flown to its stattion atit Dobodura, New

(lin ieal After at long walit ait thle airstrip neari Brisbane, in tile early morning

darikness, the C-47 took off withI its paissellgers in strapless bucket seats. At.

Trownsville, Auistratlia, 700 miles northI, the Jplane stopped briefly for fuel, andI

lien flew st raighit across the Coral Sea to bnind, aifter allot her 700 mliles, ait,

Port ŽM oresl)2, New Gulinea. Thalt tuligt , t~le group wats b~illeted ill tile (tor-i))itory of at s11all officers club, and onl thle following morning, tile scrub typhus

teamit, headied by Dr. Francis G. Blak(' mid( Dr. KennethI F. Maxey, took off to

fly through tilie gaip of tilie Owenl Stanlley Ranlge to LDoboduria.

By this timre, Port, Moresby mnid Milne Bany had1( become st aging areas

mIli( 1 trai.;sJort at ion t ermiinals. The war liad llove(Iol Onpaist Buna and~ IDobodlura

ill) toward t he MnIrkiani Valley and aroundl thle coast towarid Finschluinfein.

It wats ait about t his t ille thalt Banses 1), A, and 1B (Port 'Mloresby, 'Milne Baty,

and Orol 11ay I) were designatte il s lilt enmuledial t V Section, tUSAS( )S, aind provided

with Ita simnill Ileieq tia Ht ens.

The surgical consultaimt, Colonel Parsons, who was just finlishing at trip in

New Guiinea, went out of his wily to tissist t(lie new mtedhical conlsult iiitt. on his

first, tour. Ileie acompatnied hint to Milnie Baty mnid introdluced himl to thle

Surgeon, Base A, anill to several of the local hospit iil cominmitnders. This wats

cooperait ion of at positive natulre, whlich wa-Is most helpful lit anl im port ant

tiue of a(Ijulst rient to at new 1111( strange environment..

Aks Colonel Thoitmas visited the stilttion liospitills inl New Gruinlea (fig. 162)

mi tnI lked to thle variious iiedlical officers inl t hemit ,lie foun t11Ihatt (lisenlse problenis

fell into it patttern quite diifrerent, from tlte p)111tern which 1111( hbeen anticipaite(I.

Whele it .1aJplitlese force of somei 11,000 trnoops lim]( crossed thle Owenl Stanlley

liange, over thle Kokoda Traiil, in Akuguist and Sept embher 1942, mid1( 1121( con)ie
Fiwu;v. I62. 11 7t h Sinti muIion t~I Punw \Iuru-sbyN'w urmin, October 19 13.

wit [fill :)2 mii les of P~ort MIoresb * v, it wva st51oppedi at Ior ha iwn bY thl-vve ad verse

forces, (I) v.11iaiit Atist rafiaa troops assisted bY U.S. forces, (2) seiiistai'vattOill

and( (:)) dliseasev. The tw d( 1iseulses whichi were k iowri to hlave wroliglit Iha voc

Ill J.Japa Ilese trCoops, andI~ which also uIfleet ed U.S. t roop~s Ill the a t'ea, werE'1

mi~al-la n a d lseli N11 te ev.I

Work at headquarters.- ()if Illis retur ni to mrishaie,.m coloinel nhonias

prelpared 1ciiiiioi'aiidhiiis Oil a1 itiiiiibei of subjects, il-iichi(hili(r moiiii iistakes

ill thle siupprJessioin anid trevatiltiett of01, iii the (hiagilosis anid tieatiltilit of

sCeII 1 ) vpI : iAts; thle problieims of psyehioiieiit'osis as tw *ev conicernied iiied icad anud

flute offlicers ; and l'iig-iis infect ions of thle feet. A repi was also prepat-ed to

,I reques(,-t froriilie (11 Office of' thle Siirireoii Geiteral fo. Iniformiat ion oit filaiiasis

if) th liSonlthJwest Pa;cific. .11) o, (hIls maiterial Nla.s submnill ed to 111 i ('hief,

P rofessioinal Services, I SAS( S.

( (oIoie Tholoiis, (11i.i1ig. hIls stayv a I lieadfqfiiltters iii IBlisbllae, visitedl t li

141 Ii (General I lospituil iii Melboulrie, t lie 118t1t Ii Cenie I hospitall illSvutv

Alist raIli,l the l~ 1051 (;eiendil iospit.il ill (;attoli, Australia, andl twvo stat iou1

hioshpials. By vpecial s aiaiviie ift wi Ci(oloiiel IDwicali, lie also visited i lie

Sixth 1.S. Ait1V Recotidilt iiiii:(" 'enter a t Rociamiiiptoli. Atist ralia1 (fig. If63).

IIci I I i II iI I
W,

SeconId four of' New (Guinea h1ospitals. Il AnwJinriII IliloI:'~i I

ii I~:-~ i I~;~ \) '~ IiiI. Ii -tI Iii I i i1I t - \\(,~I*( I I,11ccitt I

1)1d ( I l 2 7 l
lnt' & i~i'ttl IIto: 12 111 Stlie I , nit(m I t a ) rOinI.M iIt(itl, b liii, (;u t(-% ieei-:ti P ta l elt.

fl, I lit' Slilrot0l. S''iXt Ii 1>.lily, S anid t lie at tack foi('( SaIliliiw fl-mii Levtt' Gujlf

1to ii.oii oil 1; .laliiiaiw v 19-1., but ()rtleis a11iived lv dit tlv lit'ort' (lillmi~kat loll

traiis Iivirin- him back to USAS( S andt mrdei'lii himi orm thev prieseit to) it'iliaiii

.it x : vt v. This,. illi act. \\.I-,io~) sitce 90h Iw vlit ()I* a fiiilvical cmoisuilha lit's

-ittivit its toi'rithle calo' olf Huli sick whot I't'qliire lio)Spitallizat tIl andt are ()f

lii) iiIIIle(hdiatt' toiiii'iil to a combllat army1 . The wt ior II0 pen'it'lit cmllcerll

ol Sei-va t iiis liitlini~li It' va1 uiahie ill soiuo' lii111- Iire miita * voera 11011 or

[liiditb lit'ust' I'moi tle III lI'm 11iii t l (i )f thle thfea t er si r-emii s olhit'e ill phi ilii i ii

to ta1kt ove ba w \iO'whn thei ar-iiiv turnis it ov'. T~n lirzi roiisuilltat

laws,- aIli act ivt'p ItI lit tlit' cal- * v tal of t.i'1oi11e..Ht eii s\eii Ici

(1011iMltalit is iiitit'llimv nnIi' fl'tt le ifteri t it, -ziioke o( )fi b te has cl elt'iltt awa\.iv

N1.1iiiv prdlolit'il ~vt'i st Iiioliedo. Ilr-iiiit'l I.1ilu.taatt of hdiot'rs aiitl 'lecliil(1111

\\at1 lind' v:?t Iiwee aii 1) ill I ospitals. Seh itvera Dastike Jtlnollvli 1 1*0 isvr Wt'lo it'it'le
w 4l

w lli ((411 v~ 1( li 1 'i ý .1 (1(111' ed I t' I I 1 1 I() ) I I a . IIB tI... I s"I ( aIi eI(i I lt)!-J. I 1IL I I

ToA l l) mi ni la. WSlivedii lt lif m spit'ltnis ( )ll-teiuioved to Nizti mil

IL I1- Iic v(1 si I lit I~r Iaw4 llui Ih I'i s.s. tli I II( an d I Iip Iiiv. e

1 ~ ~ ~ ~ ~ ~ ,I ~ 4lt ~~ol vi't1 I . . T e .\ I r lcIIiiIvIiitIl e\r liiiii.'
SOUTIIHWEST PACIFIC AREA 491

MC, who also functioned as venereal disease control officer after the incumbent

officer, Lt. Col. (later Col.) Ivy A. Pelzman, had been evacuted for dermatitis.

Due credit must be given to the Army Air Forces for cooperation in repeated dusting of the entire city and its environs with DDT (fig. 166), which

kept the fly population well controlled and prevented spread of disease. In

the disorganized filth of Manila, however, an unprecedented increase in venereal

disease was inevitable. Soon several station hospitals were filled with patients

requiring specialized treatment. Dr. Joseph E. Moore was sent out to observe

tihe situation and offer advice. The whole problem rightfully belonged to the

Preventive Medicine Section, but this office was inadequately staffed, with a

single officer of little experience, and liaison and communication with the

Office of the Surgeon General were poor.

Hospitals were established in Manila in buildings which had been left

standing, one of them the grandstand of the Manila Jockey Club (fig. 167).

Except for two field hospitals, all the units sent to Manila were relatively new

in the theater; some had arrived directly from the United States.

Colonel Eppinger, with 20 officers recruited from 10 different hospitals

and about 35 nurses, had arrived in Manila to care for the internees of Santo

Tomas shortly after their liberation (fig. 168). When this mission was completed, he returned to the Chief Surgeon's Office and soon thereafter departed

for the Zone of Interior, where he was assigned to duty in the Medical Consultants Division, Office of the Surgeon General. Colonel Thomas requested

that an assistant consultant be assigned to serve as executive officer of the

consultant section at Headquarters, USASOS, in Manila. The request was

approved, and the difficult position was ably filled by Maj. (later Lt. Col.)

Wilson M. Wing, MC.

Routine duties kept Colonel Thomas in his office at Headquarters,USASOS,

a large part of the time. One of these duties was a review of the MOS (M1ilitary Occupational Specialty) classification of every medical service officer, an

arduous task, since it had to be performed all at, one time. A comprehensive

chart of the officer personnel of the medical services of all the hospitals was

completed and was taken to the Office of the Surgeon General by the Chief

Surgeon in July 1944. It showed graphically the extreme weakness in the

area of B-3139 officers, who were the better trained internists

Hospitals in New Guinea were closing and moving to the Philippine

Islands and the new general hospitals arriving in the area were poorly staffed

and inexperienced. Colonel Baker, Chief of Medical Service, 54th General

Hospital, was again placed on temporary duty as assistant medical consultant.

He performed an essential service visiting the hospitals in and around Manila

and also made one visit to northern Luzon. Teams were established to brief

the newly arrived general hospitals on administrative and professional matters.

A preliminary plan for the creation of an Army school of tropical medicine

in Manila had been submitted to the Chief Surgeon, USASOS, by the medical

consultant, who had been assisted in formulating the detailed plans by Lt. Col.

Charles A. Armbrust, MC. The purpose of the school was to emphasize the
IloII Ijlisl,ý l Ii~ l;IL 1S. \alU~ .11id e "ITOii i III S l I ' roi'X.i\ IlloicZ P llo a, wel t l Ise

I21th e pl ve to Iiie li4wvý-. andi &2Iitf lI mpedi~i 1.l iee t IiuhIo ufrteu. .1 1w il )iil
I 1 .411d o licef-S III-I 11iv tli'I 414'' s runli14' I i\ I 14lll ( ic ofth

fl'"It'ioInIll lervii. 14A:t0S pl%'enit. 4)1frle oI'ei aleaIv I et o Ile I'I4 1).ha i

Newvi1' Gin0'2 l~ea Afll '. vI-IIM4'4',;l Ilt - iis Golea r'l -I)o 11 411-~l. Coilonel Thllmelei

lilt collnill 1. 44111. l to e( t-.e Itu III-.l\ iZ(I

The444 51' 41 It 'ie I ca I ls la i m cn'.o ,0 nte t 7 )m dc
AC 1'1\ Ill-' \11:111CAl. I'll\-1 I

T+

Vi"I Io. 16N. s:11111, T4,111:1- Nhnil:i, Philippine 1-Innik. Fvlru:ir.% 19115.

The v*-JIo(I I)\ I

I I , the s1Ir,_jcII cmi,1111 lilt , Ndio N\4)111(1

IVIIIIIT .1 stl)"11,81c I*oporl. N In I I of Iliv more 111inii 1,201) pallems mi S WO -WV(Tf1I.\ \\olIlldvd or Ilovd(.41 sill --oI. Sol'\ The "Illel, Ad, Sen 11,11 \\ :Iý I III,

4)111\- IwOlk. I rallivil sill-voll (ill 1114, S(TVICv. nild oilk. a few of I Ill. Illedic.11 ()Ilicvrý,

h) it \\vrv cap'lldl, 40, sen 1114ý, w\ nss*slalllý; 141 11,111. A p.11-

11:11 ('11111oll to this (111ficlill had bi'vil I'milld ill the 111111Z.111oll of 111v son lcc-ý

Ill 1114. bn-w. Al olle Imsplial.ollicvI., I'l-mil 1111-voship phllmm-ý

\\vrc loildill"'. \:1111:11do At allother. officer, a 4 11)

phooml \\vrv 1,41IM1,11111-r Irrou'lilork, will 1114,11. Hill S.1114:141(wn .

A Iw-; Imspi 1 .11 . ollivers rvIml-I 1 l1q, for 41111 .11 1 \\ 4) lio\\ v\ aclin I Hill Ill ),-,Ili I n I,

I \\ v I.q n I ri I Igr \\ I, rv I I (, I I vI 1) illor jilif

I Il I Ilv pn-4 , I Ile periml v\pvI-Iv1lcvd 1) Ilospil ols \\ as IIIIIIIedill 1-1

-11*1 cr I Ill,\ m vre fqw1lell. The j 111111) froill .1 coll-m, (fl, 0 14) olle of 2 Ili)() pal i

I 11 1 ho voill-so of :I fo\\ \\ ecks 1.4,presvilled .1 1111-1, \oIIIIIIv of \\ork. I'alvi.. .1s 1 Ill.

I'll' IllM Vlý ard :11141 1 Ill, lln-w sinbillm's, I Ill' llwýpllal I-villaills bus v 11111 1.(-

(111*11ý to :1 Illon. florliml v\i!-1vIlcv.

It 1ýý 411, lilt- lltllw-ýl 1111porlonvo 01,11 Im-;pIl.II slnff!-ý be .1111-mlvilled III Ow

Vil I'l do 44 4)[wrollmi. \\Ili.ll 111v vwomll 141.141 is vwI-;SI\v, .11111 111.11 Ow oll

Il 14 ý I I I : I I I I I I i I n 4 -4 -111 it I d I , I I I ý I 1 4 1 , I I I r: I I I 11, 1 - I I I: I I I I ch o licv. If 'In . III)l

.I \ :1 11:1 I'lo 111 14, 1 ).1,1, I'l-I )I it Ich oill p( w a r I I w i-So Ill liel co 11 I)v (I I-:I I

I livil 1114, r \ rmi Ill- I villpill'o I'll.\ :111.1chell fr(olli Ill other

Im'-w, Ill \011ch 1114. 14).111 1, II'diler ill- In \\1114.11 111111, :11,1, ýl 'I"rif Il".
P \l'I 1 11 A [,I'A

\W'dl. MC, I t!

I

F I'lle ficod Ili IwIp illrr 11("pli'll, mill 'Iddillmlol pormillel 1-ý -ý11111)1.v to

,, I, III('I) Ill 1)('114w ill 1111-11. d lillr- Ilm 14)

O w Ill 11.11-41 \\"rk. .1n . A l If, 1.\11:111-ýIloll \0 1oll Illo

hill .1 verloill iiiiii, iho cAlher (if their \\oirk It 1'-ý

111:11 foolil- 'Illd 1111"Itu'll (dliccl-ý call ho :111,11-hed t4) 111),plink

If) -Ioff- I'm- l1w Iii-I 2 mfmlh-ý .4lor Iliv\ ý,Inrt

'I'llo ( 111of Ille ()f 1141-ýpll-ds

(d' mcl-ImIdill'u, .11111 11-.111,1111114-d 111-ý oppl.m.11 If) III(- Sllr'_rcml. IlItOl,

V, :wI Hill Os I lic N\ or

film cd ml :I Ild I Ilv'o did Iml hi-f-mill, m orcnm ded.

Levtc. I.cl I vl'-ý \\ 1*11 1.11 1() ( iclicl-:11 I )vfill Ill I )IIcf-111hrl. I m d vnrl

I..\ 11.\ '(di'llel \\ livil 1w ;1-ý :I I I :Icilf'd 11) 1 hv " M 11 1

A rlm fill (1111 w ill ýor\ ('41 'l- 1114-d ir.11 rm l'ý1111 nilt Ili I Ilf.

SI \I I I A rm :I, If(- I Ile 1)111(1111ý \\ VI'v

fill() ploco." Tlw loffer- vmlI:IIIlv'I. :1111miur I)Ihol, Illo

Ow I'.S. Arm.\ \\;I- :11111("t rvod.\ 14 )relill(jill-di

if- I'll-l"11 -dollifir, It) Ilw 1-:1--doll Arm\ :111d If, m. ("-'A1-'()S. T\\

1111. .;6 111 :111d .-Oo ll. Illf. 111-141 .11141 111f. 4.4111fc l Iii-Ir

I'M ilp'lillf" \\w jId I Ilvil c(illiv 1111411-1. 1 1w 11 1 A
496 ACTIVITIES OF MEI)ICAL CONSULTANTS

the same time, general hospitals, station hospitals, the 27th Medical Laboratory,

and the responsibility for evacuation of patients from Eighth U.S. Army hospitals would come under Base K (Leyte).

Clearing the area, sawing down trees, building roads, drainage, and putting

up buildings, including plumbing and lighting, would have to be accomplished

without benefit of heavy equipment and with only irregular native labor to

help. Vehicles were being taken from the hospitals for the motor pools. The

133d General Hospital, for instance, came in four LST's, borrowed huge

trailers, and moved all their equipment into a slightly cleared area. They

were ordered to take patients in 3 days and did so. On the other hand, the

44th General Hospital came in with pup tents and K-rations. The 1 3th

General Hospital came in with tenting, basic mess equipment, a jeep and water

trailer, and one truck, and all their equipment was in the harbor for want of

transportation from the docks to their area. All of these difficulties developed

because engineering problems were several times as great as had been anticipated, and there were no engineers for hospitals. Even if the hospitals had

had their own medical engineers, Colonel Thomas added ruefully, they would

probably have been taken away from them, on the ground that those who had

were being obliged to give to those who had not.

Three general hospitals, the 44th, the 133d, and the 118th, landed on the

beaches at Leyte during a heavy Japanese air raid on D-plus-27-day. Negotiations for a favorable building site had been carried on with maps before the

landings, but these arrangements had to be countermanded under the pressure

of battle needs. The 118th and 133d General Hospitals were located near

the main road running along the eastern edge of the island, and the 44th was

placed near three small airstrips formerly used by the Japanese, and intended

for reconstruction for use by U.S. planes. Actually, these airstrips, which

were suitable for the light, small Japanese planes, turned out to be on soft,

earth which defied and finally, after weeks of frantic work, defeated the engineers. 2 'Meanwhile the Japanese dropped paratroopers into this area, and the

44th General Hospital found itself defending, from rapidly dug trenches, part

of the frontline perimeter. By bad luck, these trenches were dug in an area

which was heavily impregnated with hookworm (Ancylostoma) larvae and EndamJneba histolytica left from a recently evacuated native village. The ensuing

epidemic of acute hookworm infestation will be described later.

In the same letter, Colonel Thomas reported that the Sixth U.S. Army

had conducted several dispensaries for native civilians as well as two civilian

hospitals, one beyond the headquarters and the other in an old schoolhouse

(fig. 170) near the 36th Evacuation Hlospital. They were staffed by personnel

of the 250-bed station hospitals, with a census of about 120 patients each, which

were supposed to he absorbed by the 133d General Hospital. Personnel of the

PICAU (Philippine Island Civil Affairs Unit,) had no idea how medical care

was to l)e supplied to the Filipinos or how to decide who was to hospitalize

2 This delay resulted in 10 (lays without any air d(efense after the Navy with its flattol*; had been ordered away.
F I INN I i P \' I I I \1,1' IN 1! IT

OA' T

NO

4W

AL

p i, I% I!, V I t.l. - 1;.

I
498 ACTIVITIES 01"' CE2('J ONSULTANTS

themn (fig. 171). It wats runderstood( t hat six Filipino phvSICia11 usWere Worki ng

inl thle areal, bitt obviously I hey were not1 ettotigli to take over.

The 44 thI a nd I 18t rai l iiospri t ' s, it wa-Is reporpt e I Ia er, were geptting~

their equipment slowly. 'I hie 1241h Stat ion Hospital wvas helpingrt the :16'th

I~va2ciilt loll I 105jiut n. Th~e 13j:1(1 ( ;etrerrilI llospi tjal wa.s buIildling~ whil*e lit thle

saine iine hoimsiturg 401) patilents5. All the pr'ospect1s of engoinleer. help~ conisist ed

of blueprints. Colonel Thomras wats experielaitig (lificltlties, inl some of tire

forward ilosjpit rils beecause of t ralt1sjport lit ilt probilemls; oil sorie of hIls 1I rips,

water btufralOes Were Ulsedl to ferr *v his vehiclie acrloss st reamis.

C olonel Th'lonrais repiort ed thatl ( 'olonlel ins lIa t his sulggest ion, was

phai lining to 11t2 uit 0 teami of one( oitheer and1( three t echnticianis from the( 26th

Nledical 1 Ibaliora tory-3 to an evalcualtionl hospital which wls, to go ill onl 1)-plusI -day or I -pljs-4-daiy behind eachl of the corps inl thle next operalt ionl' the

labhoraltory* would revert to its parent unlit whenl that( utrit wats ready to futnct ion.

These liahoruitornes wouIld providle service simlfilar to the excellent service provided by 1st L~t. Walter L. Barksdale, St( ', on (let ached service, wvho providled

hie onlyv Clinical laborat ory service a vailab~le until the 27th Ntedlical L~abora tory

beganl to fulicltionl. Ile helped hourthe si( urvey Wrlits lind( thre hospitals. C'olonel I lagills wits very much p~leased wit (ii his work, and1( thle coI~nhimmling oflicer

of the :36th1 Evaciuationi Hospiital wvanted to keep hrim.

Medical care near the frout.-IDuring his tour onl Leyte, Colonel Thomas

paidI several visits to thre front. Thle Conrsultanllt inl NMe(Iivime, SixthI U.S.

Army- , had1( ret urnedi to thle Z4one of Inrterior onl rot at ion, and1( thle namled requiest for his replaicemen t had been refusedl. C

1olonrel Thomas thierefore performed some of the( duties of Army colistilt aint inl medicinre diurinrg this period.

TIransportationr w*%its p~rovidedl for his va11rious missions, althbough it waIs inl

short supply. Tire p)oor condition of tire mirriow mluddyl~ r021(15 l111( thle ilulucit v

of good alirstrip~s ailso m21(Ie for difficulties. ()lre trill wits typiical. At dalw1i,

it smaiill l,5) obiservaution plan11e tlixiedl allong tire bellcli to tire telrt ill which

(Co1onel Thomas writ- billetedl and1 flew him licross tile islandi~ to t(le ( rzrroe

(MaicArthtir) aireau, where it landed in at flat j)215t ure. Fighting wits still birisk

onl this side of thle islanrd (fig. 172), but thre jeep dIriver knew--or said lhe knrew -

%%here to dIrive very faist to get by JIapaniese sniipers. The field hospital, set,

ill) inl at chuirchyardri t ( rmoc, where tire collislilt at sleielt tile flight , was bad1(ly

b~ombedl tire following nighit. E~ven (t(li Sixthi U.S. Army IHeaidquaurt ers Ilreak oil

the (%list corist was frequlent ly (lnrkelied by air alerts. O nce, at .Ta1palrese Iriiline

wits shot down ill clearl sight and1( fell inito the( sea at qutiartel' of at mile dlowni the

shore wh~ile miost of tilie st niff wats ait mess. The sniall group of U.S. nright,

fighters spent manry hours iii thle air.

lin a report to Genreral IDenit eakrl *y inl .Juntury 194.5, Colonel Thomas m21(le

the following (summarized) ob)servaltions Oil Mled1ical ('lre nealr the front:

lin the Ormnoc areat (thle combant zone onl thie westerl side of Lieyte), he was

much impressed wvithI tile commndm~lers of two divisions fromtile Pacific Ocean

Areat. Tihey were Very mredlically minded and1( ap1preeiat ed the importanlce of

p~revenrtive nitedicilie mealsumres ill(ie tp'reselit caimnpitigli. Airiong ths iimt reris-
FT7'Z-1-_A'1"1ý

ri '2 f, 1 1 k Philippi"- 1-1:tnd Ciil \11:m- I !,it 2 1

1:1 1 1.\ I'v ! II:Ic I I I If I I I (I I w 1\, )I*f I\ I'll It 1 4 If w r 1

III I %% cri.4 ht( .tI\ (11(il.l. moll di-111:11 Ili' lc-ý

14 -

ch-ni-1111-1:

[Wrinhh. I I I( )ýI If 1 :1 1,4 W\\ a I-d Oh Ow lilt alld the

11-o (d 1:1111ol-ý. HwIll III, thr-w [fill- \crv cIIlIIII-ýI;I,1ic nbmll

I I I I I I I' V

I I I I I fill) 1111pre'-wd \\lilt the Ille,114-:11 ývr\ Icv pl-m Idvd

I I I I I I I I I 1 -4 IIIIp :I Ill I I I I I I I I I I I I I ,I ) I I : I I \\ I I I I -I I I I I I I I I I Ill M Iq I ;I Ic:l. T h e

IIc:II (dIlver, Irmiled [Alcil

f I 1 11) c: I n I I lperfirki I I m I )I I - I I I f I : 14 -k I ) f I'; I I I 'I c-. I I 1 -4 111 -4 ý (I f I I, I.I\

4 ý 4 1 11 -I I I I I I I : I I I I ) 4 1 , X I I f I I I Tho , v Imil I I kcvp Ill Ilafivill - Iwf-:111-w III* 111v Imp-, :11141 c\11-villolv dillicult fill 1. lit 'llmilli'l. .11-ca,

I I H I I I Ill -ýp l I :11-ý I n ý 1 14 ý I I I r 114 1 1' \ I I A I I( I I

A I :I I r; I I r v I I I I

I'loull-Imfli 11-:1114criod III it fn )III 111w :;(,lilt

\\Illch \\:1, cIq)-Iwr dom fl.

Hospitals for natives. W hIlo lic \\n-ý :it 1 N )1.1 Nim-e-J) * v.

I 1141,I)ll;ll h 11, lin I I \ 4 I'll 11 1 Y A A I A I v\\ II -.I All-

\ 1. 1 1111 - ) ( f i L'. 1 -4:; T Ill-ro I,\ IT O fill 1 -111:1 it )-ý I)I 1 :1 1-ý

I III-1,11--d i I I I I I'c rf ýf I 1 :111 :1 4 ) f N I 1\% ( I I I I I Ic ;I 'It :11 11 o4 1 Ill :11)(1111

-)I) p:1 I will ;11141 co p;I I'll, 44 If,:l I 111.ý: ;I LI fillillher 44 1111111:11 Will -ý. Ft I r

I Ili114,11 111 1 he \\ :If-. A \( I A I , 11:1d booll falo'll lilt() I ho A IIl ro II;I it AI-IIIY .

I
At the hiospit al iii N v~ %\ Giniea, t here were 2 Yomiti nii ed ica I offhicers, ail

e'xperien~edl w~arranit officeer, andl (10 at teiul.iiits oill (lilly. Svveral of thle atI(llbidlits wvl'e ablle to spea~k Eiludisli as wveil as pid-iil Engl(ish.

Sonstnfict ion or t lise iOsj)italS Vkluie(I 1*roiii .are to a b~illh ill theV oli

lit Port Moresh * %, thle bllildhinZS had chieflY t it) roofs andl walls anid woodeui

floors. Ill adii t lo, (1tV Sbree siiiah l a(lS, NitIII t ha tchled roofs and1( opeui Slides,

Were 1)11 t Oil t On ple J)Sover tie( wa-,terI. This araii.iiiIS wasiiCeSSa i-V

b-caluse thle shore rose abruptlY from t he beach, anid, as, frequueii fyN happens

fii New G uinlea , t here waIs a jaIlCit\ 01 of\T lee roli uiil Oil which to build. 1The

l)at ieiitS hks V on Oli fOor101, onl blankets or' oil thinl, palill-woveiu touts. C'oloniel

Thloitias was told( that t he~ .pre ferred thIi s to .1l t11Y(in of' bed.

Thie variu 1115 iseaseS \VI,( ee ireOlesergati (W wit,( (lyeiie' .111ll

uihbeicuuhosis Ill Otie( Ward1, I ,viupliopat bias ill alflot her., anid t rop~ical ulcers.. .tiol

V,\- w liti a ilot her. There was a Ia rge grol p of' arthiiritIides IS, 5(11WI m ili (Iselitery alai I umii from the iu~idireuiouis st rainl of grouiococens which wa.,S

Said to lbe very widespread but1 otld OCCasioialv1. to ca use 111ret11in1is or- OJAht ialutia l. \ lost paI~ltS t shiaI 11,ii lookorii ; Ouie wa_,s said to ha ye 1,30)0,000~t red

blood cells pele cubici iiillihiiieter. and1 1.5 p~ercenut ieiulo-lobiii ; t li highest heal thy

l1II'i0t-lOIiui wa-;s 70) percen~lt.
SOUTHIWEST PACIFIC AREA 50)1

Malaria knocked these patijents down whien they mloved1 to nlew areals

and became infected by at strain different front the one to whichl they had

immunity. The Australiani medical oflicer onl duity intendled to try our therapelit ic dlosage of Atalbrinle, its he( wats not supplosed to Ilse quinine.

Tulbercllosis wats said to be onl thle, increase, hygoiene being lpractieally impossib~le to teach andl many trib~es b)ack in the jungle not yet having had anly

Contact with white men. The nattives in Japanese territory were farhing lbadly,

ats their food wats taken front them, andl many dlevelop~ed b~eriberi and scurvy.

Filarnasis wats encoumnteredl, and Colonel Thomas observedl an instance of

brawny edlen-a of thle breast said to be dule to this CondIit ion, though inl his,

op)inion it looked more like tublerculosis. He saw lit tle skini disease, though

one p~at ient hadl t inca imibricatta covering the whole body. There was said

to be at grelit deal1 of pneumlonlia, wvhich resp~ondled well to sullfadmazinIe.

LABORATORIES

Thle, whole laboratory p~roblemf in SWPA was difficult. Each hospital

1121(] its owvit lab~oratory, which inl stat ion andl evalcualtion hosp)itals5 wals usually

uinder the control of at Young mnedical oflicer with no more than thle averagre

miedicail training. Technicians were locally trained, and, in many instances,

laboratory work wats iot. reliable.

This was not, the situation, of course, in units set up l) rimiarily ats mnedical

laboratories (fig. 174). One such unit (or at part, of one) wats usuailly alssigned

to eachl base, but it hald no0 direct official contacet with the laboratories of the

various hospitals in thle. base.

Colonel Thomas recommlendled thait. at consultant ble app~ointed to arrange

for correlation of laboratory work throughout each base and1( for proper training

of technicians to be apploinited to medlical laboratories. Although this recoinmlendlation wits not ap~provedI, at school wats set upl in New Guineal to traini

technicians in tropical medlicine precedlures. It, was at con~sidlerable time, lbefore

this school wats established, .11)(1, wheni it wats op)ened, the number of already

falirly well trainedl technlicianls sent to it learned it greatt deal of trolpical medicine

which they dlidl ot nieed iii t hat p~art icular area.

Colonel Thormas concluded that if hie were confronted wvit~h the same1

sitnuat ion agalin, hie would persist in at temp~ts to set up1 local arrangements,

in eatch batse wvhereby well-trained laboratory p~ersoninel could instruct p~oorly

trainedI personinel with thle simple purpose of improving their t'chn~iques2C il

such everyda2y prob~lemus ats the dIiagnosis of malairiau by thick-smeaur Jprepatrat ions. In a; fast-moving, war, there is time only for first things first.

Medical general laboratory.-Wlien it was learned ill 1944 that a request

had b~een nuidle to Tihe Surgeoni General for a inedlical general laborat~orv to be

sent to SW PA, plants were Itianl( for its most eflect ive ut ilizat ion. Colonel

Piticofis' idea wats t hat a. 250-bed stat ion hlospitall should lbe erectedI ill Close

p~roximtity to it and1 shiould function ats t he I losjiit it of The Rockefeller Inlst it ute

func-tions iln connect ion with (11vli lit rgc Inst it ute laboratories. P~at ienits wvith
4I ~ I 14 I\Ii IT ho' V4 1. 1 SI I.I

ii ~ :l. 1li4Ii2~lI Ih~ll14\ ( 1)4' l)114 4)4 1111 I l l'u i ll 11-ie61:1ie ( A\lulx \1 ' 14 -

1,0l I 2'c 4'.I:I hl4.4)114141\ \(4i4 1 I4Ilh4I 41 1i1co I 111it'1 1 111~l~ilit 1(Itý 111 Rt11 a \\ i 111144-f. 4 

l4'sj44II-wI~q I. t (- 44II 1 I lit' 1. litI- I H l I lt 111( 1 1Iva I I 1114 \\ iler4I \o '~44' I livi e 11d l -1:1 11)1

tl he li4' lil4 l )Iw I I I. IIoI ; l h i l o fl fi lt o a l e i h

IV iI~ 1 1*1 114I14I1 Ill 1i )444 ':I 1-.1 tI' I1\'44)'1 I..\4 .'\ :114 I~
SOUTHINEST PACI FIC AREI*A 503

formled good ser.vices onl thle outskirts of Manila. By this time, (011(lit ions

in local laboratories hlad(l reatl impiuJrovedI.

Whlde this plan11 Iia( beeni inl prepara tion tit hieadquarteris. oloniel rhPnions,

then in New Guiniea, sent iii a request foi- Maj. (later Lt. C ol.) A. MceGehee

l a1rve ' , M(1 , of thle 118th Genleral Hlosp~ital, to lbe madle available to supervise

at Special ('linlical research probldem in at New Guinean hospital. Itisteadl, Major

Hlarvey was recruitedl by the Office of thle C huief Surgeon, H~eadlquarters,

IISASOS, to serve as chief of tilie miedical service inl thle research stat ion hospital planned, anl assignment in whuichIlhis special abilities could have lbeenl

fully* used. Maj. (later Lt. (C0l.) Frank Glenn, MCI was recommllenided i)w

Colonel Parsons, Consultant in Surgery, USASOS, to serve as chief of the

surgical service.

As time p~assedl andl the research unit, was not r'ead * to funcetion, M\ajor

ha rvev1 was Inade available t emlporaril 'v for thle project for which lie had been

requestedl a 11( joitied withI ( lapt . (la1ter NMaj .) Frederik B. Ba lug, M( ', inl anl

excellenit (4iluiclal auld laboratory studY l of tilie relation of Atabrinle to atvl~ical

lichieni Ilantis (p). 549).

CONVALESCENT CARE IN NEW GUINEA

Tile general care of soldliers, no loniger ill enough to require hospitalization

bult much too weak to ret urni to thle frotitlinies was a. problenm encountered in

eveýry hospital visitedI in New Guinean. Oil 29 Februar * 1944, ( oloniel Thomnas

submitted the following (sunmmarized) rep~ort on thle, prloblem to the (Chief

Surgeon, USASOS, directed to the attention of Colonel Pincoffs, Chief, Professionial Services:

1. The imiportaint, problem Of convallescent, care of patients in New

Guinea involves features pecuiliar to the area.

2. A beginining has b~een made by setting uip the, 139th Station Hospital

(50 T/0) --150) actual beds) in Oro Bay* (Base B) (fig. 175) andl thle 90th St4ationl

iiospital (:50 r/o-150 actual beds) in Lae (Base E). Similar untits tire needled

in Millie Bay (Base A) and Finschiuhafen (Base F'), even if general huosp~itals

aire later estab~lishled in these areas, since aill patients who remain in stationi

hospitals 2 weeks or more requjire supervisedl physical recondlitioning before

hey r-iet trin ito t hir uniiits. Tent, facilities canl be expandled as tile needl becomles

evidlent.

3. The supiervision and dhirection of patient activities inl the 1-(pIT)sed

units should( b~e ill thle, handls of especially adapted muedical officers who are

outstanding in phYsical stamina, leadership, knowledge of militarY discipline,

anml comiprehiension of the psychology of the soldier. This type of officer

is niot common. Much might lC (lone by training p~romuising young medical

officers.

4. At thle. present time, anl excellent convalescent unit is funcetioning at

the lo5thI General H~osp~ital, andl a similar unfit formerly funct ioned tit the

42(1 Genieral H ospital. Essenitial p~ractical exper'ienc(e was g"ainled lla both
iri

IL ,

•TA
SUI~~ )( IAJB I F.. It A IJEA

KIL

N-4-
ACTlI VFITIES M.,i MEM M.\i

aopll. tht lld officeer p erslieiiu ote ii r cellend .lid~ cliitfo oival'c~thspeit's

b'r e hesig-iat('( to or~aI.i/A'I lie oj~eratioll of lhe 90th~ and1( Hthi StatiOii

H os~pitals.

ill IBi-w F to function S(11 1liII 111.1( and loo1ow ill Size I,~ l(evil,4 (develop). Thie'se

hi~l~si'lal Nvill not1 alitellllt rehlallilitat ioul of paet, iei it 'viifIerii fromul uervouis

fhisordcleI5. alt ho'lll atcit 1iei1 wi iiiid 1t conidit ionis of 11his kindl Illighlt welil lhe

'Ib4( 14o ret 111,11 to(111 vhI alfter. n -iloi't slav.

C. Matou li-]itals. il11ileld(d 14)1. ('oliv;lf-(elt (*aI-0 -.Zi(I(l1(l be b4'IlI('(l

ill a8111:1S ill Whlich' focilitieS, for1 ouitdoor' work alal I''(Ierv11(11ol are zivailalble.

The oild v dirlect aclt ou Inikel'il on these re('(lw1wlll'ldations' wa-, the prois~l~l~

of 1\%() 1:11-4. '4livnilescellt hospiitail,'i Il Ow l'h11pihilic~s, wllivil prov)ided( miuc(hi

lfloeedl f:1l bi'1lit I('m" thle over-flow of "vil'endi hiophitl" ilIeaviullz thol 11(11 fol'ls

Mon 4'' li ll. l pal ilets.

I-A A\( :1.\ON

1The ev'Ic(11a 114 oh Sic'k 1114(1 caslil'h 'Iil:1lt h's f'romi forward b)115( ill

jimpll -1i:; i111 pro 4 lil~l 4)41 l b 1 hi1) hi 1114 II' luill 'I a 11ohi ('(ll hilsioli Ii 1(1 . ( )ie'e.

fo' *;iýnlc,. I-l~ lI4. -'tilt oli hI1451)ital ill Ow lieas'' at1 Oro B;iv Kinse BI se-lt pzlI ie~ls
SO'TIIWEST PACIFIC AREA 507

for evacuation to a general hospital in Australia. A station hospital in the

base at Port Moresby (Base D), however, where these patients were awaiting

air or water transportation, studied them again and sent them back to duty

with their unit in Base B. In other instances, an air force unit commander

refused, on the advice of the unit medical officer, to keep patients, and the

process of evacuation was begun again for them.

These and similar experiences made it evident that final decision concerning

evacuation must be left to one station hospital or another, and it was decided

locally that the hospital which studied the case earliest in its course and was

most familiar with the unit status should make the final decision. After the

base surgeon had approved the decision, it would not be changed in any station

hospital which subsequently received the patient. Under the evacuation conditions peculiar to New Guinea at the time, this procedure worked smoothly

and efficiently.

Confusion also arose when hospitals in advance sections and bases evacuated patients to general hospitals with "G.H." inscribed on both the Field

Medial Card (Form 52c) and, in red pencil, on the Field Medical Record

Jacket (Form 52d). Many errors were made, sonic due to hurried evacuation,

some due to the unfamiliarity of units newly arrived in New Guinea, and some

to the paucity of professional personnel in small forward hospitals with the

qualifications and experience to make such decisions.

It became evident that final decisions must be made by the first large

hospital to which the casualties were admitted, since there would be available

in it both the professional staff and sufficient time for proper evaluation of the

needs of each case. Correction of these improper policies had not previously

been effected because authority to instruct or correct advance bases rested in

Headquarters, USASOS.

The principle requiring reevaluation and sorting of patients in each hospital in the line of evacuation was sound in itself, but in New Guinea it led to

delay and, many times, to improper therapy. In some cases, for instance,

casts had to be removed many times.

Since responsibility for proper treatment and disposition rested on each

hospital, most hospital staff members were reluctant to release patients to the

rear without first attempting to accomplish as much treatment as possible.

This policy caused delay in the patients' arrival at general hospitals and sometimes actually jeopardized the end result. Sorting of patients, if properly

carried out, requires mature judgment and wide clinical experience. If these

requisites are available, sorting can be properly accomplished in several hours.

It, was necessary to emphasize repeatedly that medical officers should not

attenmpt final sorting or treatment of patients suffering from clinical conditions

beyond the scope of their professional training to handle.

In a report to the Chief Surgeon, USASOS, dated 27 January 1944, Colonel

Thommas described this situation and made certain specific recommendations

which imay be summnarizedi as follows:
508 ACTIVITIES' OF MED)ICAL. CONSULTANTS

1. Since evacuation follows the line of supply both by air and water and

since the( line of supply changes for military reiisons, the whole problem of

evacuation requires catreful supervision on the pairt or bafse and port surgeons.

The dlifficulties niust also be called to the attention or, an1d fully explained to,

the Surgeon, Intermnediate Section, andl surgeons of all blases andl ports.

2. Surgeons or b~ases andl ports sh~ouldI refer indlividlual caises for fact findlingto suitab~le consultants whenever theyv aire avatilalble.

3. Base surgeons, acting withI the adlvice of' suiitallel (onSiltl ants, should

dlesignat e ind~ividulal hospitalls in their lbases for thle treat ment and1( disp)ositionl

or certnam typ~es of cases.

4. Problems of' air evaicuattion should lbe freely (discussed between the local

flight surgeon land thle baise or p~ort surgeon, to settle such matters as 'ondhit ions

unsuitaitble for aiti traivel; thle select ion of pait ents who require special prepara-1

tion or (are in transit ; fil(ili ties for* t real went which may or miayi not be a vahiblae

in transit ; anid care of' property Such ats clothling, bed clot hing, litters, anold

slpecial equipment which maty be in short suipply.

5. Ship lliltoonl surgeons ainl ot her Ineohical officers chiarged with caring"

for patients dulring~ eviteuition by water should1( rep~ort to the loca;l baise or p~ort

surgeon's office for (discussions ando advice.

6. Reports should be miade to thle (Clief Surgeon, USASOS', through

channels, by comima noing officers, of staition andl general hospitals, these reportsto cont ami pertinent facts concerning the condlit ion of patients evacuiated to

their hospitals.

As at result of these reconlmendlat ions andl observations, an ofhicer was

appointed to supervise evacuiation throughout thle theater front the Office of'

the C hief Surgeon. Thereafter, evacuat ion proceedled in a. much mnore

orderly and efficient manner.

Utilization of bed space.-By the midd(le of the summner of 1944, the Chief

Surgeon had become more than usually concerned over the difficulty of providing

sufficient, hospitail bed catpacity for casualties in forward aireas. in ant areat

coimposedl of IniallN small bases, somie of wNhich (developedl hit er into very large

supply and st aging aireas, thle problemis of transporting, building, and supplying hospitails were hot simpulle.

There wits a conist ant, struggle with1 staff officers atit General hleadquarters

and other hieadlquarters to Obtanin aulthorizat ion for sufficient, hospitail beds iin

tile planning st ages. Every step was olifhcult. There wats never enough

tranisportat ion or engineering to iieet all the needs, and priority always went

to combilat lprojects.

The( setrcitv of hospital bedls req uired t hait paitients be evacuiatedl at the

earliest miomnent. that wats safe and~ sensible. Basic rules of evacuiation, however, somietimies hiad to b~e taI'll sgressedI land1 pat ienits who 110 sho(l not have beeui

muovedl, somuet imies Ieecauise thfeir cond~it ion wits too serious and somuet imies

because it wats not seriouls enoughi for evacia tution, were sent lowg (list a uces, to tilie

r'ear. ( )n thle other hanid, ait every hospital , fiesere wvr gu1it I v of ret aining

patients longer tiha il was reallY nVCiecssa rv.N
To a ugi i(nit fastver d isposit ion of pat ient s. Colonel TPhom ias p)repared t Ii t

followving (sitInIniiarixt't) let ter' which'I wits appIrovedl I thle ( iiitf Surp-gol oil 2

Atigast 1944 antd wais forwa rdedl to hiosp~italIs t Iirongl" i Iase sect imli si rgeol is:

1.While every effort Ini ist be Itlial( to ret'tl Ini thle area11(1 jtrlie capal)it

of plerforminilg luseful ftiiet ioiis. valnaidbe bed 5s)iit(' sioiltl not b e lit ilizeti for

tilie vare, of nIleii withI t iiie-coisuililiiig, condititons whl(l t heir. Subsequienit, I~ts'-

fuilness is (obuitfuil or likely' to be seriotislY imilpaired.

2. Ini at recenit ptibll~ivititoll fromi tit Olie Ice of thle '-uIrgeon (l elivierl. it wals

statled that patienits who i vjuiired iiore t liii 1 21) (lt*v f lhospitalizat ion Nvotild

lbe evactiatetl as qiziick a is p)ossible. thle Iltinjorit V betw~eehi 3(1 anid 6(1 day' s and

all by' 90(11 dy.s. lIn thle SW PA, hiowtever, old*v 27 p~ercenlt of evvitilees had1( left

lhe areai bY 6() days anud only 54 percelit bY 90 (ltl*vs, whIiile 2S Iperven ltwere

evacuul ted a ft er' 120 daYs. (Oblviouislyv. patienits eqillgeauato were being

hleld iii thle SW PA miuchl too lonig. 3. It is therefore desired t ha t, all patilent s be ('arefullY Vs('r(evilied, with Ii

View toward evaeuiiit lug I hose whot will retluireI1 lilt tillilistl~lYloll" cog ('olv'115(eli'e

ats 5001 its 1 hey (.1iii be t I'll lisl)ort etisd ev Such pat ieiits should be brouight

before at disposition boalrd early'X. atld a1ll ot her adiliiiuist ratilv pelrocvdllre shouild

be (comp llet ed proi iiptl lv. Thvs vies' se.s sh ouild Ibe r'eport ed oil thle Weeki Y Bet

Staiut s Reports Its iijt% ,ij~trih vci o to tlI v Zone of Inuterior, so as,. t~o a voidl

all1 possible dlelay~s ill eviit'uiit ibg thleiii its sool its t hey' are tIl raislport at le. Oily

pat viclts who giNve promiise of being" ret iiriied to tIlt v withlini thle arleal evacatiltoll

policv shouild he u'etuiiud ill hospitall.

NULRSES

As so~on ats thle station and evactin lion hiospitalts inl New G uiinea had their

('lits 5li p11lor't abIle h ospitl s erm'~e l a i( th li'Iase 1111( I een cleared of th e lakst

luir-kiiig. andtiusallyv starlvill hg .Jpaliese. Ilthe iiiii'seslssigiit't to theitse hiospit als

were senit for (fig. 176). Evein thele, th litdaIgi'Cl firoii eivieui * silipers anid ailr

ait tactks. whliile le'ss, still existedtl. Elvtlt(rbit'it v was prlov'idetdt Sooii a ftvi. tlit'

liospit als wvei''stt up1, bu~t, tvt'i'v i l~i t ,( tlit' build ings wtere kept black no'st of tilit'

timei foir fewii of boiiibiiigs.

LI vilig coindit ions Nvert' alklwasi'uiget .1, althlolilil ever-Y t'flort wa-Is uiiadIe to

liiiakt t leit'i t oleu'ablvt (fig. 177). The overall mnot if' was i11uid. lIn (t( li'tailyk ru1sh

foir Ioca tioiis for var'iouis inlst alatint)ion, lioslit uls had to ta ke whiat th *itv couiltd

gtr't, aIIdI thelt'i ln'rsolliliel hald to gtet ulst't to minld. For at lollg ti lint, t lut'lt waIs

it() I'll lllilii Nvulett'. Sliowt'i bluithls we're im prov'isedt froiii oil tI riiiiis or. ( ov'rliiiit'it-issiw' calls, buit lthev Inith lit tIt imlprtessioni oii th lit'iiiud. Flit'ilit ts for

li uit 'v wertv s 'aiit . St't' IIiii' nielasiii'ts w Vt'bt tcom pi lict edttt.

Elven a fter'~ t I'ali sport ait loll to thelt base Was' al'ailalldt' anld itIrIIses wei't

hioiised, thbert' werte lio fiucilitit's for theltui to visit twthit' units. PEach lit It grov

wa.Is istolatvtd , ant)I work, haiindrv, anit let'tetr writ ilig, weirt Ilthe oiilv (Welilipt boils.

Whlti t'uisuiultit'is wterte rece ived Ill large- hIliibt'rs. I. liee' wais (line millv for work.

Malla*v of th lit'iiins's slifit%'r'd fro'i jllvp *\sicuul .1litd lit'rvtliis hutiguit'.l bilt Oit

Sick riltt' illiltlbig OIlltn %VuuS V4'v low~, andt theitir vllit'it'iiv, s'lise tof tit antI
cli 44'rf il ('ildllillce (If hardsipilj) were lIII"li. Ever.\ liiiit visitedl was p~roudi of Its

iilI 115.)a(itl 154'sv coil lii tel to cat ch 1i p with tiIheir 1111its as Sooin as p4 )sSIbiv.

()it14'( oeccasioni. a C 47 cairriiwillir 111ses, Ill of licers nicr4)5 tihe ( ora ,ea

frioim New ( uiiiuie tell Inito thle anedii au 1 li phlle veiit to sewir('I for It did~ niot

\i',utors to) tw lie oul tlivc.,I Pailifi we're akavs wevIcllIivl but ~l'e1) iiiuie*

()Isfo .14 vi ailct v of1 I-eaolils. Seats Ill pl)liies li455i1w ti Paciific were few andl

limiii to ob~taiin, wiid repe~late I' eyhiests for visits bY IpI4)l'~essial l.Il~' to

New (miiuiea neeioi anisweredl.

lit Sept ender I'194-1, a lar-v par-t (of Cooe T1)11hiouias' tII( \V;e ws sehtwit \\Ii

Dt. ( ol. Ilater ( oL)j I'r-iicis It. ljetuajde, Nl( ' from t lie ()tlice of the Suiu--woui

Geueriia, iii New G iuinea anud Liter. ill lieahjiuarlteus Ill Biishaiiie. Ilhls visit, the

O)1Ik o)iie Ill Iiliiiost a year ly bv .1Ineicftal or siirlo-Ica loiisiiltiiit f romt this, offlice,

\\as ýi g;italv ;il1pp4'iai lld. Illis f reshi Ipoiint of vie\~wa \\t. ,iI itii., .iiid hIls

*vl11ii, Of experietice \\ ithi tropical diseases, Ilil ii provided hackgu'oliuud for

hit l'i45t ill,_ com a i)ii5111.

j);lm'li b~v Ilivi (.11144f of hIl I'levil'li Ivl' \I(liciile Sevrvilcv, lBri,-z. (.11. *i;iie~s

'Ni11hu1101is, 11iTi~ed to iiipv)l't till ai-o'; (Ifi-. 7I T 14'h iiv'li (;'oienvaI visit 14
hi~ m.; i:I77.-- 1 N r-ivs ot 30th EiIvacuationl I OJ Pl:I.I:ratni. \Iitidamm, P~hilippinle Islanids,

NIa~* 19 15. A\. Niiri- qIlmlivrs. B~. Sl~%%- 11:1h impiromisvdu %%ilh (oil drminis.
a V M

Fic ia 17hS4~.- Maj. Gcn.'- Norman T( Kir k, u,~~l'1 smi ), wlivral 1 Iw t 1) ropical~h'4 14 1ch'.

lOPd B)' -"h)II f1l 14viz-i .14411 N 4I~~II.W hýC ie si('lrafI114I-m 4'II''4-411q v\1' ri,114'g4114

t~he4 sill- Ica'4 111114e-'I i alt(l4 -t Iiclla i I114' (~lIII I)4Il4ch (ir4)114' i cas144 mii ili cs~ (4) lltl44

( I '42 11 e IIn 1:41I l I.h i 111~ . i 1 1:4 Iva I ) )4'4I Iva ewI4II I.en ba':lU-n 4':4 el'. whc Il, en

to xyt, her VS SO lindIAI)'ltr ha be'\ lf\KIvitll i,1 Ig lo e

I4) IiII!. 2 Ills 144411' j. toI lvj 4 Cml)4'4'414114 ill- 'Ile ( idiithe All'41 :ied l4':4IlR4 lI )A.
"(11 '11INVEI-T PACIFIC ARFA

4r

I Im 7!ý. I"r ig. I I'l-W ry, i-il ilig. 19111 NIt-dic:11 1 :11)4 w:ll or ' v Ilt-rc

:1 -1 1111.\ ()I, 'rhi'l i, in ")I. I )\\ i.-All NI Kuhn'. M ( " q.\I 1.4.111v rig,111 .

-I Illoll 111 .-4 of blood 11,141 bi'vil re(IIIII-I'd bY recvIlt N .1 c.1sli'l I I le, : sv ver.1 I m

11 (1111 I't III WO cc. , I I I( I m Iv I I n I I reve I\ v( 1 5.( H H I cc. A t I I I Is I I I I w )I I I I s I 1 .11 I.\

v( 1*1.4 )11) 11 le Z ( it I( 1 )1* 1111 1-[( ) r, \\ I I I I .I I I I( )I I n I ;I I I Iq )I I I I I s I'l-I ) I I I

I 'r I I ol In II I 11. 1 n 1141 1 tnsv I I ( 1 1.1 k T I le 1) ros pvc Is I I In I 14, 11 cv( Is

B.Iw N1 ýS;Ill F.IbI.111) \\ollld Im. v\c1l ."I'v.11vi., sillce Ilivre likek- to Ili, more

shvIl4r.lu'llivilt \\mlllds .111d fo\\vI. I-111v \\mIllds.

S1111.111ml III 1'espect it) blood b.111k supplics \\.Iss0IIIV\\IInt com 1)11(.;l t vd.

';ijil. Albel-I T. W.11ker. M( " VSV Silru'voll. 7111 FIve( AIIII)IIIblow.; Force,

11:141 Iml IIv;II.d (1IIicI:dI.\ Ille v1sif of I Ili- blood I"Illk offiI.I.I. from IIIv Zone

Id, liltel-Im. and :mno vd. ( ';I pla Ili Wal ker \\ ns I'ijsl I fin 1)1.\ prom I

40, 11 it, I I:it blotild bn Il k perfol-111.1 1 Ice III I lit, SW PA. :11141, 11' pw'sible, Ill. \\()111(1 Ilke

it It) cml I In I Ic n ;I I()C; I I ()pvI*: I I W I I. Al ( 111' 111milvill . I Ills sevilw4l n fol-111141.1ble

IIIldvI'I:IkIw_': Io Thimins. 1"'T I,\ hich 11.1d bvvil sIIpp1.\ Ing. I he

;I--; bus IIII c;I'(I'II? les from Ilarbiol. .11141 PIT-MIM-1 :111d colild i1of

:141dillml. Illerv pl-4,14vills of InIllspil-11.1114111. SlIpplIVS

OfId vollfallivi.,4. It ('141,11(d ldro 111:11 Ille 111.1.1m, porliml 411, Ille

1,14,40 Ilooded 1) \ I 11v 1:1,1\ forcil ý'ilollld Im. 'ýIlppllod I'm. I he III\ .1ý'Iwl b.\ I he S:111

Bboml Bonk, \\III] I'l-mil Itwol ;Is IIcCVss;II'\
WTIVITIFN (11" MIAHCAI. ('f1_\S"i.TAN'J,4

kipIlk

Fi(;1 m. ISO. doli\4-red it, h.\ L5i" hu'lli

Nh.x 1915.

St 1"I'LIES

III Spill, Ifl, 111v dillivililles and pi-4)b1cills :11111vildiliu, their doll\4TV,

Illore \%cre fo\\ shm-hu'v., III V;IcIfic. Col-1,11:1 Illodir'll

slipplics \koro slim-1 III s(III)v for ill(, first 111111o Ill

Ilcrv

ensilmdS. 'Illd F11,141111 (Silbophell), ns woll :Is :.ýolllv silruic.11

cxlnlll-ýlvd. The -dim-la-c \\;I, I.vIIvvvd b.\ flowil I'l-olli Soll Fl-:111-

CISCO. The slim-I'l-o wn., .14-collfiled fol. 1) 1. tliv IIIIv\pvf.l('dI v loll"..111d c\I('IIsIV(1

I'v\11c collipol'-'ll '11141 the 4-mislolit rermilling. 44 shippillu, di.'..

CH NIC \11 IM F'STIG VHON

('111111c.11 Illvez-4i.-rntiml wný III)t by Ilvaqlqllnrlol.ý.. ('ýýASO'-".

11 Is 111*111. 111:11 Illodic.11 porsoillicl was '11\\n.\s ill slim-1 sIIppl.\ Ill 111c S\VPA.

Imi-liculorlY fluring- Ilic Iii-I 2 Yvnrs. It Is olso [I'lle 1111:111 1114,411c:11 111licors ill

I 'll forword orens (I'd not linve 'Ippropri:111v troillill'-1 I

1,111W :11,11,11. T 114, rc I% c I.v .I I I I I I I I bv I. f? f oct .. I -'; I () I is, I I f) IN f.vI ý J.. I\ I I I ý I 1 11 --w ellied 14) Illo

--will 111) 1() well-4-sinblishell shilliml Imspli'll, ill MlIch IlIvY cmild lmv(ý 111.111c

Ilsofill oltsvi'vallolls mill v4dIvoed vAllable Ill 1*()I.lll:i I Wil.

Recollillivild:1111mis 1() tills wore seldmil appl-m-ed. OIll' of Ille v\-

4.1-pliml, \\o-ý 1111f. Sind I. lundc b.\ 11.11-ve v :11141 CaPlaill B111.1ýoll .111\1)1(.;Il

Wholl 1)1:illlls 11). -W)). ( ';Iphlill B'll - well solill 1() 111v .11-co to pill-slic

Ill 111:11"Iria. 11*1- I'vporl-4 \\4-111 (111-ovilY lo Ille ( '11144, Profvs-ý14)11.11 Serv-
,,I it I:ST PACI I'll A 1, VA

low it,

.7

if cro not -11cli

Wive 10, 11 le 'I I If f )I I I vzl If I 11.1 rt ors

I I lit, ( m l-ýllll fill I it N I I It 1.

A sk it I I osI for lil:1 Nvos i Iv \ cloped I t I liv 52d Ex lilt I I 1 1 --ýpl I I I

Mt I Io si ;I I Imic( I ()if Wood I. Irk Is I; I lit I, New ( ', I I I it ea ( 1). 5.7), l , .

V;I (.1111 Wn I oh-w rv: I 1 10 11!, \\V I'll 111.11( 1 M 1 111*111 \ if-loo -,Isv-ý id,

.111d wi sill-vvy of :I W11111-cok (d' Ilop'llills \\:Iý

V:11TI(Id ofit. ()it thf. \01(liv. forlillialt-k- 4-11(mu'll, Iliv \\,It. Illm-od 14)() [:11. 1m)

fo-ýl If) porilill 11111ch IIlvcsIP-,.IlloTI.

Part 11. ( linical ( :misideralions

G F' N 11, R \ 1, ( ) BS V It \ VF 10 N S

to the dlscllsý,Iml of spel-I'll It fill'-do be \\c1l to

(111111114, 1 fo\\ 4il, Ilw vill-wi \ ()I* proldvill., \011ch Illvdivol (diii-vi- vilcifililivrod Ill

the Swillm o-O PýIvilfic. Iml-IP-111:11-1Y .1her Iliv Iliv.1siml 44 Iho Philippilw'. N In I I.\

id, Illcill %\vIv rvýldllal.

Tllv liallve scell ill 111v Plillippiliv ISI.11141., as \\vll Is Ill Nv\\

(11111wn cwl-ýI-ýIvd (0, :1 sill-14, romil r.117-w4l I (ir .-) fel-I :IhM-o 11111 4-111)"Illid (lit S141111

b.1flibm) polvý; di,-,. 11,2). This elvvnilmi m,:-mrvd ;i vviAnIll :111141fillf 4d, pr4fliclimi

wro list such Ilim ch-mile v IM's ;1*.; nilt s . I I I --'s N I fill :is 1(,-ý of 111

If()\ :I If(,(" :111(l I'l-ce v e ll I I I :I I I I ) I I \\ :I If I'l I I I I I I I I I n v

S ; I r r: I I I I I I I f I I I'l - I'l I I I I I I v I I I I I If r I if I n I 14 11 1 1

r n n I I -ýq - I 114 1 4 1'( ,1 hich evelit 11:111.\ viv ch-ni-ed 1\\ I v 1) v I I I v

.11141 m. -ýpl q.;ld .1 1-1,111141 b.\ -olrfocv I-nilm ;it or. Illo (.4111,111
AcTl\ lTll:,, oil.' A11:111CAl, 1. 1 AV I s

Flo.i w IS2. imiko, ill l1w Philippillc 1-1:1111k. NI'll- llýv 1.1,

in'll p:111-11- ffl 111:114-11"d

it wo..; S111:111 miller 11:11 ench full I vo:l-ý \\ ell ns dollwsl 11-:Iflllll.ll, v-11-1-led I 111-ce

Ill- foill. vnrlvllv-ý III, lwnl-ý11(-, ill .1dililli'll 1() 1111kcs :[fill mosquilt)-

hm-lio

Ill No\\ Iho 111hcylvill, simill 11.111ve villou'l."; lisil.111 v \\vl-v -ý1111:11ed

ill 111114. hlck fit' Illo kllvýl, .11141 llwY cml-ýlillllvd Ill) problem ill "illilnIlml 14) the Al-111v vv-vpl throw-rh 'll-onill ImIllitiml. B\ collinisl, Ill le,

used 1,m-cIllllV:l114111 (11, rice, ;111(1 flll-ý hilld \\.I-; Spilled \\1111 urmlp:-ý (11' the'.-w 11111o llwlsoý. S111CO

I I I I I I I I I I I I I I 1 4 1 1 11111 4 1 ; I I I I I I n I I w I I I ) I I I \ I I I

I : I I I () 11,; .11111 fill ()11,-Illllils .11*(,;is. 1, (w illim tok ., Illv ll()spil lhlv 11.11,1Vvs lm d

little 1() 4dVer 1,,.S. :111(l Ille S(ddiors 11;ld 1111h, 11111V 01, v loh from

their li(,I.\\ Ise, 1,(,\\ \\ wild 11:1 ve ("'W;lped solliv

1 :1111114,111 , 'llid .1 hhý 1111111 her, Ill* rollr-w, did 11,11 e-w:( Pe.

I ]I I v .\ 14'. 1 ho :11-c.1 11) 1 ho I ll ( lelicrol 1 lo-q)II A \\ .1ý- ho:1 vllY

i I I I p n --'I I !I I ( -4 1 \\ I I I 1 114 'Ido \ Ill Ill I I I I I /-,'. h I l'i 1) 111 , i 1 4 111 1 v

I I'll im i I \ I, v 11 NV I i I i I i i :I k I I, r t \\ I I, I hore \\ :i,ý ;ill mll wen k I

I'vI )1 114. 1 )n if I rl it I I , I 1111 -,ol ler:1 1 111 :1 In I-W CV( )I I I Im 11 iol I 1 (.1 )sl I it )p l ill 1.1 . I I

,I 1ý,l wcl rf I , :1114 1 1 :1 1 or 1) 1-m ol I . I ho I I I it, cmidi I Wil 1*111)1.4 -ell 1 (ýA I ;I li ml I wo;i k 4 d

:I I' 1.\ . St.\ cI 14 it (will d 1,o;l-w. A ho 1 ( ;rlWlIl I 1q),pll ;11ý I Ill, roýldlla I. v

cn)p (d' llifect I I ,I ll

\\Ill(-Il 11;1(1 1:11141rd :it 1114' :1111o 11111c :1, 111v whel. lwspll;&, ollcollillervil
souTrniwr~ PACIFIC ARIEA 517

Observat ions ait the 76t I~ St at ion Hospital in Levte wvere typicad. Diarrhlell

acvoiiited for over at third of ab)out :1,000 adiiiissioiis. D * senite (1v accoullit ed

for 400 admiissions (bacillar*v , niosti Flexner t *ype, inl 190 calses; atinelbic, 11ll

trophiozoites, fin 21 ; and caulse ilindeternililied ill thle remaining calses). Th'lere

were 1:30 Cases of c.011i1io01 diatrrhbea and 47.5 cases of acute gastroenteritis. Tile

caulse wats not (leteCrmined inl anly of tile cases of this groul), liut it, 'IlCild(ed

S.Vi~ldrOlieS t hiat in soiUe hloslpitalS were (lialglioSedl as iiiflulelza or- deligue. Othber

dIiseases o1)ervedl includledl nalaria, polionivyeli tis, lbalait idilaSis, giardhiltsIs,

ulcerative colitis, and regional eniteritis. There wvere tihree cases of syphilis,

all new, and~ sonic other venereal diseaises, but, no gonlorrhlea. A possible caise

of scrtl) typhus with rising Iroteas' OXK titer wats also observed.

In someC hiospitals, at cond~itioni wats ob~servedl which for the first, 2 or 3 (lays

looked like influienzat. Abdominal Cramips Il~ld (liarrhele t henl developedl, buti

neit her aiieielae nor sail]noiehlu Ie couldl be found ill the stools. Viruis stuldies

wvere planned for these pat ienits.

MALARIA

General considerations.-\MIalatria was not a disease which Could readily

be disniissed. In various areas of New Guineat, the inalaria rate wats as high ats

anywhere iii the world. A good many of the nattives were infected withI filariasis, practically all of theni had intestinal parasites, and niatlaria infection wits

alniost universal. It was imipossible to prevent Contact of thle LU.S. 501d(hiers

with t hien, for t hey wvere very useful to the Army in hielping to clear thle jungle

(fig. 18:3) coconut. groves and in applying thatched roofs to rapidly erect ed

buildings of native type.

The particular strain of Plasmodiurn H~xax encounteredl in New Guinea

wats extreuimelY virullent , anild miosqjuito control wats particularly dlifficult un1der

tlie con1(lit ionis iiil)Ose( i).w war. Thlenitilitarv yprograni lwals glenerally -to neuitralize

lie Japanese troops inl at given areat; to turn the base over to USASOS; to push

back thle jungle to inalke rooni for staginig areas, airstrips, supplyl (luliilps, anid

hospitals; and, ait thle samle timle, to rid the area of 11ala2rial mosquitoes. The

soldiers worked under great (difficulties. The hieat was intense. In somiie areas,

it rallied labiiost datilY, the (downifall totaling 180 inches per year in thle Milnie

Bay, area. Bulldozers and labor battalions worked imi shifts aroundl thle clock,

an1d their rations wvere limited to what could be shmippedl iifrequently* from

Australia, where very little canned food wats available because not. 11111i of it

wals Used1.

Preventive measures.-It is anl amiazing fact that within 3 or 4 mionths,

the U.S. mnalaria survey and control units, with the hielp of Armi engineers,

were ablhe to convert the niost highly inalarious area in New Guinea, aroundl

Milne Bav, to an~i area in which the monthly inalaria ratte was frequently lower

thanl ally where else iii thme island. This wats accomplished b~y a variety of precautionary ineasinres. Nati~ es working onl Army p)rojects, were inovedl away

from thlein for (distanices of 2 miles or- more when daylight, began to wane anid
lici t 1141, 11.4'F1 44 1 rd'j44.4 1i 114,11. It''4 \\:I, 1,1*1111 4411'- 11,1:1 1111, hild I)( 41114414

-I-' 441 \ \\ il c1141'i1;11111:1 1,.lc \'I \t l

\\,. tI 11 ,1-41 fill4 1141 11 ,44 L I: 1 4 - l I'w 1111: 2t'l \\14 - 1- rd4 4I I I II- 144 11,1141,m -f

Il Il1 44 it' -Pod like \ 1 1.\\ - 14 11u1 1 411()o I\lilt4 14 411 4'-11 \\[l 41 l 

111411' (1114 A 144:441 \\:I fo~l~ilII\ :l111111 11411 1114A \1() ho 1'11 i 144k 11 1

I.11 ,111 I 111 1 ,1 11 , I'4'2'1ll' 1 4 1 1Iil .1l'11 44 111 1141 the 4-1111 l~l-' lilt OIl4'I4I4 111

41 111 1 11 1,' 4 1 1 11411 o l t 111, A il i
DDRf''T I 

TAKE.THEIR.

ATBRINE

Treatmnent.- 1'11e ii iteiito uaai i i~ s I h I-iia iii istoriival ep)isode, thle coiiiIlet (l('s-(ipjtioii of' wvliicl is lbe~voiid the ".ope' ol this

(lAmpter. QIIIIIIIIv, whiichi 'lorIlledl witli Ata.-briiie 'Idala sl~loc~iioliii iiaplitlioite

tpailia.(IlIIIIe4 iiailithloiite) the '.o-cahlelvd Midd~le L1Ist. tri('Ut rneii 'as w still the

ialoy of, e III the British an1d Alustraliaii Armlies. Quinline, hlowever.

was III short slupply * b'r US . Ariuiv persoiiriel. ( )i the othier 11ia11ah th lie se of*

Atabritie was ('i~t ii&'lv hiew, and the orig52iiul (losa-v (;] pills a. week left much1(

to be ilesiriih. 1i was. vvenimitlal ileterlhliiied thiit siiplpressive (loses, t-~keii

IT , uL"irlv1, (liiiiiiia.tel all1 f'ormsn of 11alar11ia other timan that calused bY P~. 'rr

aii siipiwessevd cliiiielu s.vn uptolins of tha~t variet v du11iriii lherapv. ''i ds

Ilmr t rea lilleit of, rIiahaiial at tack., had to be ('St abuished bY trial and er-ror.. It

is, oI, (oiisiIerablhe Interest hamt thle schevdile fiialm ,v work('( out III SWiPA, o f

lar-( doses fbr several (lays (ait first , 0.2 rini. every 4 hours) f'ollowed bY ~Iliiiitenajice dloses, proved to be ideiit ica~l III piwineiple, thowugh s"l~ltly lagrIII dosagev.

1ti1ii Ohe schevdile ehlaloratel III the Uinitedl SIatvs, withi thle help of blood-level

deter-liiniiiatniii on t reateil Pa't iiits, bY D~r *bu11iiue A. Shainlioii. Lieuiteiiaiit

Bangr, eulipiped w~it i a. phluoofluiorouiieter, was able to provide accillirte data1

Imr 11lie fitiall (let eriiuiiiat ionl of, optiuiuIIIIII dosalie schevdules.

Research studies. Nalaria received Iln.oea 1t eiutionl and hand Illore mna ip~ower effo)rt devoted to its prevveilt ionl t haiii all oilier (hiseases puit to-vit her

(fig I S~).'I'h'e r~esults wen, "zood. Fhierv wviie oildv Iwo or. t hiree cases, o(4ee

bra!. malar.11ia and only v f~ew of, buiackwaler lee.It is inot too 1iiuichi to say thai.
"4h*i "C-- - v.Al*r-lil
A-V

apt

RL

I r

ohm
522 ACTIVITIES (W MEID('AIC ('0 N ,ULTANTS

the effort devoted to malaria played a major part in enabling the U.S. ArIny

to perform its role in winning the war in the 'Southwest Pacific.

Lieutenant Bang, in addition to the photofluorometric studies just mentioned, carried out other studies of fundamental significance.

The Australians, under the direction of Brigadier Fairley, set up elaborate

clinical experiments at Cairns in northern Australia. When a malaria commission consisting of Dr. Fred C. Bishopp and Dr. Robert B. Watson visited the area

in July 1944 and were invited by Brigadier Fairley to visit this research unit

at Allied Land Forces IIeadquarters, Colonel Thomas was allowed to accompany them. New Guinea mosquitoes were used to transmit New Guinea

strains of Plasinodiuin to volunteer Australian soldiers. The good and bad

points of treatment of malaria with quinine and Atabrine and of its suppression

by these drugs were clearly defined, and Atabrine was finally adopted as preferable. Other interesting observations were also made at Cairns.

One of many studies on malaria suppression conducted independently in

U.S. Army hospitals was carried out in a general hospital then stationed in

Australia. A group of 10 officers took large doses of Atabrine and submitted

to daily examinations of the optic fundi for expected signs of changes in the

optic nerves. No such changes occurred, but 1 serious and 4 mild psychoses

developed among the volunteers. Since toxic reactions to Atabriiie were

sehlIom encountered, except for occasional men who suffered from vomniting

and unfortunat ely influenced psychologically susceýptible companions to follow

suit, it was concluded that these volunteers had become confused and then, in

error, had taken excessive doses.

Toxic delirium from Atabrine, although it, was occasionally observewd, must

have been extremely uncommon. At one general hospital, Major Harvey,

chief of a section of the medical service, detected and described a group of

patients who presented peripheral neuritis, which is a little-known complication of malaria. The association of atYpical lichen planus with malarial suppressive therapy by Atabrine is described elsewhere (p. 549).

More studies would have been carried out if the two photofluorometers in

the area had beenl released, as requested, to the general hospitals whict, had

arranged for their requisition. On 27 Februar 1944, Colonel Thomas made

the following (summarized) observations to the Chief Surgeon, USASOS, on

malaria:

1. Many questions relating to suppression, treatment, cure, and immunity

in malaria remain unanswered. The Office of the Surgeon General recognizes

that manyv of them can best be sought when large groups of nonimmutie soldiers

enter highly nmvlarious areas. .hlalariologists trained in special branc'hes of malaria research have therefore been sent to the theater, and requests have been

made for observations on particular phases of the disease.

2. It is recommended that one or more hospitals situated in highly malarious areas in which environentital malaria control measures have only recently

been initiated should be desigimated for the hospital study of malaria.
SOi'TIIWESiT PACIFIC AREA 523

Major Harvey, of the 118th General Hospital, is suggested as an officer

well suited to supervise such a study because of his thorough training in clinical

medicine and his brilliant record as a research worker in pharmacological and

physiological subjects. Lieutenant Bang, is suggested as a part-time or fulltime laboratory consultant to the group of workers proposed, and Lt. Col.

(later Col.) Gottlieb L. Orth, MC, is suggested as consultant in problems dealing with infection, suppression, and mosquito control. A small number of

technical laboratory personnel will also be required.

3. It was also recommended that a training center be established, in connection with all training of divisions which had been extensively exposed to

mosquitoes infected with malaria parasites, for the purpose of rehabilitation

and further study of soldiers experiencing primary or recurrent attacks of malaria. Followup studies can be made by the medical officers attached to these

centers.

4. The last recommendation in this letter was that frequent and rapid

correspondence concerned solely with professional matters be carried on with

appropriate officers on duty in the Office of the Surgeon General.

This recommendation was included in an effort to open up direct communications between specialists working in the United States on all the problems

involved in malaria and their opposite numbers in the SWPA. Such conimunication was forbidden for military reasons, and only routine monthly medical

reports and similar correspondence were permitted. This restriction was a

real handicap in the management of malaria, and it was responsible for some

of the delay in establishing a satisfactory Atabrine regimen. Interchange of

information by airmail would have been most helpful in this and in other medical fields.

So far as is known, there was no direct action on any of these recommendat ions.

DYSENTERY

Dysentery was never a major problem in the U.S. Army while it was in

New Guinea or the Philippines. Through the foresight of Brigadier Fairley,

lhe Australian authority on tropical diseases, Australian troops were provided

with an ample supply of sulfaguanidine, which was most effective in suppressing

dysentery. On the basis of this experience, the U.S. Army stockpiled large

quantities of this drug, and, with its use and careful sanitation, the condition

was usually under control.

There were occasional breaks in sanitary technique, usually when one unit

moved away from a location in a hurry and failed to observe adequate precautions in the final 2 or 3 (lays in the area. Then, when another unit nmoved into

the same area, outbreaks of dysentery were apt to occur before the area couhl

be satisfactorily policed. Credit for the fact that so little trouble was encountered from dysentery in SWPA belongs directly to the routine sanitary measures insisted upon by the Army Medical Department.
524 A.'TIVITIES OF MEI)ICAL CONSULTANTS

In October 1943, when the hot weather became even hotter, a few cases

of dysentery were observed in Base A. In Base D, while diarrhea diminished

slightly, the inumber of cases of Shiga dysentery increased relatively, and one,

fatality occurred, after the patient was admitted to the 116th Station Hospital.

Shigdla dysenteriae (Shiga) was recovered from most patients, and treatment

with large doses of sulfaguanidine usually brou( lht about recovery.

Because Colonel Thomas had been greatly impressed by the therapeutic

effect of intravenous sulfadiazine in the treatment of another infection, meningococcie meningitis, lie was anxious to test the effect of this drug in severe

cases of bacillary dysentery, and chiefs of medical services in various appropriately placed station hospitals were requested to try it. In the only suitable

(case found, an immediate curative effect was observed.

DENGUE

Dengue was widespread in a number of areas in New Guinea. Since this

disease is transmitted by Aede,4 aegypti, which is not affected by measures commonly used to reduce or eliminate malarial mosquitoes, nothing much could

be done except to give the patients symptomatic care. Although some characteristic breakbone fever cases were observed, with the typical secondary

rise in temperature and extremely severe headache, most attacks were mild.

The short, duration of the attack and the absence of severe sequelae prevented

dengue from being an important medical factor in New Guinea. This statemuent might not be concurred in by General Denit, who suffered one of the most

severe attacks of the disease which occurred in SWPA.

SCRUB TYPHUS

One of the most dramatic( diseases encountered in SWPA was scrub typhus

(tsutsugamushi fever). Small, scattered outbreaks developed steadlily as the

fighiting progressed throughout New Guinea. A very virulent outbreak occurred on Goodenough Island, where the Sixth U.S. Army had set up headquarters in November 1944, and another very large one occurred on Owi, in

July and August 1944 (fig. 186).

Personnel of the 9th General Hospital had cleared an area on Goodenough

Island, andi, with some help from engineers, they had erected their own buildings. They worked in fields covere(l by kunai grass which, though it was tinknown at the time, harlbored the rodents (fig. 187) and the deadly little mites

that transmit scrub typhus. Some 30 or 40 cases developed among the personnel of this hospital, anl there were a number of fatal cases, one in a medical

officer.

At the time this outbreak occurred, treatment was symptomatic, and the

precise pathological lesions and deranged physiological functions were not

known or undeerstoo(l. Later, as post, mortem material was collected and it

b)ecame evident that t he widespread involvement, of the capillary blood vessels

produced lesions in all organs of the body, the signs and symptoms were more
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SOUTIIHVEST PACIFIC AREA 531

control measure in a recent outbreak. As a result of these experiences, it is

recommended that this method be used in all troops before their partic;patio,

in combat or in combat training. In both circumstances, it is considered to

offer the best protection available at this time. Engineer troops working in

suspected areas and staging troops among whom typhus has appeared should

also have the added protection of this measure.

Methyl phthalate in 1-gallon tins is now being received in this theater

for clothing impregnation. Thfle issue is on the basis of 10 ounces per man per

month. Issue is restricted to troops designated for duties which will involve

exposure as just described (fig. 192). Requisitions should be accompanied by

details of the circumstances which render the use of this agent advisable.

It was something of a triumph to persuade the fighting man to adopt and

carry out the painstaking measures which prevented scrub typhus (fig. 193).

The complete story entails the pioneer work accomplished by the Australians;

extensive research by the group from the United States of America Typhus

Commission as well as by others; overcoming Sixth U.S. Army objections to

the time-consuming and complicated control measures; and, finally, the mass

impregnation of clothing by Army laundries. The story of prevention and

control is told in detail in the preventive medicine volumes of the history of the

U.S. Army Medical Department in World War II.

Rehabilitation and disposition.-lIatients recovering from scrub typhus

were found to present a real problem in rehabilitation. The disease had acquired a fearsome reputation, and convalescent patients, as well as many

medical officers, were frequently convinced that they had suffered some permanent damage to the heart or other vital organs.

Technical Memorandum No. 10, published by the Office of the Chief

Surgeon, Headquarters, USAFFE, 29 August 1944, advised a carefully supervised program of physical reconditioning for these patients, combined with

ressurance as to their ultimate recovery, as follows:

Reassurance may be soundly based on the careful studies carried out in

this area on large series of convalescent patients in whom the physical signs,

the X-ray findings, the electrocardiograms, the vital capacities, and the exercise

tolerance tests were critically evaluated to deternine the frequency of residual

cardiovascular damage. The results of these studies indicated that therp is

no evidence of permanent organic damage and that functional neurocirculatory

symptoms were no more frequent than they are after other severe febrile

illnesses. It may be concluded that, though vascular and perivascular lesions

occur in the heart as well as in the lungs, brain, and other tissues during the

active stage of the disease, the recovery from these inflanunatory processes is

complete, with very occasional exceptions. When pennianentl disability persists, as it does in these very occasional cases, it takes the form of varying

degrees of deafness, diminished vision, involvement of the peripheral nerves,

or other residual (hanage, chiefly of the nervous system.
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S•UTIIVWEST PACIFIC AREA 5:33

r( PHUS

hmJn

YOUR AREA PAITES 

ITES LO7K LIK.E

CARRY1 LOO HITE3 

TYPHUS

WEAR LEGGINS USE REPELLENT,61Z

KILL RATS, ROPENTS BURN KUNAI GRASS.

Prevention Is the hest end on4y cure!

"I mI• ]!) 1:I. ;.ter .1i urging i" re ( lit -e me es :Ig:nillst ,cruni typhus.

duties. It, wits desired that fuill advantage he taken of the resoirces of this

center for the reconditioning of all long-term patients no longer requiring

hospital care but not yet fit for return to their former assignment. The

center provided a gra(led schedule of physical activities unler medical supervision, I hospital scale of rations, aid recreational and educational feat'res.

rliaiiiiing was carried on in an environment of military discipline until the

convalesceit was (determined to be fit for reassignment.

Careful judgment had to be exercised to be sure that patients who could

not be expected to perform any militarily useful service, even after rehabilitation, were promptly evacuated to the United States.

3. The third group of convalescents froom scrub typhus fever consists of

those who because of the extreme severity of their illness or the development

of complications would plainly bee unfit for military service withtin a period of

120 days, counted from the day of their admission to the hospital. These

patieuts were to be transferred to a genieral or designiated station hospital, to

be evacuated to the United States on tile reconumuemhdat ions of at disposition

board.
5:14 ACTIVITl1IES OF MEDICI(AL (4NSUL'PANTMs

DIFFERENTIAL, DIAGNOS IS OF ACUTE FEVERS

Mildd at tacks of (lengtie wvere (illgltosalble o1nlY by thle association of tile,

pat ienlts with 1) at wiets, Who were siifferiiig miore severe alt tacks. Thle same was,

true of mildh alttacks of miamv ot her febrile diseases enicoun tered inl New Guinea.

The diagn.1ostc (leificullt les, lin fact, were suich t hiat t he Iiedlical ser'vices inl 11a11

stat ioul i051)it i.1lS I)egalij to ('lit (,I- larIge 1i1i111liers of cases ats "'feveri of uiiidet erilmi lied

orig~in'' (FU()). At oiie t ime, t here were so n11a1 * N suchi (liaglioses thlit C oloniel

Tholionis was instructed by th1w Office of t he (he 'lufSilrgeolliHaqures

USASOS, to Iinvestigate tile miat t er. Ill everY calse whichi lie ohse ved, tilie

diluniosis was ill real (olullt , tholili.1 oceasioiill11v t here was at fairly well founded

susp~icion t hat tilie (lisease lay* inl one or' aniother special (ittrp (IZOI. Jin his

opinion, very few of these cases representtedl miildl breakthlroughi attacks, of

mialaria.

Ill view of tilie impilort ance of accuralte ('lassificat loll of disealse, bo0th for

proper treatmieiit and~ stat ist ical puirposes, Co'lonel ThIliouits prepared tilie

follouvingc (suiI III arizedl) mlat erial Oil tilie (differenitial diagiilosis, of aculte fevers,

Which wals publdishied ats Technical N\ Iemioranduinn No. 7, Office of th1e Chief

Surgeon, H eadq(uar'ters, USA.SOS, 21 March 1944:

Malaria. A p)osit ive smevar solildl he Ob~taiuied inl as many11, cases of mlalana, ats possible. if tilie first smlear. is iieg-ative. add~it ional smevars shold~i~ 1be

taken at da1viynit ervals. If' thle genleral condlit ion is g"oodl, it is proper to

withhilold t rea tileit or several la ,vs in til he fror to get a1 positive Smlear, hutt,,

wheleever thIns is (lone, thle pittienit mu11st he watchied very' closely; liti primary

f'lllci pa run Il inflect ions. atlthI ough impa asi tes mna , ylbe verY scanlt Y inl thle perip~heral

blood, lie mlay p~ass, in to at serious (condiition withIan a few hours.

Thle (lesii'al)ilit v of' ge(t tilig a1 loSiti( Sivesear- befor-e anit imalarial treat menit

is 1)e(lillfii mst not prevelit treatnielit ill til * patieiit who p~resenits svniptoins,

st roligdy suggestive of ma211-lari, pall icimlarly at t ert iaii fever. Such cases

should be reported ats ''nialaria , chliical (hiliglosis. '' Symptomls of' cerebral

mialariai deillaiid prompt t reatimlivi l, ir'respectivye of whtat tilie smevar show~s.

With hohIi ng 511 pprevsi ye At abrinle for 2 or :3 (lat*ys inl anl efrort to get 2,

Positive sinlea i is li kelyv to be i neffectivye. Wit Ii holdinlg thle drugIl foi' a longer~q

period is 1u iijlist ified.

Whieni Pat ivis aire t reated oil thle p~resuimptioni of malaria wit hout at posit ive sinlear andi( tilie temlpera ttire does not remain iiornial after- 48 lionrs- of

treatillent , a nothI er cii use for thle fever shol b01(1le serioulsl v conisidlered. Some

p~atienits withI aai will run at fever for 3 or more (lays, it is true, but theyN

colist itiate only v a 5it smal groulp.

Dengue. 'ThIiis pirot ean di(isease is charact erizedl 1) '5 to 7 (llitvs of fever,

vit her so-callledl saddleback or colit imious; lieadaeclie; 'et ro--orl-itail lailt mil(OII h(t iviti shliflisioli ; hiackalice a11(1 penn r1t icula rl liilscill~irl pailis ; iiid at rash,

which lisumallY appears Onl t(le fourlt il to thle sixthI day. While t here is consideleiblle vii lriut iol ill thle seveni , v oh' ,Vi vijitoins and( (ihmlit ioli of' fever, thle

diagniosis of, (lengue wh~eli thle t ehlellit walre elevattion lasts less t iltn 4 (lays
SOUTHWEST PACIFIC AREA 535

should be viewed with suspicion. Very mild, afebrile cases of dengue probably

do occur, but the differentiation of them from other short fevers is not reliable.

Upper respiratory diseases.- -Common nasopharyngitis, sinusitis, tonsillitis, andi bronchitis are usually readily distinguished as such if the examination is a(dequate. Fever may persist for several (lays. Upper respiratory

symptoms are usually minimal in dengue. At this time (March 1944), influenza had not yet been recognized in the forward area.

Diarrheal diseases.-Diarrheal diseases are usually readily recognized.

Fever is frequently associate(d with diarrhea and usually associated with

dysentery, but diarrhea also occurs in malaria, dengue, and typhus. In tile

(liarrheal diseases, fever and (liarrhea either begin together, or the diarrhea

precedIes, rather than follows, the onset of fever. The degree anid duration

of tile fever may be out of proportion to the number of bowel movements.

Effects of heat.-Certain persons, particularly if unseasoned to hot

weather, may develop fever, headache, abdominal cramps, and muscular pains

after working in the heat. The picture observed in New Guinea, however,

frequently does not correspond with textbook descriptions of heatstrokes,

heat exhaustion, or heat cramps from loss of salt. Diagnosis should not be

difficult when tile history shows a definite relation between the onset of symptoms and heavy work in a hot atmosphere and when the response to rest and

tile administration of salt is prompt.

Typhus.-Typhus may be difficult to diagnose in the first few days of

the illness. The onset is likely to be more gradual than in dengue, with the

fever rising gradually for the first 2 or 3 days and then persisting for 10 to 14

(lays or even longer.

Helpful points in diagnosis include the presence of an eschar, which can

he found on careful search in most cases; adenopathy, particularly if it increases over a period of a few dlays; and the rash. Confirmatory evidence

is obtained 1)y agglutination with Proteus OXK, which is usually present by

tile 10th (lay and which reaches a maximum 2 or 3 dlays after the temperature

has returned to normal. A titer of 1:80 is considered suspicious, and a titer

of 1:160 or greater is usually considered diagnostic. The diagnosis of typhus

when the fever lasts less than 10 days is seldom justified, and the same holds

for cases in which the fever lasts longer but there is no eschar and the OXK

agglutinationl is negative.

Enteric fevers.-Only a few cases of the enteric fevers (typhoid and

Salmonella) have occurredl up to this time, but these diseases must nonetheless

be borne in mind. They 'ae to l)e (list inguished from typhus by the absence

of an eschar; tihe (lifferences in tihe skin rashes; the negative Proteus OXK

agglutination; tile increasing titer in the Wi(lal test; and positive blood, stool

urine cultures.

FUO.-The differential diagnosis of many of the fevers mentioned cannot.

be made on admission. In cases of short duration, the diagnosis is often best

made when the patient is discharged, when the clinical course, tile symptoms,

and the character of the temperature curve can be carefully reviewed. Even
53(6 MAIVITIES 4W1 MEDIICAL. CI)NSU.T'ANTS

then1, a tI e ifaIvl clinricall a ppra isal may still i ot manke it possiblde to l)iace thle

calse ini aliy pll-tiicuriar cat egory.

Cases of' this kinI id ma be recordedI as F'U(. Even iiiider wdverse -onl-

(liti1011, howver thle nin iiher or cases thl~us diangn osed shi 11(1 riot const itut e

more thanit 10 to 20 percent of' aill febrile admilissiolls.

INFECTIOUS HEPATITIS

Infecit eouts liepa t itis bega ii to be at probleml ini thle sprinrg of 1944, withI

thie dlevelopmlei t of* isola t e I caises illi areals 1,1ar remiove( l fromi eachl ot her a 11(1

with Io 1 i0pallarerit riietb1(1 of spread(.

Th e firist hi rgev group of' cases whIiichi uiglit he dlescrible(l as epidlemlic ocen rred(1( ii thle tatsk f'orce which inii vaedI thle nieighiborinhg islands of' Bialk aind

()Wi, arleals inl whichl at scrub tyvplius epidlemic 111)(I occuirr-e(l. Althlouighi a few

caises of, I epa t it is (le velopedI 1 efore thle first caIse' of' scrub1 t yphuis wats olbserve( I

frlont thenl oil, thle two outhlreaks paraolleledI one ariot her unttil thle scrub tYphus

wals coit rolle(l by elintiui t i g thle mit es, whIic Wcitws anecotipJlisl iedI hy clica ii g"

metIl scrubil gr()wth 111and taill k umiai groass, amt(l by inip~regmat inrg clothliing withI

iethl plih tlialate. Ill Juily, August , andI Sept emb~er 1944, thle outblreak of'

iii feetolous, hiep~i tit is lissui tie( I not aide prtloprt ions.

The in vasioni oh' L~eyte took place just aftr thle height of ft(li outhbreak onl

( wi , a11mid all thle liospi tials ill thle Leyt e alreal receivedI a great ma nv paitienits,

sutffer-i ig fr-omi I epa tit is.

Clinical and Elpidemniological Studies

WithI thle cotncurrenice of (Coloniel 11 aginis, Sixt Ii U.S. Arriiyý Surlgeon.ý thle

outbrevak of hiepa tit is in link a rd ( wi was st tidie by I\n lAj.Jaiis L. bonnd,(1

N IC, gnist roent erologist fronii thle I O5th IG erneral I lospi t al, an( LitI. C ol . (Inter.

C ol .) Will iam iii . Va ridlergrif't , A\IC, (mIid ie, L born toryr Service, itIi (sl Genieral

I lospi t al. They spent a bout 6 weeks in A ugust rad AIvSp neii llr 1944, collectilig

in lrot-im t ion, observinrg patlei v t s, a11i(l tanking e\ iii rst i e labhora tory tests.

Thier' also ati iiipt ed to cultIiva te at virus. Th'leir jprelimiiiria reports, which

iricli(le(l all1 thle (In ti a availa ibe, wereT Seli( t0 (1lie Smrge,"Ohi , Six thi U.S . Ar ilii

Ocetober iilil Novemiber, andI t heir finail rep~ort was senit to ftle(' 'Iiief Suirgeoni,

U'SAS( S, Is D ecemb 'er 1944.

While ill Brisba ne, C oloniel Tiorniis preparedI initein acn for thle area ETM\ 1)

(Essentia l Techniical M\Iedlical ID1a11a) a1( tid lso wrlote Techinical Mvleriorali(lirI1

No. M,. which wa-is publishedI onl I Ocetober 1944 by the O)ffive of't ilie( 'lief

Surgevoli. I leadq nlilt (1-5r, 1 SAFiE.. Thei (Intil oil infectiomis hiepatiltis coriti. irie(

ill thlese various reports 1and( ot her pubhicat ioiis fiily be suniiitiarized ats follows:

Historical note. ( )m it reks of jan iiialce lhav e beenl repl-ot ed for ait least

I 00 rear'-s 14 atidhve been parlt icnilarly rumiierouis ill Ilmiliies ill wartimie. O ver

52J011 (ses Were reported in thle W tion hnq-ii Munrg thle ( 'vil WAM ini lie

cour~se of 8; years. (hit brealks hanve occur-red ini WorldI Warl II ill Brit ishi troops

inl thle Middile Ealst amid( aniiolig U.S. t roops in Northi Africat and~ pri-ict cilly all

ot her a ieiis.
SOUTHlWEST PACIFIC AREA 5,11

Epidemiology.--Opportunity for study has led to increased knowledge of

this disease in recent years. It is now believed that tile etiologic agent is a

filterable virus or group of viruses, although attempts to cultivate it (or them)

have been unsuccessful.

The disease has been passed from patients to volunteers by several methods,

including nasal insufflation and intracut aneous inoculation of serum and whole

blood. More recently, filtered excreta have been shown to contain thle virus

and have produced the (disease upon ingestion by volunteers. This observation has introduced an important concept concerning the possible transmission

of the disease by contaminated water or food.

The special epidemiologic studies in the investigation, just referred to, of

the outbreak on Biak and O(wi revealed no common water points, swimming

areas, or messes. The affected units were not ill closely adjacent areas and

had no common meeting places except occasionally at open-air motion pictures.

There were no common prior staging areas. The only Navy personnel who

developed the disease had been ashore in the involved area. It was concluded

that the virus had probably %been brought in by U.S. soldiers and sailors and

that the variety of spread pointed to a vector. The common fly and a species

of Phlebotomnu. were suspected, especially the latter. The incubation period

was between 3 and 5 weeks and was most often 4 weeks.

Clinical picture.-When infectious hepatitis occurred in outbreaks, the

clinical picture followed a definite and characteristic pattern. The onset in

the majority of cases was characterized by fever, often followed by a latent

period during which tile patient might feel perfectly well. The onset might

also occasionally be characterized by a chill, headache, and general malaise.

Then would come an acute phase, from the fifth to tile seventh day, ushered

in by anorexia, nausea, sometimes vomiting, weakness, and pain in the upper

abdomen. Jaundice ensueid, associated with an enlarged and tender liver in

about two-thirds of all cases and, occasionally, an enlargement of the spleen.

About a third of the patients had a slight temperature elevation at this stage.

About a thiir(l of all the patients ol)serve(d had n1o history of a preliminary

febrile stage and became aware of tihe disease only when they not ice(I yellow

seleras or dark-brown urine, usually associated with a distaste for food and

slight lassitude.

In from I to 5 weeks, the jaundice began to clear, and recovery was usually

rapid, lasting not more than a monthi. The mildness of the illness and t i'e

length of convalescence were thiought to be directly proportional to the aiiiount

of rest. Patients kept in bed on Owi until tile jaundice finally (leared practically all did well. The only fatalities and complications occlurred in patients

who were evacluated. It was thoughit that return to duity before tile jaundice

had fully cleared predisposed to relapse and prolonged tile convalescenice.

In the occasiolal fatal case, a sudden lapse into delirious seminomi took

place 4 to 10 days before death occurred friom acute yellow atrophy of the

liver.
5:~~8 Ac'PivITIE'S (I F MEAIII(AL CO NSUL~TANTS

lit Deceiib er 1944, Colonel Thioiiias ob~served1 two fpl t ents Oil Levte who

di edl of jalliill ice with Itii iiIS1iia finidiings. 1100 di(ied slli(IenYItIV 11( ii llexjectedli'v

lift er. t hey 1121( lbeei jauld~icedl for ") (Ill bSIefore adiiiission land 2 or :3diy(2 s III

tlie iosfi hil .Necithe I idP f11(ever, lantd liitether wats a pparezi tlyN very Ill. Chlit -

(11illY tlie( cliltse of (eleth wni WII 2'iitv (' )iiiitItIii' e(leillial Ill btoth I~t C2e, 2luitop5 %

showed thlint 21111 live lobes of th lielungIs were totailly, involved in) all elkirlv bl)ood ,lX

pleleiillOia lim.Te I rliteli 211( lan boitcli were Palile landiid (li t 10 colit iilil pus.

()It(' J)lItitent I11liadeI110orrII210ges t hroughiout thle kidnteys land ill thle ilitervetiIricuihl. Sept 11121, suiggrest jug at su~ddent cill'ldillc (JellbII, but1 t hese ft ndings were not1

presei ill lie secontd caist. No p litiogerts (plagu e baicilli) were p~resent inl

siii ('ir5 fromi tilie muilgs, bult inzcluisiont b)odies- it wenlk reedl to leam 01 o11 were

stispected. The liver iii eatch inlstiazice showed Ilitii iflil 11161,lorrii clouidy swellilzig..

Diagnosis. D~uring thle outitreAi of in fectitous liepaitit is, it wa-Is p)ossible

to susp~ect tilie correct (liligiIlosis d iir-ing tilie early-. febrile stalge. ('oiifirznaltionl

wats olbt ili nel IY ol)servilt ionl of bile ill tilet iiriile severall daIYs before jiliulldice

beca iii I evident.1

No hiist 211ce of WVeil's (liselise (infect ious hiepattitis caused by Leptospira

idero1i.(u'morrhafliae) wvas found1( iii these oiltblreik~s. The organ t5sil, hlowever,

wats isolated froml three natives of New (ininei Iby it U.S. niedlictd officer.

Inl elie inst 2111CC, thle cliiciicl picture wais typicid of Weil's (liseaise, aind( till

tile pitients respond~ed promptly to treatnicilt with 1)eliciillinl.

Treat ment.-Tre t lit ntt of infectious hiepaititis con~sistedl chiefly of rest

Itld i( lt. R~est ill bed %vus en forced ats soot its the ectidit iOu Wits suspected,

and( miiilecessiirv mfovemienit of the pat ienits Wits strictly p~rohlibit ed.

It wa-is of maijor iflhlortmiicC thait at sattisfitctorv stalte of lntutritioll be ma1inltniniedl. The (diet wats kept low ii failt, but1 t he aildlit ion of simall limloun t of

milk, cremni, or but ter wits permissible if thle illcrelisedl pallatalbility thus obtaliliedvll eiilled tile paitienit to eait mlore food. Polvvitaminl caipsules were

21(11111 iist erell t wice 21 (lily.

-Fluids were taiken freely. If vomniting initerfered with il aii in(ellte intlake,

5-percenit gilucose ill phlysiologicall sailt solut ion Nviis injectedl itiitrvenously*

inll 1ouilit 5 suifficienit to 21dcei dtl outpjut of 1,200O (ce of urine. PlaSmlil

w'.It of p~ossible V'itiate ill tilet presenice of aiscites, but this compllicaition wats

bothi latte ln 1111(1suillil.

Whenl thle hospitails Onl Leyte begain to receive paitients with infectious

hlepaititis, wounzded soldiers reqjuired major aitteiitiolt, will( ninny of the patients

with hepatitis, who were less seriously ill, were tranlsferred ra~pidly to at large

Coll v2ih'seelit h1ospitali, long" before their jliililice land cleatred u21111 Ilitd illsom

instill ievs evei i before it hald Ileglult to lessenl. Ill t Iiis hospi t 11, tilie paitients

weeforced to watlk loll, (listIMP 10ice toand fron1 Mealds. They laizu absolutely

no0 ii IrIsill zindre 2111(1 (Venl hill to In ke cakre of t hei r ownt beds.

It wats jinterest ing to ( oloziel Thontas land( ot hers, who were watcehing

hiis sit 1121 Iionl withI sonlie miisgivinigs, to note (' t(li t Ihese pit ielits 5wenit onl to

compillete recovery wlll t hat very few de veloped seriotis comtpl icaitti)115. lii

01 Ii fewcus C (14 fid5 Ihe (liseiis(' jororess to tlie( ('triil'ni st~it~xV. nieI fillIl wordl
smI1IIWE5'r PACI FIC AREA 539

onl these cases~ couldt, of course, come onily fromn followuip studlies, which were

not Ipraictical.

While hie wals oil Leyte, Colonlel Thomits receive(I some of the voluminious,

rep~orts onl st udies of hepatitis ill thle Medfiterranleani theater. Thle military

situiationl onl Leyte 1)reveiitedi followving anly of tile recominemildatiloll's coitainiedl

inl thesse rep~orts, anid thle cases juist dlescribed therefore may lhe conisidlered

to haive serveti ats at rat her nit crest itig cotitrol series.

Control.- Reconuuetda tion s for conitrol of infectious hep~atitis, Colonel

Thomats poiiite(l out inl his October 1944 relport , were tliflicuilt to mnake inl tile

present statte of kniowledlge. It wais thought that tranismission might be by

tiroplet inifect ionl, but at temp~ts had also been matle to incrinunate, anl insect

vector. Onl the other handl, denmonstration of tie. infecthing agenit inl the stool,

and possibly inl tile urine, of patients with tile (lisease suggested thle prime

impl-otanlce of mletho(ls (lesignlet to pIeveiit. contatmintation of i *ter and food.

The following, recommendations wvere therefore made:

1. All the usuial sanitary measures should lhe strictly eniforced.

2. Batittiig inl fresh-wNater streams siloulti b~e prohibitedl.

3. Hospitals slhouldl inistitute the isolation measures used inl typhoid

fever, withl proper tlisinifection andl disposal of patients' excretal. Nurses

mid( wvardl attenidantts should wash their ilands thlorou~ghly aifter every contact

wvith at patient or hits excreta. This recommendation was most important,

for several nurses had1( conitractetl the disease inl hospitals inl whlich tilese patien t s had lbeeni cared for.

4. Sinice the (luration of inifectivity was unknown, p~atients shlould b)e

instructedI to ob~serve special measures of cleanliniess (luring convalescence,

to avoid possib~le cowntamination from their excreta.

AMEBIASIS

lIn June 1945, Coloniel Thomas paid at sihort return visit to Leyte with

het( (Iolille object of facilitating tile work of tile subeommissionl 1111( other

groups5 stutlyinig schistosoniiasis and( of setting ili) it stui(ly throughout the

b~ase onl aleibiatsis, wvith plarticular reference to its prevalence and tihe correctness

of dliagniosis ati(l treatmlenit iil the various hospitals.

Thle amnebiasis program Was accomplishied b~y airranigeneilts with the

Ihiise aireat surgeon to have Col. James Ilordiley 111, MIC, Comnmanding Officer,

I1 iit Geiieral H~osp~ital, instructed to malke at survey mid~ submit at rep~ort

onl t his (liseatse. lin addition to fact finding, ('oloiiel iordiey, inl thle course

of his invest igat ion, wa-is ab~le to (lissenlihiate at great deal of useful iniformat ~io

a11id to inistittute vallualble clinlical an1d followuip st uIdI I(es.

Essential Facts of the Disease

Tile following facts are taikeii from at lecture oti tile subject which Coloniel

Bordley gave at the Office of thle Surgeoni, Base K, 25 .June 1945:

Incidence and epidemiology.-Ani increasinig incitlence of amehiasis

has beeni rclporte(l inl Base K anilong- hospital patients, inclutding not on~ly cyst
540 A'TIVITIIE (F .1I•ILM.\I, CONT'.TA.T,

carriers hut patients with active amelic dysentery. This increase may be (lite

inl part to greater awareness of the (lisease an(l better diagnostic study of all

patients with diarrhea or abdominad complaints. Cases which formerly escaped attention have unquestionally been brought to light by (1) multiple

stool examinations and rectal smears, (2) more frequent use of the sigmoidoscope, and (3) more frequent surveysof foodhandlers. The incidence of amebic

dysentery is relatively, though not alarmingly, high at this time.

As far as can be determined from recent stool surveys of the civilian

population made by malaria units on Leyte, the cyst carrier rate is somewhere

between 5 and 10 percent, no higher than might be found in certain sections of

the United States. Possibly these figures are too low, since the surveys were

not made with particular attention to amebiasis. There does, however,

appear to be an alarmingly high carrier rate among civilians, though nothing

approaching the high rates reported for Schistosona eggs and A.scaris.

If the amebic dysentery rate is high (in troops) and the cyst carrier rate

is low (in civilians), then there nmy he some special explanation for the dysentery. It is known that in experimental amebic infections in animals, dietary

and other factors may play an important role. According to Faust, there is

no evidence to indicate that the anuehic organisms in a community may suddenly become more virulent. It would therefore seem that a high carrier rate

(in the Army) associated with a relatively low carrier rate (in the population)

must probably be explained by factors other than the virulence of the organism.

Among these factors may be:

1. Decreased host resistance due to combat conditions and injuries and

specific debilitating (diseases prevalent here, particularly infectious hepatitis

an1d schistosolniasis. A 34-year-old sergeant, for instance, was adlmitted to

hlie 118th General Hospital, 2 January 1945, 48 homrs after the onset of chills

and fever. He was jaundiced and had an enlarged, tender liver and an enlarged

spleen. On the third day of his illness he developed abdominal pain and diarrhea, which were thought to he part of the symptomatology of acute infectious

hepatitis. He died on tie 10th day of hospitalization, after a stormy illness.

At autopsy, lie presented what vWouhl be interpreted as an extraordiniarv example of reduced host resistance to E. histolytica. Tliere was an enorniotis

swelling, with extensive ulceration, of tile wall of the colon, all layers of which

were heavily infiltrated with tile organisms, which had also infiltrated the walls

of the small niesenteric arteries and veins, with resultant thromboses, and were

also present in tile regional lymph nodes. The liver was studded with small

necrotic and hemorrhagic foci containing anlehas.

2. A large infecting (lose. There was certainly ample opportunity for

very considerable contaminiation of drinking water during tile early days on

Leyte. Because of the shoi 1,age of potable water, shallow wells were dug hurriedlly in populated areas, am1I there was great difficulty in keep)ing theni from

becfumfing contaminated by surface water d'uring the heavy November and l)ecenhber rains. The experience of the 133di General Hlospital was typical of

tle results of these comlit ions. This unit arrived soon after tile landing and
SOUTHWEST PACIFIC AREA 541

began to establish itself in a populated area on the highway on the southern

e(lge of tile village of Palo. Personnel had constant contact with muddy

ground that had been the repository of the feces of the displaced populace.

The native lal)orers (doubtless contributed further to the contamination during

the early period of hospital construction. Flies were all about. Meals were

prel)are(d and served in open, unscreened tents. Water came from 10-foot wells

dug in low ground, where the ground-water level was only 2 or 3 feet below the

surface. Amebic cysts were actually found in a sample of water from one of

these wells. The report is perfectly credible, since none of the native huts removed from the area or still surrounding it had any sort of latrine. The well

couhl easily have been dug through earth which had once been an informal

latrine for a native family.

It is not surprising that the incidence of dysentery was very high among

the original personnel of this hospital. It was extremely difficult for them to

st aff their kitchens and messhalls because a survey of their foodhandlers showed

that 23 were aniel)ic carriers.

A stool survey was made of two groups of the personnel of the 133d General Hospital by Mlaj. (later It. (0ol.) Irving J. Glassberg, ,MC, of the hospital

laboratory. In the first group were approximately 200 officers and men of

the original contingent whichl had been so heavily exposed; stools were positive

for E. hIstolytica or trophozoites in approximately 37 percent. In the second

group were approximately 150 nurses and enlisted men who had come from the

Unite(d States to join the unit about 3 months before the survey was undertaken. In them, the incidence of E. hi.itolytica was less than 2 percent.

Conditions at this hospital were subsequently improved. Natives were

moved from the immediate area. Water was piped in from the mains of the

Palo municipal water system. Messhalls and kitchens were adequately screened

and flies reduced to a minimum. Tent floors and raised walks, finally, kept the

personnel out of the mud.

Base K served as a hospital center for both combat and garrison troops on

other islands and received large numbers of patients from Mindanao, Mindoro,

Cebu, Negr'os, Luzon, New Guinea, Palau. and other islands, on which the carrier rate was unknown. The sanitary conditions on some of the more recently

occupied islands were still much as they were on Leyte during November and

December. Many of the patients hospitalized ati the 116th Station Hospital

were members of a combat division said to have acquired their infections in

Palau.

Diagnosis.-As was generally suspected, the most recent survey of hospitals

showed a wide divergence of understanding about the reporting of aieliasis.

In conformity with Army Regulation (AR) 40-1025 (12 December 1944). there

were three choices: (1) dysentery. amebic; (2) amebic infection, nonintestinal

location: and (3) E. hi.tftolyf/ca carrier.

The survey disclosed that earlier a number of cases had been reported as

amebic dysentcry instead of amebic infection. Over 900 patients were presently under treatment in hospitals for amebic infection, but there seemed to
542 ACTIVITIES (OF MEICII(AL CONSULTANTS

b)e not more than 167 cases of amebic (Ivsenterv among them. A certainl proportion of these patients undlouiltedll: hadl nonspecific diarrhea, awl thoroughi stool

examinations hiad dlisclosedl a fewN amiebic organisms.

"Ifile (lifferenit at ion bet ween truei( ameiiiei lvsefl t ry and dliarrhea in a mebie

carriers is not always easy. Furthermore, the aIccuracye of thle (liaignosis canlinot always he dletermnined by reviewing~ thle case recordls b~ecause tile clinical

nlotes5 oft en tire not suifficiently (let ailed. Ini quest ionalble cases. t lie diagnosis. or

alleicdsnery canl best beetbise ydmosrtn tile typ~ical uilcer's

throuigh tile sigmioidoscope or by studying the character of the exudate (pus

an1)100(loo) in tile feces.

It is thierefore strongly recommended thalt. pairticulair attention. be paid to

the character of tilie excretal and that siginloidoscopic examinations be lperformued

Its oft en as necessary. If at patienlt withI acuite diarrhea (lops not have bllood

and ]I)tS inl his feces and (does not present dlemonstrab~le ulceration of the lower

bowel, tile primary (diagnosis should be recordled its '(ijairrlica, cautses Undletermulinedl, alcute",' and1 the secondary diagnosis as "'E. histodytica, carrier.''

It, mutst, of course, be assumedl that the specific bacteriall dysenlteries have

been ruled1 out lby culture of the stools before this (diagnosis is makde. The

reports aill seem to indlicat e at surprisingly low incidence of lbacillary dysentery

onl Leyte. TbIus is puzzling in view of thle sanitary conditions which prevailed

(luring tilie first several nionths after the lainding. In November and early

Decenmber 1944, many cases of acuite dijarrhea went, unreport ed andl were

cert ainly not adequat clv studied. Aniong p)ersonnel of the 118th Generail HosIpitial, which est ablishedl itself in November in ain areat not much b~etter than

that dlescrib~ed for the 133d General Hospital, dliarrhea wats very common, buit,

it, wits seIldoim accompanied by fever or constitutional symptomis. Mlost of

time personnel accepted it andl(ldid not report sick. Many, durimi- severall noc.-

turnal air raidls, were personally faced with thle (decision whether to take the

long, muuddy walk to the latrine or to head for tihe slit trench. Yet t here wits

no bacillary dysentery, at.t least. of at clinically recognizab~le type, lbecause of

settling inl ;In areat of pool- sanitation. Perhap's sonmc of this good fortune wats

due to tile fact. that tile sulfa (drugs were handed out. liberally to time p~ersonn~el

of miost units.

Unlike lbacillary dysentery, amuebic dysentery (hoes not, make its clinical

appearanlce during tilie ealrly, poor-sanlitaltion periodI of a1 campaign. This

should be borne inl minid~ in making the diagnosis. Owing to the long and var.-

iable incubation period, manifestations (10 not appear for weeks or months,

whereas in b~acillary (lvseit erv, the incublat ion p~eriodh is usually 2 to 7 (hays.

In volunteers who Were fed amieb~ic cysts by Walker and1 Sellards, tile inicuhati1011

p~eriodl varied between 20 andl 100 days. The prevalence of amuebic infections

is thierefore likely to b)ecomie evidlent gradu ally and1( insidiously, ats inl tilie faimuolns

Ch'licago ouit h)rea-k and1( is hmappenedl onl Leyte. There wats nione of thle expliosiveniess which clharacterizes out breaks of b~acillary dy~sentetry.
SOU)TIIHWEST PACIFIC AREA 5443

Results of Survey

Colonel Bordley's final report contained a (Ietailed survey of the various

hospitals studied; an analysis of divergent methods of diagnosis, including tile

use of such devices as purges, sigmoidoscopes or proctoscopes, and an elongated

glass eyedropper for collecting material for microscopic examination; techniques

of treatment, including reported successes varying from 60 to 100 percent in

ridding feces of cysts and trophozoites; and criteria for cure, disposition, and

sanitary precautions.

The survey created a great deal of interest in the hospitals on Levte and

raised the standard of medical practice in this particular disease. Had the

war lasted longer, the usefulness of the investigation would have been extended

to other areas.

colonel Thomas and Colonel Eppinger prepared a technical memorandum

on amnebiasis which was issued on 21 November 1944.

DIPHTHERIA

On his way to Australia in October 1943, Colonel Thomas had stopped

for a brief visit ati the 18th General Hospital, then stationed in the Fijis. ('ol.

Benjamin M. Baker, M(C, Consultant in Medicine, SPA (South Pacific Area),

gave him a full account of the prevalence of skin diplitheria in that area. Many

of the early cases had been missed in the wards of the various hospitals scattered through these islands, but when Iiedical officers were alerted to the possibility of the condition, many more cases were brought to light, and the diagnosis was confirnued by culture. When he arrived inl Australia and later went

to New Guinea, Colonel Thomas passed on this information, particularly to

officers of dermatological wards in which cultures of suspicious lesions had been

miald(e.

The first active cases recognized in SWPA were observed on visits to

Finschhafen and Hollandia in October 1944; there had been small outbreaks

in each of these locations. Previously, cases of peripheral neuritis following

skin ulcers or so-called jungle rot had been suspected but not proved to be

caused by the toxin of the diplitheria bacillus.

The following (summarized) information was prepared for Technical

\Iemorandumn No. 17, issued by the Office of tie ('hief Surgeon, Headquarters,

USAFFE, 23 October 1944, and was also included in a section prel)ared for

ETŽ% [D's:

1. An increase in the number of reported cases of clinical diphtheria has

recently occurred in SWPA. In one base, there hlifs been a small outbreak

of the disease in a virulent forni involving the larynx and bronchi. The attention of medical officers is directed to these facts, so that individual cases mav

l)e promptly recogniized.

2. In tropical areas, the diphtheria bacillus attacks the respiratory tract

I)ut also, not infrequently, attacks any ulcerative skin lesion or open wound.

TTechnical Memorandum No. 20, Office of the Chief Surpeon, Headqruarters, U'SAFFE, 21 Nov. 1944.
544 ACTIVITIES OF MED)ICAL CONSULTANTS

Its presence in such lesions may readlily go und~etected. In somne. instances,

out breaks of phar 'yngeal dijplitlieria have been tracedl to contact with cases of

(liplithlerititc skini infect ion.

:3. The frequent occurrence of p~eripheral nerve palsies and pharyngeal

lparailYsis due to (iliptheria hils also been rep~orted h'oin another trop~ical atrea.

In slnie inistanices, investigation of thie cause of thle motor nerve lesion has led

to cultunre of the throat or of the ibase of skini ulcers which provedl positive for

viruilent dijplitlieria bacilli. The possibility of t his association should be borne in

mindi~.

4. All patients with sore thlroats should have throat cult ures taken when

they are adlmittedl to tile hospitall and should be isolated pendhing receipt. of t he

lalboiatorY rep~ort. All skin lesions or infected wounds with susp~iciouIs charlacterist ics should also he cult uredl, andl necessary isolation should be maintained

until the lalboratory rep~ort is r'eceivedl.

5. Throat cult ures, nasophairyngeal culitutres, and cultutres from) gra nua

tions at t lie base of ulcers or infected wounds should include routinely streaks onl

Lofflier's mjedia or other media selective for (liplit heriat bacilli, such as trvptalsetelhInnt e p~lat es if t hey tire available. Whenever njecessary, hospit al commlandlers

Should requiest tile aissistance of thle nearest mediical laboratory in the Army or

tlie CoilmIIunlicat ions Zones in establishing this technique. All positive c-IIItures ob~tainied in hospital lab~oratories should be forwarded to tile nearest

mnedical laboratory for control and for necessary virulence tests.

6. Hiospit al commanders should inmmediately report tle~ occurrence of

clinical lipl)it heria in their coimmiands to thle. Base or Task Force Surgeon. Thle

inst it ution of nmeasures to prevent thle spread of thle disease wvithin thle hospital

'Ind in ot her units of the command is the responsibility of the Base or Task

F~orce Surgeon.

A few isolated cases of diphitheria were encountered in New Guiniea and in

the Philippine Islands, but the disease caused no further serious trouble..

POLIOMYELITIS

The first cases of poliomnyelitis enicouniteredl iii SWPA were ob~servedl onl

Leyte in Novetmber 1944. It, was kinown that thle dhisease is endlemiic in thle

Pliflippine IslandIs, and1( that it miighit assume a particularly deadly formn in the

ILS. popuilat ion.

When thle first cases occurred, it was thought that they might, represent

One of thle mlore unconimmon Varieties of virus (hisealses, such as Japanese B

disease or equine euiceplialoiiivelitis. For t hese reasons, onl 20 November 1944,

tlie Surgeon, Sixt h U.S. Arzm 'v, requested tha lit teani he sent to Leyte, to

st udv thle out break. Colonel Tlioimuas was dlisp~atchied withI this t eani for thle

pinrpose of mainking clhinicadl observamt ions onl t lese cases. Two virus bacteriologrists, an ep~ideim iologist , anI en tomiologist , and four specially trained laboratory

eeclliiiciauus dhepart ed fronti New Gruineat, 25 Novemb er 1944, and arrived ait

Tacloban 48 hours lauter. All imeimbers of the teami excep~t Colonel Thomas
S0UT1hWEsTr P~ciFi( 5RE 4 5

were personnel of tile staff Of tilhe I 9th Medical General Latboratory. A report

wats sent to thle Chief Surgeon, USASOS, onl 17 December 1944. Tile following

(sumunarized ) (fatt atire tatken from it.

Incidence.- -Between 1:3 November and 17 December 1944, 4:3 ciises were

observed in U.S. troops onl Leyte, in personnel of Army and Ma\hrine Corps

uniits Scait tered lalong tile, easterni coast from Titclobain down b~eyond Dulag

to Abuyog. The cases were sciattered throughout the task force, lbut no0 orgainlizatto Iiu ad mtore than one case except for a howitzer baittailion of' the Miirine

Corps, which 1111( two caises. In 33 calSes, there wats residuall parly-13sis. In

thle other 10 cases, the symptoms amid signs conisisted of headaiche, palin in tilie

lumbiar region, weakness, fever, and ain increased spinall fluid cell count, but

there wa1s no residulla parlallysis.

When three of the first five paitients died early in the atcute stalge of the

(lisealse froni bliull~r involvement aind at fourth died aifter 3 weeks in at respiraitor,

helt virulence of thle lpreva1iling mnicro-organism couldl not be dloubted. Subsequently, miilder calses wvere Ob~served. The niortaflity ratte among troop)s

p~reviously st aged in New Guineai, who were fighting in thle nort herni pairt of

Lev* te, wats ext renmely high, W1 p~ercent , whereals am11ong troops stagedl in Hawaii,

who wvere fighting in the central part of Leyte, it, wits unusually low, only 5

percent.

Ultimately, the rate per 1,000 averaige strength in the Philippines wats to

rise to 0.4:3 in 1945 and 0.84 in 1946, til inicidlence not, exceedled in the Armyv

until 1947, when it reached 0.98 in Korea.

Diagnosis.-Speciniens for virus study and for gross and microscopic

examinan~tion were obtaiined froiit autopsies in six cases, and tilie virus teaml,

in ii alit ion, collected stool land( bl1oo( specimens froni paltients wvith t he disealse

aks Well ats fromi suspected aibortive catses and froiii contaicts. Injections, were

maiade nmiiedliattely into hi boraitorv aninials, including nionkeys fromt at neighborhig island, aui(1 material front aill sp~ecimiens wats sent to thle I 9th Medlicial Genleral Latborattory and thle Army Medical School latborattory. Prefil nmalry

reports of tissue eximliulintions promptly confirmued thle clinlicall diaignosis.

The virus of polioniyelit is wats isolated at t he lalborator~y of tile Arnly

Medhical Scol rl edcl etr Wisinti, its ell ats by Dr. John R.

Piaul, Director, Comnmission onl Neurotropic Viruis Diseases, Arm.Ay Elpidetniologcail Boaird, from two fatald and two nionfattail catses in the paralytic group. No

paltilogenlic viruises were obtainied fronit thle 10 paltients withI preptiralytic poliomiyelit is, althiough tilie chinlicill pictlure in all respects, including lpleocytosms,

Wats tilie samile ats inl tilie pllarayt ic- group. In .Junie 1945, at final ai11( ver-Y exhiaust ive rep~ort of the laborator * studi~ies in thlese 4:1 catses wats mnade by Ma~j.

May E. Troissell, MNC, and his grouip onl tilie. virus teani front thle 1 9thI Medical

General Latborattory.

A numiber of caises simniihir to thle caises in thle preparalyt ic group were

Observed am11ong comtitacts who wvere not 2idiii itt ed to liospitials Or wvho did not

halve lumbar punctmires. 'M.1 any such calses were mundolout edly diaignosed ats

t~YJiecal denguie. Ill fact, ret ro-orbi taid padi in nd backaiche Occumrredh in iii mn

5641070' C. -2
546 ACTIVIiTIES ()F MEDICItAL (0N)N5UIr-k'rsNT

of tilie pa~ralyt ic calses, and1( thle pre'valnciie of denigue iii te litarea miadel thle miiist ake

ill diagniosis aliiilost tlla~~voidablle.

Evidenice of mienimgeal irritation led to the diliignost ic Itllibar punclture

ilsix SIXa'ses. Ill tile remiziining case's, flaccid parzdvsis or miarked weaknes's of

one or more of the extremities poinited to thle dialgonosis.

Source of infection.-The source or reservoir of this infection was a1

baffling questioni. No recent, cases of Poliomyelitis ill Filipinos, Were discovered

by visits, to civilianl hospitals, and none had b~eeni reported by tile Phiti'ppine

public health service. Certain facts pointed to the possibility that thle disease'

mighlt have been broghit. inl bv carriers amiong troops from the Unitedl S~tates,

wh~ere it wAas epidlemfic. Ill 01W areat, thle 'ondhition decvelop~ed 35 days after

the soldhier hadl arrivedl On Leyte. Inl another area, three c'ases treated andh

d ischla re(I ats IyulIplOcyt ic chiorionieningi tis dlevelop~ed 2 wveeks afteri thle

arrival of the meii; these cases precedled tile Paralytic cas-es ill that area by

atbout a muonthi. About hialf of thle. cases were inl soldliers NAvlio had lived oil

farm~s or inl Very Small rurlal commuiiities. Although manY individuals wh-Io

linu beeit ill contact with patients wh-Io developed paralysis shiowce(l signis

inl diclat -e of lpreParialytie P)oliomye'litis, onily one mani, a med(ical corpý,ianai

(developed tile Paralytic type of disease after contact, with patients. He had

at tended p)oliomycvlitis patient-s inl respirators froin 3 Decembler to 6 December,

and lie (-amte down with the disease himself on 17 December.

Observations inl tile 'Middle and Far East, madle during tile war and

sublsequlieii t V, showed t hat similar out breaks of lpolionivl~eit is occurr~ed inl

troops foreign to thit p~articuilar country without any apparent. inlcrease in

ulcidetice inl ally age grouip inl tile indigeniouis population.

It wits impossible to make a proper inivestiizationl inl thle heat of b~attle,

when (distances were so great, transportation so (liflicuilt , and ot her dlut ies so

pressing~. One could only coniclude that, barring, some ext raor( i iiarv inifluences

fronm previous milit ary service inl raising indhividu al resistanice to a viruivlet

strainl of Poliomyelitis viruis, the outbreak ili the troops inl the 1)ulamg area, was

Calls(ld either b)y onle or nmore very attypical pohjolinyclitis Viruses of mild viruilenice

or h)v one( or more iietiirOtrolpic viruises capab~le of p~roduicing tile (iiillaiii-Barr(6

synlhromei.

Clinical picture.-Cliiically, tile dhisease followed the p~attern ustial inl

adullts. The age varied from 19 to :35 years, wvith anl average of 2:3.5 years.

Thme initial invasive phasi~e wvas not observed, although several pat itilts

relportedI hav1ýilllng ha l lighit colds a few days b~efore becomingi ill. lit 10 v)ase,,

tie onset was not unlike denguie, and tile patients, inl fact'. were adlmit ted to

hospitals with this tenitative diagnlosis. Thley comuiplailiedl of initenlse hleadaeche,

paiii onl movinig the eyes, backach.e, anid fever. Five patietis had chills.

Severe headache wvas tile presenting symp~tomn inl 17 of the :33 paralytic cases

and in till 10 of the preparalytic ca1ses. Filve patienits wevre admfit tedl comlplailimin

of severe abdominlal pati l; inl t his grouip, the admission diagnlosis wats appen~dicitis ~ ~ ae ~ ~ n il t atrovtiteritis ,ie inl the other two. Onie patictiet was
lIoth 1-It to I alve 21, l)lck St rad I I, tuld( af Iot I Ier was 1 Ilos1)i ttlized I becti tte of reciir-rentce

of it. p)(rir-etit ab1sc)5ess.

T[le maiijority' of palt ivn1ts whot dijed, its5 w.ell its t~liret whoil survived. hi2d

SOMV1t invllvemen~~t of resjpir21t loll, landt aillothIei' jiltielit 1121( some tInvolvement'i

of the titoraciv mullscles, oil the left side. Abiominidt respir-atioln wa-If ablsent ill

W1 lealst two of the fat ld calses and1( ill 01 It pa1t ientt who recov) ~'ered

Ill th clt isi' ill wI icli r'cord IS of the1( t't11i)erlitt fr Aver ntl 1vIiilable. thlerte

wit,5 a fairl co-rtellit loll iietwteiil thet Iltl$ZIit luld( (tirlirtioli of the fever. 2.111(1 thle

severit ' vof thet tiisellse. Ill three faltal c.Ises. ill which thle telillperat re was

knownt, it wits, ill) to 103' F. ill at patient who dlied onl the :3d(Iltly: :111) to 10I5.'s F".

illiit pat ient who diledoi Ol the 26th1 (lay, aifter hineit (oliiIpletelY ptImi-alYzt' anld

flltlaitaltiied ill at respirittor: antid up1 to I03 1 . ill at pittiett who died oil tihe lit(11

(Illa*V. ~\lost of thle patientits whlo recovered had fever. tin Iiigrier 11ii2in it0 V F.

bu11t two had1( fever ilp to 102' F. and( uthree fevvr tip to 104' F., for several

dayl~s, wit il (all-y resi utahl parlt'aYs15.

Ill 10 c~lis(', p21 ralvsis vals linmit ('( to onle or. both of th lIower 'xt renin t es,

lilssociat et ill tili et' i list 1llct5 withi weiktiless of thle abdiloiizil muscles. Ill

three( of thle fattal calses, tilt legs and1( t runk we're nlot involvted. Ill 2alot her

tIltli'i case, l*l~v.t;hvil'limied to re hest atit't li alt' C 111~litiscle of lt'gst it lollk. thorahe

aother. O cuset invot 1 lt'vement rersn' )1 ted tom vhad a b itlr loltl tofaca t2run.thv515, xv i , 

cltearted inl 4S hours. Aunothietr 1had invol vemen'lt of tile (WIThi 7thI, atnd 10(thi

U1,11a11111 nerves, Whichv tlisal)1)t'aled t'lliteYil i few dlays.

inllidtilitionl to the' fatithl ellst's, two othIer p21 tIelits hadl evvilent of 1)1111)21r

inlvolvemen'It. Letihargy or- delir-iumi wits pre'sent Ill threteliases anti illsoliili

ill ot1e.

Six paitien~ts hald to be ('atlim'erizetl, viid two could not defecate withlout.

(1114111i11s. Thirtee patie(nts, two of whom were, -oltisltl 2,1 tv ill rt'spl~it'2tr5, de'velopted

lectilitit, 11 lllcers. Ill ont' (case, jillindic(' alppealred oil th 1t1lth (itly; it Avals

th1u11gb t to represent infect ious Ilepattit is llfirchalt t't to poliomlvelit is, si1lt 11iiaui

stitrtitldiit' 's's, of thet kinld were occuringTll aft thiiis tiUlit'.

The whii te blood ctells wtere counlited' inl 12 vat~sts. Theyv vatriedt bet weeni

6,500 mid1( 16,40(0 ctlls per cubic miillimetetr.

Tbetre "-ils lit corrt'eh it'~i)(twtn tewel it', tiuniber of Avhtitt b)1ood ctlls ill thte

5j)Ifnal fli al 2111 iit the xtel'it of eii lv- rt'sit 1112 pa1ral1.NVSis. Iti falct , 5t'vtll i)? ttint s

"withi de(fill itter'i(111 1)21'illysis ha ti fewetr t hutn 10 cells, wvithi I tialaveraige of 5.

In contraast, ill two oif tile, prepl ll'2IVyt ic case's, th vl'cl.s werte over 100 ill 0u' 11V1(1

330) ill thett othettr. Thle i-lgitst cout.tt ill th lit'1)1ilyt ic cases(' wetre :347. 458,

547. ii.11( 70(0: 10 othetr 1)21?iet',t hi21( Iltirt' tilall 1(00 vetlhs. 1'villpilttvtles

Iire(omlilmited, uiSmlIllV ill th iE n2tgt' of 75 to 95 pevl'ct.[it 1121 ftew va.lVl-lypntictrt's,

tittv spitiall flidit silolved at predlmintlint mlid limirkt'( shtift to lymiphtocytes.

DER MATIOLOGY WAL (20NDI)ITONS

Sk -il d isva'lt" consotitutted at worrisomeit prtblem for tiitst units, fewv of wihichi

hild( th 1'services of, 11 t r~ltule(I dI('rtlttologist. Every unlit exp~ressed (I14' (desire for
( . , ; ' IpId JIh ,fV uAItI)d s 'Ir~ (I.t F urod uiv T.o

NIi IrI 0111(1 ist he I (illl-s 1 .ui r.eic ,i N )Ii( N(4dif v I Iw

silrgw), USASO S, Sonuui m uurt USA I*WIESIAC.

filii d te h i i ved('( .
SOUTHiAVEST PACI FIC AREA 549

in imi-proing, tind staind(ardizing thle dii(niagosis of skin dsaewihwr

most difficult to manage in a trop~ical cliniate under the st ress of wartime Army

life.

Atypical Licheni Planus

A study of 26 cases of atypical licewn lplanls in Decembher 1944 fromt thle

Malaria Research Unit, 3d Medical Lahiom'atory, was of considerable inte(rest.

When this unusual form of skin disease mnade its appearaince in New Guinea,

no cases had been seen in SWPA, nor- were ot hers known to exist. Before very

long, the suspicion arose that t here wats some connection b~etween tihe long continetie use of Atabrine to suppress malaliria and thle (levelopmnent of atypical

lichen lplinlus. The informiation wats dieliberately sup~pressed1, because Atabrinle

(discipline wits extremefly' (difficuilt to niaint ami and becauise this drug hiad to be

empflloyedl to prevenmut thle illilit ayliailhanicap) of a high malar121I-iarte.

Reports on thle sub~ject were written by one or two dermiatolog~ists servingr

wvith hospitals in New Guinea, an *iil, ait thle suggest ion of Colonel Thoimas,

thle subject wats St udiedl andl elvortedl i)v Major Harvey, Captain Bang , and

Lt. (latter Maj.) John M. Myer, M'NC, with the hielp of several Sanitairy Corps

officers. Their work showed that sone latypical patients, with lichen p)1lanims

in which Atiabrine t herapy had been int errupted exhibited ain actite( flareup of'

tlie. lesions when the drug Wats resumed. This olbservation wats suilsta ant iaitetl

in various studi~ies ofl patients who were ret urned to the( United States. lin

these st udies, it, was also found that., I-Sions wh-1ichi had Complete~ly cleared

reappeare( aft er several muionmtlis of renewed At abrinie therapy.

The study of Harvey, Bang, andl MvIer wats the first to give some Clear-cut

evidlence of the( connect ion lbet ween attypical lichien planus anti the long-continued

ingest ion or Aktaibrine. it wats ( oionel Thomas' opinion that t his sort or cliniical

researchl, limiite(d( andl pragnmatimc t houghi it was, which wats set lill ias the priobldem

dlevelopedI and the ojpportunity' perm'Iit ted, wats about all1 t hat couild be hoped

for in ain area like SWIPA.

There were good reasons, ats the C hmief Surgeon, and the( Chief, Professional

Services, U.SASOS, pointed out, for not publicizing the( connect ion lbet weenl

At alrilie and at vpical lichen lplanuis, ats follows:

1. The nubiiiile of' cases was small, andl thle paitients were all receiving.

carefuil stud andv111 treat ument.

2. Ifr even at rutnor of such at relat ionshilp lecamnie wvidespread amiong thle

troops, it wouild result lin still frm't her evasion or thle inist ruct ions to thlemi that

they must take At abrine (p). -518).

:. Tilie uise or this dgwats absoluitely essentitt m to plrev*ent hmr1-g bodies or'

troops front~ beving incapacitated by mialaria . amid, thIerefore, no such stat emuent

b~asedl, ats it still wvits. Ilargely. oil ini erenice, sh oumld be miinade ofli ('n1l or ci rcula t ed.

Thle situnat ion in respect to At abrluite and atypical I ichvie plan uis wats t.Ypical

or tIme, muisin forum a1t ion and muisa pprehiension wh michi were al\wa vs recurrenlt amid

troublesomie ill t his are-a.
550 ACTIVITIES OF MED)ICAL C(ONSUILTANTS

FILARIASIS

On his first trip to New Guinea, in October 1943, Colonel Thomas learned

tIhat cases of filriasis contracted oil Tongatailu Islan(I in SPA were under

observation in the 52d Evacuation 1lospiial, whiich was th(en on Woodlark Island,

off the eastern tip of New Guinea, under the Sixth U.S. Army. With the assistance of Colonel Dart, then serving as Surgeon, Interniediate Section, in

New Guinea, Colonel Thomas obtained permission from the Commanding

General, Sixth U.S. Armsy, and Colonel Hagins, the Army Surgeon, to proceed

to this island. On thfe way there, and again on the way back, profitable visits

were paid to Colonel H1agins at Sixth U.S. Army Headquarters on Goodenough

Island.

Maj. (later Col.) Joseph B. VanderVeer, MC, C(hief, Medical Service,

52d Evacuation Hospital, arranged a demonstration of the patients with

filariasis then under treatment. Only one or two then showed activity in the

forii of swollen lymph nodes and lyniphangitis. The information collected on

this visit wNas incorporated in the ETMD, SPA, for October 1943, as follows:

Since occuupation of Woodlark Island by U.S. forces, about 30 cases of an

atypl)ical epididyinitis and vasitis were observed, all in men who had previously

serve(I in Tongat1)u.

T'his disease is peculiar and atypical in the following respects: In a large

numb)er of cases, there is no history of a previous urethral discharge. Vasitis,

evidenced by lower quadrant pain, is the first mnmifestation. The spermnatic

cord is involved to a much greater degree than is usual in a gonorrheal epididymitis. An inflammatory hydrocele is generally present in the early stages of

the disease.

A single microfilaria (Wuchereria bancrofti) was observed in a wet blood

smear (coverglass tecinique) from one of these patients. The specimen was

secured from trie peripheral blood 0at 2100 hours, and the presence of the microfilaria was confirmed by three qualified medical officers. No microfilariae were

observed on stained blood smears, many of wvhich were taken at various times

through the day and night. The disease was presumed to be due to filariasis

(Bancroft's) oil the basis of the observation of the single microfilaria just

mentioned and the fact that all the patients with the syndrome had previously

served in Tongatabu, where tilis disease was prevalent.

Thie clinical manifestations began with a dull, aching pain in one of the

lower quadrants, which gradually radiated down thespermatic cord of the affected

side. The abdominal pain was followed by painful swelling of the epididymis

and vascular structures of the cord, without involvement of the vas deferens.

About 30 percent of the patients developed hydroceles, two of which were of

such size that aspiration was necessary for relief of pain.

These patients were isolated in the hospital at the time of Colonel Thomas'

visit, and further studies were being carried out in an attempt to substantiate

the presumptive diagnosis. Their infectivity could not be readily determined,

and since their period of hospitalization would be longer than 30 days and
SOU'TrHWEST PACIFIC AREA ,i,.1

treatment in a temperate climate was probably indicated, it was desired that

a high echelon decide upon their disposition.

Colonel Thomas suggested to Major VanderVeer that an antigen be made

from a lymph node subsequently shown to contain filariae and that it be used

cautiously for skin testing. The suggestion was carried out, and a report on

the experiment was submitted to the Office of the Surgeon General for publication. Permission for publication was refused, for two reasons, that the

photomicrograph submitted could not be definitely identified as showing

filariasis and that experts did not believe that the antigen used would have

given positive results in the patients and negative results in a control series,

as was reported. The reasoning was perhaps sound, but it was felt that a piece

of clinical research accomplished in the jungles of New Guinea, without benefit of equipment or consultation of the medical literature, deserved some commendation and encouragement.

On the recommendation of Colonel Thomas, these 30 patients were transferred to the 118th General Hospital in Sydney, where they were carefully

studied and later reported by Maj. (later Lt. Col.) Thomas McP. Brown, MC.

The return of some of these troops to a nonfilarious tropical location, 6 months

after their symptoms had disappeared, showed that this interval had served

to desensitize them to the lymphangitis syndrome.

Filariae were observed in thick smears taken in malaria surveys among

New Guinea natives, but no other active cases were encountered by the medical

consultant. No case is known to have developed among U.S. military personnel in the SWPA, no doubt owing to the active avoidance of contacts between soldiers and natives and to the sanitary regulations which reduced

flies as well as mosquitoes in camp areas.

SCHISTOSOMIASIS

Schistosomiasis constituted a major clinical problem in the Philippines.

The risk of infestation with Schi.vtonoma japonicum flukes had been anticipated

before the invasion of Leyte, and both medical and line officers had been warned

not to drink or wash with water from streams and not to eat native or any

uncooked food. It was not always easy to obey these regulations. The terrain through which the early fighting took place necessitated standing for days

in wet rice paddies and drinking unfiltered water. Superchlorination of

drinking water was advised, but it could not be supervised. Doubtless, too,

the sight of civilian Filipinos standing waist deep in all the streams while they

washed their clothes encouraged carelessness. Before suitable shower baths

were provided, many soldiers probably washed with water from streams.

By the time the campaign in the Philippines was concluded, it was estimated that, more than a thousand U.S. Army personnel had been infested with

S. japonicuin. They represented the first cases of this infestation in the U.S,

Army. Tfie majority of cases developed during the early days of the invasion,

when, as already mentioned, the troops had to fight through infested rice paddies

and Army engineers had to work in water up to their armpits repairing bridges
55:2 AC'Ti%*iTIEs (wFM~u~. OSLAT

that. the retreliting. .Ja1pnese liad (lest royed. rhiere wats io known waly I hat

these mnen couldl have a void ed conitact withI thle cercainile, whiichi were a1)11 ida ii

in mnost or the fresh watter onl the eaistern side of the islaind.

Research and Ptiblicationis

At a meeting of survey units cidled by the Sixth U.S. Armny nialariologrist

Maij. Daivid R. Minltter, iNt( , iii Novembevr 1944,1 a fair-advantOe case of sciuistosonitasis in a native wa~s presented, aind at nunmber of Pert inent, quest ions Were

ratise(. Amiong thent were w%-hal formis of clothling other than rubber b)oots

could prevent inifect ion ; does superciuloriun~ition purify walter; anld whalt nielnstires shold~~~ be usedl to enaidicaite snails. It was a1greed thait very lit tle wa-.s

known abhout thle early stages of thle (limseas and that local bites and uui icarial

were likely to lbe overlooked by troops who haid b~eeni inuerse(I in waiter for

5 to 7 (lays.

Caipt. failcolmn S. Ferguson, Snt( , maile at survey of the coast aind found

Walter availalible inl somle wells aind two rivers free of' cercariale. Ile found no

"sinuil's onl the west side of' the island. Tesal eesal bu . m

long, andl alout I in every 200 to :100 wats infected (fig. 195). The technique

wils to (dry themn 2 datys, thlen matsh thIeml aind examlinle thIem under at low-power

microscope. The hiapitnesse Were Malking an elitboraite survey of schist osomuansis

when they were interrupted ; they were using Germain stains, which were better

than t hose atvailatble iii U.-S. laboratories.

Fioiliiiiitt'lY, recordls of at catreful survey of Leyte for snixils infested with

Sc'iixto.voina cercariqe inade in 1939-40 by the Philippine humian of heMtIi front

NInnuila were rouind lindist urbd by thle .Japanese- Ai'mv. These recornls showed

areaVis ili) 1ii1d dlown t he ealsteem coast of thle islaiIld a11d Well lip the Leyte Valley

harlboring tilie snaizil host , Ollonewnania qua~lra.vi. Caipt ain Ferguson conifirmned

this, finding ats Imany ats I infect ed snaili in every 75 to 100 snails examined

near houses ini souti areas.

Calpt am Baing. Iransferred his inte(rest from mialariai, which was not at

probldem ill L~eyte, to shiustosominsis, 11111 w11s given Small but quite adlequat e

facrilities at the I1181i General Flospit al. Here he and his aissociaite, 2(1 Lt.

Nelson G. 1 lairst on, Siti, together wit h Caipt amlFerguson 1111( thle 501I MaIlaria Su rvey Un it, imaie ittt (resting ob~servat ions onl the effect of treatmIent

in schistosoiniasis jap~onica in laborat ory animials. They also made some

pn)rmges in est ablishting mnetlhods for the use of relwelents when infested water

couldI not be a1voiledl.

At the 1 26t h General H ospit al, Colonel rinnitan, chief, N ledicall service,

studlied aind reported at series of paitients who Showed( signs of earily cerebral

in volveuiient . At thle 11 7t h Staition Ilospit al, N iaj. Albert S. Johinsont.Jr

MIC, aind N laj. (hit er Lt. Col.) NIaixwell G. Berry, MIC, (discoveredl aind describ~ed the siginoidoscopic pictutre found to l)e pat hognomnonic of acute schistosomiasis. Nlaij. (latter Lt. CoL.) Mark NI. Braicken, NIC, Chief, Laborattory

Service, 27thI General Hlospitali, published original olbservaltiouus onl falt il ear-ly

catses, lIt 1he spring of 1945, atfter Colonel Thomais had ret urned1 to Nianilat
?• d1 "TI'VI.C T IP.\''lEI.'I( .\AR;. 5A

I 1 I1 1 14 I 1 1

llI(;lRf 19)5. --simils of the type hdrlm oring cer(( riaw, tr1misflhitters of Schis siUolilinsis.

cuhe ii ceoli Imeley's.

from the Sixth U.S. Armyv, he andl Major Bracken prepared all artilde on sehistosomiasis for the ,iewly phlaned USAFPAC wonthlly medical bulletin. This

artl ie sunimmarized the isltorical, cliniical, and laboratory ol)servations made

on the disease in various hospitals and laboratories in New Guinea and Leyte.

As a result of observations on the first acute cases of schistosoiniasis

(p. 551), Colonel Thomas prepared a paper with the help of Capt. David P.

(Cage, N\IC. It had lbeeul hoped that this rel)ort would prove instructive to

medical officerst lhrouglhotlt the theater, but ulblication was delaved in the

(O)fice of the Surgeon General becli use the article recommehded that treatment

bhised on a:( conclusive clinical di iagnosis be instituted even before mature ova

coulh be delliolit'ralted ill the stools. The lieed for tihe earliest possil he treat -

mnelit to put i stop to tissue da(niige from further deposition of ova was reglarded

in the thealter as a real ail( uIrgent problehm. The paper wais finlely pu1blishied

in tlhe tuIlh fin ,f the U .S. Army .l[hdieal Department."

The information coliaiilemd in Techlnical Mhemoranlum No. 15,'+prepared

by (Colonel Eppinger aid Colonel Thomas il( Oct ober 1!944, is suniniarized

elsewhilere.

S'l'hmmis, If. ., I r., m l ;a , . .:YV lh m lc--' fE rl hihs izi .q ni: fl.I..A y .

lvelt. 4: 117 21MI, AIIuilSt 194-n.

6• "ul'lch ical .ivilm -:11,11, lu N .)•. L,, M)li'ev of flhv ('hif 'ýlum',.'c n I ,Vll~thrIS\ I" E, 21 4 CO . 1911.
554 ACTIVITIES OF MEI)I('AL CONSUIrTANTS

On 25 April 1945, the Subcommission on Schistosomiasis, of the Comniission on Tropical Diseases, Army Epidemiological Board, arrived in Leyte

and was housed in prefabricated buildings in, Tlacloi)an. [he meml)ers of

lhe Subcommission were Dr. Ernest C. Faust, professor of parasitology, School

of Medicine, Tulane University of Louisiana; Dr. Willard H. Wright, Division of Zoology, National Institute of Health, U.S. Public Health Service;

Dr. Donald B. McMullen, associate professor of hygiene and public health,

School of Medicine, University of Oklahoma; Maj. George W. Hunter 111,

PlhC; Sgt. Preston AV. Bauman; and Sgt. James W. Ingalls. Their work

was implemented by the use of laboratory animals transported by air across

tle Pacific, and much gratitude is due the medical supply section of the Chief

Surgeon's Office, USASOS, for its effective cooperation. [lie Subcxommission

stu(lied the clinical ol)servations made in Army hospitals and confirmed and

amplified Captain Bang's observations.

Early observations.--All medical officers had b)een instructed to look

out for early clinical cases of schistosomiasis, even though it was hoped that

protective clothing, particularly shoes, leggings, trousers, shirts, and in some

instances rul)b)er boots, would prevent penetration of the skin by S. cercariae

andi that other precautionary measures would reduce the chances of exposure

to a minimum.

Early in December 1944, Colonel Thomas was asked to see two patients

with possible early schistosomiasis in the 36th Evacuation Hospital. They

had been in rice paddies (not yet surveyed for snails) for about, 4 days. Liater,

when they lay down on dry ground, they had severe itching about the hips,

which they thought due to ants. Still later, they were in foxholes filled

with water for about a week. A week before Colonel Thomas saw them,

they had developed severe cramps in the abdomen, without fever or diarrhea;

the single loose stool each ha(d passed was without mucus or blood. 'ihe

leukocytosis was 40,000 to 50,000 per cubic millimeter, with 30 percent eosinophiles in one case and 20 percent in the other. There were numerous hookworm ova in the stools in both cases. 'ie formaldehyde test on blood serum

was negative, as was the euglo)bulin test. No schistosoma ova were found.

The lungs were clear, and the ab)domen was negative except for one fingerbreadth hepatic enlargement; the liver edge was smooth.

It was concluded that these patients had hookworm and, possibly, schistosomiasis. About the same time, Colonel Thomas examined several late cases

of the disease in Filipinos.

In other patients, the first suspicious clinical entity was generalized urticaria, with or without abdominal discomfort or diarrhea and with or without

leukocytosis aiind eosinophilia. 'Ihe clinical symptoms cleare( up promptly, and

stool examinations were either negative or, as in the cases just described, revealed hookworm ova. The cases were regarded as suspicious, and the soldiers

were told to return in 2 weeks for repeat stool examinations.

Meantime, on 30 Decemnber 1944, in the laboratory of the 36th Evacuation

Hospital, a specimen stool from an officer patient was found to contain ova
SOUTHIWEST PACIFIC AREA 555

with ('haracteristics of immature Schi.to.soma ova, and 2 days later, anotl)er

officer from the same unit presented similar findings. The summarized histories of these patients follow:

Case I.-A 25-year-old Medical Corps captain, serving in a portable surgical hospital,

arrived in Leyte on 20 October 1944. His unit supported a division which fought from the

beach landing near Tacloban through rice paddies along the road to Palo. Later, the unit,

was camped near Dulag on the road to Abluyog.

About 1 November, the patient had a mild attack of dengtie, from which he recovered

in 5 days. Hie remembers swimming in a stream for 20 minutes on 15 November. The

current in midstream was too swift for swimming, so lie and his companion (case 2) stayed

in the still water near the bank. Two hours later, he took a shower bath and washed with

soap.

During the first week in l)ecembcr, he, like many of the soldiers throughout the task

force, suffered a mild attack of dysentery, which lasted 4 days. The illness was characterized

by anorexia, diarrhea with blood and mucus, urticaria around the waist and thighs, and

fever, lie seemed to respond to the usual course of sulfaguanidine. About 10 days later

(16 l)ecember), however, lie noticed vague upper abdominal discomfort, and his appetite

became poor. lie also developed a dry cough.

HIe was sent to the hospital on 27 l)ecember. Here his temperature rose daily from

normal in the morning to 1010 F. in the evening; one evening it reached 102' F. Exa'iination was negative except for a slightly enlarged, tender liver. The spleen was not palpable,

and the lungs were clear. Roentgenograms of the hlngs on 28 I)ecember showed a few very

small areas of infiltration in the central portion of the left lung. The findings on 31 December were the same.

Blood counts, which revealed no anemia, were as follows:

28 l)ecember, 12,300 white blood cells per cubic millimeter; 67 percent neutrophiles,

13 percent eosinol)hiles, and 20 percent lymphocytes.

31 l)ecember, 12,750 white blood cells per cubic millimeter; 56 percent neutrophiles, 23

percent eosirnophiles, and 21 percent lymphocytes.

Stool examination on 28 D)ecember was negative for blood, pus, ova, or cysts. A repeat

examination on 30 I)ecember, after magnesium sulfate, was positive for Schislosoina ova.

After ova had been found on two other stool examinations, treatment with Fuiadin was

begun 2 January 1945.

Case 2.-A 33-vear-old Medical Corps captain, serving in the same portable surgical

hospital as the patient just described, had the same history of swimming on 15 November,

and his movements were the same. During the last week in November, hie was hospitalized

with what was thought. to be dengue; he returned to duty in 10 days. For some years lie

had had a smoker's cough, in which there had been no recent change.

On 23 l)ecember, this patient began to run an evening fever, with chilly sensations,

and 5 days later he was admitted to the 36th Evacuation Hospital. There his temperature

curve was similar to the curve described in case 1. On physical examination, the lungs

were clear, which was confirmed by roentgenograms. The abdomen was slightly distended,

and there was well-marked tenderness over the liver, best demonstrated by fist percussion

over the epigastrium and just below the right costal margin. The spleen was not palpable.

The red blood cell count was 4,200,000 per cubic millimeter. On 28 D)ecember, the

white blood cell count was 14,400 per culbic millimeter, and on 1 January 1945, it, was 14,450.

The neutrophiles were, respectively, 64 percent and 41 percent; the eosinophiles, 22 percent

and 34 percent; and the lymphocytes, 14 percent and 24 percent.

Stool examinations on 24 I)ecember and 31 l)ecember were negative. On 1 January,

after magnesium sulfate, the examination was positive for Schistosomna ova.

Treatment with Futadin was begun on 2 January.
556 ACTIVITIES OF MEDICAL ('ONSI'LTANTS

At this time it was not thoughlt that swilmimin in a large, swift river, in

the still watter near the baink, was sufficientl significant to eliminate the need

for careful invest igalt ionl of these lpatients' activities to search for other possible

caulses Of their illness.

Clinical Conisiderations,

The etiology' , clinical aspects, t reatmentt, andl prevent ion of schistosoml-iasis

had alr1eady been (described. Ini Technical M\ emoranduim No. : .7 31 Malarch

1045. clinical aspects of tilie disealse, laiora1t orY- refillnements inl (diagnosis. and

precailit ionarvN mesrsWere (lescribedl in miore detail. obhservat ions in U.S.

Army troop~s had ind~icatedl a cliaract erist ic clinical S.Viln~lre uponl which a1

p~resumnpt ive (diagnosis miight be mnade before the oval of S. japom C1111 could be

(lenllonutrated inl thle feces. This, was import ant in initiating, early treatment,

for the periodl of (diagnosis was, sometimnes prolonged, even inl Patients-- withI

severe svniItolils'. Tile diagoisiOi cotlll( iot be p~roperly made from clinical tinlding~s allone uinless there was a1 clear-cut Iiistor oif exp~osuire in waters known or

suspected'( to be inifest ed. Persisteiit efforts, should be made to (lemiolst rate

Oval in feces when treatmlent Iiadl been st artedI oil tilie basis of a1 presumptive

(1nlagosis-.

A summiary of tilie clinical and laboratory (lit a in, recimicatl M emorandlum

No. 15 follows:

1. ( 'hinica] sv inpt oini leading" to thle diagiiosis of schjist oOlil iasis appear.

du tring thle sixthi seventh, or eighth1 week after exposure 2111( are of varying"

severityV. Some patijent s are seriously ill, wit il high fever 2111(1 greait loss of

wveight . ot her pat ienits are alsyi~i)llitnat ic, and1( their (disease is discovered

only in tile course of rouitinle stool and blood eamulliizitioiis. 'More severe lililliifest at ions, apparently appear earlier after exposure and1( iiii represent massive

infect ionls. Inl anl analysis of 40 cases, synmpt omis in order of frequency were

fever in 38, headache in 33, anorexiat in 30, nonproductive couigh in 27, Chills

in 21, abd)(oninal cramps in 12, urticairia in 10, diarrhea and backache in 7

(each, and( prur iit us in 4. It shouildI be not ed t hat neithler' urticaria nor (liairi-lca

is a frequent sympihtoim.

2. PhiysicalI e'xaiiiinat ion reveals a slighit ly or modera tely: enlarged liver,

whlich is nearly always t end er to palpation or: heavy pruso. The spleen

is felt early inl tilie disease ili about a quarter (if all The. l luings are usulally

clear. t hogli- occasionlally, coarlse rides or rlionclii ('211 lbe hleardh. Roentgeniologic ex\amIuinat ionl of tilie lungs occasionally deiiioiistraites, scat teredl small aireas of

iinfilt ration.

3. Thle t elli jierat tire is usuially low in tilie morniing but rises inl thle aft ernoon1, reaching froml 10) j to 1050 F., (lepeni gti pon thle severity of thle toxemia

in tihe inividiuah m cilse. (Kat ayania dhisease) . A sep~tic, sp~ikinlg t emlperatuire

curve is very cha~ralcte(rist ic, but elevat ions mlay be irregular. The fever falls

1w lysis aftemr thle second~ week. It is affected only slightly by treatmient. Thle

itchnicni Nivniflorandum tti No. 5. 0111ce of th 1w li nier siirgeofl, IlivadIquart ers, USA F FE. 31 'Mar. 1945.
SOUTHWEST PACIFIC AREA 7

pulse rate is proportionate to the fever. In a few eases, the respiratory rate

is elevated, andl respirations may lbe somewhat shallow.

4. Onl prod oscolpiC examination, characteristic pseudlottubercies call be

seen in the wall of thle rectumi or lower sigmloidl in about t wo-thlirdIs or t 1w proved

cases. Biopsy of these nodlules (which is not adlvised ats a1 routine procedure)

yields groups of ova. ]In appearance these nodIules resemllle those seen inl thle

lbladd~er waill in (cases of Sckhistlosona hae~natobinni.

5. The stool is normal or soft. Schi ;toxonia ova are found for tilie first

time from 6/12 to 10 weeks after' exposure.

A simple technique for stool examination follows: From 13 to 20 grin, of

stool is emullsified inl :00 cc. of normal salt solution, then filtered t hroughi six

layers of gauze andl allowedl to Set tle for one-half hiour. The supernat ant flidii is

Poured off, tile specimlenl is washied twice more with normal sailt soluition,. and

the seliniient is examninedI miicroscop~ically. This technique gives excellent

results. Direct smeatr of fecal niucuis viel(Is only about a third as many lpositive

examinations ats tile coneen tralltioni methiod.

Undler high power, tile large ovumn (60A~ to 80,u) is seen to contain a1 welldlifferentiatedl mniracidhiuni which may exhiihit movement, and so-calledl flamme

cells can be made out. Immature ova1 aeT found inl the stools fairly ortenl. Thley

may b~e much sitaller than mat ure ova and niav be conrusedl wit h ova of other

wormis such ats the fishi tapeworm (Di phyllobothrium latumi) or the roundw~ormi

(Asearis lumbricoides,). This finding should hbe recordled as "' Immature ova--

possibly S. japonicui,'' but it should not be accepted ats conc(lusive diagnostically. Subsequent examinations usually reveal mat ure ova.

6. Eosinopbilia, is present in nearly every case. A rapid rise in the total

number of cosinophilles is characteristic of the acute phiase, inl Which they often

reach 20,000 per cubic muillimeiter. In this p~haise, ain increasing Ietikocytosis

accompaniedl by ain increasing percentage of cosinophiles (from 50 to 70 petrcent andl sometimes 90 percent) is almost. pathognonionic. In later stages,

theceosinophiile count often faills to 5 to 10 percent..

High cosinophile counts may also be encountered in the acute phase of

infestation with hookworm or Ascaris. There tire other dhifferences in the

clinical pictunre, however, W hiich (list inguishi schistosomnliasis fromt thIese dhiseases.

7. linoccatsionail catSes, a hithierto und~escrihled svn(l-omiel has l)een aissociatte(l

with cereb~ral involvement. There is slight or mnoderate (disorientation, or

even comia. The iariaits -e weak, and lone or botIi seem patrailyzedl. The egs

aire at axic. Deep reflexes airc exaggeratedl, andl there may he ainkle clonus.

Sensation is uisually normal111. (i'erebellar symptoms may be present. There

is low-grade fever-, ats Wvell ats at cha ract erist ic leukocytosis with cosinophilia.

The spinal fluidi may contain at few lymiphiocytes or may 1)e normal.

Treatment

Standardl formi, of treatment for schistosomiasis were outlined in USAFFE

Technical Memorandum No. 15.8 It was recoimmendIed that treatmient be

Sce' foot note A, 1). 5.53.
558 ACTIVITIES oF Mi.EI).AL (CONSULT'ANTS

started ill typical Cases even before ova Were demonstrated in the stools. A

Ip'ererence for one drawg or1 another cot1ld riot, be expressed at this tillie. Bot h1

tarlt'ar emetic and Fuaidin were ltsed.

Tartar etietic had catsed a iniiber of tinpleasant reactions, and it was

recotii ietl(ided thatt it. be lused with cautition. TIh1e solution co01ld be 1)miade by

adding chemically puire tartar emietic to pyrogen-free distilled walter w~hiich had

been brIought to a boil. In several hospitals, it had been fou1nd1 useful after

whe first three dloses to diltite the tartar emetic in 1,000 cc. of 5-percent glucose

soltition and administer it slowly over the course of an hour. Injections were

Stlopped if a reaction occiurred. ('oughing was not. a serious reaction, bint

vomnitinig, uinduie nervousness with shaking, severe arthralgia, or collapse wit li

fall inl blood pressure were serious. If they occurred, the next (lose sioilld lbe

rediuced hy 0.03 or 0.06) gill.

Fua(lin, to date, had been well tolerated. Tile efficacy of etietitie had not

been proved, and Anthionmaline (lithitiini antimony thiomalate) was still on

trial.

All patients withi a diagnosis of schistosomiasis shouil be given a complete

course of treatment before arrangements were made for their subsequent care.

Disposition

Seriously ill patients and those with involvement of the central nervous

svstem were evacuated to the United States without delay. 'hose whto had

persistent clinical signs or positive laboratory findings after a course of treatment should also be evaelated. Patients who appeared to have beeni cured

and to have regained their health could be returned to (duty but required fre-

(puent examination of their general condition and of b)lood and stool specimens,

in accordance with instructions in a letter from Headquarters, USAFFE.9

Preventive Measures

Before the invasion of the Philippines, an attempt at widespread distribution of inforination concerning sehistosomizusis had been made, btut so many

troops were on the move that large inul)ers did riot receive adequate infornamtion. This situation was corrected promptly when the troops arrived oil Leyte

(fig. 196). The Sixth U.S. Army had taken pains to inform all its medical officers concerning this disease before the invasion. That the forewarning was

not in itself adequate protection was clearly apparent. As soon as possible,

all fresh water streams and rivers were posted with signs and cartoons depicting

the dangers of schistosoniasis, but drivers of Army motor vehicles persisted

in washing their vehicles in these infected streams (fig. 197). It seemed, when

tile plan was instituted, that tile horrors of schistosotniasis were made to sound

adnost too drea(lfil when they were broadcast through tile wards of hospitals

in which patients with the .disease were being treated, but past experiences

SLetter, Col. R. E. Frall,, AGD, Adjutant General, llea:(lquarters, USAFFE, to commanding generals of major

commands, 5 Mar. 1945, subject: After-care of Patients With Schlistosomla.ls.
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562AC~t%*IVi'iEs I F 'mumt Ici.xsu. U NSI'IATS

Offili-V Of the Surgellon (e01Nt'r1, hai 111111i1.21lV done not hiitn. to correct t Jis

III Ib lS''ixth U.S ~. A.11ii% t here w',s Stitithir1 hiistililt'rsttlitdig of tli hil'~ lue

of 11 collistlit atlit ill ps : vliti~t , v to liti arl-1Iiv OIl tleint' iizic. It does' not1 seeiii

likely thait thle sautedtlfhicultv, wles ~vtl ver occil aiin fromi hick of undaersturitdliti

1111d1 coopera tionl bet'weeni thle meinetlil antid neitrojpsychintrt c set'ivs'5. Ill t(le

isola11ted antd fa il-111" hugreat in which t lie New ( nineni figlit lgtin-i ocrred.l constiltalilt selt oui etncounit ered veach othI er, lantd thley' were' left to solve (hI eir own

problemuis, with It o ont' to guiidte or. help thlemi. Unltot inttitelY, fromi thle st ailidpoin t of tilie Arniv nieuropsvcl I ill t rnc se'rvice'. peat't elili e provie tstotie n of t het

st resses5 which cri pple soldiers during wvarl. The M edical C orp" it, well it, lt'e

whole iiietlit'l professiotn, Should niot forget thle iuiijport'lit lessons it leartined

lie 11,rt- wa-1Y trot U its exjpt'ienices, both pijosit iv l'atit tiegit i v(. ill psvcliia t i

dutinitg W~otrld Waiti 11. Etilighite t'tt'l d lttf ('otistilt antits atit tueticiti consultants

(c1n11tad shiouiltd contrnibute (It) progress in) t his fie'ld.

Concluisiotn and( RecommendtiI~ationls

So that~ tilie sa tiit sit ta ti lo dloes tiot recuir, aret'as of coopt'riit iollnd anti wys

and ineatis for comiibinetd effort sihould h lltIhoraltet inl sot)(i.t det'il for tilit

fu ture instriuct ion of mnilitia rV Ileiiit'lal vouisutlt antitS. DI ui nitg ont' pteritd it a

i eatqtiart ens, I.SASOS, C oloniel 'l'liouilias prtepare t I 1t' a pt'li liiilll lii1W 4 rft tOf a1

theire wVl it) Iol lptoltitilit *N to rewryite' it ill 'ollij int't ionl with til lit'ntropsychltrIit'

consultanti I, t it(' report wa'Is flevt't Subittti edttt for ahlpr()vill land piub~ilicaIituion

'lThe prtoposails tiiatle ill it, Ilowt'ver, p~oint ed to a1 bortdtrlitte problemtt which

uit'eet't Ithe cotbiined atttention of the stenior conisiiltatits inl nt'uropsycliiatry

'lThe suihst ant't' of t his rep~ort was" as follows:

'liT'e orglinizaltion of sjptciall station hiospit als for the' trneatmeitnt. of

nltl pJ)5Vlott iv )s~vchlit 1it pat iet'ts wats, rtequired't ill SVVPA by thle short agt' of

traiined netulroj)svcliiat ist s atit tilit need for adlditiotial facilitites for trteatmetnt.

Most stat it)n, evat'ualtionl, antd fiteld hioSlit als hald nto lieitroJ)Sychiaitlists.

L 'n'artIi itiig, recognizing, and handling propel~ly tilie functional aspecttts of

Ieicit'tcl and surgical stiato's wats tilie resp~onsib~ility of tinit'intrs, of lthe lios'pitail

stalf amid wats thlit gret'a tr ht'cautst officer latititnt s w~ithI fulltict ionl comipjlaints

we're not, treatedl in thlit s-ptciail stationh hospitazls.

2. M ost, inetdical condititions hauve, to list' a situple0 t twin, anitImport ant

p~sychiological sitde. No'uirojpsychiiat ists rteportetd tihat lpat ietsii rtcti vtet fromn

tied icil anda surgical servictes iti ot hetr hiospitails halve not htenl bla'efit eh

Ipsy('hitlogivaillv durinig theitir hiospit al st aly but instead have btetl actuallly

imiaptededt. This corret't' 11)10 stiatv totf aiffairs tequires prompilt at tent ion.

:3. Great imatprovtetent ill thle diagtiosis and care of funictional disease can

hie efftectetdt ill int'ticall antI Surgical wards if chiefs of service will keep t(lie'

polem hlt'ii lpetiiiost inl theitri tiinds. Thtey should faiiliatlize t hiemselves withI
SOUTHWEST PACIFIC AREA 563

available technical nieniorandunis and articles in current medical journals on

this subject. Opportunities sholdd be made available to attend staff meetings

at psychiatric hospitals and to obtain formal and informal instruction from

consulting neuropsychijat rists.

4. Much so-cadled psychotherapy consists of studying the patient's

psychologic react ions and giving him appropriate encouragement, an explanation

of his position, or both. This is no easy matter but one that requires understanding an(I tact. There are, however, a few primary rules which should

govern tile approach to every hospital patient, as follows:

a. Tlie imedical officer should treat every patient as a soldier, with due

regard to his rank, branch of service, and Army experience. That is, the

p)atient shouhld be given full credit and suitaile coml)liinentarv comment--often

better imll)lied than expressed directly -for bravery or interesting experiences

or si1li)ly endurance when the going was tough. Such an approach shows the

patient, as well as other patients on tile ward, that his Armuy career is recognized

as of primary importance ; it is the reason he is in tle hospital and is the reason

for his getting out of it as quickly as is consistent with his disease or wound.

This attitude is the hospital medical oflicer's biggest contribution to Army

morale. It does not mean rigid military formality, I)ut it does mean punctilious

observance of a respectful attitude to the patient as a sollier.

b. Tile muedical officer should be alert for indications of worry, discouragement, discontent, or anxiety and, when he observes them, should develop a

technique for drawing the patient out. This holds not only for the patient

with a majority of fu nctional symptoms (often loosely called psychoneurotic)

but also for the patient with organic disease colored by, or associated with,

minor b)ut still important psychologic difficulties. Every good history should

reflect, the patient's state of mind as well as of body.

c. Many battle injuries and diseases, if not most of them, in combat

troops introduce new psychological situations. Perhaps, for the first time, the

individlual's physical integrity is threatened, and he develops concern and a

feeling of insecurity. On tile other hand, he may develop a sense of relief at

merely being wounded and not killed and may have-at least in his own eyesan available and justifiable excuse for escaping from further danger. Everyone has, in some way or other, used illness as an escape mechanism or as a means

of obtaining sympathy or attention. These and other psychological effects of

disease and wounds required careful consideration andi treatment.

d. Prompt and thorough study of each case from an organic point of view

is essential. Unless this is done, the patient's doubts are unresolved and magnified. As time drags on, he senses uncertainties on the part of the medical officer, and having had time to learn the ways of the ward, lie subtly takes control of the management of his own case. These developments complicate the

solution of the psychological problem. In a station hospital, 5 days should be

sufficient to reach a stage in the diagnostic study at which immediate disposition can be determinedl; that is, transfer to a general hospital (though not

necessarily at once), or further treatment in a station hospital with a view to
564 AC'TIVITlIES oF. MEDIC~AL C(INSULTANTS

returnu to (lit ,v or t ranisfer to ai corilVal escet It liospitial, or conisultatiton Nvith ita

Psychiatrlist to help Outline furt her disposit ion.

5. Speciallists ill tilie caire or lworierliiev p~sychinitriie c'itses, have bwen iisseitibledl ill Special staltiol losjit alls dlevot ed to lps 'vl Iillt li(* (liaigIliosis at uid treatilment

i lere, aiccuratte (lireren tiltatolt or casesS inito vail-ioiis Scienitific Subiv)(isiions talk(.,-

Iplace. Ser-iously ill psycliot ic States aire (jikl dgnploSedl. 111( thle p)atiellts

lire' t Illi I~srvrrv( i to grvlierlill ospitalls. M\ irlder clises alre divided inito psvc h1o1lienrosis, Simp~le lii I nt Iiililli(lj list mleit, t ind colist it it tonail psyci lojli t hiic staite,

a a1d aipproprili t t reaitment is aiccord ed catch group). Grouip psychiother;, pw.

Occupliat iolili t hera jw, exeris'~4t 1111d1 cont trolled rela xa tioul providle essei it ii eleaaures to augimient at limited alillonllilt of indhuvldnlil treatitmelt.

These hiospital units have proved highly efhicien t aind are ret uintilig 85

tpereenit of' paitints, to (liltV ill all) liverliore or H 6 (Il vs.

61. Thie hi111(1ioli or tilie ol~igililll field , evacial~it loll,* an n ilStlit oli lhospital~s

is to assist thi Is )rOgrlimtl b co D'ingr every Paitienlit a loteltit1 jasychiologiehld

p~roblemn. Thiis lit tit ude will Salvye 11 great (heall of' t inie ill thle first hiospit al to

which tile pat ienit is ardiluit ted, an1d, mlore illiilortallitl 'v, it will save even mlore

itime lii thle 5jecial hosp1 itils. Fiaiall.y, it will returnu to (lity Some1 Palt telts

who muilst othlerwise b~e crowdled into Special Itospit alls, aind it wvill mallke 2ii1 other

palt ienits lea~ve tilie hios1 it Ill with Iimprlroved l moralle.

Ini New Giuiniea, its mighit have been eXJeetedi, mnedical units wvere also airfected 1) ,v tilie t remlel I(lolls Strlesses 1ilreaih V list edh, lind( Hi SomeW tistialices, Officers

broke dowvn. A medical laboratory, Iin onie such.[ instanilce, lost its conlnilaui(iligl

officer, wvhio wias eVaieilat ed Oil tilie (liagliosis of' psychlosis-- -coli fused St ate,

anld tilie nlext Sellior. of ficer, at major, lissumied command. Wilien tilie Ilaboraitor *

Wall', ilnvest igat ed(lidrinig a roult ine visit bvilt inlspector generall, it wVits 1111-

me(d ill tely% a pparenit that lie hi11( niei ther tilie a~mimiiistlilttiye nor1 tilie lprore.,sionii

aibilit.Nv requisite for tilie posit ion. N one of thie stabdiivisiolis of tilie laborat or v

was- receiving appIrop~riaite supervisioni. No Otte couldl aecomiplisli efrvective

wVOrk. The morale01 wa-s SO 1)11( t hat onle exelenelt Officer wats round glil bY

tlie inispector genleral of having 'onisumiedl a1 considlerable 1part of thle Ilaboraitory:

allcohol. 111d it riot beenl for tilie t imlelvN visit of tilie Imedicall conisult atilt , this

yVoungl oflicer. might have beenl found gruilty, by at court-mar11tial alnd returnried

homle In disgrace. When lie wats tranlsferred to aitot her unlit, however, lie founld

it coligenlial metier ill working 01) sei typhus, ' and he did br1iillliat lv t herea fter

1111( wvits finailly p~romot ed to thle rank- of major.

Part 111. Conclusions and Recomnmendations

ANALYSIS AND CONCLUSIONS

Duruing Nvitrtline, thle professional activities of the 17.S. Armyi M ed ical

C orps, whtichi from nlumlerical Il ecessitY alre calirried ouchiefi', Ol v1, lv reeeultl *lv illdlnit ed civiliain phi'ysi'illilis, require SupJer'visioni anid correlit ionl. This, fact litas

been (demonist rated anid is widely accepted.
SOUTIIWEST PACIFIC AREA 565

III Worild War I1, the niachiiiwi'y that developed to accomlplish this sulpervisorv and correlative lulict ion, ill large part I brouigh the efforts of General

M\organl, consisted of it loosely organized lbody of consultants. The groulp.

which begain withI consuiltants in miedicine anld surlgery, aind, somiewhat later,

ill netiiropsv.Nc hiatr iw, inl this office, wits graduially extenlded to incltide tile theaters,

service commnan(Is, armnies, and base sections. Tile programl (levelopedl witIilouit at tab~le of ol'aniatii Oll, wihltan esalie st andhing operat ing ')rocedlirve

and withotit any% indlividlllal (direct ion. It answered at (iffereit, needl inl each comnmandl and assumnedl at differenit p)ositionl ill relations to each local organization.

The consuiltaiit svsteni 1)lossonied tind~er somet suirgeons and strulggled

uii(Ier ot hers. It correlated the wvork of grood uinits, and it suipervised and,

through1 trainling" anid edulcation, imiproved the work of poor units. In the

end, it play* ed a miajor role iii the medhical activities of all cominaillds.

Tlei( suiccess of thle systemn wats lasedl On three factors, as follows:

1. It fullfilled at need.

2. Its persoiniie wats chosen onl the basis of professional training and cornpetence an1d, to somle extent, Onl tile basis of 11iiayexperience, not oil the

basis of academnic or mnilitaryv rank.

3. It operatedl on tile principle that the visiting of uinits was its startinl(r

point and that visits mulst be painstaking and hielpful. From their own firsthand

SI iidy of actuail situlations, thle conisultants (discovered and attacked existing

Iprob](lems.

A consideration of the cofIs(itaflt sy, stem its it operated in SWPA leads to

certain genleral conclusions, aind these conluetsionls, in. turn, sugg-est, methods(1

for effecting imiprovemient.

The Professional Consultants' Position in the Army Organization

Consuiltants are staff officers serving onl the staff of a surgeon. Their

province is professional services, each ill his ownI Specialty. Inl a1 sells, they

performn the well-uinder-stood Army fuinction of inspect ion, incluiding visits to

unlits, wit h slilbseIlieiit, reports 1111(1 recommend~at ions. Inl add(itionl, they Ileconiplish another new and less well understood fuinction, that of instruction.

Thle consultants in, World War 11 were dIrawn fromt the facuilties of thle

leading, medical schools in the couintry. They encolinteredl quiestions fromn

newvly indluctedl medical officers, and they assumned the role of instruictors by

force of necessity.

The types of adlviineed instruction needled in wartimie Armiy hospitals inlchtided bedside, wVardI, and clinic (leiionst rations, ats well ats instruict ion in Artiy

mlethIOdS of adilission, disposition, andl recording. To ftilfill this fuinction inl

at single uinit requiriied timie-several (lays' timie-in eitch iunit. At thle end of

this t imne, the consuiltant knew the uinit miedical (or ot her) service, and the

service knew the consuiltanit. Each learnedl front the other, and niorale wits

strengt heined. "'Ihis wvas at new kind of Anniy inspection.

Thie suirgeon shouild knowv and rely onl his consuilt antts. They, in their

role ats staiff officers, shouild advise hini anld shouild IfnIerst and himl and each
566 ACTIVITIES 4 iF MED ICAL. ('0 NSULTANTrs

oilher. Wheniever practical, the surgeon shold~i~ pei'solial~v select his staff

offievrs-. IHalving chioseni thleti , lhe shold~i requiirie and( lbrinig to pass lie closest

cooperat ion ainiong thelct. IThis app~lies possibly niore to tite chief Iprofess-ioial

conisult iilit 5 thali to ot1her stafr oflicers becaluse their (ltit es involve tile iltit iltion of inniovat ions- as- well its varied intersectional cooperation andl cointact

with Ii iiijor oitins

Whleniever surgeons have chosen their own consult ants, often withI advice

froiti higher headquarter's, thle result ant r'elationis haive b~eenl agi'eealle it id have

b een funci 41l~livl successfuli. Wh enever practical, niewly appointed suirgeons~

sliotili there(for(:rebe pernitti td to select Ihltir Oi-1 oiCoiisult ants. The t Ii Pee

chiief consult ants, to Tihe Surgeon Genceral shiouldl coninbiiie to htelp to priovidhe

UP lieiost suiit able groupi of consult ants in tlie( various hieadlquarters ait lower

levels.

Other staff officers spend front 90 to 98 p~ercenit of their tunie perforiniiiii

staff (Jut ies titt headquarters-. P~rofessionial c'onsuilt ants' miajor funct ions are

Iperloriiied away fr'onti headlquart ers, in the hiospitail uniit,, thieiiselves. IDifhicult les thlen arise ini develop)ing thleininjt o coitipetent staitff officers,.

( 'onisul t antts who Spend half or- t wo-t hirds of their t iiie in] tilie field finid

thicimselves writ ing rep)orts and mnaking recoinnienda nt olts which are returinted

to t heir own desks for iniplenienutation and comipletion. The nieedl for Hose

coop~erat ion bet weenl thle consultant sect ion and the( sect ions of personnel, p~laiin.,

supply, preventive inedhicii, aim!( recordls requires cost ant l availablde oflicer

persoitii in the consultant sect ion. It therefore lbevoines imiport ant to (,st ill)-

lisli t lie consult ant systen, in, thle overead tables of (lisiatrimi iond11 to p~rovidie

a dequat e p~ersonnlel for the accomiplishmenvt of thle duities t hat aire to be perforitied ait the variouis headquarters onl tlie( different levels.

The Place of Consultants in the Wartime Medical Corps

lin World W~ar II, thle iipproxiitiat ely I ,300 mledical officers inl the Regular

Aýrmuy were used to fill inipJort ant ('011 iauid and statff posit ions. As it uiii

mnat ely developed, the direct ion of practically all professional maitters. relatitng"

to inedicmnle, surgery, 1111( neuirofpsycltiatr liecnte ev thle reslponsib~ilityv of at -oltstiltna it syst(Il cii otmip)osed enfirely of civihiiin phiysicians called to active duty.

ThS was not t rue Of prePvent lye Medicine, (lent ist ry, veterinary mnedicine.

nurs--ing, nor was it true of ot her activities such ats planninilg 1111([ training,

hiospit alizat ion. itud niedicail Supply.

Since tile finial responisib~ility ii pratct ically every- major conitiiand restedl

in at Regular Annti v (01111 a lt suirgeoli ttlid siiice staflf act ion ait the highest

level was Oft en involved, it would lhav e beeii valuable to have officers, in thle

Regular Armny NIM eiCa(orps int egrat d into t he consult ant systemt. Officers

suich as Brig. ('*en W ery Q1 (hu Anllii r, (31o. Frank L~ C ole, M( ', aiid C olonel

Dart would havye conitrmibuted greatly to thle effectivenless of the svstvl eat nd(

would have relievedl indluctedl civiliani specialists of litany of their staff (Ilt ies.

whichi were always tilile-constuning alid wvhich at.t first were p~oorliy accoliplpishled.
Si17iW'ESTI P'ACIFIC' AREA 5 6

Specific Delegation of Duties to Consultants at Various Levels

The act itl. operatijonal wzi't it jC of thle conlsult allits, as- 1l1eiktlV mentiionledl,

valriedl widlely atvit %-iiotis levels. Onl thle o1ther hlandl, t hey overlalpledl iii miaii

part iviilars antid reqIliire(I clarificatiofl5s and dlelimiit at ion. liThe prepar'at ion of

('clniical. 1)lelli0rand mltil s and di rectives is an iiill it ration.

Before t he L eyt e camipaign, in October 1944, a mnumber of suirgeonis prepairedI t echnical lielioriinduims eallin-vr the at tent ion of imedical officers. to itiilportlant professionll ma tiers. Thuls,, the surgeon of' the 24t1h Division. the

mietlicid consuilt ant of the EighIt ii U.S. Armyi, and the miedical conisultanlt,

UASCOS, aill preparedl and circulallted mlaterial relating to sc iust osomn Iiasis

jalponicat. Later, in hline 1945, at TB i\ lD onl the( still)(, stilject was pt~ iblishiet

by tilie Offie ol titw Slurgeon General. Similarly, directives relating to malaria,

scrul) tVIplitis, aimleiaisis, infetctiotii hiepat itis, and other stlbjectS were circulatted front the( offices of a1 mnmber of different stirigeons.

InI aditliion to thle walstefull (Iliplication and thle confuision of conflicting

recoimmnendit ions, t his overlapping of funiction led to minisndersi anding bet weeni varlious' officers inl tile conistltanlt systen v (Cooperat ion bet weeni consmlfianits ait dlifferent levels on mattiers, Pertaining to Professional suibjects

shlould hav1Ne been close and cleairly tinderst ood, ats it wouild have been if their

dulties at.t ealch level had1 been clearly dehnled.

Functions Relating to Personnel

The( consult ants camne to platy at large part iii thle evailmattion and assignnment of pwroessional personnel. TIhis is another funict ion tihat -hlioud have

been carefully considIered aind fuilly described ats part of thle standling operatting

procedtl ir of consuilt ants.

Shouild thle need again arise to call 40,000 or more Reserve or Civilian

physicians into the Army, it wouild he wiqe to obtain the services of at prominenit civilianl physician to serve ats depuity chief of thle p~ersonnel section in thle

Office of the( Suirgeon General. Only in this way (otiltl direct, iimmediat e

contaict be est ablished with the local souirces of new personnel to ob~tain inforimation necessary for the most efficient utilization of these personnel. Direct

cooperation bietween consuiltaint anti personnel sections is simple ait the airmy

level. At thle theater level, it will reflect the( system thait is in operation in

the Office of the Surgeon General. To have the part the c onsuilt ants tire

eNpecteti to play inl thle Control Of profvssional personnel clearly ouitlined in a

manu11lall or other official, puiblicattion will dot in ticim to eliminaite the difficuilties

mll his regalrd t hat existetd in World Warl IL.

RECOMMENDA~TIONS

Time following recommmiendations are mlade w~ith lia vew to elimiinat ing thlese

and ot her difficuilt ies andt increalsing thle efficiencyv of tilie consulltalit systemII

I . A st ainding Operating PrOCedtliit siouhi be delineated for wairtimie

consult ants separa tely ait thle level of eatch headquairters.
068 ACTIVITIES OF MED)ICAL CO4 NSULTANTS

2. Taibles of distribution or orgainizaition should be anthlorized b'r neVCessariv consultant personnel tit tihe level of eatch headquatrters.

: 1. Anl assistaint consuiltant or execultive officer shouild be added to thle

conisult ant sect ion in luglier hiea(Iquairters. to remaiin tit headquarters aind be

aivailaible to implllemlenlt the (ltites and reconinien(lit ionis of thle conisultaint

there.

4. TIhe activities of aill consult ants in ai given headquinarers should be

placed undler a depuity surgeon in charge of consultaints. This officer should

not be burdened iwv other duties usually hazndledl lb the chief of the lprofessionail services division.

5). Surgeons ol manjor (oluniands should haive a prominent pairt in tilie

choice of their luedhical consultaints, just is they have inl filling other staff

posit ionis.

6. M\ edical, surgical, midl neurolpsychiiatric consult ants in tlie Office of

lie Surgeon Gener.-l should combnl~le to help p~rovidle each leie(qutlarters withI

ai suit ab le group of consultzants caipable of cooperaiting with vatea ot her.

7.In timue of emergency, in aill sect ions of the Office of' thle Surgeon Generail

aind pair t i(ularly in tilie personnel section, ai deputy chief should be (Irawn

from naitionallv prominent midl specially tratined civilian sp~ecialists.

S. ( 'onsuIltlknts should be rotalted from theatters into thle Office of the

Surgeon General to serve ais assistant chiefs of aippropriate sections.

9. Consultants in higher headqmarters, should haive as one of t heir primanry

dutties the assistaince of' consultants at tower levels l)V visits to variouis hieadIquairters, aind by tile maintenance of close coniinuinicat ions.
CHAPTER VI

South Pacific Area

Benjamin IL. Baker, M.D.

FACTORS IN MEDICAL CARE

The professional care for castialties in the South Palcjfic wits significantly

ii fi iencCel by several fet ors whichi at first seemi unrehitedl. No lust orical

acecouint of th lie edical prolblenis faced onl that widlespreanl battlefield wotil(I

be comiplete wvithouit first conlsidlering thle inffluence lil)of professioiial pritctice

of' a joint Annyi-Naivy -ommaitnd, thle meagier training given manny inedical

oflicers, for their mnission, the Vast alrea inl which olperatiolls were condticted,

21n1d thle (list ributiion of' lisettses in dithatarea.

Human Factors

'[ie training, a n(l in(loct rinatiionl of l most iliedhicail oflicers for thle varliouls

prolblelfls t hey were to encouinter wvas far I roiii ideal anid undler thle circumnstances, tillder tilld ably so. The deniands of the overall mihitairy emiergency

0-1ilhierged aill others, aind nedlicall suipport 1,r1 over'sea tacetica l nId service

forces, whether it wits aideqllate or not, haid to be providled when those forces

were reailv to niove. TIhere wais neit her the timie nor the orgiinizattion ait uinit

acetivaltion and1( staging areais in th lU 1nitedl States for aiscertainning the professioall comlpetencev of' Lospital staiffs. There wits no opportuinity to obtain

niore personnel for t hose that were deficient nor to transfer personnel fi-oit

those thalt ha1d anl excess of a ble itien in cert amn departinients. Pertinent miiilitaty ni diei intelligence wats fragmientairy, anid the tiisseiniiintion to prof'essional nien of' stich inf'ornualtion ats wats availallble ait thle tittle waIs limited

f'or realsons of Iniili t a i' seclirimiv. ( onseqtiently. doctors, for the miost pairt

only recent lv recruiteld frloml civiliain lif'e, Were often suldlenly conf11ronted oni

isolaited islan'id baises wvith diseaise prob~lems t htt they were ill p-repilured to meevt.

( *om1petent prof~essional lealdership was of~tenl not aivailaible. One biase with

at me1dical loaid far exceediing, the caplicity of' its hospitalls wats 51 afi'ed with Imedical officers whose professional qualiificat ions were not lipl to deiniminds, whereats

another hand anl abundnchne of* specialists w~ho.. if they saw the plit ient liat all1,

were seeing t hemi long aflter the critical period for the treatmtent of their tlisealse hald p~assed.

In SPA (Sout Ii Pacific Area) (matp 4), the U.S. Navy wats in comninanti over

till forces. Thie Senior Medical] Officer, U.S. Paceific Fleet, had the finial res.poilsihility in all mantters relalting t~o thme treatnment and p~revention of (hiseaise.

569
570 A(TIVITIES OF MEDICAL CONSIITANTS

CENTRAL PACIFIC Palmyra AREA

Maokin Fanning

GILBERT Christmas

N oouti., Beru i I O"

SOLOMON ISLANDS "., I.Canton

ou 9 oi n v i l l e '-

V ,u ISLANDS MAR"UESAS

Georaio New SANTA ".U"..Tongorevo ISLANDS "• CRUZ /•

[ .O .

I 1 , L O11 ar1oIn ISLAN D S 4/ 4S o S A M O A IS L A N D S

i. " NEW

Espiritub., FIJI IS.

Santo %t HEBRIDES s Ba Bora • ' • 6"0 Tahiti 2.) Vifi Levu COOK'- ah LL TONGA IS. iS. b. NTongatapu '-LANDS New\' S Caledonia S O U T H P A C I FI C A R E A

f-

"T- 0 1000

o NEW STATUTE MILES ON THE EQUATOR , Auckland ZEALAND

MAP 4.- South Pacific Area.

Decisions on the deployment of medical installations in the area, the use of

supplies, evacuation policies, and actual professional practices were made by

Navy command and implemented by island commanders through their surgeons. As a result, the responsibilities of the Senior Medical Officer, U.S.

Pacific Fleet, were enormous. Though his cooperation with the U.S. Army in

all medical problems wias admirable, his organization was small, and medical

control was too loose to provide for efficient operation.

There was a shortage of administrative personnel familiar with professional

problems and the means for meeting them, which led to a lack of efficiency

in the use of medical organizations and personnel. The sick and wounded

frequently passed rapidly and repeatedly through a succession of Army and

Navy hospitals, and consequently there was little uniformity in professional

practice and evacuation policies. It was not until August 1942 that a U.S.

Army commander and his surgeon arrived and a start was made in coordinating

Army medical activities.

Geographic Factors

Geography had an important influence upon the care of patients in the

South Pacific. Troops were stationed on a series of widely separated islands

from Bora-Bora and Tongareva to the east of New Zealand in the south and

eventually to Bougainville and Emirau Island in the west. Bora-Bora, in the

Society Islands, is 3,051 miles from Bougainville, in the Solomnons, and 2,545
s(WI'I PACIFIC ARIEA 571

miles from Aticklan(I. New Zealand. Auckland is 1,127 miles fromi New

(aCitleoii, 1 ,598 miiles froiii ES-Pir-it i Slllt( il til e New'. Hlebrid1es, 2,107 mile,

from (11n1dlealcanal, inl the Solonions, and 2,467 miles from Bouginitville (fig. 199w

The rapidl Shiftinig of per'sonuiel and hiospital equ~ipmiient froml one isl~lal(I to

anlot her watS alwayIls difficult lu11( ait t ifiies iiuipos-silble liecallse of a1 shor1tiage of

translisortiat ionl, alnd phlans for muovemient s of anll size ha1d to be nua1de long ill

adlvanice. As thle iuiilit arv sit uat ion ciatinged, linies, of suppl)y aind evalcult ionl

rolt Cs alt ered. 1. navoida1ble inefficienicv ill tile use of 1)rofes'siolil. persolniel

frequently result ed ats troop st rengthus, diminishedI onl oIW island aid incerealsed

oil alriot her. Oft eti, by tile t imie 1i051)it ls were constructed and ill oiera1t iOu

lit onle location, thle miilit arv situnat ion hald chianlgedl to suchd at degree thalt they

were baldly needed inl an1 emitirely different arleal. Thuis led to long, unnileces-salry,

and~ costly evacialtionl of patients.

D~efinitive medical slulplcort. hald to Ile givenl to smlaill garlrisonls Onl isolat ed

islainds when p~ersonnel could not he quickly t rainslortMe to ain atdeouat e hospital

inl tilie next miedical vechelonl. This frequently ledl to long periodls of relaitive

unaclt ivit v for Compulet ent uiiedicall officers who were badly neveded elsewhere.

Distribution of Diseases

lin a region so dliversifiedl geograjipicailly, ecoiiouicaillv, and( sociailly, there

were widlely valriedl disease lilizar(15. Ill New Zea'land, 'tilie probilemis' of thle

initeiriist wvere simuilar to t hose encouniteredl inl thle Middle Atlantic St ates', but

inl tilie Solonlionl Islauilds t hey were vatstly' different. New Zealand, New (Caledonlia. an1d tilie Fiji, C ook, Society, and1( Marquestis Islands were noniiialairious.

whereats the New H ebrides and thle Solomion Islands were int enselv mailarious.

Thjis- epideleiiologic peculliatrity permit ted the transfer of iiialairialized inioividualls

Or whole organlizationis froimi nit ensely mailarious aireais to areas where thle disease

(didl not exist. It, uuia1le )os'sible valuaillle research concerning iaai.

Filairiaisis of thle nonperioohic varietyv wats livpereildeiiic oil ishlands inl tilie

ealst eri' port ionl of tilie arleal, anld thle olisealse affected lairge numbers of t roops

before cont rot measures were inst it uted'. Onl the islands of thle New H ebrides

amid( thle Solonions, nal tive reservoirs ats well its Vectors (if filairialsis wereahm-

(1:a1t, but thle t rainsiliissioui wats periodic, and for reasons that are niot. altogethler'

cleari tilie olisealse never becantie of reall miiiit ary iiiiportiauice. Large epideimiics

of den'igue developed onl Espiritui Santo and New C aledoniia, and sporadic

caIses Were encouiit ered elsewhiere. Onl all islanlls, withi thle except ion of New

4ealanlid, troops cauiie into close conutact with Iinative populat ions who'se hygienic

pralctices, chiefly those concernied withi time dhisposal of feces, were priiiit ive,

Mid( (hisealses spieaold by conitact with Ii111i112il1 excretal were comimion.

Thme na1tives of tilie Sot hi -Seal Isla mids were highly suisceplt ible to comimioni

cont agious (hisealses such ats inilnemeiza anid mneasle~s. Ill spit e of tilie occalsioniall

occ1urren1ce (if at disealse of high con)il iuiiiicabalit v ill ~ t roopis, thalt nio not able

epidemiuic dlevelop~ed is a1 truibut e to Ariiiv pr'evenitive mnedicinle prauct ices.
At "I'l V I'll I-:,- "I., 111,A)ICAL 1, 1 AN I.,

ýý WAL

to

00

to.

-od.,

JI

dpoooý

AL

Ira 7 -

hm Llc, ipf* N o-\\ 1-1:11101. B . 4.\\ U :dl .4 It'll in. 1114, S111
SOtUTHAIFI 1,1'.REA C A'\ 7

Deployment of Hospitals

From what has been said of geography and the deployment of troops over

scattered island bases, it is clear that the chain of medical evacuation and

supply was a difficult one (fig. 200). In general, transportation from one island

to another could not he effected quickly, and the sick and wounded, whether or

not they needed the services of specialists, were often treated by whatever

inedical officers were available on the spot. Undoubtedly, the Operations

Service, Office of the Surgeon General, wa- greatly limited in its choice of

hospitals and individual specialists for specific assignments in the area. It

was necessary to send what, was available where it was needed most urgently

rather than to select, according to a previously well integrated plan. the kinds

of units that would best meet specific needs. The same may be said of the

redeployment of medical units after they reached the area.

For example, the 7th Evacuation Hospital, a 750-bed affiliated unit front

the Post Graduate Hospital of New York City, provided medical support for

the force that in April 1942 occupied Tongatabu, 1,808 miles from Guadalcanal where the first combat occurred. The hospital's large complement of

surgical specialists was largely surplus in the Tonga Islands, but at Guadalcanal

there was no evacuation hospital, and specialists of all sorts were critically

needed. A fine installation of cantonment type was constructed at Tongatabu,

and the hospital functioned as a station hospital for the small garrison force

until early in 1943 when it was moved in two parts to Fiji. There, it was filled

to overflowing with station-hospital type cases from a heavily malarialized

infantry division, which had been removed to Fiji for rest and rehabilitation.

The hospital was moved to Guadalcanal in February 1944 to stage for an oper.ation that was scheduled for April 1944 but was abandoned. Consequently.

the 7th Evacuation Hospital never d 1 vcrcd the service for which it was intended until it participated in the invasion of the Philippines in January 1945.

The 52(d Evacuation Hospital, an affiliated unit from the University of

Pennsylvania Hospital, Philadelphia, Pa., lid1 a somewhat similar experience.

This hospital a(', ompanied the task force that occupied New Caledonia wit hour

opposition in 1942. It served largely as a station hospital there, although

some casualties were received by air and hospital ship from Guadalcanal.

When the Americal Division left New Caledonia for combat in tile Guadalcanal operation, its sole medical support consisted of the 101st Medical Regiment. The 52d Evacuation Hosl)ital, which was filled to capacity at the tuime.

was left behind.

The 250-bed 71st Station Hospital and two 500-bed general hospitalsthe 18th from Johns Hopkins Hospital and the 142d from the University of

Maryland-occupied Viti Levu in the Fiji group in June and July 1942 in

support of the task and garrison forces (fig. 201). These hospitals received a

nuniber of Marine, Navy, and Army casualties from the Guadalcanal and New

Georgia operations, but, with air evacuation to Fiji almost negligible, the

seriously ill and wounded patients had been treated during their passag-e through
A (11 1 IT I I:,- (I V clov-1 1:1,.\vr:-ý

eZ

4 lij ill III,-- lil-A I.\ :Ic ll:lI i.m . .\x ( ;I.,
V11if i. 2011. 1 12d1 Iuiii IS fis

lli1li'.le .\llilv '1114l v~\ chl4lttl'. ild Hi llsth uI en bI k () wor (I 4) m III I lit

I'4 l4' liat ()f i~115 4)e 1 lit'll 2(1 i t~il mtjial 41 (. ilm l4a 11;i11iii)(w1:1i11

a 1 ~ ~ 2 ~ n W jI nIww tt cV fal-l Ae illni I 1ov 141111bel. (di 114 IWl t'a ,11ivl

101 ~ tt' if I :l l'nt~l Iio-piiaV () r (4lle elliat 1 rltt . WI-v i 4lv l Wer1lie 11 1 , 11()p1 litll Illii

pe1 Md1 Io'imil I 4 i iiitl te rel(ll'aiil exite Ill11 rvilltll l i t) foiel s ita c arSeialis Ill a'ea, lian

pi444 Ill~ IXi

IvnilI I S ()'dt' . I ll. 1Stnl I ( eeril I iovnctiiI. Wa1( a 1 52lI'4i 14 the 20111 ca
NISenior ( o1ýu1tant ill M\edici'l, (M)tice of tie Surgeoo I USAI''A: (olnsilit'iit ill

.\lvdivjto'. Offtice of Ih lo' 8igeol, CSAV1PO A; and (Thisrilt~art irl AMdir'inc, Offi1ce of i lle

i1oiiil plan1) of' the (hief S"dli'geoi1, llS lAFI , he served Ill till. ( p1jci(ity (ul.ii

illost of thle wvar i I h 'le ara auId wvill be i'efelried to ill t his chiapt er astSh le arv't'

(('O)ll~ll alit ill meiciCl(iie.

NNlieii (oov Ba011 11ker Ir'porte 1'( o,(Iliiy Ile be-all at once, thriIoughi coil l'er-

('lievs wit Ii the Ch'ilef Sirl.zeon. U'SAFlS1PA, .111d( Ilieiiilersf ol is staifl, to fbiiiuihiai'-

]I/c hiiiisell, iiiorv i~'iill with di tl medical prob)llemis 'onifroniting~ interniists

ill the are-a. Onie of, C olonel Baker's firist a (tivit les was to IiliquIir Into thi 1le

(Ii iii it V oh pi'o Iessiolii]civ I 'al 1vi hg givveli pat ienit s withI d i-se~i(s and1 to ad(1vise

thle ( hijel Siii'goti oil corriect ive lpr(ced I('il-s nic'at edl. Ihie (c0nsultnt ii i iad.

.I [it hiojit v olilv itisohi v as lie, spo)01W iilll(Iiciill N flot t Ile pie SIII'iZColi a1n(l illiaIe

ri'IOti11i]iefl(laitioiis to haim. Thle C hief Suii'geoii him1self' was hiiiiited ill atithiorit v

IW, thle posit1ion of h'Ile NMedical D)epartmen('tt ill ('st ahlishi(lv Ari'iY ('olilialiild arll.

I 'ec.iiise thle top) comiimanid ill thle a 1'('U was, vested ill thle tahv Ile iililluence of

Ari'mnv Medical D)epartmienit persoliliel Ill est abhislirrali 'Ind l d ((' itrgielig.I edal

liio('E'diil'C was fiii'thlei limiit ed.

Colonel Banker. was floodi'NV priepaired to iiieet ,il.ianv of' tw liprloblem(is that

COIIonhovtid 111111. Ilis pn'vvionis uiliil'ir aiveXperienice wvas limi1t ed, his trainuillo Inl

.Al'iiiy anmilisinismt ive p~roc'edure'(s nerlio'ilile ;Ill .11 hs viewp~oint otimil 111 t r1v1

meici'l(al Icss(iiiimed( "ial f'ioiii less thniii a Veal's" s('i'vi('( oil a sili"]v Aislad base.

There Av'mer iiaiiy factomrs iffectiil.- thle ('ale of pat ients cithelid'(ir'ectly 01' ill-
St)UTII PACIFI[C AREA : -

(IId -ii 1t Ilitllto NJc(ici4ulw e Mict1 tlite I' ~5iileielat o l 'le lzsil

CIIiligl'5 tha~t reqired ludY and ri&c;i t ll h iatgO (l4)Ctioll f 5 id c zorret lVoVne

Soitile , l~lS that w o11tl'fIsuchII sei"iedlliV thtI'Iii delit a lde ani d poorvia ones ( ITPol .it 

work noiie a tt teli* owl I'll( ores)1'thir i'i'ouenly 11111 nding'lipola tbu

Per1s11"ci li onnel management. AstFli I' wvlit oiiil, i'et b0?)ca)lie ofvou li tha thei'

(1alail cap *op am11 prope nelvlit t'o f lie po fesqulif al (fudSilifi'U peoni f'iiediconahilitile n Il d prpel' 4liife lWlitiit~xv goo sialistbad 'Fieetlled'tit ca Je hisi concept isal

w~orkedi olt civiilie ( )fhcicv' of t Cole lonelo BakeeraNzi lfow toliu raiiizv hof nie'ich

Specia.lly a i~ istriitlo'proilliliii n theieiii w)1tltasiidctdadslof niuiiiiill l tl'suthit

clitllt -cveii lie Soul Ii Pacificd hut -ii that) hi.t It) d f t' t n ii d v d -il ' work uniidier

HuttI7 slprIcal seie iiuniu l eadporoeddpo
578 A("'V ITIES 0F11 M EDCL Ci0. .')N51 L'ANT1S

Arniv praict ice of considlering its d10(1 or qualified to render p~ract icailly tiny

p~rofessionial serici(e was too widlespr!eadt. The in forina liol Onl persolniiel

records inl tilie Office of thle Chief Surgeon, H eadqujlarters, t'SA F'l-PA, wits

not suflvicent to inform Coonel Baker as to thle real professional quahlifcat ions

of medical officers. Onily after ai conid~(era*le dlelay atid frequieint visits by

Colonel Baiker to fiirfltiiig hiospit als (Iid it Ibeconie a pparent that there wa*Is

a st artlin~g short age of wvell-(Iualiliedl iIedhi(al personnel. It was also not ed

thIat' iiitiy ab~le ineii wer'e lost thIrouigh normlall evacut(tiltion, and(l he qual21ifications of rep~lacements were oft en disappin~)it ing.

Thle iuiosst oiitstaildin deficiencies oif liospital stairs were eventuiall v

corrected by the shifting of persoinnel and1( thle eiployment of seialwiksts singly

an 111 s t eamis, Onl temp~orary (luity. Fail too little p~ermfanient redhistribut ion

wa~s accompillishied, however. The Chief Sur-geon, USAFIS1PA, was, in tian exi'emlely difficuilt lposit loll ill regardl to persoiniel mlat ters-. I le was conist ant ly

short of mledical officers, esp)ecially those wit h real adilmin[ist rail lyie ab~ilityv.

I sluiil bases were emi-i~ndependent, and island commnanders,. theier suirgeons.

and thle Coill1111 lding oflicei's of t heir hiospit ads aill too frequent ly at tempt ed

to block thle transfer recommended by higher comlmand of highly qualified

mledliciil speciallists.

A fui ther implledimient to thle efficient shifting of medlical officers, was thle

mnattel' of rank. Promot ions of mlen -wit huut hiospit als were lusually rapid.

P~romotiton's oft en depended more upon01 lenigthI of service. hiospit al assignment,

per'sonial relationships, *111( tie pr*essur'e of' hospital1 comlnianude's- aind islanid

b~ase suirgeons thiatill upn rofessiontal abtilit y. Anl iuncompetent lieutenanti

coloinel who was chief of a nudi~iail service could( not be rep~lalced b 11 highly

qulalifiedl cap~taiun assignled to his service, aluid there were few posit jolt vacaincies

in other inlstaillat ions or headquarters to which inicompetent professioniail

officers could1( be~ reassignedl. Rec'laissificait ion procedures were almost never

empllloyed,

Supply services. Thle professionatl conIsuiltantIs were frequently.~ concernedl

with nail teu's of stiilply. ()i souiie islands, t here were coiiiplvtely equlipped

hiospi tal s ill at Nvell-intttegrat I '( ai i'ialngeitiei t. Under these circtiizist atces, t here

Avere relaitively few uaiajoi' stiilply lprohleins. Whiat, witas laicking iii one hiospit all

could frequent ly be obitainmed inl atnot her, oi, paitients could be mloved fronit one

to ainot her liospiail. The situiaitioni wais eiltrel (liffren when large gairrion

forces hiad~ aiccess to only ii siiall station or field intstalllationl. The equipii encIt

of thlese units dlidl oit enMAdvl thN"ii to Jirovidle all of the laboraitory autd speciail

exaiiininatiouts req ii iied. Therefore, it Wats neVceSSa u'3 to air'raliige for' Sl)(ciail

issue Of supplies 111d equipiijiielt to such htospitails iii ordler to priovide t(le

essen tiaul reqluiisit es foir thle pr'oper' diaigniosis antd trieanit iit.n rlhiv lauck of s~ulplles

wumi lairt i('iarily- prouitinen 1. inl ext remlely forwaird areas whlere crit ical shioirtages

sei'iouisl iiit erfered with Iinvidicail (-tire.

Liaison activities.- Colonel Batkeri frequent ly visited (t(li surgeons of

bases aund of I itnical unit s I Iimotghiout thle area. IHe assiste e(I the base surgeons
SOUTII PACIFIC AREA 579

along professional lines and served in a liaison capacity between them and

the Chief Surgeon, USAFISPA, on matters of personnel, supply, and evacuation. These associations were, in general, mutually helpful to surgeons and

Colonel Baker. Though many objections to the ways in which professional

consultants operated will appear in the records of medical activities in the

South Pacific, there were many favorable reactions to the assistance they

gave in improving the quality of medical care. The following extract from

a report by a division surgeon speaks favorably of the consultant system:

The recent detailing of consultants to the staff of the Chief Surgeon, USAFISPA,

has been a great aid and has given a healthy stimulation to field medical installations.

Colonel Oughterson, Colonel Baker and Major Sofield-surgical, mnedical and orthopedic consultants of General Maxwell's staff-have been ideally suited to their assigned duties. Their

visits and discussion, their help and their advice have all been invaluable. They provide

the necessary liaison to higher medical echelons and are warinly welcomed by all units.

They live with, talk with, and work with the medical officers of all medical installations

in the chain of medical evacuation. They bring new ideas, rel)orts of cases evacuated,

and in general provide the link that up to their coming had been lacking. Items of equipment

hatve been obtained promptly and efficiently with tile help, and even personal delivery,

of these officers. All three hold meetings, give most interesting lectures, and are continually

seeking new means of improving the Army Medical Service. They have certainly been

most helpful and their intelligent, friendly and close approach to the medical officers of

this division has been greatly appreciated.

Statistical data evaluation.-The Statistical Section, Office of the Chief Surgeon, Headquarters, USAFISPA, was small. The section consisted of one officer

and a varying number of enlisted men, most of whom had little or no specialized training. The officer, a Medical Administrative Corps major, had been

a noncommissioned statistical clerk in the Army for many years. At Hea(lquarters, USAFISPA, his primary function was to consolidate the weekly and

monthly Statistical Ilealth Reports (Form 86ab) from various bases and medical units. This meant that only a very limited amount of statistical data

was available to the professional consultants. It was possible to obtain reasonably accurate information upon broad trends of disease, but more detailed information had to be garnered through other than routine channels.

Accurate statistical reports were obtained in several ways. The Malaria

and Epidemic Control Organization in the South Pacific, a joint Army-Navy

organization, gathered reliable information by an individual case card system.

Through this, the medical consultant was always apprised of the situation concerning malaria. Other data could be collected through special studies and

special reports obtained through chiefs of service in the hospitals. The Machine Records Unit, Adjutant General's Section, Hleadquarters, USAFISPA,

was extremely helpful in several special studies, but the amount of time the

unit could devote to medical material was greatly limited.

The wealth of important clinical material that was never collected was a

constant source of disappointment to those concerned with professional work,

but under the circumstances there was nothing that. could have been done

about it. A sufficiently large machine records unit serving the Medical
ACTrIVtITIE:S OF MEICII1AL CO NSU1.TAN~rs

I )partfietitt exIciisi viel would( hii ve iiiad it poss5ible to( collect at large attioii lt

of vomliplete111 iil ielVi-lriti itiforinait ~lo.

Preventive medicine interest. li i the a rva. preve'nt ive nIellicinle wa-s 1tititle

the ditrectiton of the N111ir621a tild Ep11didemic ('ontrol ( )ratiizaltionl. N\aj. C arlos

I). Speck. jr., N IC, at highIly qual111ifid millilr11iologtst . represeltvit t t his or-alliization if) the Chiiief Siirgeoi i's ( )lice. liie also i t egra 1t eI prevenvtiye iiied ictue

with other. Medical I )epartmenlit act ivit ies. The Chlief Surgeon, USAFlISlPA,

Wats reT wesen ted ili t li offlice of thle MiIalaria antd Epidemici C onit rod ()rgar iZ iztion by .L~t. ('ol. (hlit er Col1.) PattIl A. II ar-per. N I( , who wa-Is of "relit akssis't ance

to ( olotvil Ba ker iii helping higlii hli~lkle professionail lproellilis that overlapped

into4 thle lieu i of prevelti iviie( I l tdlile. Thei efficient m 1111krllgemeit of prevetiyle nied icili iie at ivit les coiit ri 1)1tell enlormloulsl to the( dIischil arge of Medicall

Di )eparilvt en trspotisi hili ties ill thle area (figr. 203~).

CONSU LTIANT AC IVTES IN T~jIlE, FIELD)

C olonel Ba ker spenit a ilislirojortolie t 11 (' 241 il~l li of 1I ilie li~)otl Iwo lirgen I

probldilis. to the rela ifix* neglect of other~s. These two ob~jectives -to illIJrov,

lie( treat mc1ii 1 of t111iin laia m to( provide aideqjiiate mledicall caire ill forward aniid

44)iii I nt areas -- were t imli coiisiin ilg, an C11 oloniel Ba ker wats ofteti ab1s'eii

ti'oiii Ilieadua(1(1iiirter for long" periods .At t he sa mie timei, t here were a va ila de

inl th learait~Iet int.1st s with excellei it professtollai qlal 11ficat l olls whlo colith I have

1welei (iiplo *vedi s deput tvy coistilil talit s. Softe( of I lise Ineti were ut ilizedt Its

inst ruictoirs, o~thers oili speciald projects antd specialist t earnls, but I.full ad vii ut ge

was, never, takiike of t heir ahilit ies. Accord inugly, it will he appa reui t ill whla

follows tha1t liiudiie eliplihasis had to be placed onl certaiinn phaises iof theii consuilt -

anlit's work.

Visits to hospitals.-AII hospitails wvere visit ed ats frequentl iy as tinle would

pertlli 1, except t hose ill smiallI anid part iculairly isolatedc bases. C oloniel Ba ker

WOUi d rep.Iort to thle conuna 11411 ing oid ber a 141 d ;i5,('1I55 iiiedIical Service problemis.

The'l Iii'q 11itv of t eaniwvork existing bet-weeti th lieel I icval a1nd4 su rgical serv iceslOlie t wo illilijor ser-vices ill Arnily liiosl)i tills dii i tig, wail irne -cotil ib sually be

dlleermliiell bv coti ferring' withI the two, chiefs. ( oloniie Ba ker's attenda~iluil iat

WHrI' rollitld s, (1i5ps1)45 ou board meet tiligS 1111(1 stui ir fereice 1111i a i xtii- 11ill k 

tionl of clinlicall ltilld iluitops ,N recoirds enlabled huhl to) evillitltle the professioalil

qua11lif ica t ions of t he chl ef (if t lie filvcil' el ser-vcev and hIls stair I.

'Illrot ugh these visits, C oloneil Baker fre tuei t ly learned~ of iiew\% p~rolemihs

fromt hotiIl the professionlllil 14 admniiist rativye poinits of view. It gaive hill tilli

opport itlit v to) disseniuiiate iniformlatiton lIe( hadl gilt liered ill ot her hospitals aiid

to att Ietlilpt toI se sonlic of ti (lequst ions 111t liit 'os 1 ltl irose ill th lie iiiiis

of nllei I ial offlicers, whose ou tlook was icsatiyii nrroiwedl by their sepaira tion

froni1 l~rlwl~leNd 11ctiVit it5.

Supervision of laboratory services. --- For af long, tinue, there was- no lilhor tonvcot istil tai t Ill till' ii eii . ill thouht11 dive \%.Its -geil itved''o for otie. The a~reat

had11 it shlortiage of colliijeteciit of lieris andi( techlnuician s, andI tlie( uork of the lIa -
a rA-

\iuhoini he;Ixi'i haiti v It) i e1'IPajii I lt i''Ie t~ ii~i m Iarn o'Ijii I)~e a e I Il I a l proiii-I Rut) \0 111 c ul vil1.

( ~i~u~ah 1iiiI I~ . .2Ilv . )- A is I.i~ ~ h 111 Ishau1h11, ('1:111 (4 '('t11iL-Ia diitl Ollo 21i. nvll'Vhy

oI it oh) (-4 ;imvdi..Ihet ~ti ~itIi ish~I. ~R i ''Iiiiitt ~h4I

Iu -ta f is h'1eiiiaI it o l 111.t cerli as~ ll t \\vt~Iellv di''mv \\1 iI III mw l * lt
WTI \ HA I:s I 'V Al 1:1 IIC \ 1, 1 *4 I\Iýl I.TANTMAA 90A % W41111. VPIt- I

0-7 16 TV MMOPRW%,

all

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AI*III\ 1:11mor'llf)n III I Ile'll.c.1, I ho I'lk (d . Illlwrx

III III(. fonvardnrco. A dr-wrihill", lho SIT61.1,

Ilic 1.11mr.111,1-Y could providealld Iho lllvnll-ý of

r 1 4 1 r v 1 411

1( 114 r 114 'I'l k , I I III I'l 14 .1 1 1 1 1 1 111, V )I I I rvý, .11 it

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I I o I r I : I I I I I I -
SOUTH PACIFIC AREA 583

Michael, Jr., MC, of tile laboratory service of the 18th General Hospital was

selected to organize such a provisional laboratorv.

The work of this officer contributed inestimably to the high quality of

medical care given the sick and wounded in the Bougainville operation. The

medical service for this landing was organized under great pressure. It took

consiiderable imagination and ingenuity to select, procure, package, and transport essential laboratory supplies. The laboratory went in with the second

echelon of Army troops, and much of its equipment was scattered in the confusion of the invasion beachhead. However, Captain Michael managed to

collect his equipment and established his laboratory with surprising speed

(fig. 205). Soon after its establishment, the hospital changed its location, but

this was accomplished with remarkably little interruption in the laboratory

service. All essential examinations were provided under the difficult conditions of combat. "The Pasteur Institute, Bougainville Branch," was stamped

as an unqualified success (fig. 206).

Teaching.-The dissemination of information that would assist medical

officers in giving the best possible (care to the sick was one of Colonel Baker's

chlief ol)jectives. Various means were used to accomplish this, but the principal method was through personal contact. Opportunities were provided

during general ward rounds, by consultation on special cases, 1b observation

and teaching of laboratory procedures, and by participation in staff conferences

during hospital visits. Colonel Baker carried withi him a projector anti a

numl)er of slides of educational value. Regular hospital staff meetings were

supplemented by scheduled meetings attended 1y all medical officers on a

given I,,"' Special weeetings wre organized whenever circumstances permitted. ;,id a symposium was held whenever special subjects required additiii"' attention in a certain area.

Visits to field units.-Colonel Baker made a special point of regularly

visiting the medical battalions of all divisions in the area. He met with their

medical officers, held conferences, and attempted more effectively to integrate

the activities of field medical officers with those of hospital staffs. Officers or

enlisted technicians of field units who needed special instruction were often

placed on temporary duty in an installation that had personnel qualified to

teach.

A serious cause of dissatisfaction among medical officers of field units was

their feeling that in some ways, men assigned to hospital-, were favored. There

can be no question that this objection was a valid one, and the consultants

realized the hardships impose(] by inflexible assignments. In the South Pacific,

a sustained effort was made to make some amends to field medical officers by

the creation of as many educational opportunities as conditions would permit.

An area directive set up regular programs of instruction and provided for

limited rotation of officers through fixed hospitals for purposes of specialized

instruction.

Distribution and preparation of medical literature.-Early in the war,

hospitals were seriously short of medical books and journals. In soni affiliated
il'l ,I .Si: I I, 

hd.Ij+l' ,lhldll+d \\ 4l'I\,', ;dlhdd111d l'dh4I\. iII,' l'llIddIl;d11i-. l1411- 1:I 11l\ : r11,.u1,1,+I I,,

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F IC -isls-I~!'sirIl st I t-si- II s IitIs-Ii-s Is ;i si IIs- st i
Council revached himit re-izularlv niv ey were ait imiportattt, sourc~e of litifortuat lol

aId oftel henldped to c Iyslj 1a ect s liiiier dIiscuission or inivest imi tion WithIiin

tile alreal.

Coloniel Baker wais responsible for preparing. portios of rep~orts t hat (eleult

With ttlie (I jagitosis and1( treat 111(111 of, (IiSease. Ba1sic in Corltalt ion wa-s guni t Iivier

1)V fersoiial1 conitact with Ii tiedicall officers attid bY "' udY of regularll tilolitlily

ET\1 I (Essential Teclmittic Medicall D)ati) reports "rouin tilie balses. bitt tilt,

s -tliof refport lgr was deficien t ilt amt tinportmaitt resp~ect . The separate

rep ort s or Severall Iiospjtilta s loca t ed otl one balse wouild be cuitsol ida ted in t lie

balse sturgeolt 's offlice anrd forwarded to area I ieaidlq naners. Colonel Balker hIldc

no0 reguilar opportuni tyt to seet, Itese itt(ividunld hiospit al reports, lanid Inii uli

valtia 1ble tItat eria.I was lost ill tilie coilsolidlat ion process, ill addit ion to thitle andt~

efror~t

Whieit Colonel Ba ker Wits alwatv fromti headquarters, thle iitan replorts

tliiit a tt1i ved crea t e (I a1 Ia rge bacl-iog. Comtmtandt~ reports ott itted ical topics

oftenl ha'd to be preparved Ititi-1iedly whlei thley, would halve beent ittatle tItore

viluallble hald t ltete beeni titore t itte to dlevote to thevir Iprepmaration. Thle saute

cotmmt entt a plplies to C olonel Ba ler-'s ed uca .t iottlI actfivitieS a111(i gelteraIl cor-0111

sJpoit(Ietce wvit It c~liiefs of' service itt Itospi tials. Tile professiolltal coislstIa hitt s

Siscitssed ftlequien tl * tilie (hesinrabil it ' of htalving at pubit 1icat ionts officer Itt tilte

(itiefSi rgonts( )f licev bliit tilie plint %it ws never p~ursuied to cotitpletiont. Thtis

l)la11t woiuld lhave resiultedl ill Ittore eflicienit (lisseittiltationl of vallital)le technical

in font iationl.

Research projects. One of('Colottel Balker's ditties wats to develop research

project s, tomadvise tilie Cili ef Sttrgeott. USAFISPA , of t iteir prttct ictl aipplientijont,

amit~ to keevl) nite stir-geot (;~l ittformted of' resutlt s d itnt Iitt i lit ave a fppl ivitioit to ut e( Iica PI pactice elsewihere thitan itt t ile 'oliti t I P ific.

Thiis cliapt et will inclutde at suuit uarv of somte of thle tItore imptjortantt

research projects relat ed to~ inttternal mtedicitne il the airea (p). 607).

ME'DICINE IN THE FORWARD AREA

Soonl after. Ii is alssign ii en t asits tledlic;1 conlsult a lttt. C olotnel Baker itt de

b)rief visits to tilie font'1 .500-bed stat ioit liospi tals ott New ( 'aeldon in. All of'

these ltosJitills were crowded with Ii ptivitts who hiad beett admitttted (hirectl *v

ft1ot ii thle guitrlisolt force or by eva cit at iort fr1otii thIe forwAalrd arlea. MedIic. \I I

probldems wevre pritttar-il ,v sititIlar1 to thlose wit It vhiicli t Ilie ('oitsitlt attt ltutd b~ecomie

fa Ilt il l~ (btttie prev~ious I I tttotttits ill at geitet'ill liospitial at Fiji. Thle visits

to Newv ('aedotiut St rertgt ltetied lhis cotnvict ion thalt too 111.any paitiettts wvere

ev.acu t ed froti ifotwarol areals. A ('otist a itt st reanit1 of pawit t s flowved to thIe

rearll, ptilsi gll bt ii btriefly ait otte ittedlica iltstiallat iontafter antot her bec. use thIe

niumbtler of beds wa-Is iitsiitlicieutt to itold thlemt.

New (Georgia Operations

At Muntift.t ott New Geor~.itt Islitin tIitt tilie Soloonu s, whtere comtblat was

jutst eitldi hg. professioitil probldems were sttildied with (Itle Ite elp of t ile 'Sure~onl,
SOUTH PACIFIC AREA 587

XIV Corps. The greater part of three divisions had been emplOyed ini the

combat operations. Hospitalization had been provided by tile clearing companies of the three divisions augmented by one platoon of a field hospital and

a small convalescent facility organized by the 37th Infantry Division. These

hospitals were quite unable to provide adequate inedical care for the large

number of casualties. Not only were the physical facilities inadequate but

also the professional qualifications of Medical Corps personnel assigned there

were not equal to the( difficult professional service demanded by the situation.

Disease casualties were very numerous, consisting chiefly of patients

with diarrheal diseases, infectious hepatitis, exhaustion states, anxiety and(

panic states, malaria, and common tropical dermatoses. Because of the

shortage of beds, there was no alternative to rapid evacuation to the rear on a

(list ressingly large scale (fig. 207). Guadalcanal was the next base in the evacuation chain, but hospital accomnmodations there were quickly filled beyond

maximum capacity, and further evacuation, first to Espfritu Santo in tile

New Hebrides, then to New ('aledonia, to Fiji, and finally even to New Zealand was the inescapable result.

Conferences with hospital staffs throughout the rear area brought to

light certain highly significant facts. In general, tihe most seriously ill patient's could not initially be moved. They were hospitalized in the forward

area, although the shortages of physical facilities and qualified professional

l)ersonnel were greatest there (fig. 208). When t hose patients finally arrived

at rear area hospitals where specialist, talent was concentrated, they had usually

reached the convalescent stage of their illness or were simply to be miove(I

on to the United States. The vast majority of patients evacuated early were

those, with disease conditions that (lid -ot warrant their evacuation, except

in the sense that, they were physically fit to travel. They were consequently

nioved from one hospital to another in an effort to keep hospital beds available

in the combat zone.

When the records of hospitals in rear areas were examined later, it was

found that time after time patients arrived who had largely, if not entirely,

recovered from the illnesses that hald originally led to their evacuation. This

practice used transportation facilities and hospital beds uneconoinically,

caused much duplication in the use of medical personnel, and was detrimental

to preserving the combat ef'ectiveness of troops who were urgently needed.

An illustration of this unfortunate practice can be found in tracing the

course of two hy'pothetical soldiers a(Imitted from combat to a hospital at

Munda for the treatment of exhaustion and diarrhea. One was retained in

a clearing station on New Georgia. After several days of rest, feeding, hiydration, and symptomatic treatment,, he was returned to his organization no

less fit, physically or psychologically, than one of his fellows who had patiently

accepted his fatigue and diarrhea and recovered while remaiining on du(t.

The second, evacuated because of tile shortage of beds, eventuallv ended up

in a hospital ii New Zealand, althiough he Ihad recovered from iris fatigue,
ACT[\ 1,1111:11 "1., M1,111CAl, 4*41INS1 1. 1 AN I

db 4

APPFifi ui. 207. Ti:m4l-r st' %%,mriolrd 1'roji 1w:11 1.1 VI\ -:1phillo.

I fill\ 191:'.

111111,_,or, .11141 (11.11-1-hen I dov or I\\o ()III of In 1114. vicall. coniforlablv. .11141 04,11k, I hopitll Ship.

The offect 111mil a Ill'u'll pen-villou'v of soldicrs \\ Im lind S111111,11.

1,xP(1I*IcI1c(1-ý 11,-ý Invýcapablc. Thv dillicully \\fill Mlich theY cmild he rellirlied

to 41111v In the f(inv'Ird :11-on \\.Is I-ollu'lik. pr(q)(wholml to the dist.111ce Ihv\ had

hecil c\ncli'lled.

11(1\\I\ oppoillivil cmlý;1111,liit I-v;w1led .1 S111111,11. conchisioll nhor

:I I-1114111th Ima of the 1*()I.\\.tl.(l 1'ru'vill IIIvI,;lII-v,4 \\vIv Alcelm'd

14) impi-mi, Ow Iflodefili'lle profvý-;Simml con. ý_vf\vfl S111*ý_11c.11 P.11110111 I M

CMIII).If zmlcýý.

A S111(k of correcliVe lindvi-1.1kvil kv the

'111ol, S1iI-.L,:vfljj, I It If I liv help of I If(' profvs-ýIofm l com-41111 .1 fit

Step., 11.1d '111-v:14k bvell lakell to '111(win1v I Ili, sit 11.11 Iml p'll-ti,111Y. A laru'v -oill-ral hospikil wid I 270-bed shilion hospil.11 \\crv I'milvd 14) Espirill? S.11111),

h\q) -MO-bed !onliml 11(ispilol, \\crv III the proves., of coliSirlictimi it

.1fid Ili fivid hospli'll svfit to N11111d.i. 'I'liv (.()I]-

111o nim-clilvill (d, ()Ill. (11, l1w -encrol Imspit'lls I'l-mil

FIJI bill 11111ý1 IIIf)VV \\8-ý PI*c\vIlI(,d bY .1dimillst r:]I Ivv (d).jecliolls.

'I'liv :111:11k,-JS I (d, the Nv\\ Gem."';J .- 1 1) Im ý 1-:111 oll .

-di(m o l 111:11 I'11.1do llinto
'I'l I/AII I* , AiV

itti ChI1-nm u(rII, ul a (in i": I? 1: V 1:', I(I.i- 
iiit'ldi('i suipport wats Voiitflot ii theit combaiit it i'a. Efforts wer nt'i' ialit' t

onice It) avoid at simiilar difficulty dutiring tilie pendainlg camlpaign1 oil Bouigainville.

,A t ask force compiiosedt mintiily of thie 3dt 'Iarinet and1( 37th Ii tfant *rv IDivisIOIs Wiis 5('liu'll'( to atssautlt th lit' F4 es ýliC5 ugrusta Bay art'a of Bougainiville

o11 I Novembher 1943. Thliis 1 old plan in iivol vedl 1bypassinig two st rong Ta pa nest'

biSeS dlirect ly ini til litnhe of evacutlittoin. Wi~i ith his plan111 ill mind , (lie' professionial consultlt~illts iir-ged thlit a fieldl aul e'vacuiatio hotlispital he land~ed

soon aftetr Ilt'e issii ilt inisteadi of liater ini thle opertrii oll its caillted for inl tilie

landiting schdlett nt. The (ChIief Surgeon. USA FISPAk, was in entire accord withI

this r'commndil'iatioll, butt troop lists andl ship~ping allowanices Weret alreadY

firmi, Und tilet re'sponisiblet commainad was not svlpii wtleti to altring t Itm.

The t u' nos short, andl copnhltsa tion for thlit lark of hospitalts had( to lie

imptlrovisedt quickly.' plan to holste t'i lit detficient ntt'dical Support wa-Is

formulated by the Ch'lief Surtge'on. 1iSAVlSl~A. with titlit aid of tile( med'(ical

ii ju surgical consult ants. It was presenited directly to Lt. G en. MIillard

I11ii rnion. C ommninading, GenemuralI, USA FlSI ~A, NIaj. Gen. Robert G . Breetnt',

(Commlianin~ig Gt'neral., Service's of Supply, and subsequen'utly to Mlaj. Gien.

Robert S. Bt'ig-li tler, Commandia ling (Genterail. 37tb In ufanlt ry D~iv isiotn. TIlitv

plant p~reseted tm in detta il th lidteficienicies of' thle mled ical ISuppo(rt in ( utl dalca intl

and Newv Georgia, thIe antic ipiatedt saving ini litiauipowt'i and iiniprovt'mt'nlt in

MoralIt of troops, and tilit incre'ased t rea t ment possiblei for sick antI wouinded't.

Th'le planit recc ivt't t lit comlplete'app)toviil and Support of thie high command.

as did mii nvl fut uire sugge'st ions front thle Ch'lief Surge'on. USA FISPA, onl beh'alf

of tilit professional consiilt anmts. AMilinisi iat ive cotrner, weret cut, permit ting

lt'e rapid collect ion of addhit ional imed icall. quartetrmaster, andt engrineering

supp~llie's. A lig-h p~rio~rity was ob~tainled for tilit t ransportat ion of atddit ional

spec'(ialists an uthe It assignme'nt of per-stntitt atid Supplies to scat tere'd units of

(lie 371hl I nfanltry IDivision.

Suifhicit'it supplie's w~ere obtainedt to expand tilit clearing staittion to at facilityv

with Ii a I000-pat itnt capaintylt. Gre'at catre' wals e'xercise'd inl tilit se'lect ion of tihtes(.

stuppJlies inl orde'r to p~rovide' for de'finiitive tre'atmettnt for till surgical, metdical.

and psychiiattric casualties wvlo could li' ret'urne'd to duty wvithlin a pe'riod of

30 days.

Theiecessary petrsoinnel were obt ainied by thle t ransftr to thle 37thIi I tfnrv I~iviskion of oflictrs and entlisted menr of Ilt'e 52d Field H ospit al. This

hospital had beeti Schieduled to arrive at Bouggfiiivill' Onl approximate'ly Dp~luis45 day. MNed ical. surgical, psychtia tric, atid lahora tory tt'itmis wetre'

sel'ctedl fromt tile 11 GtI tteneal I lospit al, 1 42dl G enieral H ospit al, Fiji. ~t il( 39tbI

Genieral IHospit al, Aucklantd, Nt'w Zealand, at id from tlie( 25thI Evacuattion

H ospit al. Theluse mt'ii we're assigned to the 11 2th MiNIedical Bat talion ttill( were

(l ist ribuited anlioiig componien t uinit s.

Thet 371h DiIivisioni had fought in New Ge'orgia. .A thlough it had -onlriii atetd le'ss (halil i t s shiare of nonba t tle catsuai t ies it td w\Its jutstl pvlroudt of

its tillet icti record. titlie tvac(uiiition s of petrsonn tel h ad been unailtvoidablly great.

Ak ce'rtamii evacuiat ion t ratlit ion hail developed ill tilie division, its well ats in tall
sw-rii PACIFIC AREA 591

South Pacific troops who hiad been inl comb~at wvith inadleqluate inedhical support.

It was thought that all opeii dhiscussion of this withte(lvsosmdiaad

line officers might help to foster at healt hier at tit ude.

A series of indoct rinat ion talks onl coilt emllla t ed ching-es in (lealing with

the sick and wounded at Bougainville was given by Colonel Baker to small

groups of b)othI commiiissioned and nloncomfmissionedl officers. The Ihackground

of medlical service in the area wvas clearly andl frankly described. Thie reasons

for thle shortage of medical support tin previous operations were outlinedl. It

wvas p~ointedl out that a p~recedlent had been estab~lishled wvhich ledl soldhiers to

believe they would be evacuatedl (quickly from thle combat zone to the coinparative comfort and safety'N of a rear area hospital if they became casualties.

It wvas emphIasizedl that this lpractice seriously redluced comblat efliciencY byV unnecessa ry* loss of nmapower anid frequently jeopardized the future health and

wvell-beinlg of casualties.

Linle officers wvere informed of some (letails of the medical plan, suich as

the provision of anl adequate number of hospital beds to take c-are of exp~ectedl

casualties within thle condiat area anl(l thle, presence of teams, of medlical officers

qualified in aill important specialist cat egories. Thle adlvanitage to serious

Caisualties of having thle b~est possible definitive care readily available in the

comb~at zonie was strongly emlipasizedl.

Linle officers wvere urged to consider the merits of thle, plan and explain

it. to their men. It was pointed out that confidlence could be built uip in troops

b sugil t hem that filie b~est medical care in thle area was to be provided for

t hem onl the sp)ot , not (lays later in hospitals hundreds of miles away. Thle

chief caulses of muedical andl lsschiatriic lprohdelils (Jluring~ comllat were reviewed,

together withl thle i'ldis1 )ensable role t hat line officers play in the( colit ml of

disease conditions such as malaria, diarrhea, (lermna tit is, andl lsYcliiatric

disorders.

The consultants, thle. assemb~led specialists, and the IpernianentlY assigned

inedlica1 officers of the task force held frequent conlferenc(es conlcernIing sliit)1l3,

professionl ,1 rocedulres, the (list ribit ionl of Specialists amlong units, and the

adliniiistrative and operational control of all anticipated medical activities.

The iniitial assault and( establhishment of a small beachhlead onl Bougainville

wvas made l)y the 3d Marine Division. Six (lays later the first echelon of the

37th~ Infanttry Division arrived andl began to extendl the beachhead.

The ta(ctical situation had anl Imp~ortanit effect onl thme kinds andl numbers,

of mledlica1 problhem,-, encounlteredl. 'The ob~jective of the olperation wvas to take

anml defend anl area in which airfields couldl le constructedl. rhe locality had

not been occupiedl recenitly inl any numblers by either Jlapanese or natives.

As the p~erimieter of thle (lefeinse was extendled (fig. 209), the natives, who had

originally Scat teredl to thle lills, began to seek the securitY of U.S. lines. Large

patrols sort led well be *yond perimeter limits, and communlicable dlisease rates

began to rise (fig. 210).

Durinig thle initial pliase, neither (disease nor battle casualties were great,

andl thle deiuuuird for hospit alizat ion was slight . Recurrent jinahria, tippler
oil II \11 I \ I ii I'\- I. I'

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41( v:41111411.4 ill ;111:n1:111:1 :41141 :1 ,4 1":I 14 41 i 41 l~l 4 11 ' 4'lil):1i44144\II Ii,' 441 .\I:11411r14

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Ill~j4l - IletII l~lills2 1114'r I 41 1411 :14 .1111 ' 1 ;14 44 l4 xl:41i:I.11114M

ll t 41I41:1141 44 '4'14111iI 11v 1lp(lot4Ix~4II l4t- Icl~v. 1 of1 A1,11411:4llc

44114'of 1 i44 -41114 :I It ll- 41 fil 411 41:1114 111Ill'11t:411 4411pp1i(1i41s l~l Of ,'112:1;' J:lr 1 411.:~ 411

t:t411 1 :14' 1.1vt v 1 4 4If Ill 41( I I t Ill I 14~ 1 ( -;I I ~ c,41111 i ~ 11 4 111 44 41 1 4 411 il Il I 14 I i
SOUTHI PAC'IFIC AREA

pI't at ion of vague Sym ptoms. and muany patijents wvere treated for hookworm

disease wh en thleiri sym lpt ous wvere ca used(b sonmet hing else. The difficuilt v

of denionotrating hookworm ova in light infest ations and the stubborn resp1onse

to t herap~y lva(i to fuirt her (diagnost ic difficulty.

" Disease aiwareness,'' at diagnostic pit fall whenever dlisease occurs in

epidemic proport ions, Wits (101inmo0n in t ie( Pacific. This awareness is at good

gumide to dhiagnosis, lbut it van lead to serious errors when followed too far.

C onmmon (ha rrhieas wvere so univers-al soon atfter the landing-s onl nearly all

is4klnds that carriers of bacillary dlysentery were often unwvit tingly dhischargedh

10 (lilty aind n1111ny cas1,es of amneiahisis wvere overlooked because adlequat e labhoratories were lacking. Most febrile diseases were quickly calledl malaria

wit hout labioraitory conufirmati ont andl were t reatedl as such. This cauisedI

conidte'ablde hiarmi to the patient in those cases wvhen woundls of' the head,

cerebtral hemilorrhag11e, or meningit is were t reatedl as cerebral malaria. The

reverse wats also thle vase. ats exampilles were discover'ed proving that death

front cerebral malaria too oft en resulted after a1 faulty diagniosis which deleayedl

thle use of ant imallarial t herapyw unmt il it was too latte.

Psychologic Factors

Frustration, maladjustmnent , mnalassignmen t, nostailgia, and nmonotony hand

a profoundh efiect uponl tlie( accept ance by thev soldier of' his military fatte (fig.,

212). It is undeniable that these psychologically dleteriorating influences were

un usually intense onl Pacific islands. The islands were isolated, living conditions wvere bad, food wats mionotonous, recreational facilities scairce, climatic

condition oppressive, and there wats ait abundance of strainge diseases whlich

could result inl permanent ill hiealt h (fig. 21:3). The universal use of Atabrine

gave m1en1 at Sickly and repulsive complexion. There wats at general loss of

wveight, frequently of alarming proportions, ats wvell ats (hermatologic condlitions

thalt stubbornly resistedl t herapy. Patients withI mailaria, dysentery, at battle

woun11d, or infectious hepatitis presentedl usually more difficult emotional

p~robldems t hanl t hey would have (lone in thle civilian p)ractice of medicine.

The lpsychologic reaction of soldlivrs, to strainge dliseases wats p~articularly

troubulesoime lin cases of' filariaisis and malairia. M\edical officers t hemselves

were uncertain of the course these (diseases would take andl frequently made

contradictory statemtents regarding them. Since patients, soldiers or line

officers, frequently regardled ainy medhical officer's opinion ats authoritative, they

were often ill-informied and uinjustiflably atfraid of their illnesses. The nat ural

conlsequience was emotional reactions leading to exaggeration of the symuptonis

of organic disease, the (reat ion of fancifuil ones, invalidism, prolongation of

hospitalization, and loss of nien for overssea service by evacuiation.

An important insight into the psychiologic reactions of soldiers to their

environmnent , thueir miilit ary experiences, Mnid t heir (diseases wats shown thiroughi

an1 inqu11iry into the a litt umde of infantry soldiers- who were lprestimuially in good

hiealth hi ani onl (duty at thle time Veterains of an infantry division t ha t had
I~l''~:ll~\4'lhI :I~I(414\X- I~l~I4'll Illj [TH)11 i4l\ 44l' N1 I -:11CA C Ill 2444I.TA T

1)444III 1:11.*~I()f Allo 1 A lil )44 if'l4 N i.\ :114 khmol\ .)411.x 19l J)'443, . I 1

;Irf 1:11 L d rI44 l .1 ic 144 nol). I '.141*441I il'X 11:141l 1441 11 ,Ill~~4'll L44)4 hor1eti41

14'c li I Ill11
I IIr ;low\\~ 1111 Ilti) 

- lin ~ 'li ii p t1il t iiiitled 1 lw ill z~id. it t'IIiW tli'!li> iii j):Ilii-ll-
598 ACTIVITIEs OF MEI)ICAL CONSULTANTS

diseases were unconunion. Acute rhcunmatic fever, Iemorrhagic nephritis, and

other diseases associated with virulent liemiolytic streptococcal infections were

rare.

Though large geographically, the South Pacific Area contained a comparatively small number of troops. No more than six comb)at divisions were

ever in the area at one time. The irncidence of malaria was high in the first four

divisions to arrive in the theater, but by early 1944 mosquito control had greatly

deterred malaria transmission.

MORBIDITY STATISTICS 1

Data from the official statistical records have been analyzed to show the

incidence of disease in the South Pacific under varying conditions of medical

care.

Malaria and other causes of evacuation, 1943.-The havoc wrought by

malaria in the South Pacific is strikingly illustrated by the following figures:

In 1943, as the area strength increased from 110,000 to 176,000 there were

151,577 patients admitted to hospitals. Of these, 60,000 were treated for

malaria. The number of available hospital beds increased from 4,200 in

January to 14,815 in December 1943. Some 22,265 patients, more than 14

percent of those hospitalized, were evacuated to the United States. The

breakdown of the classes of ailments that caused evacuation and the percent

of total cases were as follows: Neuropsychiatric disorders, 28.45; malaria,

14.97; gunshot wounds, 7.06; gastrointestinal disturbances, 4.88; skin diseases,

3.67; filariasis, 1.98; jaundice, .85; and other, 38.14.

Disease casualties on Guadalcanal, November 1942.-The only hospitalization available during the critical phase of Army operations in Guadalcanal

was that provided by three provisional field hospitals of the 101st Medical

Regiment of the Americal Division. These hospitals were later aided by the

clearing company of the 25th Infantry Division. The hospital staffs were

not augmented by specialist teams. A breakdown of disease casualties in

these field hospitals between late November 1942 and mnid-February 1943 is

as follows:

Number of

Diagnoses admissions

Malaria ----------------------------------------------- 3,102

Psychiatric conditions ---------------------------------------- 483

Enteritis ----------------------------------------------- 416

C'eihliitis ---------------------------------------------------- 411

Fever, undetermined origin-------------------------------- 343

Upper resl)iratory infection -------.--------------------------- 302

Jaundiee ------------------ --------------------------------- 248

Skin diseas -------------------------------------------------- 234

()titis media -------------------------------------------------- 227

1 Statistics piresonted in this section are the aullhor's Compiilations anid interpretations of data iti official statistical

Soutlh Pacific Area records.
90UTII PACIFIt' AREA 599

Number of

Diagnoses adnissions

Heat exhaustion___ 141

Hepatitis, unclassified ----------------------------------------- 96

Tonsillitis --------------------------------------------------- 87

Urethritis ---------------------------------------------------- 54

Arthritis ------------------------------------------------------ :35

Asthma ----------------------------------------------------- 27

Epidermophytoses -------------------------------------------- 24

Peptic ulcer -------------------------------------------------- 20

Hemorrhoids ------------------------------------------------ 14

Cardiac conditions -------------------------------------------- 13

Scorpion bites ------------------------------------------------ 9

Amebic dysentery -------------------------------------------- 7

Sinusitis ---------------------------------------------------- 6

Pneumonia -------------------------------------------------- 2

M umps ----------------------------------------------------- 1

Other, unclassified ------------------------------------------- 34

Total -------------------------------------------------- 6,336

Diagnoses and disposition on Bougainville, November 1943.-The situation was vastly different during the Bougainville operation. Only one Army

division was committed during the early phase, combat was much less intense, and preventive medicine was of a high order. The provisional hospital

was competently staffed with specialist teams and had an excellent laboratory.

There were just under 1,000 admissions during the initial 6 weeks of comubat.

Medical service patients on 24 November 1943 had the following diagnoses:

Numtber

Diagnoses of cases

Dermatologic diseases ---------------------------------------- 29

Nasopharyngitis ---------------------------------------------- 22

Diarrhea ----------------------------------------------------- 15

Psychiatric conditions ----------------------------------------- 15

Eye and ear infections ---------------------------------------- 12

Malaria ---------------------------------------------------- 10

Asthma ----------------------------------------------------- 9

Unexplained fever -------------------------------------------- 6

Arthritis ---------------------------------------------------- 6

Other ------------------------------------------------------- 20

Total ------------------------------------------------- 144

It had been decided that patients would not be evacuated if it was likely

they could return to duty within 30 days. During the first month of combat,

only 22 patients with medical or psychiatric disease were moved to the rear.

Diagnoses and disposition on Guadalcanal, February 1944.--In February

1944, there were three 500-bed station hospitals in operation on Guadalcanal.

The average daily census for one of these was 478, with a total of 845 cases
600 ACTIVITIES OF MEI)ICAL CONSULTANTS

being processed through the hospital during the inoiith. These cases were

broken down as follows:

Cases processed

P, i cent

Types of disorders Y, -her of total

Neuropsychiatric disorders ------------------------- 118 14

Respiratory diseases -------------------------------- 101 12

Internal medicine --------------------------------- 60 S

Malaria ---------------------------------------- 5.9 8

Gastrointestinal disorders-------------------- -- 49 6

l)erniatologic (disorders ---------------------------- 49 6

Others ------------------------------------------- 409 46

Total --------------------------------------- 845 100

There was a 30-day evacuation policy on Guadalcanal at the time. Of

the 845 patients processed, 62 percent were discharged to duty and the remaindier were evacuated to hospitals at Espiritu Santo, Fiji, New Caledonia,

and New Zealand for further treatment. (fig. 214). No deaths from medical

conditions occurred during the mont1ih.

A further breakdown of these cases reveals the following diagnoses and

dispositions, with those not evacuated being discharged to duty:

Number of cases

Diagnoses Treated Evacuated

Malaria -------------------------------------- 59 11

Nasopharyngit is-------------------------------------- 41 0

Bronchitis ------- --------------------------------- 24 2

Jaundice ------------------------------------------- 20 0

Asthma --------------------------------------------- 19 16

Gastroenteritis -------------------------------------- 17 5

Cardiovascular disease ------------------------------- 14 13

Diarrhea -------------------------------------------- 12 0

Peptic ulcer ----------------------------------------- 10 10

Spastic colitis --------------------------------------- 7 1

Nenrocirculatory astlhenia ----------------------------- 6 3

Pneumonia ----------------------------------------- 6 0

Fever of undetermined origin -------------------------- 3 0

Filariasis ------------------------------------------- 2 2

Pleurisy -------------------------------------------- 2 0

Htyperthyroidism ----------------------------------- 2 2

liscellaneous ----------------------------------------- 25 5

Total ----------------------------------------- 26) 70

Troops in New Zealand, 1943.-A different impression of the incidence of

disease was reported in the area ETMD for January 1944, in a study of hospitalization of personnel in the 25th Infantry Division, which had been removed

to an area favorable for rest and recuperation. This combat. division was

moved to New Zealand in November and December 1943 after approximately
SOUTHrI PACIFIC~ \UK\

4)1)'IiI 144121 41. '~lW;~ 4)I414'I4'(l No4) (4\'Ao.1;mii .SoptomI ori4 '~ cii lt ;

14) a lol' 4 9 i(i''I' dIvso I \\hpI:I ill d le to14I': h4i ke 01144 I4l4) hi brin weekIsl I':lY nsi 11

I o Iii.I 1.0004 X4l 4' .4.4rlc~ p:44 ie444 s ad414S 14)4 4')4:5III4 (IS':Iddi (- Io~ ;I 1144'on I4 14 (1

ii lln I~lil 444:1 plvsra I\4 14I lo l ()\VP~ I hck4:o -il

11:1 ý h 1oll ~ )(I 'I ~ ollll, llplvl III11i , \Is. 111 -1-1.N.of t l-c ics /,,-,. lol

4112

1 14 : j
602 ACTIVITIES OF MED)ICAL CONSULTANTS

Number

Diseases o.f cases

Nasal diphtheria ------------------------------------------- 2

Diphtheria carrier ------------------------------------------ 2

Influenza ------------------------------------------------- 2

Chickenpox -----------------------------------------------

Gonorrhea ------------------------------------------------ 1

Total --------------------------------------------- 55

Of the 700 patients admitted as malaria suspects, 564 were found to have

positive blood smears and were given ant imalaria therapy. The parasite species found in these cases were as follows: Plasinodium tqriax, 541 cases; P.

falciparumn, 15 cases; mixed, I case; and undetermined, 7 cases.

Hookworm ova were found in stool specimens from 88 patients and Stron-

!Iyloide.s in 5. In 68 men, ova were found on the first stool examination, while

from 2 to 5 examinations were necessary for the remaining 25. The first

stool examination was negative for hookworm ova in 67 men who had eosinophilia greater than 10 percent. Of the 1,000 men in this series, 23 percent had

eosinophilia greater than 8 percent.

The incidence of aneiua was remarkably low. Of the 93 men with hookworm or Strongyloides ova in their stools, 20 percent had red blood cell counts

below 4 million, and 34 percent had hemogloblin values below 80 percent. On

the other hand, of 907 men without helminthiasis, 15 percent had red blood

cell counts below 4 million, and1 37 percent henmoglobin values below 80 percent.

The lowest red blood cell count was 3.1 million, and the lowest hemoglobin

percentage was 60.

The urine examinat ions were essentially normal except in one case of chronic

nel)hritis and one case of diabetes mellitus.

Among the 1,000 men, 22 had c(utaneous (1i)htheria, which accounted for,

roughly, one-third of all admissions for dermnatologic (lisease.

Chest X-rays of the 1,000 men revealed the following (diagnoses:

Diapinoses Nuituber

Qf cases

Ghon focus ------------------------------------------------- 45

Primary complex --------------------------------------------- 36

Diaphragmatic adhesions ------------------------------------- 16

Pneumonia ------------------------------------------------- 16

Calcified nodules ------------------------------------------ 14

Pulmonary tub)erculosis --------------------------------

Scoliosis ------------------------------------------------- 3

Cystic disease.. ------------------------------------------- 2

Thoracotomy ---------------------------------------------- 1

Miscellaneous ---------------------------------------------- 11

Total ----------------------------------------------- 151
Causes of death from disease 1942-44. --An at tempt wvs mad(e to obtain

iniformt ntion cotimel.ii tg the cituses or (lenthi fronti d isense in thle Soutih Paciftic

blet ween I Sept 'idi he 1942 and 31 August 19414. No Olitiii can he nintad- that

thie figui ms ('11 jileI it ie ttit iy accura('(te 'lt1, but theyi~ ar'e thle closest It j)J xi'O iiatiou1lnen tht i11 he Ilitelitic under thI e ('i i(ti I list a nees ince coiiiplet e recordls were

n1'ever a vailabiIle foir study~l. A numberi wi of denathIs occuiirevd onl Navy hiospi talI

shi ips, in Navy hiospi tals, 1111( il inau m Army ) h ospi tals ini thle forward areas itI''15 11(

dant a on thlese p~atins Ott lnt 'oih be t I oi'otghll analyzed Nveie never itvaii ablv.

C oloniel Baker t'evivwev thle re('ors ol as idnw dv ln t s~ as lie could. AL suinmatry

or t liv dait a revealed th~at I eeWere 133 dent hs due to In ed Iical antd psvclii tilte i

diseases. The 'ombin~ledi ineliml lind~ psvelinit ic disease death rate per at1uin11n

per thI ouisand was 0.4, based upon anm a vei'ge area st rengthI duiring tithe period

of' I 5(,67S. Eight eeni porCeuit of dliseaise (lenths 1111( 0.78 p~ercenit of till (leaths

wer'e dute to iinala rut. Betweven 1 Oct ober 1 942 and I August 1944, the best

a vailablle figures indicaet te tha t 78,042 atitttaks of' mialaria occurred a niong Ar'iiy

p~ersonnlel ill the areal. This iiieanns tlie( atta uck (deathI rate for i12111iilan wvas

M)036 percei I iglioriig t lie2 imionti s ini wiliie no dent us wem I'loI'te(1. Iu-i irg

lie muiii period (I (Get ober 1942 1 August 1944), t here were 1 ,356 cases of

pneumoioia with 21 denthus, 01' a imortality rate of 1.5 p~ercenit

MALARIA

Ti'rentmennt or mJarnIuJD oeciipied so Iinuit'l or thle t hue of jiemhdic ofli(eI'5

ini thle area t hut itiny account of miedical activities wouildi be inicompil)ete withlouti

sp~eciai I(onisiderat ion of thlait (diseaise. Thiis will h e (donie briefly, Its vaious

utsIpet s of thle sub~jec't ar'e dealt with Ii i anot her vounne in t his ,HSer .2

The miajority of (doctors Who wenit to thle Souith Pac~tific varitiiv in the war

I nu lit tle pract ical kniowledgev of' iii1111121 I'm. Th'lose wvithi specialized train inig

Wei(T reSer-vedl for' in alait ni con trol organizt li~i onis, bu1t th e d (velopmiienit of coniitrol

oti it lairge seiile was slow (fig. 215). Nledical officer's wer'e forced to learn by'

th eir' own experien('ev. Ma uny mistaikes, oeccurred Ia'rattse of thle shiortiage of

officers famiiiliart withI the (difficulties found in t reating imalaria.

A few miiedical offi('eIs, pa rt icularlhy soin e fi'olii thle Soil t lieast e.n-i se't ionl of

tie( U nit ed St itate(, en ue to thle Piacific with Ii superficial batckgr'oundi iii thle

ordinary iiiitliumgletiet of' clhinica'l uinaaritnu, but their influence Was gener-ally bad11.

Theiri expjeirience'( withi thle tise of (jlhuiuile ill thle contolit1) of r'elitplse in inalitriit dute

to at stmiut i ofr~ i':rt liii tha i'apelu ~s slowly lntd led t heimi to ittrttibu te lpiolperit es

to thle drug t hiit it dloes riot posse'ss. Sutpplies of' quinlimti were sniiiI in thle

Paitf ic, ittid its use was Ii init ed by ord(er' to pattientits who (coul1( not toler'at e

'Atihlbiii e. Thie chaitn(e s(cutt terinig of t liwse '' tuiiilti slpecilt list s" thr ioughiout.

tIialiv meica(i(il uinits is blieevedl to hiave (lone iiiuchl iiiii for most of t hem

re(tainiedl t heir enthtlusiutstil lot' (flihiite and Wantied thle fitilur'e to conotrtol r'elapj5tse

illi aI a iia ('itcusedl by P'. ru'a i' otth le en forced use- of At 111 i te.

1Ncliedi DI )'prtmeni, United St ates Army, Internal M lediehe in WNr ii War It. Voluime II. I nfectious tkenses.

tIN 1, I.:grat lon.)
AI 'T I\ IT I I F \1 I: I I I

Awl

IAN*

4FA

rw'lld.
SOUTH PAC'IFIC' AREA 605

Nature of Malaria Observed

Epidemicity.-Doctors locatedl onl 1)0h Iihighly malairiouis aind nionmlarililious

ISlain(S )laid am1ple Oplportlunity to dlead with the disea1se. In the New Hebrides

a nl thle Soloni jus, which were ml enlselv inValar111iouis, cont rol lw SUl)pprSSIVe

nie(Iicaltiofl wats p)oorly form uilat e( landl supervised. ( onsequienti , in the early

stalges oft the wall, clinicail at tatcks were numnerouis. Whienitroops were evaicuated

front thiese aireais to reatr lioslpitails, whet her evaicuaition wats for matlaria or not,

slipp1ressive imuediliction wits ltal wthdlraiwn, aind alfter a short latent period

initial aittacks or reaict ivat ion dlevelolped.

Whole organlizaltions w~ere !liOvedl fromt mualar11iouls to nonmalar1,11ious islandls

in] tilie hope they miight regalin the 1)hysicall fit ness lost in thle uinfalvoralble enlvironnient of combhat areats. Parta of the programn of rehlalbilitatiion for these

troop~s in 1943 wais to w~ithdraiw suippressive miedicaition in the hope thait mnalaria

wouild bulrn it self ouit. lihe (hiscouraingvl resuilt of this p~ract ice wats the (levelopmlent. of anl alarm-11ing amnouint of chronic, rap~idly recuirring diseatse.

Species incidence. - Nlalairia inl the Souith Pacific was almnost entirely from

infection with P. falciparuin or P. rirax. Cases of quatrtain imalaria w~ere almlost

at cuiriosity. In fect ions front P. facpri lrng zeomia -JiIeiS,

with the numliber of infections fromu P. rirax increalsing as control mnealsures

progressedl or when troops were remnovedl to notnmuailariouis aireats and trainsmnisSion celasedl.

This reversail of species incidence is strikingly illustrated by the experience

onl Gnadailcanal, where at lairge-scaile epidemic of malaria occuirred (luiring, the

latter parit of 1942 aind the first half of 1943. Early in 194:3, many troops

who had ac(juilred malariat onl Guadailcanad were removedl to nonmnalairiouis

areacas, andl suippressive medication wats withdIrawn. It wats olbserved that thle

infect ions duei( to P. Jalciparum decreaised steadhily buit were replaced by ones

(Ilme to 1P. rilflx..

Thme experience of thme 147th Infantry is pairticuilairly pertinent (p. 612).

Trhe greater part of this regimient wats onl iluaidalcalnal from latte 1942 to May

194:3 before being moved to Western Samoa for (lemalarializattion. In May

1943, cases of mialairia onl Cti(aiadlctimal were abotit equaitlly dime to P. falciparurn

aind P. rdrax. Onl Samnoat, after several diff'erent, therapeuitic regimes lNasedl on

uise of Atabrine had( beeni g-ivemi to the entire regimient with extraiordimmary

supervision, mialaria cattse(Ib 1' . falciparuim almost disaippealred ; rouighly

4,000 caises of malairia developed wit hini a period of juist over 6 months, only

14 of which were (hue to P. Jalciparumn.

Specific effect of Atabrine on the disease.-Medicall officers concluded

that Atatbrinie, even in suippressive dloses, exertedl a specific effect onl infections

from P. *falciparuin thatt p~revented1 the dev-elopment. of clinical activity. This

hals beemn coimclusiv-ely established elsewhere 1w carefuilly conmt rolled exp~erimfenital

stumi(I. The amaitzingly low mnalairia miortallity rate, the ratrity of blackwater

fev-er, lamnd the comlpara-lt ivelv low incidence of mialigimant nialaria in the areat

hals beenmiattIrihimtedl to the aIpliiremit specific effect of Atatbrimme.
606 ACTIVITIES OF" MEDIC'AL CONSUTAWNTS

Morbidity and naortality.-lIn May 1944, Colonel Baiker sentit m iemlorandumilt

to till hospitals ill thle alrea requlest irtg irformitiaionl onl tilhe numlber of calses. of

cerebral maklaria, blackwat er fever, ruptunre of the Spleen, severeaie a

aissociated with mia aria, dit l(leatis altibt 111aide to mialariail. ;kll h051)i t als

replied, and thle followingp informat ion %%-as cotmpiled: Cerebral mialaria, 461

eas-es; severe anemia, 14 cases; bl)ackwater fever, 1:3 caises: andf splenic ruptulre,

6 eases.

The casualty r'ecordIs in tlie Adljutant General's Sect ion, I leadquairters.

USAF'ISIPA, were examinedi for informalt ionl concerning malilaria ats a1 viause of

deal It. Bet weeni 3 October 1942 and 1 September 1944, 24 dea its wer'e

dlirect ly attrItib)uted1 to mfailairia. Of thIese, 16 (66 percenit) were (liagnoseI ats

cerebrall mallariat. Undoubt edly, Some of t(lie remainintg S record~ed ats malaria

wvere act ualtllv instances of cerebral mialaria. Blaickwatter fever wats not1 recorded

ats thle cause of at single fattality. This illustrated the impijortance of cerebrall

nailaria ats at caulse Of de t it.

Occasional cases of hiemloglobitinria inl Negro t roops wvith mailaiaii treated

by Plasniochil n napliht oat e (pamaiquine miapht hoatte) were observedl. Ten of

these calses were Stutdied ats carefully ats laboratory facilities would~ p~ermlit, byv

I.A. Col. I lenry E. Swartz, MIC, and ('apt. (later Lt. Col.) NI ilwardl W1. Bavlis,

NIC, of the 2.5th I'Aactiat ion Holspital 1111( Nvei'e rep~ortedl inl Nlavy 1944.

Diagnosis and treatment.-The diagnosis of mialaria dlepend(s uplf)i thle

ident ificat ion of plasmodla inl the peripheral blood. Inl spit e of endfless eff'ort

to tealch this flnndamlenitt l fact through circulars, let ter's, (lirectivyes, mnid personmal

inst ruct ion, careless (liagnost ic habtits persisted. Mie(icall Officers repeat ('(fl

clairtieci that thle clinical fealtutres of malairia were so characteristic that it was

liei tier just to the pat ienit nor of Scientific imp~ort ance to withhold1( t rca mentt

uint il laboratory* tests had coitfirilled at Stuspecte efi(liagiosis. Mfedicall officers

frequently dlefend~edf (liagitloses based oil clinic(al findinlgs aloitle with thle erroiieOuis

('011en(vioni that prolonged suppressiv medflC~icat ion madle it dIifficutlt to demlonlsi rate Jiaras~it es dIurin~g clinical at tacks.

The (linger of wit hholding therapy inl suspected catses of cerebral mlalarial

Wals almit ted, however. Officers wer'e ur'ged Jpeisolailly and by, writ tven

dlirect ive to treat these pat ientts lpromplltly without waiti htg for laboratory

coimfirmiat ionl.

Epidemics inrtiease Ilalreei'eie5 of at (isealse lind( lead to erroneous (Iiagmios'es

illiia vatriety of c'ondfit ions that (develop) coincidlenttally. Inl the "-oiit It Pacific,

Somte troo0ps Were SO Itaiyseeded With mlrathalt it waIs a1 ('ost itilt mneVitace

to diagnostic clarity inl cases of infectious htepat itis, lengtgie, scrub typhus,

pnieumontia, mteninigit is, or inttracraiiial hentorrhaige.

Alt arleal (direct ive onl 1ta1a11i1 emphtasized the import ance of the closest

sort of (diagnlost ic Search'1 and1( promptit, vigrorous ti'tifr e iimet for' aill suspect ed

cases of cerebral mialaria its well ats ot her rualigniaimt forms of thle (lisease.

D)iagniostic' lumbar putirctutre wa'Is re'ommifend~edl for' 11ll patients t5suspecte oi (f

uitavinug c'erelbral mtalaria , menin igit is, or ('erebral hlemiorritage. The p~rocedurie

uindou ii )(NNY', p~reVV('td t I rita- SV seiouIs ei''or-S.
SOUTHI PACIFIC AREA 607

Relapse as the chief problem.-An hinhevent chatraicteristic of malatria (Itie

to P. rivax is its tenmleticy to relapse. As time passedl, the major matlariai

prob~lem to internists was the control of suich relap~ses, which vary~ considerably

with different stratins of P. vivax.

The malairia st rahits onl (iadailcanail p~roved to have a frequient relap~se

rat te. Early ill 1943, hospitals to which 1)atients were evaicuatted from

(miudalcanal were havig, thie same experimene. Attaicks of matlartit were

(reatedl by thle cuirrently directed methods, and the pattient, wvould often haive at

relapse b~efore he left thle hospital.

Fatiluire to uise quiinine inl adequtatte aimountts wats the explanatloll most

frequtenitly giveni for it situation that faist becatme seriouis. Hospitals were

overcrowdled, physical and psychologic fit ness of malaria patilents deterioratted

rap~idly, and mianiy evacutattions to the Unfited St ates resulted.

Qulinline had beenl provenl to be less efrective inl cowdrollinig mialairiat relapses

than Atabriine, vet medlical officers throuighout the area were quiietly condlucting

exp~erimenlts with quiniiine and were spreading rumiors that resuilts were far

sutperior to those obtatined with Atabrinie. Mapharsen (oxophemarsinie hvdrochloride), bismuitth, and latter even penicillin were aill tried1 by enithulsialstic

therapist s, with (liscouiragitig resuilts.

Study of Relapse on Fiji

Ani ext remely favorable condition for invest igating tile probl)em ofrlas

ill paltienlts wvith hiifectimois fromi P. i'iraax existed ait Fiji, at nonmalatriouis island.

Thie heavily seedled Americal Division, whinchli had beenl remlovedl froml sliJppres'-

sive medlicat ion ill tile hope its maaiawould bulrn itself ou1t, wats statiloned

there and( providled all)n(lanl It clinlicall 11111 terial1.3 The (division wits to remain

ait Fiji for approximately 9 months, providinig a stiitalble ainalysis period (fi~g.

216).

Orders were isstied (hirecthig tile admission of aill suispected mallarial pattient~s to the 142(1 and 18th Genieral Hospitals, tile 7thI Evaicuat ion Hospital,

the 71st Stattion Hospital, or to the clearinig comlpanly hosp~ital of the 117th

Medical Battalion. A card system for recor(Iing individuial mialariat attacks

airid at followulp phlan for till hospitals were evolved.

Letters and verbl~a inistruict ions fromt higher echielonis urgedl thait the uise of

quiinine ats anl antimialariail be abandoned except iii highly selected eases inl

order to conlserve dimuilishiing stockpiles of the (Irtig. Experience of Fiji had

proved conclusively t hat Pi~snochiin napluthuoalt, iii tilie dloses employed, wvas

of little, if aniy, valute inl controlling" relaipse inl calses (Inc to infection wvithi P.

rit-ax. Ftirt hermore, its effects onl the gastrointestinal tract were so trouiblesomle t hat medical officers colisidleredh its uise uiidesiralble mid1( large miiuibers

of soldiers refuised ouitright to take it.

3 Fsseniii TechiviIIal Meiv cal Dalzti, I Iemidqlarters. I ,A FlSPA, for April 19144.
-WIITE OF MEI-. 1NULA

114 alise ofI, lie ,ilowii jii.idequaceie, III the othr4Iill~ the tinhiI'lwitlt of,

tijalaria-I At ablwIIIe %%.,S Ciisid(eie4 the (11-11- oI* chloice In thle ae.()hJ4eet lolls

Wer rised t hat1 it was toxic. t l.1it It could not cotit I-ol ciia14 i:li aflte l4whiow

sliippressive :1i1d freivvieii I lir Icaii Ils-. anid 1t1 1ia 1'n filed to all1eviate fevwer

.ii141 othe si' 5 Ilp 0115 i o fl i* iiai n, tj hicklYI 1, (11111liri4.

Nle( I(-,I tI Of IIi h - -ice (ii ) te 4 - -1w I kIe I ie v IIt tl o 4 I( 11 'l l d. Iit lla1ttte I 111 ~ Ia r rIia.o1 I o io

f*.icts. about Atlibr11ie. andi~l lie n-1111t of I s I hI14I111 of tw dle Iill - Ow lIe li ,i ited ~I itsIII

lia21d not remIilitd Owi ~itI Pacific. The tIm-etlical StA,(fl, Ow e ISt I ( wei.'ral I lospItl cotI i ded111 t fIatI, ki I i wI I of q lie aISorpi*l loll. aIld excrt- 1 loll of I( lie dr 11 1 m

lt' I Io a I of I tIIs coiei vu Ilu Ic rat I% 'III to III a I II%,It waIs w iieI Iq- 14l41. If I'Ihese dIlat

44)11141 be siifpjlie'd. e revisolievl, Atlwmii b ii~li l ,I t possi bk bv4 Iise(I ill a1 1 tIlat

wo0uld iiJo 111 v v t ie( co~lt r-ol of, rela pses IllIm pa leivIts -,%it hi11 infec It nIs. floulii

P. ~rI*

Therapeutic value of drug. ( anpt . Roget. A. ILewis, Nlh( ',ws~sh~i'lthle

taIsk ofI' deeoIit a met hIod f'or rmikinii (1i;i11it1 it%-( ivest iniiites, of AItibriuic Ill

11I4. blood. Ill mplite oflie criti4- lack of' Spec-(ialzed( eqiiipuIIemit .111d shortage-t

of ~ ~ ~ ,4\ raeit.(itaiLwis arl~l IA. ( on l. 1 chafI.l( Na~e ' eeo

:1 jiract meal unilnt 14)41 fo iii:1illui suchI I vt ia~i. "Iiiti 'l'lcir SYS1t'hii

tlevciwl('tl iipl)i visiIml fhiriit1i1~ihaitisofuuki~m elti ~tiastain1
SOUTHI PACI FIC AREA 609

ard series of serumlls nmade upl wvithi At abritie andi extractedl as tile unknown

seIrunlis Were. 4

'11w stu idies that rolloweti were organizedi iwv ( ooiiel Baker, wAho was then

Chief of tile mledical servic-e or the 1sth Gi(eneral H ospital. Tlheyivwere later

taken over andt expanded by C olonel Schaffer.

A. variety of treatment routines Wa-is allot tedi to tile several IioSlitalls at

Fiji. Atabrinle waiis used ill largeo- and convent ionially sized doses, for short and

long periods, with large- initial (loses, andl in vatriouis comb~inat ions with quinciniie

and1( Plasmloehiii imaJlit hoate. It was soon apparent. that. no Combination of

these (iruigs and 11o reasoniably sized (lose of Atabrine wvould control tile high

relap)se rate. These conicluisionis were based Onl relapse rates inl Cases ofmari

cautseId by P. vrwax af'ter various treatment regimies over twvo specific periods

of time.

1. The relapse rates after treatment over anl 84-day period were as followvs:

Number

Treat menat of cases R~ate

Atabrine-i. 1 gin. t.i~d. for from 3i to 4 weeks ---- --- ----- .----. 218 76

Atabrine-0. 1 gin. t.i.d. for 7 days, 1P1asinochin-1() ing. b.d. for 5 daYs,

repe'tition of both ------------------------ --- ----------------------- 1N 68

Atabrine ("flash'')-1..I gin, in fromn 12 to 16 hirs --- - ------------- -12) 7.5

Quiiniui-Froin I to :3 weeks of quinijnje in the varions uisnal do-ses ------ ---- 50 62

Atabrine and Qiiinimi-Various combinations, usually 0.1 gin. Atabrine

tCi.(l. for :3 weeks and 0.3 gin, quinine t..i.d. for 1 week --------------- ------ 70

Atabrine ("27")-0.3 gin. t.i.d. for :3 successive days ----------------- ---- 177 69

2. The relapse rates afrter treatment over at 70-day period were as follows:

Nii -

ber- Free

of interTreatment cases rat Rate

Atabrine-1.0 gmn. in 2 (lays --------------------------------------- 2:32 310 70

Ataibrine-0.3 gin, in from 5 to 25 (lays phis 1.0 gin, in 2 days --------- 5 2 30 86

Atabrine-! .4 gin, in 1 day pluis 1.4 gin. 3d day ---------------------- 53 30) 65

Atalbrine-0.6 gin. in 7 dlays --------------------------------------- 192 :37 72

At abrine-1 .0 gin, in 1 da 'y phis 0.6 gin, in 6 dlays ------------------- 122 45 8I

Atabrine-0.4 gin. phus 0.6 gin, in 7 days ---------------------------- 90 45 70

Atabrine-0.9 gin. in 31 daYs phis1 0.6 gin, in :3 days ---- ------------- 73 45 63

The following conclusions were. drawn from the studlies that have been

briefly diescribhed here,

1. The serumn concent rat ions of Atabrine of a large group of men t aking

tile samne (lose vary over a wvide range b~ut lire remaiirkablly fixed for tile indhividul~l. Thus, ''high level'' aind ''low level'' iien remain so.

2. Excessive urinary excretion of Atabrine does not account for low blood(

levels.

3. Mlost. Atabrine disappears from thle blood quickly when its admiitiistration is stopped, l)Ult (Ietec-talble anmouints remain for wveeks.

4Schaffer, A. .1., ,n' L.ewis, R. A.: Atabrine Stuieuhs in the Field. I. The Relation of Senirn Atabrine Level to

Breakthrough of I're~ lously Contraicted Vvlax Mala~ria. Bull. Johns Hopkins I map. 78: 26&-281, May 19146.

56c4!)Tov 6- 4
610 ACTIVI'rrF:s (wF MEiDII(AI CO)NSUL1TANTS

4. Rapidt reat~t ivajtion of 111ia1621fllollowingo treatmient is associated withI

excep~tionailly low lbloodl-Atilbrinle cotle I I'llt aion.

55. Large init l d10ses of At abIM1V ti on~trOl thle fever, parasite mnia , aili

sympllt oms of alradue to P.* rir(IJ' is quickly anid ats well ats qujinjinej.

61. Nonev of thle t reatmient regnimes empljoyed reditie d ie relaipse rate b~elowv

612 percent foi' it given p~eriod of' observa tion.

7. Thel( hit erval between relap~ses is intucli short er wh'len quinine is ( ie( antimialarial empijloyed t hanl it is when At lbrilie is Itis((.

8S. 1High initial (loses of Atiabrine, as- compared withI conventional (loses,

do not alter significantly the relal)5e rate. The samne is true whenl high and

low serumu concentrations of thle drug are uised( ats the basis for comparison,

excep~t as just noted in conclusioni 4.

Toxicity of drug.-Throughouit t he courise of thlese stutdies, thle dangers;

of At utbrille to.Nicity were c.m refuulvIY beeded . O bservers wvere jilt Jres'sed by'

bhe unanticipated gastrointestinal tolerance of men for large (loses of At abrine.

There were few e-eJpt ions to t his occurrence. J1aundice, suppression of bone

marrow activity, andl termitiatitis attributed to lie utse of Atatbrine were not1

observed.

The only important mianifestat ion of intolerance airose in ft(li cent rall

nervouls syst em. It was thle subject of Special Studity b~y N I j. (later Lt. C ol.)

I brakti I0V. N ewell, NIl(, of the 142(d General H ospitali, and C apt. (Ilit er Lt.

C ol.) Theodore I idz, N l( , of thle 18thI General H ospit al .' Parts of thle suinnilary

of their report indlicate t hey reachled lthe followinmg conci ilsiois:

'Iwent 'v-eighlt tasus of toxie psychois~i duirinig or followhig the t herapti'it ic administration of At alritin are reported .Alt hough tihe lsYcliot ie r(act iotli oevcurred ili less than 2

pat ie'nts per 1 ,00t4) treated withI Atabrin oil t his islandit, the ililiie'r of mienta~l react ionls

oblserved is bl~eievedl thle coiiseqellilce of the heavy dlosage frequientlv lit ilizedt in the t reatein'iit of mnalaria. Psychoses (lhirinig t reatnnett w"ith 0it.3 gin. daily for 7 (days oIccuirred rarely,

fo r only. two cases were seeni, though large mituilthers of lpat ents were treated ill t his mlannier.

Thlere appears to be at rclat ioiiship behiWev'za the frequiency of psycehotie reactions1 and the

anuou it of At abrie tiul an lie( rajlidit v. with1 which it is givenl.

TIwo c'ases are reportedi in which tuie psychosis not onlyv 'e~lvredi after withditrawal of

the diruig, hut recurred whein At abritie was again givei, n.d11 againl clvare-d after cessat 14)1

(If therap. .A ltither ease is cited (If a subject who took the drugr experitnent ally, niever

ha 1viliig had mallarhia, mid hecaiin'iiiliv mid i sv thot i. The three casi s t ge t her indicate'

delarly, that At abriiie cause's psvciiotit' reactions11, and~ that mjalarial fever and thev rvelese

of m11 alarial t(xhi is iwied illot be' i't iilogic factorIis as h1as somile't imest b~een hypi ottil 1 izvt.

III illost inistancees lthe 11ve115is s aiplpeared etuii-ig, or jiniiiiediatelY following, ft(e voelirse'

of treat nilit . lin a few pat ienits, who re'evivedi very i arge amounts (If Atalbrile' ove'r a shoert

pe'rio o( (f time11, thle' onIset wats de' me '( and1( occiuIrred( I afew d ays a fte r till ce ssa tion of th erapy

loxeI~ ilsvt'*10eh 5 are expected to t'lvar afte~r remol(val of theii toxic agviit . Eighlt of the

28 flat ivnis fali icI to r'colver ade leuitately Nitt onlyv 2 wve'ri ohbser ved fo r mnore t hai a. month111

after I the oiise't (if tlin, p~sy\chosis. It is l;rtobable thla t t lo( reactions11 rvpf-vesenIted( scbizopliri-niv

p~sychose's wlitil hlad b~e'en prve'iiltate'd by theillnessil'5 or Otill thie'rapv, althiotlli l t(le possi5-

bility (if tilt llreuiit'tion (If ipermlaiwnt'i dlamlage by large' allIolnts oif Atnalrilt'e vaililt Im,

811111- 818, Mitzy 10140.
SOUTH PACIFIC AREA 611

The clinical pictures observed varied widely, and resembled acute excitements of a

manic or schizophrenic nature, severe depressive reactions, and paranoid schizophrenia.

The presence of confusion, and particularly a sudden onset, with confused behavior and

clouded sensoriuni, in a l)atient who had received Atabritie distinguished the reactions from

nontoxic psychoses. Rapid recovery after cessation of therapy usually helped confirm

the diagnosis.

The occurrence of psychotic reactions was found to be the major limit ation to the amount

of Atabrine which can be given safely. Because of these reactions and because of comp)laints of mild confusion and the occurrence of convulsive seizures in other patients, very

heavy dosage was abandoned by one hospital, after which Atabrine psychoses again became a

rarity.

Awareness of the possibility of Atabrine p)sychosis should lead the physician to appreciate the importance of early signs, such as feelings of confusion and of intoxication. Such

awareness wvill permit more prompt withdrawal of the drug and, in some instances, might

prevent a frank psychosis. Prompt diagnosis is essential to proper therapy, both in the

immediate stoppage of Atabrine and in the handling of the psychotic reaction.

Seven cases are reported in which the patient suffered a generalized convulsion during

or immediately following a course of Atabrine administered orally for the treatment of

tertian malaria. One patient had experienced a single convulsion 8 years before, and in

one case the seizure may have been cauisedi by hypoglycemia. In the remaining five cases

no basis for the convulsion could be found in the patient's history or by the examniattions

which were carried out, other than the coincidence with Atabrine therapy. It is known

that Atabrine, particularly in large (loses, can be toxic to the human central nervous system

als it produces psychoses; and animal experimuentation andI the rel)orts of the intramuscular

use of Atabrine musonate have shown that toxicity can take the form of epileptiform seizures. It is therefore believed that the convulsions here rel)orted were the result of Atab)rine toxicity. The occurrence of convulsions during Atabrine therapy is extremely

infrequent. Only one case is reported following conservative therapy, and despite the

frequent usage of unusually large amounts of Atabrine on the island, the 7 cases represent

an incidvence of far less than 1 case per 2,000 malaria attacks treated with Atabrine.

Sulfonamide studies

Tile value of sulfamerazine in the treatment of malaria caused by P.

i'qax was investigated by ('apt. Ephraim T. Lisansky, M(C, of the 142d General Hospital and his collaborators.6 This study was most carefully controlled

and executed and led to the following conclusions:

1. Sulfamerazine and suifadiazine exerted a slow and mild action against naturally

acquired Plasmodium vivax in vivo. Oral Atabrine dihydrochloride exerted a much more

rapid and now definite action against this parasite.

2. Both sulfamerazine and sulfadiazine successfully aborted the clinical manifestations of relapsing vihax malaria in the majority of a small series of cases. Atabrine dihydrochloride successfully aborted the clinical symptomis of relapsing mi,'ar malaria in all cases.

3. These sulfonamide drugs were not as effective as Atabrine in alleviating those symlptoms which persisted after the paroxysms were aborted.

4. The sulfonamide drugs were only partially effective in clearing the peripheral blood

stream of trophozoites and schizonts. In many of these cases ganietocytes persisted.

Atabrine dihy*drochloride cleared the peripheral blood stream of parasites in all cases.

5. Positive smears and clinical symptoms reclirred in almost all cases treated with

either sulfonamide within 25 dlays after either of these drugs was discontinued. Those

6 Board for Coordination of Malarial Stillies: .Malaria Reports, vol. 1, No. 17, Wiashington, 1943-46.
castes trvatted w~ith A.taihrine hadi no cliniical brecik-thlrotiglis or positive iinvars tIliriiig IIIi,

samlie 1wtriotl of I jilt.

6i. A e(.nij)iaisoli of helt relatit he eliczicY of Ililt two ,uilfotnainiidc drugs couild not bc

mlkile from thlis~ sinlil sqrivs of cascs.

7. I Ieitiiatm-iar ocecirrtc in I oif I I cawes rceeivilig stilfainierazine. Toxiv rvact itils

I werel mnioifc.,wd hv 2 oif 10 cases reveiving siilfoliazitie. 1 lenaluiria occurre-d ill one( anld

tOe other de~vlope-d hItikopeiiia antd :a reduictioni ill gramiitihwtes. Iliose cast's tretated

withI Atabrinie revealed no0 toxic reict ions.

8. Th'is~ re-port stihmijis ev'2deiic tha lnet Oherl siilfamierazim, nor stilfaidiaziiie was a

irimit' (tillvtlroelloridle was :I much nuire ciefiecvo t Iierap'it ic al.~vilt t hanl either of I hese

S11lfolmiai(ihs :igainsl t his st rain oif ntaturrallY acqutired rit-ar malaria.

Studv of end r-esults

;Ihle At ut'ricia 1 1)t isioti lost hi rge fl niuhers, or tien t hrolugh vielacationl

to fithe Uii ted Stalt es bclt'list' of O~aIn thele'sW w n re traisf i 'err( to service

orglimi~zat ions awill con Iinut it to exhibji t rrequie it react ivat itis of mtala ria.

Thieste 1210I11 a lONr(I Htl 2111 xcletol)ortl11121t IVII V to studtyI thle totall ellect or chronlic

Ca~pt . PhIilip A. Tutuitilt y, \ IC, C apt. (later MIaj .) Edward N ichiols, NIC,

N11j. (la1ter Lt C ol .) N il rt ill L. Sillpgel1(I, N I( , 2111( N I Ijolr I itz, 1iII of tilie

1 8t Gel ;'rer~il I 105ji tal, se'lecte fo(1 ro cotmp2lelt e physical li121 psvrhiologic stilt 'IV

5(1101 liel who badt sit lt'erel 1t01 ormoeliOt' hl icks orf, 1111 I I uls ('(lipijre'12('tisve

iflvest igaktioul gl ye collifa loiite to) iele ill thle arleal resjpolisihblt rti' tl. ll p'IoI)

tcies 1)37 dele ilolls( raing t tha lil o ilneas i'l-l ibe orgali c (11211211igV or. tlysfl'lit (ion

resulte '( f romi the weigi it loss wi ll debility that21 were zi ii ost it cotistmi it sequel

to ('hiroltii tiil11illti. Thiese S ' il jptoliis steemedt Imor~ie relted1 tt to tilte wily ilitdiViti ialls adljuste tol 0 tdirmlit c l rzid21( to conicurlrenit sit tillt jouial ractiors

1,111111 to) tilie effects oh, tit'le lil n1112ill alI011t.

Attempted Denialarializa tion on Samoa

TIhe t ermi ''dt'talarializattiou'' ,refes to 21tIffle 1)1ps to ril heavily inifected

troops of ini ilia 1 t 1) *l y rt' lilotig theil frotmi ullaizi -iolis. islaolds, wvitilitrawinig suplp)ressive mtethicat iou, admiltliistt'Iihig to eachl luauti 21 iOU111i' tf, 2inttiiIIllarIill thlerapy,

I~l(Id aillowiuig cliliici1alt attacks to dlevelopI. It, wa-Is hoped t hatI t11111iilar woli(1

blliru itself olut.

Th'lis pralct ic' repea01 Itedly produted.t ~isilt isf 211 tor results. Malaria.

Caused by I'. foilhdjmru111m subsided promiptlv, but1, ill that caulsedl by P. irirax,

relapjse's were frt'(jI('it. Spleieomiegallv 2112( plrtisitemill, without symtpto)ills,

becamie e'stabllished't inl iiiamy thou. 'rol f~kilo'l to) gzjln w~eighlt or, to regrIlill

vigor, t'vactatimis were~t mimhero)1is, a11id tilie Wa'2ste or hosp1ita 211ed's1 WaIs eIIriiioIIs.

nie en~tire imrociti'tlre jlroveti to Ile hiighly itiefrective.

147th Infantry

TIhtis regrunietit 111rriVe(Il it CI lIIitlealciiuia ill S('Vt'ral ech1ejlons; the 1st Baitt 21-

liot onl 4 Novemiber 1942, t 1e 3d Butt alion pilus sp~ecial tmitIs onl 29 Noveumbter

7 TuIii i~iy. 11. A., N vicol~ Es uiwlIM.1.,ld1117, :Ani In vest igation of t he Effiects of liectirrent Malaria;

tOrgumimiumd P'sychologicalI Analysis of t5) Soid ier. Medici~ne 25: 17-75, Februaury I1946.
SOUTII PACIFIC AREA 613

1942, and tile 2d Bat taliori oil 7 Februiary 1 943.8 rfliese troops were given

qulininle suilfate as at ilalatria suppressive fotr a shiort timie, lbut , onl 29) Novembher

1942, at weekly (lose of 0.4 gnin, of Atabrine lbecanile st andard for suppression.

Onl 12 May 1943, the entire regimient left Qtua(ialcanal. for the Territory of

Western Samoa01, a1 noninalar211ious group of islandls.

Onl Samoa, Atabrine wats vit lidrawni fromi a~l troop~s at, various rates. One

group stopped Atabrine suddenly. A secondl took Atabrine 0.1 (,,1i. :3 t imes

datilY for 7 (lays, restedl 10 (las,1dm tilien repeated tilie course before (liScUlitinnuing aill niedlication. A t liirdl grouip stopped At abrine for 10 (days and waks

lien treatedl precisely as tilie second groupj wits. 'Ilie fotirt Ii grouip took At.-

abirine 0.1 gin. :3 t ilies (laily for I wVeek, reste(d( for' 2 (layi s, took 'l~lasinocliiii

naphithoate 0.1 g-in. twice daily for 5 (I vs, rested for 10 (lays, an Ow1t in repeated tilie cycle. Tile fift Ii gr'oup cont intlue Atabrine stippresi ye nilelicat ion

for 6 weeks anld then stopped1. All clinical. attaicks of malairiai were t rezitedl by

tile staindard qufinine, Atabriiie, Plasmiiochini naplit lioite regimnie Put jents

were thien given no antinialarial. druigs unless furthier attacks developed.

Approximiately 90 percent of t he Iil('l wvit Ii long mialarial exposuire developed

the disease, .n1 approxiimattely 85 percent relap~sedI at least once. Thle following conclusions can be draiwn fromn tilie results or tile variouls treatilmeids crivenl:

1.'[lie sup~pressive regimie followved onl Guadalcanal cuired few, if anly,

cases of mala11ria Cauisedl l)v P. 1irax. Mass thierapy w~it Ii Atabrine or with at

conimbinattion of Atabrine aind lPlasiochiin naplitlhoat ic aso was ineffective in

curing latent infections duec to P. ?*rax.

2. 'Mass therapy did not, alter significantly the number of first. relapses.

When Plaisniochini naphitlhoate wats included in the miass thierapy, it seemned to

aid in lowering thle peak mialaria rates and to spread the experience over a longer

period. It did not alter appreciably the final outcomie insofar as initial. attacks

and first relapises were concernedl. Phusmnochini naphitlioate maiy hiave aided in

reducing sliglitly tie numiber of total relapses, but this point, vais not clearly

estalblislie(1.

Physical fitness at beginning and end of demalarialization attempt.-

Between 24 'May 1943 andl 27 November 1943, there were 2,313 first, admis-sions

and 2,597 readnmissions onl Samoa, making a total of 4,910 admissions, from the

regiment, for malaria. The troops had been removed to Samioa for the plirpose of rehiabilitating them. Soon after thecir arrival there, 'Maj. Paul Harper,

MC, condicted a physical survey of every fourth man onl the company rosters.9

He obtained the following results:

8(i) Essent ial Techinical 'MedIceai Data, lleadquarters, TI5AFISPA, for April 1944. (2) L.evine, \. D.. and Htarrier,

P.: Malaria and Other Insvet-Born,' Tiseases in the Soul h Pacific Camp laign, 1942-1945, IV. i',rxasiological Observations on Malaria in Natives, aind Troops, and on Filar lasis in Nat ivi-s Amn. J. Trroj. Mudr. 27: 1It9-1I2S (si upp.) May

1947. (3) D~owns, W'. G.: Results in an Infantry Regiment of Several P'lans of Treatment for V'Ivax Nialaria. Aiun. J.

Trop. Med. 26i: 6i7-W), January 1946.

0Report, Maj. Paul I larper, MC, to Coimn 'ialing General, SaImoan (itonp. 7 June 1943, subject: 'Medlicl Survey

of Every 4th Man in1 3 Batta lions of the 1471h Infantry After Leavingow ui alci jul.
614 ACTI VIT 1 O'F' ( 4,' ME.'I ('lt. ( ' )NS•ILTANIS

Perccnt of .sddiers

for 111,,

Weight: Ist Bit. 3d Bn. groups

At or above Armv standards -------------------------- 57.8 54. 9 56. 3

At or ab)ov'e lminimt) re((irements --------------- 36. 3 36. 7 36. 5

Below minimum requirements -------------------------- 5. 2 8. 2 7. 0

Color:

(oo-d ------------------------------ ---------------- 17. 3 13.4- 15. 4

Fair------------------------------------------------- 65. 7 75. 1 71. 4

Poor ----------------------- 16. 8 I. 3 14. 1

Nutrition:

Good ------------------------------------------------- 27. 5 -11. 9 44. 9

Fair --------------------.----------------------------- 65. 7 52. 3 59. )

Poor ---------------------------------------------- 6. 3 5. 6 6. 0

Palp, h.phci -.--- ----------......... 6.3 0. 0 :1. 2

Shortlv after it, I)became Micessarv to I'esitile Sulppressive medic'ation in

November 1943, a similar survvey wa is conducted by IA. ('omdr. (later (C4apt.)

Walter G. Reddick, M(C, USNR, and Ist. Lt. (later N.laj.) Benjainin

L. 1luntington, N(IC, who rel)orted the following to thC('lijef Surgeon, [JSAFIlSPA, on I I)ectemehr 1943:

Percent of soldiers

•I Pft'rttge

for ltwo

Wr1ig0ht: Isf Bit. 3d Bn. groups

At or above Army st:adards ------------- - 49. 4) 57. 6 53. :3

At or above miniiuini rvquirements ---------- .15. 7 3-1. 7 40. 2

Below minimum reqliirifnviits .- - ----------------- 5. 0 7. 7 6. -4

Color:

(Good ---------------------------------.- ---.------ 37. 8 43. 0 .10. 4

Fair --.----------------------------------- ----------- 52. 5 45.8 4-9). 2

Poor ------------------------- 9.6 I 1. 1 10. 4

Nutrition:

Good ---.------------------------ -- 55. - 6,. 7 62. 1

Fair - ----------- .- - - 33. 9 23. 6 28. 7

Poor - .---.. . . 10. 7 7.6 91. 2

Polpable spleeirn ------------- 20.3 3 15. 9 Is. I

Palpoble liver- . . ... . . . 24. 9 20. 0 22. 4

Positipr smrncur - - 19. 2 23. 5 21. I

It ca ll bseell that tihe titinull er of palpal)le sp)lee'ns had increltled considerably and that slightly over a fifth of the mnen had a febrile pal'asiteiulia. Otherwise, for practtiial purposes, the variations were not- signilificant, except thatl

the November survey was made after the trool)s had slpen lt. months in a itoticombat, area wit h good food and regular hours for vatinl,, sleeping, and working.

Il order to render tle regiment fit to return to a, Specific assignment, it

was ,.eCo'ssary to reinsiiteut Atahbrine suipprssive mediteition. This promptly

reduiced the high malaria rate. It is significant that a survoy conducted a year

after thle resumpttion of sulppressive medication revealed only 0.3 percent of
SOUTH PACIFIC AREA 615

men with palpable spleens. The general physical fitness of the regiment had

improved remarkably.

Almerical Division

Attempts to demalarialize the Americal Division on Fiji met with much

the same results. Physical and psychologic rehabilitation of these troops

failed to occur, and it became necessary to reinstitute Atabrine suppressive

medication in order to rehabilitate these troops and return the division to

a combat assignment.

It was apparent that troops in the condition of those of the 147th Infantry anrd Americal Division were not. fit to return to active duty after many

months of attempted demalarialization. A large number of malaria patients

were evacuated to the United States, but many remained who were having frequent relapses of malaria due to P. vi',vax.

Studies of Suppressive Therapy

The only course of action available was to attempt to control the remaining malaria by resuming suppressive medication. It was hoped, but not known,

that this procedure would be effective. Many medical officers believed that

Atabrine might lose some of its suppressive properties because the parasites

acquired a tolerance to the drug. It was important to settle this question so

that plans for reemploying heavily malarialized troops and treating those in

in malarious areas could be formulated.

Americal Division.- -An experiment was set up on Fiji to furnish the needed

information. The subjects for this study were combat units of the Americal

Division which were to engage in maneuvers under conditions simulating as

closely as possible those of jungle combat.

One group was kept as a control anrd given no suppressive medication.

Another was given Atabrine in quantities sufficient to establish blood levels

equal to those that would be obtained by the current suppressive regime when

equilibriunm had been reached.

The results of the experiment were clear. 'Malaria in the control group

remained roughly at the level it had been during previous months. Malaria

in the experimental group was almost completely eliminated. The cases of

clinical malaria that did develop were usually in men who had low Atabrine

b)lood levels.

This information led to a policy change concerning the use of heavily malarialized troops. Thereafter, troops were kept on continued suppression

whether they remained in malarious areas or were removed to nonmalarious

ones for rest and recreation.

25th Infantry Division.--This was the first organization to continue suppressive medication after removal from a malarious area. This division arrived

on Guadalcanal, 25 December 1942, and became beavily seeded with malaria

(fig. 217). Atabrine suppressive medication, ilthough ldirected, was not
-

C'.e

I~itj ~ .Ile it:i IX \\1I 4Ilti'- 1 fIX i led 'I'llt 1.()1 (Iu 1111 I IIlle Icý IX I Ii I i' , I t I(( 11 i

pcvled ~ ~ ~ ~ ~ 10 ~ ,11 ~ A1,1wlll ~ ,rewr hl tutudl(I\-11 l
SOUTH I'ACIFIC AREA. 117

would b)e t iet same outl)ir3t of malaria that had lbeen repeatedly observed after

shorter periods of suppression were terminated.

A group of heavily exposed men of tihe 147th Infantry gave promise of

providing an answer to this important (juestion. The group was followed

through various malaria experiences from its arrival oil Guadalcanal in Novenmber 1942 to Iwo Jima in August 1945. The period of observation included

heavy malaria exposure, light. exposure, i itial atabrinization, deatal)rinization.

long-continemd Suppressive medication, and finally terminal deatal)rinization.")

It was conclu(led from a study of this group that long-continued Atabrine

use is high-ly ef'ective in controlling clinical activity of heavy P. viax malaria

seeding over a prolonged period, provided proper attention is given to tile all

important matter of Atabtrine d iscipline. Furthernmore, it seemed justifialble

to conclude that Atabrine in suppressive doses over long periods destroys a

large amount of malaria due to P. vivax that would have become clinically

active had suppressive control been withdrawn sooner.

In November 1943, a letter from The Surgeon General to the Commanding

General, USAFISPA, requested a study of the value of totaquine in the treatment of clinical malaria. The medical consultant organized this study under

the direction of Capt. (later Maj.) Robert A. Green, MC, and Maj. (later

Lt. Col.) Evrela A. Larson, MC, at the 31st Station Hospital.

Comparative study of quinine, totaquine, and Atabrine.-Th eantimalarial

effects of quinine, totaquine, and Atabrine were compared in a series of patients

with clinical malaria from a heavily seeded artillery battalion, and the studywas reported in the area ETrID for April 1944. Cases were treated in rotation

with the three drugs. With a negligible number of exceptions, the malaria was

all caused h* P. rirax. The results of this study may l)e summarized as follows:

1. Totaquine caused disappearance of malaria parasites from tile blood

stream in a time slightly greater than was the case when quinine and Atabrine

were employed.

2. Totaquine controlled fever and symptoms as well as quinine or Atabrine.

3. Incidental effects consisting of nausea and vomiting were somewhat

greater with totaquine than with either quinine or Atabrine.

4. The intervals between attacks and subsequent relapses were shortest

in cases which had been treated with totaquine (13.7 (lays), longer (15.2 days)

iii cases treated with quinine, and longest (37.4 dlays) inl cases treated with

Atabrine.

5. Of 80 cases treated with totaquine, 65 percent relapsed at least once

(luring the 8 weeks of observation; of those treated with quinine, 70 percent

relapsed; and of those t|reated with Atabrine, 38.7 perceent relapsed.

10 Baker, Ii.M., m iad (hy i i:lt ln) 1t1i a t, I).: The EfTeet or i,eno-Con inmvii Supprm'sst ve At abrin, Medii.cattion

Upo•n Iil:ises )for Vivax Malaria. Trans. Am. (liji. & ('inia:tol. Assoc. 58: i45-1."2, 194A. ';er al.so 1Bull. JoIhns I Iopkins

l Iosp. 81: 295.-34, N ov-iember 1947.
618 ACTIVITIES OF MEDICAL CONSULTANTS

Studies on Immunity

"Medical officers wondered whether the prompt and effective treatmient

of clinical attacks might not prevent, or at least uliit, the development of

biologic resistance.

In the sunmner of 1943, Maj. (later Lt. Col.) George G. Carter, MC, of

the 39th General Hospital investigated this matter. He permitted the attacks

of malaria caused by P. virax to pursue a part of their clinical course inl a small

group of patients bvy withholding antitialarial drugs. However, satisfactorv

results were never obtained because the group was a transient one and Major

Carter had no means of making certain his subjects did not take Atabrine of

their own volition in order to enjoy the pleasant attractions of New Zealand.

Early in 1944, General Morgan. The Surgeon General's chief consultant

in medicine, requested ('olonel Baker to organize a new stuidv of the problem.

The fundamental prerequisite was to obtain an experimental groulp thiat co(1ld

he kept tinder observation for a sufficient period to provide reliable data.

Through the cooperation of the Chief Surgeon and the Comnmanding General,

USAFISPA, and the Commanding General, 43d Infantry Division, a group

of volunteers was made available for 1 year.

Major Carter was selected to head the investigation, which began in

March 1944. Seventy-two men were allowed to have from 10 to 12 paroxysms

of malaria due to infection froin P. rirax. Their relapse experience was

compared with that of a control group whose malaria was promptly terminated

by Atabrine therapy. It was shown that a certain amount of imnmnity, as

gaged by subsequent, relapse experience, could be induced, but tile immunity

was not sufficient to justify the use of the procedure ill the practical management

of relapses in patients with malaria.11

OTHER DISEASES

Arthritis

In early 1944, ('apt. Frank 'McCarrv, MC, ('apt. (later Mlaj.) Owen B.

Royce, MC, and Lt. Col. Bert E. Nhulvey, MC, all of the 21st Evacuation

Hospital (fig. 218), observed anid reported on a peculiar condition on Bougainville which was not recognized on any other island iii the area."2 The disease

occurred in widely scattered organizations of the Bougainville force. During

March, April, and May of 1944, there were 124 cases admitted to the 21st

Evacuation Hospital. It is knowin that many nmore with mihlder clinical

manifestations were treated and returned to duity by unit medical officers.

Forty-one cases were selected for particular study, although the clinical

findings were generally similar in all of them. All b1ut six of the patients

were mildly febrile for an average of 2 days. The average fever was 1000 F.,

with tie highest rcac'hing 1010 F. All had polyarthritis consisting of pain,

I1 Essential "'Iech nicI .Medical Data, liva Iqtarters, ['S AFISPA, 15 May 1945. lnclnso re No. 16. 12 Esse,, tIji T(,chn • .eical M e I tealI )ata, Ileadquarters, Solith Pacific Base Conlinawln , for August 1944.
141444 (iti: 21S. 1l~l l2Il 21 1 1441 te ts,11:111~1 Ill)-il44441, i lPl~ Aprld l4It1.

lX11111111111 d411 41 10tim andI4 .1 144 1 ,I)te\14l, lV.1-14Ie R dI wS k llI'l I;

12e.511 je 1 I ( l.. \Ve ; I i. I \I( v . l i.' r( I I 1411"1 4(11 "1e ( \\ iIs 2 111. 1114 I if i I r

I~~~~ Ciltlei
620 ACTIVITIES OF MEDICAL CONSULTANTS

Just how many- cases there were is iiot known, but C'olonel Baker's experience

later led himi to concludie t hat lie nutmber was considlerab~le. Amiong these

were a few instances of serious bulba r pa ral ,vsis, suggest ing diphtheria.

Suspicions were Confirmed when a smafll epidlenii of phlaryngreal diphitheria

dlevelop~ed in the Amierical Division after it mioved from Guadalcanal to Fiji.

Cutaneous difphithleria was first recognizedl by Capt. (later Lt. (101.) Averill

A. ivebow, MC, early in 1943 on New Zealand. A series of investigations by

Colonel ILiebow, Lt.. C'ol. John 11. Bumistead, -MC, Maj. Louis G. Welt, NMC,

andl (Capt. (later Maj.) Paul D. ýMacLean, 'MC, of tile 39th General Hospital,

continued uint il the elild of the war."4

M~edical oficers were slow to accept tile ratiher freque~nt occurrence of

Cutaneous (liplithieria a110ioli troops who l111( been exposed to extremle tropical

cond~it ions 21s Iiiore tha a t11 mere nue(iival curiosit ' . This was largely owing

to at shortage of adeqIuate laboratory facilities and1( properly trained laboratory

per'sonniel. Evein af ter tile existence of the (disease was widlely pub~licizedl by

Colonel Baker t hrough personal interviews aind two circular letters, mnedical

officers remna med skeptical and often failed to ob~tain laboratory confirmiation

of diagnostic sulspicionls.

Colonel I iebow and othler (lipli theria experts traveled thlroughlout the

South Pacific givinig dlemuonstrationls 1111d1 teaching elemental (diagnostic facts.

The (disease grailually becanie accep~ted ats an important one, isolation was

enforcedl, 1111d case totals fell.

Intestinal Parasitism

Troops thiroughlout tile South Paeific, wvith the exception of those in Newv

Zealand, caille in to close contact with native Populations hleavily infested with

inltestlinal parasites. Exinlillatiolls of stools eventually became alniost routine

for hospitalized patients. Tile jincidence of anc *vlostomiasis was dliscovered

to be surprisingoly high, whereas tile inceidence of anileliasis was surprisingly lowv.

Sporadic cases of in fect ionis fromi Euda inneba hixtol!,fica were con tinuIally

observed throughout tile area, but only~ one significant epidemic of tile (disease

occurredI. This was in 1944 aniollg troops of the 37th lllfantrv Division on

Bougainville (fig. 219). Prelimiinary reports inidicaitedl at highl rate of infection.

But Bougainville passedh to the control of the Southwest Pacific Area in June

1944 before the st udy of t his epidemiic was comiplete.

Stool examliinat ions malide at tile 39th~ General Hospital (luring two cornparabl)e periodls of 1944 and 1945 illustrate the parasitism enlcounlteredl in troops

who hadl been evacuatedl from tile Solomion Islands or sent to New Zealand

after coiibatL.15

A suiiiniary of stool specimiens examnined between 27 April and 27 July

1944 is shown in thle following tabulation:

14 Liehow, A. A., Maiclxean, P1. D)., Ilumsteaid, J. If ., an( Welt, L. G1.: Tropical Ulcers and~ Cutaner~ous Diphtheria.

Arch. mIu .Med. 7S: 2Yf,-21. Selpteuiier 1946.

13 L~ichow, A. A., Milliken, s. r .,and flannum, C. A.: Isopora Infections in Man. Am. J. Trop. Med. 28: 261-273,

March 19448.
4r4

It

14 'jI

-;.ed
622 ACTIVITIES OF MEDICAL CONSULTANTS

Patients for whom examination was made Number

Parasitized patients -------------------------------------- 1 155

Nonparasitized patients ------------------------------------- 389

Total ------------------------------------------------ 544

Stool specimens examined

Parasitized stools (positive) -------------------------------- 463

Nonparasitized stools (negative) ------------------------------ 881

Total ------------------------------------------- 1,344

Of the 155 parasitized patients, 112 harbored sionificant parasites.

2 Of the 463 parasitized stools, W(5 were significant.

A breakdown of the species of parasites found in the 463 parasitized stools

appeared as follows:

Num- ber of Perher of posi- cenf

pa- tive of pa- Parasites tients 1 stools tients 2

Hookworm (species undetermined) ---------- 107 395 20. 0

Endamoeba coli ------------------------------------------ 44 46 8.0

Endolimax nana ----------------------------------------- 9 11 2.0

Strongyloides stercoralis ------------------------------------ 7 8 1.0

Enterobius (Ozyuris) vermicularis ------------. 2 2 .4

Giardia lamblia- - - - 1 1 .2

SSome of the 155 parasitized patients harbored more than one species of parasite. 2 Percentages based on the 544 parasitized and nonparasitized patients.

A summary of stool specimens examined between 27 April and 27 July

1945 is shown in the following tabulation:

Patients for whom examination was made Ni. mber

Parasitized patients ----------------------------------------- I 205

Nonparasitized patients ------------------------------------- 182

Total --------------------------------------------- 387

Stool specimens examined

Parasitized stools (positive) -------------------------------- 2 416

Nonparasitized stools (negative) ------------------------------ 613

Total ------------------------------------------------ 1,029

I Of the 20.5 parasitized patients, 129 harbored significant parasites.

I Of the 116 parasitized stools, 278 were significant.

A breakdown of the species of parasites found in the 416 parasitized stools

appeared as follows:
SOUTH PA('IFIC AREA 623,

•rll~plNum- ber of Perber of posi- cent

pa- live of paParasites tients stools tients 2

Hookworm (species undetermined) -- ----------- 98 172 25. 0

Endolimax nana ----------------------------------------- 50 66 13.0

Endamoeba coli ------------------------------------------- 36 52 9.0

Endamoeba histolytica ------------------------------------- 25 29 7.0

Trichuris trichiura ---------------------------------------- 21 38 5.0

Ascaris lumbricoides ----------------- 15 37 4.0

Isospora homini-- -..-------------------------------------- 3 17 .75

,Strongyloides stercoralis ------------------------------------ 3 4 .75

Chilomastix nstili- -.-.-.-.----------- I.-------------------- 1 1 .25

Some of the 205 parasitized patients harbored more than one species of parasite.

'Percentawes baseli on the 387 parasitized and nonparasittzed patients.

Colonel Liebow made an exhaustive study of the relation of cosinophilia

to ancylostomiasis and strongyloidosis in the area.' 6 The following conclusions

are quoted from one of his reports:

1. In certain areas of the South Pacific eosinophilia has been closely correlated with

recently acquired hookworm or Strongyloides infection; consequently its detection has served

as a convenient and rapid tool for the investigation of the natural history and epidemiology

of these conditions.

2. Even light infections may be associated with a marked eosinophilia during the first

4 months. Consequently, before drawing conclusions concerning the significance of the

eosinophilia many stool examinations may be necessary to demonstrate the ova or larvae,

even if sufficient time has elapsed for oviposition to have taken place in the intestine.

3. Study of large numbers of hospital patients continuously evacuated from the islands

has shown that peaks of eosinophilia and leukocytosis occur between 3 and 4 months after

infection, but the eosinophilia is probably still useful as a criterion of hookworm or Strongyloides infection as much as one year later.

4. Hookworm infection as indicated by eosinophilia has been widespread among combat

troops in the islands of the South Pacific, although severe hookworm disease is rare.

5. The infection affect- chiefly front-line infantry soldiers, is in the main acquired

during combat, is proportional in extent to the duration of the fighting, and is increased

by the use of native or captured enemy bivouac areas.

6. Ancylostoma duodenale has been the common species in troops infected in the South

Pacific.

7. Biological cure, using tetrachlorethylene, has been difficult to attain, even in lightly

infected individuals.

8. Continued re-exposure of the large number of men already involved, as by further

campaigning in heavily seeded areas, or a decline in the quality or amount of the diet, may

convert subclinical infection into disease of military importance.

Diarrheal diseases, infectious hepatitis, filariasis, dengue, and scrub

typhus were all encountered in the South Pacific, some of them in large epidemics. They presented important problems to preventive medicine personnel and to internists who were responsible for the diagnosis, treatment,

and disposition of cases. No particular contributions were made by internists

to the management of these conditions.

16 Liehow, A. A., and liannum, C. A.: Fosinophilia, Ancylostomlasis, and Strongyloidosis in the South Pacific

Area. Yale J. Biol. & Med. 18: 381-403, May 1946.
C11APTER V11

Central Pacific Area

Verne R. Mason, M.LD.

The caliipligiis ill the Pacific Oceani Areas' I Iurhlig World War 11 were

of jpecllliarl Inedlical significance froit anlumbler of reasonis. Thle attacks were

Iiia(Ie b)y amhibjlilious15 laiiligs of relat ively small tatsk for'ces to cap~ture tile

(orill island)(S 1111 were, if) genleral, combin~led act bus of the Army, tile Army

A;ir- Force, the Navy' , tilie Naval Air Force, and the( M\ arines. Thtese assatult's

oil lie( beachles of t he Pacific islamids cailled frot lilgill' coordIinatedI activities

of t he lmedlictd services of thle various coluloiielits of thle Armled Forces. In

gelierail, Ohe ishlands were parts of v'oral aitolls, mnid the clinaiate wits hot and

h uiiiuld. Potabille fre~sh waiter wits practically never available. Sanit arv con-

(litiolis Were primitive illitill atreals occup~ied by thle Ja1panlese for'es, aii(I after

t ie( ('amlpalign hald hIsted it fewv days thes area~s becamle (latigirots ror tilie

as'saulit trloops owing to thle inicrease of arthlropods wherever umihitried dead

were numnerous. Onl one or another of these island(s, p~ractically every- exotic

dliseaise o iitr imiport ance wits encoun tered.

The( caimpaign inl the Rytikyu Islainds wits thle first in the Pacific in which

adlequatte amoun111ts of whole type 0) Wood were available. It is probable t hat

duiring this action wvoundled troops received more blood by t ranlslusionl per

bat tie casmalty* thlan inl any previous campaign. D~uring the early.N part of the(

aissallt., thle field hospitalls anld smaller inistalliations were tle only* medical facilit ies available. Moreover, patfients inl shock must be treated ait. the earliest p)ossible momnent alter injury. For thiese reasons, somle commlienits hiave beeni

lniaide hiere onl thle organlization and equipment of the field hospital.

Thle exotic diseases eiiwouliteredl in thle (CPA (Centrail P~acific Areal).

11a1p .5, have beeti dlescrib~ed chief!l*y as- t hey occurred in relation to niihit arv

campjaiglis. No attempilt has lbeeli tiiatle to wvrite a dletailedl descript ion of

(diseases of niilit air imiiport ance inl this area. Such inrormnation is readily

avih~'li ble elsewhere. What has beein at tenmpt ed is at (discuission of thle occurrence of such diseases under thle lbattle colilit ions of World W~ar 11 andi~ methods

evolved to control them.

A st udv of .Tapantese 11 encejvlilit is onl t lie island of Okinawa is described

inl sonic detal m becautse of Its inhierenit intecrest. So, also, aire thle epidlemics of

(leliguie fever that occurred onf Saipan andl the met hod of miosquito control that

"I 'F e conini m1: I I 'ael fie Omae~n A rensd(uring mnost of Worli I Wa~r I Iconsisoted of the follow ins! I hr ecstihiore I I atve nnam Ift(

nivx en: S~outh1 Paclifi Arun.. Centrail Pacific Area., andi North Pacific Arena. This chapter pe'rtains to mne. ical ('0(51 Itllat

act ivitiles in the Centrail Pacelifi Arna. U.S. Army Forces tin this area were under thle commiand known its the l:Lwaliiat

I e I artnIienlt front lMt9 tnt iil Angntst 1913. when thle comtmtndm I .. Armyv Forces in the (Co-tnitl Pac:.ific Area, waise.st allishvil. This cmmna:nd toccium, U.S. A rmy' Forces Paciefic Ocean A rn~ iJill Juy JIMt4 and in filly 1945 it was redesivnated

U.S. A rmy Forces Mt iddl Pac 'ilfic. rmi letrin "Ctntrail Pacific A rem" will hec used t hroitghout thle chlapte'r unless, specific

reference to one of thle- foregoing A~rnmy c'0iititnid. is iimed le6 25i

5649701'- Of - - 42
626 ACTIVITIES OF 3MEI)IAL ('ONSI'LTANTS

U. S S.R.

NORTH PACIFIC AREA

,, -- 42-,

C 1000

STATUTE MILES ON THE EQUATOR

o HAWAIAVN A 

Midw6y"

.ki- wo,•,," -k ttwo Jimo Formos Kauai .16-\

Fomos C E N T R A L P A C I FI C A R E A o Moui S 130- U

20* 'Wkeonoi , O0 I MARIANAS e Lo"aW 

PHILIPPINE Tinion:1soipon Johnston

i ISLANDS .'Guam Eniwetok * MARSHALL

I.p d Leyte •"."

S Polou,. .~. Kwojolein . ISLANDS

S~o *% =" •"" Polmyro

Fanning

GILBERT Mokin Christmas.

SC • 'ISLANDS LNScanton

a '"S N 1 M "'k•LO O. N IS .

SOUTHWEST GUiINEASUH ACFC RE

~P~ACI IC AREANS

MNAP 5.-Central Pacific Area.

was devised to stamp out the disease. Some account is given of the cases of

infectious hepatitis seen after nearly every assault on the Pacific islands;

of dysentery, particularly in patients from the Marianas, the Philippines,

and Okinawa; of filariasis, particularly in the Gilbert Islands; of diphtheria;

of venereal diseases; and of other problems in internal medicine. There

is some discussion of the consultant system and its relation to the medical

services of the Army in wartime.

This brief history of internal medicine in the Central Pacific in World War

I has been compiled from documents in The Historical Unit, U.S. Army

Medical Service, from large numbers of reports by medical consultants and

other medical officers; from relevant War Department general orders; from

ETMD (Essential Technical Medical Data) reports; and from theater memorandums. In addition, some material has been obtained from the files of the

author and from the reports of medical consultants with other organizations

in the Central Pacific. From these sources, objective original data have been

incorporated. Since much official military correspondence does not identify

the actual writer, attribution could not be given individuals in many instances.
CENTRAL PACIFIC AREA 627

EXPANSION AND ORGANIZATION OF THE MEDICAL

SERVICE

The war in the Pacific began in the Hawaiian Islands, on the island of

Oahu, on the morning of 7 December 1941. The Japanese bombing of Pearl

Harbor was unexpected, although frequently predicted, and came as a complete

surprise to both Army and Navy forces on Oahu. Since the casualties were extremely high, the Army medical service on Oahu began to function immediately.

Some events of that fateful day and of a few subsequent days were recorded

in diary form on the blotter of the secretary to the Surgeon, Hawaiian Department. These notes, with the addition of information written down during

telephone conversations, are reproduced here for their historical interest.

7 December 1941:

0915 hours.-A medical officer left Fort Shafter for Honolulu, T.H., to get

10 civilian physicians and 6 operating surgeons. These 16

physicians were sent to Tripler General Hospital, in Honolulu.

0940 hours.- -Bellows Field reported 6 wounded in action and 1 killed

in action.

0950 tours.-Wheeler Field reported 57 casualties. There were 5 killed

in action and 20 seriously wounded.

0955 hours.-Sixty casualties were sent to Tripler General Hospital. Of

these, 3 or 4 were dead on arrival. Many casualties were

being reported, and some of these were civilians.

1020 hours.-Reports of 300 wounded and at least 50 deaths were received.

The civilian physicians of Honolulu offered the services of

the blood bank and, in addition, gave what plasma was on

hand to the Army. The supply of ambulances from various

Army sources was adequate.

1135 hours.-A request was made to have Kamehameha School, Honolulu,

prepared for a hospital.

1140 hours.-Hickam Field (fig. 220) reported from 300 to 400 wounded

and from 50 to 75 killed. About 25 hospital beds at Waimanala were taken over by the Army.

1305 hours.-There were 75 casualties at Station Hospital, Schofield Barracks, T.H., and 470 at Tripler General Hospital. There

were 22 dead at Schofield Barracks and 46 (lead at Tripler

General Hospital.

1445 hours.- -There was considerable difficulty get ting enough ambulances.

8 December 1941:

0001 hours.-Arrangements were made to open up Saint Louis College,

Honolulu, as a hospital. It was directed that 1000 hospital

beds be installed.

0522 hours.-Two surgical teams were formed and sent to the Kamehamneha School.
628 ACTIVITIES OF MEDICAL CONSULTANTS

08,10 hiours. -Front Schofield Barracks, rep~orts showed :36 deaid, 25 seriously injuredl, and 7-5 lighitly wounded. Front Wheeler Field, 35 dead, 56 seriously wvounded, and 50 witIi mnrwud

were rep~ort ed.

9 Deeeniher 1941:

1105 hiours.- Tripler General Hospital reportedl 152 dead, 55 seriously

woundl(ed, and 125 siligtly wou~ndIed.

1850 liours.-All useful apparatus front thle Ja1panlese hospital wats Sent,

to Saint, Louis College.

Following the Japanese atir raid onl Pearl Harbor and on thie airfields onl

Oahut, there. were 71:3 battle casualties of whom 225 dliedl. Following aire (latta

Onl thle dlisposition of casualllties fromt 0800 hours onl 7 December 1941 to 2400

hours onl 10 December 1941: Tripier

General Schofield Ilickam

Ntiniher of paitients in hospital prior to 0800, 7 lDecetlber H~ospital Biarracks Field Total

1941------------------------------- 456 5:11 29 1,.016

Admission:

Bat tie easualt ies (seriotisly and(1slightly woluivi(le)- :140 121 27 '488

Other t han battle casutalt js ---- 10 62 3 75

Number of (Iead upjoni arrival ait lIOSp~itk z-- -- -- -- ---- 1:32 27 0 159

Number who dlied uipon admnissioni--------------------- I I 1I1 0 22

Disposition:

Battleý casuialties, to ditty --- ----------------------- 9 .51 13 73

All othersN----------- ---------------------------- 243 336 231 602

Total number of beds vacant- ---- 642 2 819) :17 1, 498

Total1 knownt deadi since 7 IDecemnber 1941 - - ---- 14:1 38 0) 3225

Total seriously wounduted since 7 D)ecember 1941_ - ----- 7 :38 1 114

Total slightly wounded sinice 7 1)ecenuber 1941------------265 831 26 :174

Total Ibattle casuialties since 7 IDeuvnber 1941-------------------713

1 Sutrviving.

2 On 10 iDeveinvuhr, 237 iadditt fon:, bedN were set oip Mu Selofleld Barracks.

3 Inetith,i 44 demid tken dtirectty to the morgue.

Organizational data.-The Suirgeon's Office, Hlawaiiani Department, wats

comparatively small tit the he'gintuing of the war. The Surgeon 1111(1 9 other

officers, together wvith 8 enlisted mlenl, 1made uip thle Staff.

Onl 7 D)ecember 1941, the staff wats dIivided into it forward and rear echelon. Onl that. (late, the rear echelon, consisting of the bulk of the aldministrative section, movedl into offices tit Farrington High School, Honolulu. A

file clerk and guard remainedi with the records ait Fort. Shafter, T.H. The

forward echelon moved into Aliamianu Critter with the commanding generall

aind other menmbers of his staff.

The Surgeon, laiwaiiani Department, onl 7 December 1941 wats Col. (litter

Brig. Geut.) Edgair King, NMC. During the laist. p~art, of 1941 and the early

p~art of 1942, ('ol. Clarence H. Fronk, MIC, tictel ats professional consultant.

All professional activities were consolidated in the office of thle professional

conisultanitt Medicinte, surgery, orthopedic surgery, netirojpsychiattry, and
C'ENTRIAL PACII ARlt .fEA 629

Fii~ it .: 2201. I )e-ticti to at I Iicka I1 iit Ii Fvt, IlIa \:iw ia, 7 I )ccerrI I wr I 1

ol lifii spet'tnltit's, N'vr ('it' all tiel tlie supJervisiont of' ( oloitti lFronik. A. more

J)Iolt's5iotia IJelsolmotl W('t(' tiItt It' a ailab I ) ,~ v t he WVat DI )ep1t ttiit'it, specttia

eot~ttIt Isobt atined I'Itoin) Armu N11051)it11. ;~of) thet islandt .I aI'i 1 bo il thIle I' nit tdt

States \\ere ;tddted to tin' Sttil-olls stall'. 111(11' dittt. tes (sisted o* stupetrvsottittt111g and~ atlvtsotN wvork ill (conneti( olI with c ltinical practitee tll

A.,. olI' )eeetiibe 1942, otli('et l)('-sttitl itt Il lt'w Stti('tott s ( )liev conlsisted'~

Sutllauti1 Itt \edit'ilte: L1. Cotl. da~tert ('o).) A\ttgntst NV. Spittl ci, MC,' \-ts aclitnzr

C onsuilt ant Int Stitztv. *at ild C(apt. (I'laer Ui. C ol.) R~obett C . Roberttsotn, MIC,

was ( o slit Ia ittit(t IOthoped iecitztv

IRequit 15 tolts Iot tietessat' ,V pt'tsotitel were sutbmitttted to thlit W.1I )eplurt -

fli(itt;ttito ta i I lv tt 'tvat I andt Illt eivi-etl'tiees, bY ra.d iogzlatIn. Th'le slttwtare

olIttltt l1111. Ptsttt11iti t' was, Itt l';tet, veINY ;icuet ilil lit earlY tuolti Its ol, the wart

tald tit-cveslitalvil thel ettiplo~villetit of, ltwal eliviliai.i lpt'tsoiiiil.

A ttiliqlie assi-littietit itt thIte Sitt'.zoti's \\.tI., 1a1t;1a of' civiliatt-1laSOtt

oft ei t's1. A ., t (1VItal "(4 It) nl'q thtte ttt o n l i loh iti iltatby Gaetltit's at a t' o t ivlsas t't

Also ttiitelt' tIlobil~i/.tolt pillts the VIS. Aitv1 Meictjal lDep.itl tuit'it nas tt'91-
630~ ACTI~VIIEr*S OF MEDIICAL CONSULTANTS

FIGCU RE 221 .- C'onsulzta:nts in miedicine, Cenlt ral Pac ific A. Col. C harles T. Young, M C,

C'onsuiltaunt ini Medicine, Office of the Surge'on, I SAF( A.

maiIe to Contrvol Ill hospitaldizatilon, 1)0th Civilian andl milit arv, to est ablishi

first alid stat ions I hrolu'ghout 0,1ahu, unid to provide for supp1lemenit ary p~rofessioiial1 Care of miiltarv personnel by civilian doc tors residing inl the Tern itory.

To accomplish all1 t his requliredI const ant liaison with civilianl agencies, and1(

tlie offlicer placedl inl charge wasespoiisible for proper plann~ing, for t raining,

an1d foi- e~xecut ion of all1 policies formulated by the Sill-~ovon and leaders of thle

1101oiiol111 'Med ical Societyv.

III M arch 1942, serviceV comm11ands were established to adminlister the

milit arv affairs of thle ot her Islandls of thle HIawaiian grolui). A siirreoiuo waS

aIpp~oiiit ed to each of thle followi ng service coiulali'lls: Hiawaii, Malui, N lolokai -

Lanai, anid Kauiai.

M edicalI supplies st oredl at Fort Shaft or wvere geiierally adequate and of'

exceilvlet quta lityv. Whle i a sh ort age occuurre(d, 1) rye st ocks were aminple to

fill it. Wart im e requnisi tioninig procedIuires of) th lrie ai: uland (cont inent al Uiiit ed

states) had beenl est ablished before 7 D~ecem iber 1941 . Durinig 1942, branclh

depots Wer'e established onl tilie islands of N' mai, Knuai, and Hawaii to 'lijppk*'

lie service eouii uiia lE s of thI ose (listricts. At tilie broll(lic dep' 1 ot at Schliofel

Barracks, thle construet ion of five a'ldlit ioiial1 warehloluses b roughit tilie total to

a in e. A wa idloulse was alo isom(plJ~eted( at Fort l{uoger. Stocks wverv fuirthe ir

dlispier'sed ill thle va rious hiospi ta is o' tilie H a waiian DiIepartmeniit for secuirit V ill

cois( of at tack.
CE~NTRAL PACIFIC AREA 631

FIGiURE 221.-Continued. B. Col. Verne R. Nason, MNC, Consultaint in 'Medicine,

Office of the Surgeon, -Ninth Service Commmnd; Consultant in 'Medicine, Office of the

Surgeon, USAF Ml 1)PAC (formerly USAFPIJA).

The Surgeon was appointed aniti-lbiological-warfare officer inl addi: ion to

his other duties. Thins app~ointmnent nila(e it possib~le to consolidate many activities inl that Iiieldl alreadyv receiving Gvenera King's attention.

Onl 7 December 1941, thle Surgeon had been mnade adlviser to the Coinnianditig G eneral, Hiawaiian Departmenett. inl aill mat ters concerning potential

(hinger from conitaminttation of' 100(1 or sources of' drinkingiZ waiter. Nfilitairy

personnel anld civilians over 6 mionthis of' ag-e were immtunizedl with smial~lpox,

tYphlidiI, paratv, ploidl A, and~ paratyphioidl B v~c'itecns. All ciemetical p)oisons

were timpoundl~ed and thoir sale and (list rilbutioil kept, tinder strict control.

Tihe principal water-supplv systemts of each islanld were investig"ated inl detail.

IFenin(ig mid( tile numbler or* guards were imt iedia telv mncrensedl. rThe depairtuteitt laborator *N (I ail , periorittled tests 1,r1 coimnitl poisons onl waiter collected

f~ronlthIle m1ain1 sources of supply. Purchase of fresh milk f'or Army niesses

wals prohtibitedl.

Tlie reimlerai implressiont derived from an exmnminatiion of' tile, records during

(ills period is t hat nIanv I.N ulctijolts wvere ceit Irmi izedl iii thle Imamids of the Surgecon,

owvIrg, both Ito tilie lack of personnel anid to at tenidenceY to (iccentraite du tties in

a single offlice.

()pcralitonl of' Ithe ilmedicall plains, undi~er tilie genermld imobilizatlion plains, funictio~lC(l withI greit Isittoot ilness 1111d1 efficientcy, antd t his (lid ititicit to allevia tc Itie

effects of' the .Jnpmitese atuIick.
62ArrivI'1'I:s O F MEDIII('A CONSU'LTANTS

Expans~ioni of the Hawaiian Departmnett and tile Central Pacific Area

IThe I'a t-riltitOil 1i"gh School ill I olotilitlii, ii "Zt*1i j) of hiew conlcrete buhld -

gsill tilie KIa IIi di ist rict , Was tnaketi over to prov ide e xpan tsioni wardis for Tripiicr General IHospital oil 7 Decembi er 194 1. ( )i I ha date, a pproximiate lv , 200)

coivi Icscentits were I I'llisicierri fr'om th at h ospiital's li 1.; tivi it build iazs-r, antd

Il('55iti" faicilit ies weret estabillishiedtll thlie school clufct ria.l. M aj . (In Icr ( ol.

D)onald C . Stiv icr, N IC, was phlacedi Ii cihiarge of Fa rr-i tit on wards. ' e 1) c

clIpacIty' v a a)IS 1proxi iltitcvIY 300.

A pailrt ol th Kic haiielm iii 11(1 Schlool was t a kei over as Provisional I lbspjut a

No. I oil 7 Decembeihr 1941. Later (4 All runst 1942). the hiospitail buecameic an

it it egrl- I pa i-t of rj~e ( sclelii I Hlospiltall. Two olcrittiting I'ootl fo5 r reserve

uise Wi 're est ibI islIctl oti 7 D)ecember ct 19411 Ill tlie sch ool ini i rlim nrv hotl were ilot

put intot ac~tive servie. 'h'li concrete dortiii1tory builjdiuig of tIli-- school lhad

240 sinigle roomis tanking a liospiutal cai aviit v of' 240 lueds. H owever, thle precip~itouis li titure of tilie t errainii 111(1 tilie a i'tiget.ljijeli t of tilie d 1.1 eps, l~jil t , a111(l

stairway, s a aide It d ifficulit to adap Pt Ihis hospi)t alI to sur~zoica I use despite t lie advnI~titire5 offere( I li its excellenit infii ri an iw, which %\-Is readilY ntIlip1able for

t'X eliv srger (fi. 222).

S iliit I ollis ( olle~zoe, if) thle ha ha a i (list rict of I olotilulit , was ta;keni over

as Provisional H ospitalI No. 2 onl 8 Decemiber 19411. TIhis wvas est a blisi ed hit er

as thle 1 47thI aernln H ospit al.

Onl 14 August 1943, thle I lawn aii-l I)epnrtii itilt waIs eXpand~edI a1( ml changed

to U SA F' C(' A (U.S. Aii Forces iii thle (Cii t ra Pacific Area). D~uring thle

fohoitOiiz~ 12 monithls, thle \ ledical I ep ii tment pirovidled suplport for tilie otfenlSi ye actitons conioe () titellv t ie( Artmied Forces of t lie Cieitral P acific. TIli e

avera izc st rengthi oh'O thleia t er inlcrensed 30 perven t duriniitg 1 943, a ml] tble a rva

contitrolled wais extetided to itnclude tilie N li rlal-AI, Gilbert, iilu N Ial i'iiiti Islandls

(fig. 223). M edical facilities were expantded to pro vile for task forces and( gilr1lsoti forces oiln tewly occupiedI islanads liti uthei lie a ii iier of hospital bet Is iii

thle Cent ralI Pacific wals t1iearlvN twice thaiit for tilie I In wajinil D~epa rtmeneit inl

1942.

Ill providinitg logistic suppjort for operlit ionls, it was tilet tvspotisiluilit v ot

tile 5th MiN edicail Siipl))I D~epot to eq uip t(le va riouts divisiotis for a iii phtibjolts

Opetra t iotis. En.vI di iivision was sitp ported 1)'b one( 400-bed fielt h lospji tal antid

01Wletp)' isiotiti pjortabiille sulri i-gt'aI fI ospijtiii. ( a t'-iSoi i for(es wer-e I'lli isl ite( 1wit il

ninlny h ospitials, from at 2 ,Ot0-bed greet icr I I ospitli to I 00-bed stiition ihlospitiils.

A llosjit ii shiip, The .1 fercy (fig. 224), was cotivertedl from anit libilialiice-t vpe

Ship to at sutrgica I hospi tial shiph.

Pi~la s werte worked ott t to( inist ire procuaremeni t of mied icalI supp)llies frouil tilie

Coniiitinet ad Untiteti Stiltes. Also, ar rantgemtentits were tmiide to ship direct Iv

to Stiipatil froti t lie contitntenital [Unitedi St ates.

MIedicialI siippiu act ivit ics were tilie respotnsib~ility of tilie .51h IMNedical

Sn uppiY D epot , widltei a uis of thati orgatnizatIion dlispersetd t Irlotigitout the

thlea ter.. A totald of 36i Warehiouses wIas OCCUtlieti, althouighi it Was pla1nnied to
I I -A 4 , ; I I I , A I Z I : A

941' V

vw.

'EJ1 jffý'A k%&

lp 7,

222. I.\p:iij-iw i d" T i ipl, I W il.,l:t] If- pil:11 :11 I\:l flit-11:1 fill 11:1 N o

colltrnllz(ý ImIll sIm-,IL,:c will 1 15, -ýIllvc Iho 1,101col Ilood 1*4)1.

dipol.,1011 \\.Iý pnsl.' Slock,:.; \\(TC COII- ýI*,delill.\ r(O.Ited. A lo\(.1 lid,

Slipply Illo lilt n Hied.

)If I -fill v 1911. 1 T M 'ellir'll Varific lin-w CoI11111:111d) wo..; oru"Iflized

\\IlIIIII 1114 1 cl 1:1 I-L':cd \\ it II I ho IC I' I '.,-ýA F I I )A. TIIv 1111-

Illedi.lic ut)IIIIII.Illd .111d frolliIII'Lr of frmq)-ý \\vre dolw-1:11o(I to III:jjm* orhelml, of,

IclI\ Itil.- (d, llw-w oclwlml-ý.

)if I Allull-ýl I In. I *sA FP-W A ( I _.S. AI-111Y Flwvoý III I he smil If

P'lo-Ific Are'l 1, .1 opol"lle 11111.111. CAIM, IIII(If.l. Iho (d, Ille

[`,AFI( TA will \\,I, 1.(,( I'll ef I -,VB( Ba-w ( 'millimild ). ( )II

I Ill. ý,l fill, (1:11 o. I "-,.k FI( VA wo-ý rodo-ýP_,Im I cd 1, *'-,.k FV( )A ArIliv Fmvq-ý,

I"IcIfic ( )4.(.:l if A rcn-ý I.

A [I IT I III, IIIZ:I I Hill. Jill)st Id, I If(- per-ýmIlIvI of I he re111:1111141 111 1 lit, VB( it 11 ( ;1-11cro I K "whidlillr, .1-ý 411, 1 Allu,11<1 I I I . I ()I,

K"crill It I I I (". \1 I (11,I)III v Ill. W o It I'l. Jvllý,cll. N I cmlýllh -

n ilt lit I \ 1:11 Hill I Il'o II., W . I cr-ý4111, N I( I lit

I f 1:11i'l. ( (d. It'. K"1111,111:111, Nk rml-ýIlllnlo

'Idmicl Rldwri-()If "Illd M :1,4q. Ymill-

)if Nm clithel. ;4.11. .1(11111 N I . NV I I hovoille

I F 1 1( )A

I if :14 14 lit fill] 14) 1 Ill, cm i'lill fill s I I I I c.1 ( I If 11.11.1 rl-'. I 'S A V 11 )A , n I I( I

CM 1, f I I 1 .1111 -ý I I I I I Ic c I I If, I' ý'l w l. In I I 1111ý \\ 4 'I'll M l 41 Ill .\ \\ I I I I I I I I ý T 4 I it 11 1 A 1.11 I.\
'i(;utitE 22:3.- 'Med~ila I'pirtoteit ambulanc~uie., awvaiting the removal of castialliv. from the

UVS.A.T. WhIm h~n S. (1(11k, Taitapag HIarb~or, Snipan, the Marianias, 27 April 19-15.

the XXI V ('aiph the 7thi. 27th, 771thi, 81st, 960ti, and 98thl Iut'antrvY Divisionls:

T14'he~ fm i~ arva ilar alt his 1111 ue eisisjstd aJ (bvi followuing islai ldts l.111d w~ere

MIak~ini. pi')it il G~it.('uiuulclztall.1 anti th Fit'iiji Islands.

A1,11ii' V Garri'Ismi Im'(ic(t' Iwov Jimia , \vai addiedl tO) USAFl"POA [in F'lIniarv1-

19,45. antd Ariii ( arlisali iFoiee, ( kiiialwa, W~ws titled in April 1945.

On 25 Apjril 1945. thle NMariaiis, Iwvo .1iiiii, anid the i'laiuu Islands Were

etuiisaOlitatvtd iHit() WNWi~ (WVe.terii P'aciic B' I'v 0([11niinaid), kvith Ci(d. E'liot

G. ( o)ibv, NI '. S'%iir-eai. III the midiivl()f t.Juuiv 19145, the S21st Hosupital

'enter' airrivedi owl 'l'iaii In th lit' \ii'iliias, III alit eicipat iml of thet assault OH

TJIai his cet'itel t'(olisi~stino gn I~ hospitals vith II Ii atith liaiied bed

(ildleitV of 5,000,) \vas 401 p'ere lit cm)Iilpit'it't wlieii limstilil ie. 'iiuied.

(Oni I Auigustu 11145, Ariii G alrisni. F'aree. ( )ll'twa,~ \.I.ý trans I'vi-rietiI

I lie (-ant r'al ()f 1VSAI'WE1l'-A( '(1 u.S. .Armv Fmaicvs W~esterii Pcl~iciie, withi

1'.S-Al.l0A, lnetniilimr 1'SAFi"I II)l'AC J '..S A.Ariii F ret's In the Mliddle'

TIhe Siir1z'aii's Officee. U1'AFNI IDPA ' . eaitimlleui to Iniviltast' In si/A' aind

1141pi-xij lY.\i As id' I Ot'iaio'i' ¶194,1 fll' follawilil a heels. ili.~ at hers, Wlt'
CENTRAL PACIFIC AREA 635

iiciluded: Genieral Willis; Col. Arthur B. Welsh, MIC, (leplltv surgeonl; Col.

(later Brig. Geni.) Elbert JDe( oursey, N1( , laboratorv conisultait ; ( ol. .John B.

Flick, NIC, surgical consuiltant; (2o1. Veriie R. Mlasoni, MIC (fig. 22113), medical

consuiltanit; IAt. ('ol. William H-. Everts, M( ', nieuropsvchiatri( consuiltanit;

Lt. ('ol. Charles F. Mc( uskey, MIC, aniesthesiology consuiltanft; and Lt.

Col. (later (C01.) Edward .1. Ot tenlhejiner, M( C, historical consultanit.

Organization of Medical Services in the Middle Pacific

Respoiisihilit v for medical service ini the Mliddle Pacific was delegated

to five major echielons of coinlnan(l. Thie Commaniding Genieral, SPB( , was

respontsilble for Jprovidinga mnedical service to all uniits iii his area during the rolluip of slmBc. The ('PB( had a primary mission of adminiiistrationi to all units

ini t he 1-awanian area midl was responisilble for furnishitig medical services for

Army garrison forces, reserve becds for bat tie casuialties fromn forwvard areas,

ain(l mfedIical supply support of comb~at operations. Headquarters. Arin ' Air

Forces, Middle Pacific, furnished anid was respontsible for inedical services for all

air forces inl the Middle Pacific with the exceptionl of hospitalizationl, which was

the res-pontsililitv of the coinnimid ini which Air Force units operatedl. Thle

WPB(' 's responisibilit v for medlical service was to provide for adlequa te hospitalization of casuialties from combat zonies anid medical supply supports for combat operations, inicluding supp~ort to troop~s mountinig from WPBC. Mledical

service at Okiniawa was the responisihbility of the Tenith U.S. Army. Wheni the

combat phiase was completed, the Army Garrisoni Force, Okiniawa, took over

the medical responisibility for units ini the Okiniawa area.

At the time the medical service of ('PBC was est ablislied, 10 August

1944, the following units were assignied: The North Sector Genieral Hospital

(formerly Stationi Hospital, Schofield Barracks), Oalhu, T.H., Triplem' Genieral

Hospital, Honioluilu, T.lJ., 204th Genieral Hospital, Oalitu, T.H., and 147th

Genieral Hospital; the 22(1, 129th, 165th, 266th, 284th, 289th, 290th, amid 337t01

Stat ion Hospitals; anid the 31st, 36th, :38th, and 69th Field Hospitals.

Durinig the following months, numerouis medical units wvere assignied to

the miedic'al service of CPBC. Some of thIese lbelonged to (livisions and ot her

large units which were staging or trainiiing inl H-awaii before going inito combhat.

Tile medical units of these were griveni hnservice traininig as part of their preparatioii for comblat.

These tunits conlsisted of Various stat ion hospitals, medical service (c0ompaiiies, field hjospitals, p~ortab~le surgical hospitals, malaria, survey units, medical

collect imi (omn1pllaies, medical service (letachimetits, imotor ambulanice comnIpanles, several greneral hospitals, an(Id numllerouls other medical umimit s.

Medical Activities and Expansion of Hospitals in the Hawaiian Islands

The history of the medhical service of the U.S. Army durinig World War 11

begatti with the Jalpimese attack onl Oaliu onl 7 December 1941. Oil that historic (lay, X Ihle m~edIical officers of Tripler Greneral H ospit al, under thle capable

leadership of thle chmief of thle mmedIical service, took over the supervisioni of
636 A(CTIVITIES OF AIFDICI(AL CONSUILTANTS

64 1

.--

1 rS -, S

FlotuRF 22-1.--U.S.A.'AT.S. Mfercy. A. AnchoredI in Tan'apag H~arbor, Saip~an. B. State- room for officer 1patints.
(TINTHAL. PACIFIC AREA 7

Fi;-m 2.Cotned .Geea W r.D.W l-eupedlbraoy
638 ACTIVITIES OF MEI)ICAL (C)NSULTANTS

all surgical wards and expeditiously organized and controlled the entire ward

service for the preoperative and postoperative care of the wounded, thereby

making emergency therapeutic measures quickly available to battle casualties.

The medical service of the Station Hospital, Schofield Barracks, also acted as

a supplement to the surgical service in triage and as a shock team in the

treatment of the casualties from Wheeler Field and from Schofield Barracks.

Subsequent history is one of rapid expansion of all the medical facilities in

the Pacific area to permit proper care of the numerous sick and wounded who

flooded the hospitals in the Central Pacific during the many operations following the declaration of war and up to the end of hostilities.

In the early part of 1942, Tripler General Hospital expanded to 1,000

beds, and its medical service was divided between two different geographic

areas. One was located in the Kamehamieha area and the other remained

in the original Tripler area, opposite Fort Shafter. Each of these areas cared

for certain categories of medical patients. The Station Hospital, Schofield

Barracks, expanded from 422 beds to 1,000 beds, and the name was changed to

North Sector General Hospital on 21 March 1942. This expansion was made

possible by establishing a hospital annex 1 mile away from the main building,

which provide(d five 100-bed wards for the medical service.

In June 1942, the 147th General Hospital arrived in the Territory of

Hawaii and became part of the Hawaiian Department, thus increasing the

bed capacity of the medical service of this area. It absorbed all the activities of Provisional Hospital No. 2, and it was set up at Saint Louis College,

located in the southwest area of Honolulu. The medical service at the beginning consisted of 200 beds, but, on 7 December 1942, 500 additional beds

were available for medicine, so that the total bed capacity ultimately approximated 700 medical beds.

In the absence of military operations at this time in the Central Pacific,

all the medical services functioned largely as a medical screening facility for

units staging in this area. Trie effect of training on limited-service personnel

and relatively untrained troops threw a large burden on the medical service.

The gastroenterologic section doubled its admissions, psychoneurosis became

a problem, and respiratory infections became frequent but were not serious.

With the influx of troops for training in the Hawaiian Islands, additional

hospitals arrived and were assigned duties on some of tihe outlying islands.

The 1st Station Hospital arrived at Canton Island on 10 February 1942. Oil

12 March 1942, the 22d Station Hospital arrived at Kunului, 'Maui.

During the year 1943, preparations were made for the future campaigns

in the Pacific. Changes in personnel were frequent, and medical officers

were evaluated and trained by the medical services of the various hospitals

for duties with troops in forward areas.

Medical screening continued through 1943. No sizable epidemics occurred. Contagious diseases were commori aimong troops arriving from the

continental United States. Scattered cases of typhus fever were seen during

September and October of that year. There was no threat from anterior
CENTRAL PACIFIC AREA 639

poliomyelitis or influenza. Patients with malaria were seen frequently. These

were usually cases of malaria with relapse which responded promptly to treatnient. Malaria was never a problem in the Central Pacific. Patients with

filariasis acquired in Apamanma Atoll, Gilbert Islands, made their appearance

in the Central Pacific, and a study of this disease on that island was made and

reported.

On 1 November 1943, the 22d Station Hospital was reorganized and was

designated as a 750-bed unit.

Tripler General Hospital continued to function as one of the most important general hospitals. Expansion continued, and Provisional Hospital No.

3 located at Kuakini was taken over by Tripler General Hospital and designated as the Contagious Disease Center for the South Sector of Oahu.

During the year 1944, there were many military operations in the Central

Pacific Area. In the early part of the year, patients were admitted from

the forward area (Kwajalein and Eniwetok), and during the summer the influx

increased with activity on Guam, Saipan, and Tinian. With each campaign,

because of the geographic location, interesting diseases (which will be described

later) were seen in general hospitals.

As has been noted, CPBC was established on 1 July 1944 to include

Canton, Christmas, Fanning, and Johnston Islands and all the islands of the

Hawaiian group.

The training of Medical Department personnel, both commissioned and

noncommissioned, progressed. The medical services continued to expand.

Tripler General Hospital took over the station hospital at Kaneohe, Oahu,

on 15 May 1944, thus increasing the medical service by three wards. In

addition, two other wards were kept in reserve for medical emergencies. In

August 1944, 115 patients with filariasis were evacuated to these emergency

wards. The medical service in this area also served to segregate and treat

minor outbreaks of diarrheal diseases occurring in the Kaneohe section of the

island.

In September 1944, Tripler and North Sector General Hospitals were

officially expanded each to 2,000 beds, were each allotted a staff of 80 officers,

166 nurses, 2 warrant officers, and 641 enlisted men, and were redesignated

the 218th and 219th General Hospitals, respectively. The capacity of the

148th General Hospital, Oahu, T.H., was increased to 1,500 beds.

The increasing denands for medical beds on the outlying islands were

met by the arrival of the 230th Station Hospital. This unit arrived on Oahu

on 28 September 1944, and, after a short period at Koko Head Concentration

Center, departed for Kamuela, Hawaii, on 17 October 1944. This hospital

took over the functions of the 26th Station Hospital.

The increased activity as a result of the arrival of patients from forward

areas necessitated the transfer of the 22(1 Station Hospital from Mauil, on 21

September 1944, to Waipie, Oahu. The capacity of this hospital was increased

to 1,000 beds, and it functioned as a general hospital, relieving the burden of

the 218thi and 219tlh General Hospitals.
640 AC'TIVITIES OF MED:1ICAL. CONSULTANTS

Before the (lepart tire of tilie 22d Stat ion Hospital, the 8t01 St at ion Hospital

arrivedl oin 19 August 1944 to take over t he area about to be vacatedl. Th' Ie

8t'll Station H-ospital, which arrivedl oin 12 February 1942, ait Bora-Bora, Soeietv

Wsands, was miovedl onl 14 April 1944 to New ( ailedloiia, and( later in tile year,

on 2 August 1944, arrived for (lilty, onl Oaliu.

IDuringr 1944, tilie incidIence of reSl)i rat 0oiY infect ions, was miiinimial. One

convoy inl Junle lbroughlt a severe st rainl of niiiasles, but slpread of thle disease

was p~reventedl by segregation of thle Patients. W~ithI the cap~tutre of Saipan,

there was anl increase in cases of infectious hepatitis and also in pat ients

convalescing fromi (lengue fever. Intest inal paraisite (5Were conlinonl findings

iii patients evacuiatedl from the forward area. Psyc' vhoneurosis continued to

bea problem, andl anxietyv states and lbat tie fatiguie re1sulting from combat.

were frequently observed. Penicillin b~ecamne available in April 1944 and

provedl to lbe anl ap~preciab~le advance over other remiedies, including thle

sulfonamide (drugs. InI the lat ter' part of 1944, thle Philippine campaigns

(Le ,yt- anld Mindoro) add~edl to the large number of p~atienits already hospitalized

in the Central P~acific.

In1 1945, the mnilitarv operations onl Luzon, Iwo JIima., anid Okinawa. led to

the evacuation of patients withi diseases heretofore not seen inl tilie Middle

Pacific. Schistosoiniiasis and~ ainelbiasis (with liver coniplicaitions) were

encouniteredl. Thel( arrival of .Japanlese anll Koreanl prisoniers of War added to

the array of tropical (diseases. Cases of filaripsis, paragoniiniasis, and inifestation

with (loreli Mi s si nensis were seen. Ill addition, thle (1ent rall Pacific receivedl

p~atients, from 'New Guinea, New C aledonia, Newv Hebrides, the Russell Islands,

Tahiti, the C ook Islands, and from simiila~r sinall scat teredl areas t hroughout

thle P~acific.

Onl I March 1945, with the transfer of tile 230th Station Hospital to

Oahum, 'IriJler General Hospital transferred its Kammeohe medical facilities to

this stat ion hiospit al. Onl 1 February of tilie same year, the Kuiakini facility

was retumrnied to (civilians for use as a civilian hospital. Ani epidemic of influenza

causedl by virus 11 occurred onl tilie island of Wllu, but it w\as not serious andl

withI the help of civiiami consultants fronm thle continental United States was

soonl Under ('om1itrol.

With ti lie approach of V-.J Day, p)reparat ions were mnade by CPBC to

ret urn to their original owners tilie public amid private schiools that had beemn

usedl as niilit ar ,v hospitals. As a resuilt, thle 1 47thI Gener-all H ospit al was

transferred to Schofield Barracks oil 25 Auguist 1945. The medical s-ervice

was establishied in one of the buildings t ha~t had formerly housed a general

hospital unit.

The 21 8thI General Hospital made similar plans to evacuiate tilie Farrington

area and to transfer its mnedical service from thle Kai nehamnelia. area.. Thel(

enitire 21 8thI General Hospit al slilsequeintly futict iotie( ii tilie originial rripier

Hospital area unitil it mioved into its new home, the New Iripler General

Hlospit al.

'I'lie close of thle war in the Pacific t hiu enidedh 3 year's and 9 months of
Aw

~ 4

Fi(;uwui 225. --( cc ptip wdui itheraii at 201ti (w~iivral llospituit Hawi iii

I ieiiie ti.hii inedlical eXplldiloii, Iiiediclet railiiing, anid t reat inelit of' t lIesick

TiHE, MEIDICAXL C.ONSULiF NT'S FIELI)

III tile -ieiiI Iiioveiiieiit acro.ss land~ adil S~ea, thle plaice of' thle Iiie(Iic.1

(Otilil a wa vi deflated b Iw Is sI-, iiie to mix-l vi thle I i~thete ir~e 11- ol (It lhe

(liialitY ( of tchnlical itiedical 1111d salutlarY ser-vices, of Ill Ar-iiiv ilisia~l~lt111o5l.

I us- specific hiti1ctilons b~ecaime clear1 III pra~ct ice. L,-O)lli t(, liv O f[e i-o"1'OiricJli

1*Ilra owe 01l. InsactiNiles III hism arac. I., iiidica ted b% I tlieitiier of C oloiiel

Mason)i from Aprili to D eceiib er I 945..

I,,roii 4 lo 26i April 19¶45, t ie 1471hI, 2l.Sth, anl 219th (ieieral I Ioslpitails

adthle 22d and SthI Sitat on IHospitals, We-re visitevl. W~ard r-olijls. were

iui1uile ~ithil Iliellilars of, Iliev stall1s. t lie labor-atories were Illspeeledl. and all1

JIt iui-. 1liee lilidjated. f~or finial actioin by thle Sm-r!coii. Bileweel 29 ApriI

:1id 41 NIa 'v, Coloiiel Nlasoii sje Ilie blood( bank, the 20111 I (jetiral Hlospit al

(fi-. 22.5), tI~ li -stil RialBse Ilosplital. anid tlIn 259( Ii ad 3~73d StatiOli

flospitals on(it iaii. ()ii and s Nka' . Ie( visitedl t li 232d (ieiiral Hospital.

t lie 4 1st -Stat on Hospital. anid (ilie ;)Stli Field Hospital OhI Iwo .iii

5.;6197W 10 it:1
642 ACTIvi'rii,:8 OF MED)ICAL CO(NSULTANTS

FiwuakF 226.- Medic-d wtir(I, 1418th (cierenI 1Iospittl, Stipan1.

Between 11 May and 19 Mlay, visits werie made to tile 148th and the 39thI

General Hospitals (figs. 226 and 227), thle 5th Convalescent Hospital, the 94th

Field Hospital, and the 369th Station Hospital onl Saipan. Between 20 andI

:31 Mlay, Colonel Miason visited medical installations onl Okinawa. Onl 1 June,

hie 374th Staition Hospital was visited onl Tinian. Onl 20 July, tile authlior

went to Okinawa for 10 days to study Japanese B encepliahitis; on 17 Septembler,

lie went to Jap~an to study medical effects of the atomic bomlb at Hiroshima;

and onl 6 December 1945 hie returned to headquarters tit Honolulu.

Thie professional medical consultant to an area, a theater, or a service

command had many duties to perforin during thre periodl of hostilities. He

grainmed much by the study of newv methods, new thierap~eutic techniques, and

new approaches to the study of disease. In certain instances, suitable (data

were available for the statisticall approach to thle solution of mledical problems.

In mall *VCases, however, general impressions gainedl by st udy of large namnihers

of patients andl by exchange of idleas with N well-in ro'ined clinicians (fig. 228)

hiad to lbe relied upon in making decisions.

Wihen World Will- 1I legamn, tile scope of therapeutic activity of tire sillfonlamlides was not, clearly dlelinecatedl; penicillin wals at novel prodluct , so fair

untri ed ; arid plasmia arid type 0 1)100( had been admrinist eredl ly only at few.

In add~it ion, thle civilian Physician, excep~t in aI few instances, was not familiar

iby training or experience with the lairge numbnler of (liseases peculiar to thle

trop~ical amnd sub~trop~ical climnat es. Furthermore, atit the onset, of tire war, thle

overall prob~lemn inherent inl thle relation of tlie Supply of specialists of Various

categories to thle demlanld for thIenin in civilian p~ract ice an(I in thre Arniy had to

be resolvedl. For examplle, thle numbler of ps ,vclmiattrists, ep~ideminiologist s, amnd

specialists inl tropical med icine and in tine conitrol and treatiluent, of contagious

(hisealu-S was woefully inadequate to serve bothI thle civilian and military popmu-
CENTRAL PACIFIC AREA 643

lation. Accordingly, it was necessary to train Medical Corps officers in specialties required for military needs. This placed a peculiarly difficult, burden

on a large number of physicians who had to learn a new field of medicine, in

which frequently they had no great interest, by means of short and intense

refresher and training courses. The manner in which these problems were

met deserves more recognition than these patriotic physicians will ever receive.

The amazingly low morbidity and mortality in military zones occupied by

U.S. troops showed how well the task of these officers was accomplished. The

development of ideas and their application to the prophylaxis and treatment

of disease in the Second World War fill a significant page in the history of medical

science.

Fundamentally, military medicine is the practical application of medical

knowledge to military needs. Of the contributions ma(le to scientific medicine

by Army physicians during the war, a few of the more important may be

mentioned. The introduction of Atabrine (quinacrine hydrochloride) in

malaria suppression, the use of penicillin in the treatment of gonorrhea, the

use of sulfadiazine in the control and treatment of epidemics of meningoceccal

meningitis, and the investigations of acute rheumatic fever prove the value of

the scientific in conjunction with the practical approach to medicine.

"The Central and South Pacific Areas included the Hawaiian Islands, all

of Micronesia, Iwo Jima, Okinawa and neighboring islands in the Ryukyu

chain, New Hebrides, New Caledonia, the Fiji Islands, and the Society Islands.

These islands are of variable origin, are variable distances from the equator,

have diverse climates, and are populated by peoples of different races and

different cultural levels. In addition, the arthropod vectors and transmitters

of disease and the human carriers and reservoirs of disease in these islands

of the Pacific Ocean are extremely varied. Many medical officers had the

opportunity to observe a large number of exotic diseases and their effects on

native populations and on military personnel who had entered areas of high

endemicity. These diseases included malaria of all types, filariasis both periodic

and nonperiodic, yaws, leprosy, scrub typhus, schistosomiasis, ancylostomiasis,

amebiasis, leishimaniasis, Japanese B encephalitis, beriberi, protein starvation,

dengue, intestinal helminthic infestations, and various types of blood-fluke

infestations.

Since numerous data on many of these diseases are to be found in other

volumes of this history, there has been no attempt at exhaustive discussion

in this chapter. Rather, the diseases have been mentioned as they were seen

in the hospitals of the Hawaiian Department and now will be discussed as

they presented problems in the Central Pacific. Later will be mentioned

more details concerning their course and treatment or their control and

prevention.

MEDICAL PROBLEMS

Filariasis.-This is a disease of high inc(idence on Samoa, Bora-Bora, and

also on Okinawa. Numerous troops who had contracted the disease in the
C C.
Ii VI U 1 1 1I 2 \"I I. ( It \U
pn d IcIIý. NhiY ¶4.

I iaszuio~is l)V fil(ldili¶ thle Maia~i'~ III ie( 1YlpIJ1I nlodes or b finig iiiiei'ofilar na

ill th blood 11(1wni ext relivIiv r'are. theli p)Iolbablv (li:(¶.loi05i xv.S IIi:1(l bw nil c'-

('IiC4'. a;fter sItulvit ui~the paitvieit a11( hIls sVyliIto~illaid d411etermIiiliiI(-his iprevioiis

¶Z4'()(11'.1pic~i oclio(ltI. It was5 tw ple W (JhCVo thle "i Ige-onl ( feiu'i'iI's ( Mfic'e to t I'a itsf)4)I' 54h(ld'5r who had4( acquiired filariusis onl .1 Pacific islantd to Ithe coit iiieit ail

tlfiitedl St: 4 tv. for netmentiet. Th'lere 'xns no valid reason to believe thaot the

(ldi5'vs wou)tld prIogI'e55 01* ("tllse IttW appr~ieciabl4e diailt i'te pat ienit wa's

I('iliov (' friomi all elldIcii(' arI'l~. 'Ilie1 l)055ililitY t hat It iiiigl~it becomle es5tabIishe'd if) th 'le tiie(I stites existed sili(ce the arIthrIopodI vec'torI Is, 1 I'('elit ill

many41 lo(':iliics (fig. 229). hIl fact, the disease ha~s exist ed ill Char~iilestoin, "A..

for Miore' t fin 50 , years l'.111d it., app~learani~ce ill soiii othiei aica ill hev Unitelf

tat4 was5. t h (I'fOI', a1 nelnot c possibilityv. The' native O kiunawan rehpneseilt 5Z

-I liltirc I'cSel'VOiI' f'or thle SprIead( of'lih I1/ bU(IIl/crf;. ý-;lllv\'Vs of' t he civiliani

pplaO)~~tio of (11t1.1t islandu and of' ()kiliawanf laihoi'c-S tikcn pisrien1(1 (li1i'iiiig. Ilie

liilit :IV c.1 lipigY J)I'oN*4'd that the liii(I'4filar~ii mnight be founhd in thle blood -it

nigdo tit pprommatIV 20( ecflo h ldvdn xmle.Fr111
L\II\1,A. PACIFlIC AIW.\

C;I'%rJ, ('f 'II t ) j 111 ~ , ' Il itn 1.- ¶22 S11:1 Irv oleli III' ee lo. )It (~ii)iLt f O w N\ iflliplel

Ill, O w t II l l l i -ill lh :t ii i ii14lll ill ():111 - 4 111:r slil pl-'t m i Io 111- i 1t"- hei '' I ' i o i '

I~Idg1I(.' Itjr sv Pt1I i I fl2 l ()IT llrli If\ vl 1. . ol i.id Te il Il-l il l VIl li )1 c~ im li
648 ACTIVITIES OF MEDICAL CONSULTANTS

disease, all of whom were Asiatic in origin, were inducted into the Army and

later discharged for disability.

Dengue.-Serious epidemics occurred in the Hlawaiian Islands, in the

Marianas, and to a small extent in Okinawa during the war (p. 678). The

disease is of serious importance in military medicine owing to the large ineffective rate suddenly produced among troops and to a rather long convalescent

period. Its control by aerial spraying of DDT (dichlorodiphenvltrichloethane)

gives some foresight of the probable use of insecticides during future military

campaigns.

Infectious hepatitis.-Acute catarrhal jaundice or epidemic hepatitis occurred in more or less severe epidemic form following nearly every minor or

major campaign in this area. It presented the same clinical characteristics

that have been described in other military campaigns and in this area had,

apparently, no seasonal incidence. No convincing data have been found associating the disease with a known vector or a known reservoir. It has been proved

that the excitant of the hepatitis may be present in the blood and the stools of

patients who have recovered from it, but its natural mode or modes of transmission to human beings are not yet known. The disease never appeared in

this area in large epidemics. No case following transfusion by type 0 blood

had been reported during the early stage of the campaign; and later, with increasing use of transfusions, it was difficult to determine whether the hepatitis

occurred naturally or following parenteral injections of serum (p. 667).

Dysentery.-Sporadic instances of amebic dysentery were seen in all the

hospitals in the area. Studies of the location of the homes of these soldiers

and surveys of the civilian populations in the neighborhood of the posts in the

Pacific where patients had been stationed were of considerable importance in

attempting to (letermine where the infection was acquired. However, it seemed

reasonably certain that a considerable number of soldiers acquired amebic dysenteryv first in the Pacific area and that the disease will be of importance in the

veterans' hospitals for years to come. No new drugs or new methods of treatment were developed in this area. The value of emetine in the acute stage of

the disease and in the early stage of amebic hepatitis was amply confirmed.

THE ASSAULT ON OKINAWA

Medical Aspects, Particularly Shock

Extensive medical planning had been done for the Okinawa campaign.

Six hospitals, with a total bed strength of 6,650 were ready on Saipan

alone to accommodate casualties from the operation. No major Army Medical

Department organizations were staged on Saipan; however, nurses from the

69th, 74th, 75th, 76th, 31st, and 36th Field Hospitals were placed on temporary

duty in Army hospitals on Saipan until such time as their transportation to

Okinawa could be obtained. Medical supplies sufficient for 10,000 men for

30 days were set up in reserve for the operation but were not used.
CENTRAL PACIFIC AREA 649

Blankets, litters, pajamas, sutures, and dextrose, and certain other

medical supplies, not availal)le to the Navy base, were furnished Navy hospital

ships and other surface craft. In addition, 1,274 Navy and 2,707 Marine

patients were hospitalized in Army hospitals. On Guam, in turn, Navy hospitals accommodated 7,825 Army patients in the course of the Okinawa

campaign.

The medical problems of a major campaign were observed during the battle

of Okinawa. What follows are the personal impressions of Colonel Mason,

who was director of a shock service during the First World War.

In 1917 and 1918, packaged type 0 blood was not available, and all blood

for transfusions was obtained from soldiers or convalescent patients. It was

matched by the use of stock sera of types II and III, and no serious results

owing to possible mismatching were seen. Blood of group IV (type 0) was

given to any patient with no serious reactions. Sterile solutions of gum acacia

were also furnished but were used in only a few instances. It was believed

that the gum acacia was of little value in shock, and, in addition, it was highly

pyrogenic. By the end of the First World War, the value of the use of whole

blood in shock following either trauma or hemorrhage was well established.

At that time, it was known that plasma escaped from the blood vessels, capillary stasis occurred, blood volume was reduced, and hemoconcentration occurred

in secondary shock. It was not fully realized, however, that whole blood was

the best colloidal solution known to replace lost blood or to restore blood volume.

At the beginning of the Second World War, there were still many unknown

factors concerning shock. I't was the accepted belief that adequate quantities

of plasma could be substituted for whole blood in most cases. This opinion was

based on experience in the use of plasma in burns and in shock following surgical operations when the loss of blood was not great. Early reports from the

campaigns in Africa, Italy, and Europe did not substantiate this belief, and

further reports by many observers showed that battle casualties reaching a

hospital in shock (excluding those with lesions of the nervous system) had lost

quantities of blood much larger than had previously been suspected and that

plasma was far inferior to whole blood in their treatment. As suggested by

that experience, blood of type 0 was collected on the Pacific Coast of the United

States and transported by airplane directly to Okinawa, after re-icing at

Oahu and Guam. Thus, adequate quantities of type 0 blood were available

at all times.

In modern warfare, if battle casualties received early are to be treated

adequately, the organization and equipment of field, evacuation, and station

hospitals, as originally authorized in World War II, must be altered. Training

in the parenteral administration of whole blood and in all aspects of shock

should be given to at least 3 or 4 shock teams. Each team should consist of

a trained internist, a laboratory officer, an assistant competent to use the copper

sulfate method to determine specific gravity of the whole blood, and also

several nurses. The treatment of shock is not necessarily the function of the

internist, but under battle conditions it is almost invariably true that every
650 ('TIVITIES ("F MEIDICAL CONSULTANTS

available surgeon is overloaded N.,1h work in the operating room. It is also

tle usual opinion that a competent internist familiar with laboratorv methods

is the most satisfactory chief of the shock service. In field, evacuation, or

station hospitals near the scene of battle, a shock ward, completely equipped,

should be established by trained personnel, and all patients in shock or with

serious wounds should be admitted to that ward. Each patient should be

examined(, the b0lood pressure taken frequently, and the specific gravity of

whole blood and plasnma determined as necessary. Careful records should be

kept, especially of all tests andt all administrations of fluid.

In general hospitals, a shock ward is seldom necessary although shock

teams should be formed to treat patients in shock in any warrdthroughout

the hoslpital.

During an active campaign, it is desirable to delegate the responsibility

for the early care of wounds of the chest and lungs to a medical oflicer especially trained in that field or to the chief of tle shock service, if no other

officer is available. Careful study of the fluid from the wounded chest bv the

copper sulfate method and bacteriologic examination will often give data of

great value in the treatment of thoracic injuries.

When blood is plentiful, as during the campaign on Okinawa, overtransfusion becomes a possibility. It was tihe impression that in a very few patients

this nmy have been the cause, or, at least, a contributing cause of death. On

the other hand, there is no doubt that a very large number of lives were saved

by large, repeated transfusions (fig. 230).

The indications for the use of intravenous crystalloid solutions are not

frequently met in war injuries under usual conditions. They may present

themselves in patients in hot and humid areas, when thirst and sweating have

been excessive or occasionally after repeated vomiting. Otherwise, crystalloid

solutions shouhl be used cautiously and usually only when whole blood is either

unavailable or available only in small quantity.

Shock teams and the shock ivard in the field hospital

The varying degrees of mobility of modern warfare will often alter considerably the function of the field hospital. The usual channel of evacuation

of tile Wounded is from the aid station to the collecting and clearing stations

and then to the evacuation hospital or field hospital functioning as ati evacuation hospital. The wounded patient in shock must. be treateed at tile earliest

possible momenit if lie is to be save'd. Shock treatment consists of tile control

of hemorrhage, the closure by some method of sucking wounds of the chest,

the proper fixation of woun(led extremities, the relief of pain, the administration of parenteral fluids, and often tile adiniistration of oxygen. The woulded

patient, having receiveid this care and having been properly prepared for

operation, is now transferred to tihte surgical service. Following operation,

tihe patient, in many instances, is returned to the shock warrd foi" postoperative

care or to the general surgical wardIs if or when it is probable that shock is under
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CENTRAL PACIFIC AREA 653

Relatively minor trauma with the loss of little or no blood 0and with only

a reasonable amount of pain may produce psychic shock or benign shock.

Pallor, cold sweat, faintness or unconsciousness with sudden drop of blood

pressure are the usual symptoms. The relief of the pain by morphine without

any other treatment usually leads to rapid vasomotor stabilization and prevents return to a state of serious shock. For that reason, relief of pain is of

great importance therapeutically. In niany wounded patients, however,

the effects of exhaustion, dehydration, and blast injury may not be readily

apparent. As a consequence, the patient's condition may be nmore serious

than the size or location of the wound would indicate, and what wits considered

to be benign shock may progress rapidly into a state of profound shock.

Surgical shock produced by operations under prolonged anesthesia but,

without significant loss of blood is characterized by peripheral vasoconstriction, with cold, cyanotic extremities; anoxic anoxemia from the vasoconstriction accompanied by marked hypotension; leakage of protein into the

tissues, probably (dule to anoxic damage of the capillaries; reduced left ventricular output, pulmonary hyperemnia; and eventually pulmonary edema.

It has been amply proved that this type of shock may be reversed promptly

by administration of sufficient quantities of plasma. Experience has shown

that, when moist rales are heard in the lungs, the plasma should be given

slowly in more concentrated form; namely, from 2 to 3 units to 250 cc. of

diluent. In all types of shock, plasma may be given early at aid, collecting,

or clearing stations where whole blood is not available, but it should be remembered that it may give a false impression of security by causing a temporary

rise in blood pressure in patients who may have had severe hemorrhage and

in whom only blood will be effective.

Patients with extensive burns should receive plasma in concentrated

solution given slowly. Since many of these patients may have inhaled hot

gases or funmes, the administration of oxygen may be important.

The patient with extensive single or multiple wounds almost without

exception has lost a large amount of blood before he reaches the field hospital.

Direct measurement of blood volume is not yet feasible in the battle zone,

but there is much indirect evidence of importance. In one instance, the calculated amount of whole b)lood lost by 20 casualties having wounds not involving abdominal or thoracic viscera averaged 50.4 percent. of the total blood

volune, and the blood loss in 16 cases with perforating abdominal wounds

average(l 24.4 percent. These figures at first sight seem excessive. However,

in many wounded patients observed 2 to 4 hours after injury, hematocrit

readings were 30 to :35 and would have been much lower at. the end of 48 hours

or later. Some of these patients followed through to rear areas still had heniatocrit readings of 25 or lower after 2 or 3 weeks and after a number of subsequent transfusions. Early drop in the specific gravity of the whole blood,

as detenrnined by the copper sulfate method, together with drop in blood pressure and acceleration of the pulse are usually reliable signs that the blood

loss has been considerable.
6541 ACTIVITIE.S OFI MiEI)IAL CON)S1'LTANT4

III anothber inlst ance, it, was reporte Ihat tM s *Nstolic blood( p~ressurles or fr'omi

.50 to (60 Iniu. I Ig were very commilon inl the severe cases-. Thle geiterad rulle of

fast triansfuisioni ii) these cases wits adloptedl, 831(1 bl1ood or plasilla wits di~lliilliStered lit the rate of I pullt per 1.5 lninltets' unt il thle blood( pressurev reached

110 mim. 11g. This was followed iby at slower rate-I p~int inl 45 uininutesunt il tile 1)1oo( pressurIe hadl leeul cornllet ely, built uip. It wits found b~etter,

ill general, to leave tilie badly shocked Jpatieit, wit ii pellet rat inig wounl(IS of

thle chiest alonle, anld very few of these p)atijents wvere transfused. hI tile mlost

Severe Cases, slow transfusion wats at tenmptedl. With Iivhea( wound~s, at sinmilar

'oniservat ive P~olicy wats adolptedl. It, W21S evidlent ill patitents either with

cranial or sp~inal wound1s that t'ranisfusion wats singularly inleffective witeit there

wats itiucli hemorrhage or grross tissuec (lest rict ionl.

Onl the average, the casualties Observed by (C01. Walter B. Martin, MIC,

Consultant inl Medicine, TenthI U.S. An, received1 3.5 pints of blood or

about 12.5 percent of their 1)100( volumie. InI spite of thle large number of

transfusions given to wounded men onl Okiniawa, few were seenl with p)olycvt hernia or ot her evidence of overloadingi of thle circulation. This th~eoretic

P)ossib~ility may be dlisregardled, except, inl cert ain types of injuries such ats

those just, not ed. If available clinlical signs point to severe loss of 1)100(, 10

or more pints of whole blo00( may lbe given preoperatively and~ p)ostoperatively inl from 24 t~o 36 hiours wit hout, any evidlence or injurY to the patfient.

It is thle convict ion of most, miedical officers who11 have beeli inl charge

of shock ward1s that large quant it ies of whole blood givenl to seriously wounded

mien before, (lur-iing, and~ after operat ion aire of thle utuiiost imiportance ill re-

(hi1cing t-he (deathI rate 1bothI froin hemorrhage and fronm irreversib~le shock.

Excessive amounts shouldl not be given, and transfusion should not b~e repeated

after the heinatocrit readlings have retuhrnedl to noruiial.

The comnplicat ed vasonitot or, osinot ic, andl fluid correlat ions inl shock

are not v et entirely* known, and( ill someC ilst ances, results of laboratory ,(leteril ilat ionls are interprete(d( (Ii feren tly b~y dlifferent ob~servers. A few physiologic p~riniciples oil which all ob~servers are agreed are applicable inl shock waids

inl ad(vaniced m edical inst allat ions. T[he following rehat ivelY simiple ob~servations should lbe of value ill reaching at decisionitas to what pareniteral fluid

shouIld be given and why:

1. With Ii iinor woundls, sudden collapse of the nature of fainting is frequenit. This conisists of p~allor, cold sweat , ext remne mnuscular wveakness, marked

(drop of 1b100( pressure, and~ anoxic anoxemiia withI some eviunosis. The hemiatocrit readling and 1)100( coun ts are normnal. 'The phienoitienon uinder thlese

circumlst ances is callsedl by- widespread vasodlilat~atioli of central origin with

consequent cereb~ral anien Iia.

2. Shock without heiiiorrhage or with insignificant, loss of blood( is fre-

(hhent. UndIer suchi ci rcumist ances, i ematortraigi ih wn

to loss of prot eiii Into tilie tissuevs t lirohighi tihe proxmnlial art erioles a1nd( velins.

Thevre is widespreanl vasodihit at ioland31( probably (lanili1ge of the smalllest, ve'ssels du te to tinloxic a tioxelinil froml blood stnasis. The blood p~ressurie faills,
CENTRAL PACIFIC AREA 655

sweatinlg is profuse, blood pools or sludges in liesenteric and pulmonary veins,

and veCltricular output steadily ('viminishes. Pulmonary edema is a terminal

event in this t*ype of severe shock, or in irreversible shock.

3. Shock with hemorrhage is the commozi event in wounded soldiers. Ample

experience has shown that in such instances the heinatocrit reading is low even

within the first 3 hours after the wound has been inflicted. Since uncounplicated shock and dehydration lead to high hematocrit readinlgs, a low reading shortly after a wound has been received means that tie blood loss certainly

has been very large. Under such circumstanices, soulld clinical judgment must

be used. The amount and speed of whole ')1ood transfusions should be determined by clinical ol)servation, )lood pressure (let erminat ions, and frequent

counting of tile pulse. Plasma in more concentrated form than usually used

may be helpful if 1)lood is not available. The sovereign remed *y is whole b)lood.

An attempt should be made to replace any loss by hemorrhage as quickly as

possible. Having accomplished this as nearly as can be deternineld by clinical observation and hematocrit readings, the condition of the patient should

be reevaluated with great care. An excessive number of erythrocytes in the

peripheral blood stream will produce erythema, not cyanosis. If the blood

pressure remains low, if cyanosis appears and the urinary secretion rapidly

diminishes, the patient is usually ill irreversible shock. Examinmition will

usually detect rales of pulmonary edema, and at this stage further whole

blood transfusion will produce increased evidence of right heart stasis. At

autopsy, these patients show pulmonary congestion, visceral congestion,

renal cyanosis, and fluid in the serous cavities. It is problable that in few,

if any, of these patients overtransl'usion played more than a minor role in

their death. Ill patients withi hemorrhage anid shock not markedly improved

by whole blood trIimsfusions, other causes for persistent shock should be sought

with great care. These include concussion injury of lungs, crushing injury of

muscle, infarction of a2 large mIiass of1 muscle, lunsuspected injury of tile spinal

cord, and fat emboli from injury of long bones and from extensive tearing

injuries of the a(ldominal viscera.

Shock is a name applied to a series of phenomena that tire harl)ingers of

approaching (leath. The terminal events in shock tire probably alwa•vs similar, regardless of tile cause or of the speed with which they are elaborated.

These events tire modified and modulated by the underlying disease or injury.

Shock produced by streptococcal disease, by Addison's disease, by hemorrhage,

by extensive surgery, by burns, or by gangrene of till extremity prob)ably

follows the same pattern; and latboratorv determinationis that seem to show

serious discrepancies from case to case may be correlhte(d when tlihe pathologic

physiology of t he underlying disease is carefully considered mid fully understood. Shock produced I" i bumn, b. a crisis of hypertension caused by a

pheochromoc. toma, or h)y i prolomged surgical operationll ti eventually produce vasodilat atioil, hemocoilceiitratiou, aioxic atioxemia of the smaller blood

vessels, osniotic imbalance in tissues with imuibibition of water, drop of blood

pressure, and disturbances of remnl function owing to hypotension and renal
656 ACTIVITIES OF MEI)ICAL ('ONSULTANTS

CVaflosis. The end results are pulmonary edema, then cerebral anemmia and

(leathl. III miany cases, tihe alterations of clinical findings and labloratorv

determinations are easily understood whlen compared with such abnormalities

already present when clinical evidence of shock appeared.

The use of parenteral fluids, other than whole blood or plasma, in the

treatment. of wounded patients requires brief discussion. Before a battle

casualty is given a parenteral injection of fluid other than blood or plasma,

a definite indication for its use must exist. A number of such indicat ions

may be enumerated, such as alkalosis caused by vomiting and diarrhea; mild

acidosis front starvation; anuria from henioglobiniuric or inyoglobinuric renal

damage; edema from hypoproteinemia following blood loss, malnutrition, or

extensive burns; or change in electrolytic balance owing to fistulas from the

stomach or small intestines. )%lost of these conditions are encountered rarely

in active campaigns or in battle casualties and the indications for treatment

are obvious. Such treatment, however, usually is of great importance. It

has been repeatedly observed in hospitals that following serious wounds the

patient loses much weight. This loss of weight is not always easily explainable. In general, it is a result of weakness, loss of appetite, unattractive or

liquid diet, and loss of serum from infected or burned areas. Every effort

should be inade to feed such patients nutritious diets with anllple protein.

The routine use of liquid diets should be dliscouraged, and such diets should

be given only to patients who are too weak to chew. All foods except milk

b)ecome liquids in the stomach. Proper postoperative feeding wiUl save many

hospital days.

The treatment of wounds of the chest, except for the actual surgical operation and the postoperative care of casualties requiring thoracotonmy, should

be largely delegated to the shock teams except in those field hospitals that

are augmented 1)y thoracic surgical teams. The first consideration is the

closure of sucking wounds of the chest and the arrest of hemorrhage by the

best method available. The next is the careful and early diagnosis of the

extent and nature of the wound and the determination of the intrathoracic

changes. Early ra(liograph ic diagnosis is usually possible and always important. flemothorax should be removed by early and frequent tapping. Pneumnothorax, especially of the tension type, should be corrected by the use of a

nee(le connected to a one-way valve, either the valve from a gas mask, or a

piece of rubber glove correctly placed over a thoracentesis needle, or a Bunsen

valve. All pleural fluids should be studie(d by the copper sulfate nmethod, and,

when possible, the fluids should bc examined for cellular content and for

mi'cro-organisms. A careful study of the movements of the thoracic cage

shiouhl be ma(le to determine whether the wounded half is carrying on any

respiratory function. Massive coagulation of the blood in a hemothorax is

probably much more frequent when the respiratory muscles on that side are

reflexly paretic. Massive coagulation of a hemothorax should lead to prompt

thoracotomy, since whnen not evacuated it is followed by either empyema or

constri(cting pleural fibrosis, necessitating a long period of hospitalization.
CENTRAL PACIFIC AREA 657

Oxygen should be given to all patients with thoracic wounds when there

is cyanosis, or wheni moist rales are heard at the base of the lungs, or when a

satisfactory airway cannot be established. Such patients should never be

given large or rapid transfusions, since these may produce acute pulnonary

edema in cases in which the amount of pulnonary compression is extensive.

As a matter of fact, any fluid given intravenously should be admninistered with

great caution to patients who have had serious thoracic wounds.

Pathologic evidence of pulmonary edema

This discussion is based on 100 autopsies perforlned at, the 14th Medical

Laboratory on Okinawa on soldiers who died of battle wounds or severe injuries.2 In reviewing these records, one is immediately struck by the high

percentage (72 percent) of cases showing massive pulmonary edema with or

without pleural effusion and the considerable number with hemothorax and

atelectasis that apparently had escaped detection during life. With few exceptions, these individuals had experienced severe tissue damage of the head, chest,

abdlomen, extremities, or combinations of these. Fifty-one percent had miultiple major wounds. Table 2 gives the details on each case as to location of

wounds, presence or absence of pulnonary edelna, pleural effusion, atelectasis,

hemothoraces, empyemas, and pneumonias.

Table 3 shows the relative weight of the lungs and liver in edematous

and nonedlematous cases exclusive of those showing pneumonia. It is evident

that the weight of these organs in niany of the patients with no pulmonary

edema are above the accepted normals, suggesting that in some cases edema of

the lungs was actually impending.

Satisfactory evidence cannot be brought. forward to establish the cause

of the renmarkable incidence of pulmonary e(iema in this group. The inference

is strong, however, that it is the result, of the quantity or kind of fluids given

intravenously or the rate at which such fluid was given. Unfortunately,

accurate records of fluid intake and output are not available. In a number of

p)atients, the amount of parenteral fluid given was certainly excessive, as was

also the amount. of sodium chloride. Some patients received, during their

period in the hospital, approximately 62 gin. of sodium chloride parenterally.

In addition to this, a large number of wounded men also received large quantities of blood. It is probable that these two factors may have been contributory

to the production of pulnonary edema, particularly if the serum protein had

been lowered by blood loss and subsequent dilution with crystalloid solutions.

The conditions under which the shock wards operated during the rush

days of the campaign amlply justified a wide margin of error in maintaining

fluid balance and in keeping satisfactory records. Large numlbers of severely

wounded patients crowded the shock wards (lay and night. It wvas necessary to

place great emphasis on speed and on the rapid administration of large quantities

2 Fýsentlal Technical Medical Data, General Headquarters, USAFPAC, for September 194.5, Appendix A, thereto.

(These data were In large part collected by Col. Walter B. Martin, MC, or under his supervision while he was medical

consultant for Tenth U.S. Army.)

5649701- 61- - 44
658 ACTIVITIE'S oF MEDbICAL CONSVLTANTSx 0

E-4~
CENTRAL. PACIFIC AREA 6.59

N~~5 = 5K1 

;K 5 K r.- -5

;K- KQ - - Z ;
660 ACTIVITIES OF MIDICI('AL ('CONSULTANTS

C6

! 5-i Ell ! ! I .:i

• . .: -.. .... .. _. --- .. . . -

CC3

tit

e •- ___ _.___ __ __

L.0

,,- . . . ..-

, • - i i i-- : : . . ,
CENTRAL PACIFIC AREA 661

TABLE 3.1--eight (grams) of lungs and liver in 100 autopsied wounded (excluding pneumonia

cases) with and without pulmonar! edema

flight lung Left lung laver Caisualtiles ______________ _____

Average Maxilinl l A verage i Maximal A veraov Maximal

With edema ---- 839 1,400 768 1, 300 1,975 2, 750

Without edema 505 925 455 700 1. 840 2, 525

of blood to as many patients as possible. The medical personnel available

in the preoperative and postoperative shock wards were inadequate in number

and, with certain exceptions, inadequately trained. The surgical teams were

overloade(d with urgent, Operative cases and had little time to supervise the

postoperative care of their patients. Too mulichi cannot be said in praise of officers anid enlisted personnel of these hospitals for their devotion to their patients.

They worked to the point of exhaustion through many days and nights. It is

oi)vious, however, that a number of patients suffered from a lack of indiividual

attention.

Summary

The brilliant achievement of making adequate amounts of whole blood

available for the treatment of shock in tie evacuation and field hospitals and

clearing stations brought an added responsibility to tUe silock service. In tile

calnpaign on Okinawa, for the first time in any area in the Pacific, more than

sufficient amounts of blood were available, this b)eing, in general, type 0 blood

wlich bad been flown in large amounts from the continental United States.

Many lives were saved by the liberal use of whole blood. In the future, it

will be more than ever necessary that shock wards l)e set up on a basis adequate

from both the physical and professional standpoints.

Medical experience in the campaign on Okinawa was more favorable than

was anticipated owing to a number of factors. Although the numl)er and types

of medical units were often inadequate to accomnplishi the mission of the medical

service in the most acceptable manner, excellent use wias made of the facilities

available both in p)himnig and in operation. In general, however, the organization andi training of field hospitals as professional units were incomplete, and

the shock service, especially in field hospitals, was deficient in organization,

training, a(nd in qualified personnel. Laboratory support, 1)oth from the field

hosl)ital laboratories and the more complete Army medical laboratory, was

inadequate chiefly owing to lack of trained personnel and to failure to anticipate

tle added burden placed on field hospitals by modern warfare.

The evacuation from the island of many "white" (i.e., transportable)

miedical and surgical patients was a significant factor in loss of manpower,

since many of those with only slighit wounds mighit have been returnerd quickly

to duty.
6 62 AC'TIVITIES OF1 MEDIICAL C'ONSULTANTS

111n 0 autopsiesi' per'ifoirmied oil sotldiers whlo dliedl of liattlt' woiiiItls or' severe

injurie ts. 72 p titereit showedt' Iii nlissi e pu111limonaryi ee( le UwithI or wVith loit pleura'l

effutsioni or hien otli~oi'x. it is probal m e thautt dent I ill th est' listan nets was

CUt IiS~t'I I lI ost i iIU IV; kr NYb It iirt'versi bIde sI lock, nitid( it is I elievet It Ii IUt t I Ie p)UII I II1-

It wasU not1 provedt thlit al. pat)11ien t diedt solely ,Nis tlie result of overt ransfuisioni or of dro~twninitg liv t he pare'ilteralU I uliiiillisir mi'Utl of cr Xst niloitis. F I I rlt'eriiitrt. it is not bielie'ved thaiUt etltnti ini thle p)Ut iviit 5 wit it actite pulitionury11

t'l'in coimblinedl ejther withi iilt'iiruI t'Ifiisioii or' li'illothiori'x wats (Illt' to

lthese ciri'tiiiist Ut nce's lkbut'. 'l iit'e it is imloret probalelit thlit tleatl tintder such

('Out lit ioiis is cailised I V Iirreversible shi' iock, it is not logicalu to concl ude Ithat l

ithese patit'iits would ha~ve bet'ii saved hand tilhey vltot bet'i givt'li largte r1111ill(it ti's

transfusion atl thins timiet Wvas the only known remedy t haV int miight prievenlt tilt'

Observations by lthe Medical Clonstiltant to the Tenth U.S. Ariiiv

Following~ alre coilii1nt'its take'n fromt thet repor't of C oloinel Martin oil tilie

opert'iltioiis of th l M' edltical IDepa rtmeitnt or thlet U.S. Arimiy duinri g the lipgi

oil Okinia wa. It maiy be nioted'l btliit deihor t e prep ilitiotllhs for' evt'Vlttlit itll of

thie less sevt're tIral nsport abl ca''lst's a rt' detscribietd is IleoTst'5ll, ,V to0 conisrve forI

the cart' or thle st've'relyv wouindetd niot only hbeIs ltiit Medic hal DepartmnentI

pe'rsoinnel, wiho wtere, il fact, ili short stupply lit O)kinawa . Ohi thie othert'i lialndi

niectiilnt t't expei'iente telstewheure has shown thalt th flit' I ut indti tlentit of

meic'htal personntel alle t'xptendetl profit ali *y onl thle pat ienIt wiho (-liilit'b t ret'ttt'

ntear tilet front aind rettiurintet promlpt ly to dtiyi . Ali esset'iitl parit of plannling shiluld lht to pr'ovide liitidqulitt' stippiv of meici't al officer., to care'

for stit'ii 1)11 t ie~ Its Ws~ell ats foi' t host'e illrgn 11 it't'tI ole ~ s01' t'

()n I -dtlv (th lit'nya of th lit1alii1pilibioiis 115511 tilt onl O kinawa~), 6 April 194.5,

wVUirI are-as. It shiouild lit iremii'mb ered thlit t ilie issatilt oui O ki lnawa (fig. 2:12,

which began onl 4 April 1945, was unlolpposed by thle JTapaneste andthat lithe itre

f~w'es a hout 21 Juine 1945. ()it 14 April 194.5. C oloiiel MaIrt in ret uirnt't to tilie

llt'lltI rtill'trs of (hlit Tentht U .S. Airmii andi thiereafttie wavs conicti'ned. togt't ut'i

withi tilie other'u conisuilt ants. withi thet pirofe'ssioinal act ivitit's of til lt'iiziti'l tinit s

Oii I -daiv, thlit consultants visited't six of tilit I 'STl l' (Ilandling ship tlintk

hiospitauls) stippoirt ig tilit Ill Aiiipiibioluis antd XXlI' Cor~ips. Alth litugi tilit

iinimber' of 'astial tl it' t that t imle was light, it \%-its tevidetnt thlit tiIIla'n)11i of
CENTRAL PACIFIC A It EA

, tllllhoibý',

APO

Fict 2:,2. L:mding 4qwralions mi Mitm%%ýt, I April 1915.

ex"'IcIlatiml wnswvll cmiceived IIId 1011

NV;I,ý ('011fil-Im'd bv subsequent obsel-vatioll.s. The Imil"(wil:4 .11(mo-side thesv

ship., 'Iffm-ded 'Imple simcc I'm. rnpid sm,1111g, ()I' IIIv c'Ismillics 11141 1 I'm-1111.1ted

their trallsh.l. 1() All's (Imspit'll ships) and APA's (11I.Ick It

shmild I)v Imled flint be-11111111-- L-dav fliv L:-;T11's I'm. the III Aillpilibi

I)I-ps lind bvell prm-ldvd NN-1111 additimml surgical Iwi-smillel 4d, 111v 1.111dill",

kwce 1) v the cm-ps This would II.IN-v beell ()I* IIIvsIIIII;IbIv 11' 111,,

C:ISINIII It's had beell livnvv cal-k- III Ille c.11111mi".11. III tilt, pIm-;v (d' Ille

.111 1111,111V sill'"ICZ11 Ivaill wa, 'Issiu'lled to mIc Ilsed I'm, CVNCIlatiml ()f cn.,11.1111les I'l-mll Ille Smith vild ()I* the Ishilld. This step prm-vd (4

L'yent and slimild be cmisidcred 11' S111111:11. c*1I*cIIIIIsI.*IIIcv.ý al'isc 111 1,111111%.

1q)vI*.IIImI-;. All. cvm-lintiml be.-all (m L-pill, S .11141 1,1111climicd Sfll()()Ilil v

:11141 vilicivild v. 11(ddill"'. st;111011.ý \\(1111 (Ist"Iblislied ml flic be.wlics .11141 nt

Ow YmI1,111 All. Fivid. At these Imillfs. ImIleflis \\erv 1-:11-el,1111Y sclcell(ld

;1-.ý I() S11111.1bilif v I'm, InIlIsIml-I I) X. nil. m. 1) v wnfer. The cmilhilicd effect (4

Hil, :111d wato.l. evm-11:111ml pl-I'velited t1w Imspit'll., I'l-mil beill"'. m-el-Mm.111led bY

cnSv." sill.".1cl] and Illvdic.11, '11 n film' Mwil 1):Ittl(,

C;IsII;IltIcs were Later, evacliallml \\*,I-; vfl*vcIvfI (III-v(.11v I() I'S"I'll I'l-wil

vel,11:1111 ()I, the ilm -thel1l Olld sm itlivi-Il benclics. IIIv '14.1 I(Ill In I III. sm il 11

411* 1111, isi.111d, \\ livil I nillsp irt 14) IfI i v fiviol ll()Sl)il;ll \\;ls Illm le dilliclill bY b:ld

2:;;')), evncuntimi by lig-111 Ariliv \\-.I, succi ,ý,hillv
A CT I IT 11: s 4 V

-Z

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, lip, -41.,

-v7

_ý7

rrrr

:;]-I Vold Ill-Ijil:d. 21 April 191.7). N I dirl ill

I Ill'I'im . 1)1.411)11,111. h ill 111ort. \\vrv 11111111w rý;

411, 1):11114. 4*.1'11:1111(.-ý ( I :I I de T lll.ý p hil-rd .1 llo'i\ v 14);I'l )It I Ill- p rotiper:1111\41

'11(w k loollis .1, \\(.11 ;I- ()It 111o 4)lw I':lflfIL': 1 11:11 1'ý. N\ ;I

I I' It A 111 )n 11 wr 111.11 1 1 ro h.( )III I hr 1114 -4 111 ýcn 14.4. (fl' I ho 1I(I'pl1 '1k

-dmck \\ it n I

I 1 4 1, 1 1111 z I I - I I I I I .I I I -I I I I 1 14 14 -k I 'y 4 1-4 .I I I v I I I

:11111 Incl, ol, 'I'llf-c (111ilqcflrir-ý 4-m-n-cled. As

i'A"ll Ill.\\ 111111 mI the 1-1:11141. 111c prid'o"It'll: 11 1114.1 titon. 1wh4l"I

1, \ illo cml-ý1111;1111' ()It fill, pr(4c"ýW11:11 :1%ýpcrf' (11' fill, liller:111(ill. Ill

;141411111111, fill, 1)1:111 fit 111111- I1I.c:II1Y ('po r;M 11'r se l"li

fill, [wrlod :14,11\11 Ill o\.1cmile \\Ifllqllll

Ill-lillo I\ I, frentmew , direcil.\ 1).\ hIp (it- pl:mr, -),171-) (d' fill. h,

4-11. Tilli'll Ili fill, 1-11,41111) AW , III.

A I 'A V I 1 1114 1 1 1 11 1,-, 1 1 W( i I I I I I I I I I I I I I 1 -11 1 1 1

W e I I A I if I I I I I I 1 1:1 111111 )l

\\(11*41 P\:w1loted Ille licIll 114"ponk In

If) hod, fill. Iho '(.ýcrck \\411111dod. 111cli, lilt, -M Illitill

1-111 1. I-P_'IIIlIvIlf ilf Ille pn4c"Imi'll pol'411111cl ,I' lw\d It laildrd 111111, 1()
CENTRAL PACIFIC AREA 665

TABLE 4.- Weeky disease and battle-casualty rates, during assault on Okinawa, 6 April through

22 .fune 1945

[Preliminary d(ata bse•(i on slummarties of statstical health reports]

[Rate expressed as numtber of cases per annum per 1.(EI1 average strength]

1)isease Battle casualties

Week ending- Number Rate Number Rate

of case(, of Cases

6 April ---------------------------------- 129 66.36 1,169 601.36

13 April ---------------------------------- 296( 152.23 2,027 1,042. 66

20 April -------------------------------- -293 151. 44 2,507 1,296.08

27 April --------------------------------- 323 188.01 2,310 1,344. 83

4 May------------------------------- 467 360. 15 1. 643 1,267. 11

11 May- ------------------------------- 358 288. 66 1,391 1,121.64

18 'May --------------------------------- 557 437. 79 1. 882 1,479. 36

25 May --------------------------------- 586 462. 59 1, 693 1, 336. 47

1 .Jtine ---------------------------------- 857 651.40 854 649. 16

8 June ---------------------------------- 840 643.94 620 475. 35

15J.he ---------------------------------- 822 653. 98 886 704.95

22 J -ne---------------------------- - ---- 913 7:731. 60 1, 326 1,062. 60

units already in operation. On an average, these additions increase(] the professional personnel of the operational field hospitals from 13 to 22.

The Surgeon, Tenth U.S. Army, placed tihe responsil)ility for the utilization of available professional personnel entirely in the hands of the various

consultants. Excellent cooperation was given by the corps and division sur-

"geons and, in most instances, by the hospital commanlders.

MNieldical casualties were light, with few seriously ill, and constituted, during the first 6 weeks of the campaign, approximately one-sixth of the total

casualties. Thereafter, there was a gradual rise iin the disease rate which on

2S May 1945 for the first time exceeded the l)attle-casualty rate. At the same

time, l)attle casualties were diminishing, so the increase was more relative

than absolute. The low medical rate had not b)een anticipated and may have

beeni dtie to several factors, to be discussed later.

The quality of medical care varied in proportion to the devotion to duty

and professional qualifications of the medical staff. In certain instances, the

professional qualifications of the medical officer assigned ha.(d been below a reasonable standard or the organization of tile service had been dieficient. In most

instances, the inmedical care was from good to excellehlt.

An advance unit of the 14th i lMedical Laboratory consisting of 3 officers

an(d 8 eldisted tcchiii('ians was landed on l-plus-8-day and was in operation

on i-plus-21-day. Owing to limitations on tonnage allowance, a relatively

small amount of equipmllt couhl be brought in. This unit perform,'d valuable service ill support of the field hospitals in the accumulation of factual

data on diseases prevalemit among ttlie natives. Of especial value was tile
too,,

I o .i I; 1 2 :; 1. 1 1 1 t I I T I I I I I

T lw 11iliol. In, I I w ri ir fiý,Iit i I I I )I I It )k ii.i I if i--,. 2ý; i lo, I I It 76)

I'll.\ 1 . :1114 1 1114 1 1 Ito I I ill In I I I it- A I-f II.\ . V I ;I I 1, 1:11 1 Iv

ITI, Thr I-o'll ArIll 11141 Nkrillo \\crv .1611111

killcd .111d 7.11,11 1:11\4.11 Of

Ihi, 11111111w r. .111 hoillo

CN-11:111i.- ill O w P :Icilir 1,,-- 111:111 :IrIII;III\ I\iII--II I,\-

Ilml IIw Illil't [I;]\(. (AII111"AMIMI alynni111cir

T II;I1 Illi- \\;I- rfIIIIIII(M Illo I'X id i-Ilf-od 1, Ill,

-111:111 IIIIIIIII(T IlIllid "ll :111.\ \\ 114-1-c m l I h o i'l.In d 11111*111,, 1

floppillu-111) iml, (-:Ipoldo ill' 11:11ldlill-,

4m Il -rd c\IT

N h w c III;IIj )ANN) ;III'l IlIt" I. 4,1)11

4.1 ;jII(l " Illor I

11141-11. 41\1T 1AMI) Jilk
CENTRAL PACIFIC AREA 667

Prisoners wereŽ eXamilledl at the 18thI Medlical Genieral Laboratory. The resuilts wvere of somle mIedIical int erest.

'M icrofilarille, either liiwchreria balIC11fti or 11'. mnalayi, were found in the

blood or W percent of the 4,563 Prisoners e xamlined.

Th'lree hun11dred sixt *%-ivof thlese pi)Psoners were examiined b),y the rectal

SWal) techniiquie, and 67 (1 S.35 percent) were founid to be harb1-oring" palitogreils

of the genus, S/i iella. One( in(Iividuual was at typ)hoid carrier. Aboutt 90 percent of' theit stools showed1 onle or miore Illetatzoltn parlasites.

H[ookwormi was thle most commjionl lieluininth found; others incluided Strmiq?/-

/o~idv-x, Ascaris, and1 Tr/ichai/is. Amuom'g the protozoal found in this first group

or stools were E~itmoeba ldstohyfica, E. clij, E'idoliraxe uiaa anml Lvmvpora

10homi ix.

CLINICAL ASPECTS OF THlE WAR

It is not the purlpose of this birief hlistory, to give dletails of thle Various disea2SeIs S(eenil l tilie iosp~it ~uls thlroughlouit tile C en tral Pacific. Sulch (descript ions

atild statist ics will be founid in ot her voliiiiies of thle official his-tory of thfe M\edical Depar-tient in World Wall 11. It shoidld be of somue interest, however,

to (lisculss liriefl * somle of hie]), esjpecially the exotic (liseaises, ats they were observed in Army hoslpitils.

Plague in the Hawaiian Islands

Mplage lils lbeen endlemic in thle Hatwaiian Islands since December 1899.

The first reported case oceurre(1 in Honolulu11, Oalui1, following which the diseatse lippeatre liat tilie priiicijpall ports, of Hawaii, Kiauai, and 'Maui islands wvithin the next .5 miont hs. No evidence of plaguie in rodlent or umall lilts been rep~orted Onl Oahu1 sinice 1910 nor Onl Kauai since 1906. It hals remained endemuic

onl tilie islands of Malaui anld Hatwaii, ats evidenced byhrluinlaia and rodent illfection, which at present, so fail ats is known, is restrictedl onl each island to a

small,1 focal areat. An increasedl number of cases, of plaguie in rodents andhua

lbeiui(s occurred in thle H1amatkua District of the island of Hawaii, during the

\rear 194:3. Following this sniall ouitbreatk, verY strentuous rat control mleatsures

were Cairriedl out in each of thle end(emic plaguie areas, and these mealsures were

of suifficienit t horoglin.11ess to prevent any spread of plague to militatry personnel

(hiring the wvall in the Pacific.

Infectious Hepatitis

Under thle terms ''infectious hepattitis'' or ''acute cattarrlial jaunidice''

are included those cases of jallndice of minknown cauisattionl-oftenl epidlenlic

ill appealranlce bhut also occasionially ob~servedh following the administration of

yellow fever vaccinie, or following tranlsfiusionl with ty1pe () 1)100( or less oftenl

with1 unittched bl100( of (different grouips, or following tile administration of

p~ooled phslasma. , he first patients wvith iaciute infectiouls hiepat it is following Vacecinlat ion

againlst yellow fever hegazi to arrive Onl transports docking ait Oathu betweenl
668 ACTIVITIES oF 3mEDcAL cO)NsuurTNTS

10 aiid 16 'March 1942. Numerous illvest igat iolns were mlade, especially ill

tithe effort to differentiate tile (disease fromi W~eils (lisease, b~efore it b~ecamie

apparenit that there wats at Causal relation b~etweeni a1clte lielpatic disease uiid tihe

Teewer~e severad hundlredl pat ients with Ii 105vacciiial hiepatitis in liospit als in the( Pacific Ocean Area, with one deathI recorded. The average inlclilbatioui periodl followving vaccination wats ab~out 100 days but varied betweeii

'10 and 120 (lavs.

Small epidlemics of infectious hiepatitis followedl nearly every assault by am1)l1ibiol~ls forces Onl thle islanlds oft the Cellnt i'uiI Pacific or South1 Pacific Areas. The

iiiculiatioll period1 of these epidlemics was not (lefiiiitelv *(l etermined. As a, rule,

however, patienits with tilte dhisease were first ob~served ab~out 3 weeks after the

assaul1t. It is, thlerefore, apparentt t hat the jiiwubat iont period of the (disease

acqIuir'ed (hliritur assaults onl coral islatidls wits short comp~aredl with tilte in-

(u1) t ionl Period in cases following vaccinat ion aga inst yellow fever. 'Mlalaise,

wealkness, and anorexia, were thle usuial svnilltonis, bult when questionedl many

of thle pat iints gave a history of fever, diarrhea, anld loss of appetite ab~out froml

10d (lavs to 2 weeks before the( appearanice of jaundiice. Fliese symptomis usually

subs'ided b)efore the onset of jaundice, and, apparently, in some patients no overt.

jaund~ice ever appeared.

A mnuiiier of simall epidemics of ja undlice were studi~iedi withI considlerable

Care, from ant~il epiniologic point of view withlouit any (lecisive results. Neit her

thle exact vector nor tilie re(servoir of the disease in the Pacific atrea wats (determillned with certainty. The ev)ide iliologic evidIence wouild seenm to favor tilie

b~elief that liealtiliv carriers- were resp~onsible for tlie( spread of the dlisease during

periodls Nwhn sanitation wats tit at teimplorarily low ebb, as immediately after ain

aissauilt onl tin island.

Durinig thle late spring of 194.5. at supply of immune serum (gamnima) gglobuliii wats iuia1le available to thle ( en t ral P~acific for uise as5 a prophlylact ic ill at

threa tened epidemic of alcute hepatitis. This, Was not used, however, since

troop)s wvho were hiospit alized wvithI thle (disease onl Okinawa had been thlrouigh

lhe campaign Onl Leyte, Where jaunli('ie wats p~revalent , and1( it seeimedl probable

that thlese troops by thle tinie t hey reached Okinawa were too far along in the

iiicuibat ionl period to warrant thle uise of gniaglobullin as at prophylactic

meiasure.

The incidence of acuite hepatitis following t ransfuision of type 0 blood

('li ot be (let ermiined accu ratecly from ti( dl(ht a obtained in tilie Pacific areal.

The problem is (lifliclilt from at statistical st auudpouint owving- to tihe priesence( of

atli epatit is invrosma-P 11oi rops inl comiiat, who alre also tilie

sami e t roops aim01 A0ong wh 1 m bt tle (casulal ties requirii i t rnsluision occurI.

Aiiot her (difficult y is tlie( lonig incublat ion period followinig tilie causall transfusion.

Ill til lie orml-1 chainl of' evaculationl, tlie( imma1jori t ,v of' im hividuaills, who wotuld

(develop hIloll ologouos serum jailndice would~ be either in at continent al Unlit ('(

S tates hiospitaml or Would Iliiie ret urnedl to (lit v in tlie( Pacific area b~ef ore svlmp0toms becanme maimifest. withi, tilie newer- knowledge of thle dilplialsic symp~toill-
CENTRAL PA('IF•C AREA 669

atology of the disease and of the significant (lifference in the length of the

inculbation period between epidemic hepatitis and homologous serum hepatitis,

it eventually became possible to collect more accurate and significant data.

Diphtheria

Diphtheria was contracted by personnel of the 27th Infantry Division on

Saipan in the Marianas. A few cases appeared about the middle of August

1944. These patients were hospitalized locally. T he division left Saipan thie

lat t ,r part of August and arrived in Espiritu Santo in the New Hebrides on 14

September 1944. While en route, a few more cases of pharyngeal diphtheria

an(I an increiising number of skin lesions, most of which were ulcerative and

located on the extremities, appeared among tile personnel.

In the 27th Infantry Division, the following cases of diphtheria were reported: Pharyngeal, 77 cases; cutaneous, 95 cases; carriers, 9 cases. In the

same division, it was observed that as patients with cutaneous diphtheria

were isolated the number of patients with naso)liaryngeal diplhtheria (lecreased

pari passu. In the month of Novemtber 1944, only three (cases of nasopharyngeal diphtheria were reported from this division. From 25 August to 25 Noveniber 1944, pharyngeal diphtheria occurred among personnel of other organizations on Saipan, the number of cases mounting most ral)idly during the first

month of this period. Diphtheria in Army personnel remaining on Saipan after

the depart ure of the 27th Infantry Division was reported as follows: Pharyngeal,

73 cases; cutaneous, 3 cases; and carriers, 6 (ases ul) to 25 November 1944.

Cutaneous lesions giving positive (ultures for diplhtheria among personnel

of the 27th Division were practically ,ill ulcerative. This lesion, of the type

described as tropical ulcer, was of varying (liameters from about a quarter of a

centimeter to several centimeters, the average diameter being I (-m. Lesions

were frequently multiple. Cutaneous ulcers were often rounded and punched

out in appearance, were surrounded l)y a zone of dull red or bronze pignientation, and had indurated, rolled margins. They were usually superficial. The

appearance of the lesion was not uniform or characteristic enough to enable

identification without the aid of laboratory study. The lesions were crusted

over or covered by a serofibrinous exudate. There was usually a thin diphtheritic membrane in the b)ase of the ulcer. There was usually no systemic

reaction, and the only symptoms noted by the patient were those caused by the

discomfort of the skin lesion.

The nasopharyngeal diphitheria was usually typi'cal and easy to detect.

In most. cases, it, was undoubtediy contracted from patients with cutaneous

diphitheria. As a matter of fact, in all theaters in the Pacific area, cutaneous

diphtheria occurred among the troops and especially among the natives, anid

it was believed that it was from patients with these lesions that the spread

of diphtheria most. frequently occurred in the Pa('ific Ocean Area. In a number

of instances, evidence of peripheral neuritis with weakness and paralysis of

the legs, the arms, and often of the palate and the pharynx as well as of the

nasopharynx was observed in patients in whom there was no fautcial diphtheria
II ~ ~ ~ ~ ~ IT ~ ~ A i ~ii I ~-' M Ij Ai it \~'Iii'\~ 'i 11

t l\\ lI xi \Ici I1II f I ll, I'll lplilht I -\ ill l- I ;I ( l izl'-.1. 1 11411d w

hi h L I jll11 -I11111 111, t I polr i ti hi ItI' hu? -It I itl il' I ll t f ill-'
CENTRAL PACIFIC AREA 671

Thle early symptomis were varied in characteýr. Tile most frequent were

headache andl chills, aini fever of tithe relil itt ent type withI nightly elevations.

Abdominal pains and mild dliarrhiea were tilie miost common -li1 gst roititest inal

comiplaints. Skint lesions in thle form of urwticaria a 1ppeared early iii ablout,

50 percent of thle cases; a few patients eveni recalled burniiig and tingling sensations in the skin shortly after having- enmergedl front the water of t ile streall

oil thle islandl of IA'vte. Thiese symptomts1 were prolbaIly causedl by penetrat ion of thle skin lv tilie cercariae of S. japimicun..

I'll ora t oirv st udies revealedl that the( white blood( count ranged] front

7,500 to 18,500, t ie( average being ab~out 13,000 per eni. min. There was a

marked eosinopliilia of thle circul Iating blood( in aill patients ranging fromt 261

p~ercent to 78 percent, thle averagre being about 48 percent. Thte sedlimntetat ion

ralte was elevatedl in all cases. 'Most of these patients lhad stools p~ositive

for tile ova of S. *japol icul. while t hey weN-re observ~ed on thle island of Levte,

but only a. few p~at ients had posit ive stools after they had arrived iii thle Cemntral Pacific Area.

Therapy consisted of intranmuscular inject ions of Fuadin. Following

this treatmitenti, tilie white blood( count. an(I seduimentat ion rate ret urnedl to nornial1 thle eosinlophils in thle 1)100( dlecreased miarkedly, ao1 d the stools became

negative. A numb er of patienits were seeii withI gastroinitest ina~l dlistress.

eiilargeiieiit of tilie liver, and jaundice; an(1 a. few were seen withI marked

evidlence of involvement, of tihe cemitral nervouis system.

Venereal Diseases

The venereal (lisease prolblemn in the Hawaiian Islands andl the CPA was

of contsidIerab~le imiportance, and strenuous efforts were ina(Ie to eradicate these

dliseases by all tilie means developed during the past years. Ini general, these

niethods consist ed of suppression of clandest ine ani( overt prostitution by

(-losing all houses of prost ituition, byv edlucation find ind~ividual lpropilylaxis,

by tracing of procurers and( contacts, by examiination of contacts, and by

reporting andl treating all individuals infected wvith iVeiiereal (disease.

Ili 1911, thle venereal (disease rate per 1,000 per annuni was 175.3; in

1941, 14.1 ; in 1942, 9.6; in 194:3, 4.2; iii 1944, 7.3; and in 1945 (in comlplete),

7.1. These rates should be correlatedl withI the numb er of Army11 troops onl

lie island of Oahu11 at anly (givell t imue. Ini November 1941 , there were :39,000

troop~s; in fiullv 1944, 162,000 trcoops; 1111( in .July 1945, 1 44,000) trmoops.

Manyit of thlese soldliers were t rainedl onl Oaliu imi( mnoved1 oil to be rep~laced

byv new t roop)s. Th'le population of I lonolu1lu wats increaisedl by large numnbiers

of N aval lpersonnel, ma211Ynyiii e civiliani warwork-ers, iimd relait ively few eleititle

warwor~kers. Iin a short timie, the number of miiales greatly outnumbered thle,

females. Under such circumnstainces, with riielativel * few womiien in thle ancient

professioni, it is probable t hat tilie niumber of exp~osures remaitinedl about constant

but tilie numiber of exp)osures per thlousaind troops dlecreaisedl and tilie Veniereal

(hiseulse rit e p.er thlousaind troops puer year nautira~lly dlecreasedl. Study of
672 A('TVITIES OF MEI)ICAL (AI NSVITANTS

clitacts in tile early parit of 1942 shiowed I lit 75 Ipercnt of an1 venerea (liseae

hin military lpersoniiel were cont racted fromi p)rofessional p)rostitutiies. rlhus,

tie (decrease ill thle veniereal disease rate &was it relative phleniomienion, asCril -

aide to at lower exposuire index per miilit ary person, althloughi the exposure rate

per' prostitute liliay act ually hiave increased. The actunal number of patijents

withI venereal (hisease inl tilie hiospitals renmained nearly constant.

Eventuially, tilie t reatm;ent of venereal disease becai me tilie responlsibility

of thle chiet or the medical service in all midlit ary hiospit als, and, withi thle inll'odluction of penicillin, treatilent followed tile general pattern observed in

aill other theater's of tile wail..

In the M Iariana Islands, syphilis was nrai' amiong mnilit ary personniel, althloughi a high p~ercent age of tilie civilian p)opullat ion gave it positive reaction to

st and ard( tests for syphilis. Segrega tion satisfactorily preventedl thle sp~readi

of this disease to mnilit ary t roopjs. INcdEd in thle survey onl thle island of

Saipan were 27 native femiale hospital patients, 6 Jipes itet prsi n

14 members of thle civilian police force of C amp 'Sucupe. When it, wats found

that at large 11mm h1er of tilie native adlult-, gave at positive serologic react ion for

syphlilis, 42 children between the ages of 5 anl I I were exalninedl in anl attempt

to ascertain whet her thlese positive react ions were p~rodulcedl by Yaws. Scars

resembIling. tilie healed lesions of yaws were observed in five aduilts. All of

tiese p~at ients gave p)osit ive react ions for syphilis. hleiiled lesions, typlical of

yaws, were found in two of thle chiilthin. BothI gave p)osit ive serologic react ions

for syphili's. TPhe iflajorityv of those AInclded in the survey were ~Japainese

civilianls. Also includled were 15 ( 'laiioirroiin iiiale adults5 aind I I Korean

adu ilts. Of thle 42 chlidren exiininedl, 21 were ('aii iorronis, andl 21 Japanese.

All blood samplles were sent to then1t ISM Medical General Laboratory, where

they wvere examiunedl by tilie Standard Kahn precipitatiiion test. Out, of at total

of 296 1)100( specillins, 5 were found to lhe unsatisfactory for examination. of

lie remiaindler, 49.8 percent were p)osit ive ; 1.3 percent, dhoub~tfuil; and 48.9

percent. negative. It is therefore appairenlt that, syphilis is very p~revalent, in

tlie natives inl the centrail P~acific islands. However, since healed yaws mlay

be followed by positive ser~ologic tests for syphilis, this fact, miust l)C considered

in the results of suirvyvs wvhere yaiws is endenmic.

Murine Typhuis in the Hawaiian Islands

Muiritie typhius hizs never been at serious problemi in thle H~awaiian Islands.

Sporadic caises haive cont inued to occur but never in large nunmbers. During

lie 6 vear's front 1937 to 1942, inclnsive, thle incidence of endemic typhus inl

hie civiliain iilid miilitairy p)opuilaitioni inl the H aiwaiiian Islandhs wats :37, 69, 59,

72, 81, and 78 caises, respectively. Trhe nmonthlly average wats 5.5 causes for t his

lperiodl. There was at considerable increa'se in tilie num11ber. of cases (diring tilie

wart. Alt hough au breakdown of data for thle H awaiiian Islands Only is nlot

available, for thle (T'nt ral antil Sout h Pacific Areas- t here were 65 cases of inurine

typhus rep~ort ed in 1943 and1( 35 cases report ed in 1944.
C'ENTRIAL PACIFIC ARIEA 6 73

Amiong U.S. Army personnel, ait, least one calse of epidemtic typ)hus wals

known to have occurred in H awaii duin-hg World Wait 11. This se Wats reported by thle 75th Station H ospit al, Schofield Barracks, in June 1943.

Japanese B Encephialitis on OkinawaI

The first caise of Japanese B ellceplitilit is was seen amnong the Okinaivan

naitives oti 10( .Juilv 1945, and upl to 26 ~Julv 1945 albout 68 pattients hald been

olbserve(l. Of these, thIree were U7.S. soldIiers. There were probalbly iiiali

More ca1ses a inonlg thle na1tives eniding in dealith or recovery without being referred

to Milit ary Giovernmnent Ilospitads. It is probatble thatt more than 100 caises

liall occurred. lihe majority of thIe patients were under 12 years of age. I'he

youlng were equally dlividIed b~etweenl tihe sexes, buIt (t(e few oldIer indIividuals

Were practically allI femalles. Most of tile paltients, originatilted in the north and

ealst. endl of tilie ishrli1(l. Iwo were miembiers of tilie samne falmilv. A Ia rge

nlumbier caiiie fronit 11eanaia Slihimn and [lonmi ai ka Sliniina. These islarinds alre

reasonably isolated, aind but, little mingling withI other Okinaiwans haid

occ'urredl.

No evidence wats ob~tainedl thlat gaive any, c-lue( to the length of the incilmation periodl. A soldIier b)einhg tr1eattedl for aitelije d1ysenit ery Ii it milit ary hospital

dleveloped at sore thIroat andl w~ithini 36 hours showed evidienc'e of encephllit is.

Tw Okinilalvas, who were sist ers, developedh thle disease- 1)Iie approxunialtely

at week afther tire first one aiffected haid diedl. There is t bius at lit tle evidence that.

tile inculiat ion Period is short: 1)ehrim)s il)out at week and prob~ably less than

9 (bly5.

A large number of thle paitients were seen later in the course of the illness,

aind linguistic dlifficult ies niriole exaci let, derniiinatiion of tile eairl *y symptoms an1d

hie (la1te of onset olifficuilt. Most, patients wvere not ob~served luntil after the

fifth daly.

It wats notedI thbut imany of thle vouing patients hadl( at col1( with sniffling aflnl

sonic cough onl adlmission to tilie hospittil; sonie, however, did not,. The usual

history wits thalt tile patit ent 1iuid been ill wvit It at headatche andl fever for about 5

darys.'hlMany pattients gao lve it bitr fiaiiyt peak. A number

of the younger paitients had convulsions and dlrowsiness, aind many11' gave it

history of twit ching niovemuents of one limib or of thle limibs on one side.

M\ost had const ipaltion, but at few hlud (luiri'lcal.

Most of tire paitients were (hrows~v anid letlmrrgic, and their facial appearance

resemblledl t hat seen in thre 1018 epidemric of von Econonno's (liseaise (fig. 236).

The face wats fla~t, ironedi ouit, andl expressioniless; andl the paitienit wats asleep

becauuuse lie ('0111(111 t remliat i imi~~ke. Ocularii svii Jptolnis Avere friequent, especially%

conjugamte dvvii t ionl of tile eves. occa-Isioallyll\ ptoSiS, an1d oft enr nv\st agn ujs.

TIme pupils were (hilatedh or sirirrhI l idi~ often unrequidu. Facial weAkniess onl one

sidle or tile ot her wats frequent. Flaccvid or spaistic ptinra'ysis of' a sinigle limrb or

of heiniiiplegic type wats frequent. Coarse jerking of at hriiI( or at foot or coairsse

3 P'ersonalI otbservat Iions 1(14' bttw(4f 10 -1111y 1945and 31 .July 1915 a Ok inawa~ by the' auithor.

5649(70k 61i -45
'i(1I ui: 236 Nai ive ch~ild V.i Iit1 vIticvpjkl aiti- ( )iwma,~ Jl.\ 19 15.

tremior of, aII 'XEt'ivitiit ,v Nva, of teii seeii. St iffness of t Ille iick w~as liatial

.ilwa vs oblsvirvetl vailvl ill thle cliiiie-al couirse. Trisiiiis was ver-Y lretfiliciit

andl it Is of, initecrest tlha t ft(li diseas ~erizdi na 11s go fjz eiE

who werv tIl bug1 it to hav tetIEanuiis. n ie reflexes were tsualy(itii rI ýt I.

Thie Ilabln ki signi was11 1uisuali p~ositIive oil one or bothI sid es. Ankle don us

wa;s f'requcint. The kliev jerks aind anikle jerks wVere 11smit iseqlt, ) ()I .x.Irgrerat ed and1( thlus of' lit t It (iagmiost ic im portanice. lvecer-ebrat e tYpe of' rIg-idt lt

Was. OCC.asioiiallY Seeni. Onev pat ieilt relmiiaimed ill thle jposit ionl of' d ecere Iwate

rI-gitlit v with fr-equiemit conivuilsive lmiovemiicmts of' thle right1 leg~. and an. 'lThe

sensrmum waIs usuall1y clouldy, but .1ll except I hose who were Imiorilumild could

be' ar1olisetl. ''l'he feverI wa~s usuallyv high, 102' to 1 04' F., amit becamiie lower

Witlhi impilrovemienit. Tliv liellrol()gical abmiormua1.lit ies wvere change1"able f'roiti

da v to dav. 1)eepemiing of' conia andi increase of' pulse rate amid4 tt'iiijn-turatlit

WCrcV gralVe si gus. lxI Akocvte c'ounlts anid uirIIlie anlaly-ts Wt're 1usually1 nitt

miiatlev. Thierie wa-;l (ous altIvaleocYt t)is of* thle cerebroslbilial flumid w\it li a

low iiminibt'r of, granuilocvtv's. The total white cell cotuint was bet wecil Wt

'tInd 200) i I li ft' cer'brospinal fliild.

The duira ttni of, 111 i' lsenst' was not ac('uiratv t'v kiiowni buit was' prtilabl y

fmoiii 1t0 to 21 la ,vs. No itlca couild be' ftr-iult'd of, 1 ossilble 5eqjuitlne at tI~w

timimt' oft Ilise obseivatilolls.

A c~ ast' liistori's ma1,Y be' of* hittrest.

C'ase I.-Nialt', age 7 1years. I Ieaiat'lte and fever betgan itI .iilv 1915. Pat jerit adtInitteti to) Iit-;uial foll 19 hJil ty 1915. Ile dveviloped cutmvid-i'os andi jinailit v to -luak.

Ii is tetuiperatur \ilt wa 101 ' F., tiut Ill. \\as Theiat-e 'l' iat andt t'- dvttiaittd t4 111vli

right.. The li-ft aliiii :111d l,41 leg Werev ill p:1irtial tlcimjti. 'lit cftri hnt'piiiat thlidi 'tiiaiitttl
CENTRAL PACIFI(C AREA 6(75

two lymphocytes. Patient died on 22 July 1945. Autopsy showed many new and old

petechial hemorrhages, especially numerous in the vicinity of the basal ganglia. There

were small areas of apparent necrosis in the left globus pallidus.

Case 2.--Female, age 7 years. Onset of the disease was on 15 July 1945 with headache,

fever, drowsiness, and twitching movements of the extremities. The patient had been unable

to speak for 3 days. The neck was stiff. Temperature was 1020 F. The patient was

comatose and in decerebrate rigidity. The cerebrospinal fluid contained 17 cells, of which

3 were polymorphonuclears. The patient died. Autopsy showed congestion of the pial

vessels. No petechiae were seen in the brain.

Case 3.-Male, age 12 years. About 1 July 1945, the movements of the arms and legs

seemed awkward. The next day, the patient could not urinate but had paradoxical incontinence. On 4 July 1945, his temperature was 1040 F. He complained of a headache.

The neck was stiff, there was opisthotonos, and the patient was practically comatose. On

6 July 1945, his temperature was 104' F. There was marked trismus. The tendon reflexes

were hyperactive. There was a positive Kernig sign with flaccid paralysis of the extremities.

The cerebrospinal fluid contained 84 lymphocytes. The leukocyte count in the blood was

3,200 per cu. mm. On 10 July 1945, the patient was markedly improved.

Case 4.--Female, age 49 years. On 5 July 1945, patient had a headache and a high

fever; soon she became apathetic and unable to speak. On 7 July 1945, her temperature

was 1050 F., and her pulse was 100. She was lethargic; her eye movements were normal;

there was marked trismus and stiffness of the neck. The extremities were spastic, and

the tendon reflexes were hyperactive. There were athetoid movements of the hands. The

Babinski sign was positive on the right. The cerebrospinal fluid contained 20 cells, all of

which were mononuclears. The white blood count was 6,400. On 11 July 1945, the patient

was very markedly improved.

Case 5.--Female, age 24 years. This patient became ill on 7 July 19W5 with headache,

fever, and dizziness. She was dull and unresponsive. On 18 July 1945, she was semistuporous, responded slowly, and was unable to speak. There were coarse tremors of the

facial muscles, especially on the right. There was pain on passive movement of the extremities. There was marked flaccid weakness of both arms with rigidity of the legs.

The facies was masklike. On 13 July 1945, the cerebrospinal fluid contained 26 cells.

On 20 July 1945, the patient died. At autopsy, the brain was markedly edematous with

congestion of the pial vessels ovwr the entire cortical surfaces.

Between the appearance on 10 July 1945 of the first case of the disease on

the island of Okinawa and up to 26 July 1945, there were 68 cases of encephalitis

of unknown causation-65 in civilians, 3 in military personnel. The mortality

was about 30 percent, with no fatalities in soldiers. The onset was acute, and

the incubation period was probably less than 9 days. The clinical findings

pointed to widespread disseminated lesions in the cortex, subcortical areas,

corpora striata, midbrain, and probably occasionally in the cord. The clinical

course suggested that there should be widespread perivascular lesions without.

demyelination and with severe but transient injury of the motor ganglion cells

of the brain.

The Military Government Hospital on Okinawa at the city of Taira was

visited by Colonel Mason, on 27 July 1945. In the previous 3 days, seven

patients had been admitted to this hospital. All of these were examined, and

each had symptoms suggesting Japanese B encephalitis. All were between 5

and 18 years of age. One had left hcmiparesis. One had atbetoid movements
6;7G ACTIvITIEs O F MED IC'AL CO NSILTANT1S

of, thle hands~l. One hald right racial pails~y. One lhad convergent sqjuint . All

WvI'e (Irowsv a ndl had( litic(la rigili ty Al cou pai tied of utah tise an 11( hadache.

All had fev:er. One( had 200) (relk ill tilie cerebIro.spi 11ad fluid. All of thlese patients hald tlie( t V jicad irotie(I-Oit . expressionless facdeS. All hald (list urbances of

lie t (11(101 reflexes, an 11 alch had( untliait eral or lbilat eral posi t ive Babintski signs.

All were natives of Okiunawa.

Three soldiers withI headachle, increased cellulair conitent of thle cerebrospinail fluid, rever. and soutie scat tered lneurological lesionls Were admuit ted to thle

,Std Ii Field Hospi)1tail. All lprolbab'N bhv hd cases of mnild .Japa nese B1 enceephallitis.

At N A I RI. (Naival M edical Research Unit) No. 2 onl (maina, tlie( brains

of at numituar of t ie( lpat ients froni Okmiutwai who had died of Japanese 1B etceplhatlit is Were examiii uedh. Tle v showed scat tered rou nd cell inufiltIrat ion ill the

Vi rclow-Robi ii spa ce. Are as of' degentera tion of' tlie( cortex antd mid bra in with

in tan niera ibe Alnaill Ilacu int ili the affected area were rountd. These areas were

riilpidlly inafilt rated by gliai cells i~id bly ast rocNvtes. The Biet evicels wvere (lauaage(l

but niot severelyv. The mi ost iiiarked1 ch ailg'es w(ere Seela ill t Itie cerebellumi. , ll

aiddit ion to t ie( lacuai rm ty-pe of deg.enerat ion there was comptllete cytolysis of

utaauY Piri tajeni cells. There wits onlyv a, little devnavelina tionl anld that only near

areas of cel dllr(egeniera tiota ill thle 'er'ebral gray mai ttIer.

A summainirv ats of' 25 Augrust 1945 was contitained ili a lpersontal letter front

Maj . Wilbur G. D~owns, MC ( , act iuig chief of' Prevent ive' Medicine Service,

Okinawa . lie stated& ''Tere have beeni I8 probiable inistances of tilie liSealSe Onl

Okinawa unnotg troops with~ 2 deaths aml 6~ svispeuted or probable examples

WithI no dea tils. All of t lhe probable t roop cases have comae t hits far front nort hIerta Okin a wai. There have beena possibly* 120 exam~ples of' thle dlisease illnatia i es

upl to this datte. All of' the patienits seen revenditly have originated inl northern

O ki nawa aund It( leFocus ait Nodaike inl tlie( sou thI has been quiet. The niort alit 'v

rit e ill natives has beeni 2.5 to :110 percenlt . We do not know any mnore about

sudlwltical intf ect ions thanl previoulslY and it is still thioughit that man11Y niative

patients wh-)o h avye tlie( disease arue nlever seen nior observed bY phYsiCia u1s.'

The viruis was isolate ei t a a put thIirough several passages inl titeie lit tilie

NAMMIl{ laboratory, . It was isolated From tilie braini auin spitial fluid of' onle

pat ient only, bitt wa-Is not isolated frotia tilie blood(.

Thle ('0111 plenent -f ixat tion teists Oi o ettea I'muta1 pat ients d urinig the( aicute and

(conlvalescenat phase of tlie( disealse were strongly positive for Japanese 11

('tic('jhialit is.

The( vi rus isolat ed hais been (let ermne t 1)i lwnieans v( of viruis ne(ut ralizat ion

stutdies to be identit cal With ti lie Nagasaki straini of JTapanese 1B encephialit is.

This is tlie st raini frouii whichi thle vaccinie was priepatredl.

Searcihi For i uisect vectors was cairriedl onl for muan iv weeks wvithI negat i ve

results. Seate rcilor antimnal hosts and reservoirs was likewise unasuccessful.

Ak large tittnber of liealt li v natives Were bled ill order to determiniue tilie

aittioluit of itmialtnue body ill ti( bleod10(1 itt tlie( 1101)v of' t liiowiig 5oiie light Onl the

endenuic and epideniic sit uat iotaiii Okitiawa. This wvork was- tiot com pleted ait

thle ('11( of host ilities.
ill Jo nh-l fv~~i il~lil o -4I4 .1ti.j Els I Iaal4.4 l\Ill44I' 14I414 it

I m .Iip llr ~I :14 ' )1 it (wle -.- Illee 4''-1):1 4:Is cl I Il'4-4 lcr W.\ l d ne Iifft 1. 11 Il 4- l i~-t

h 14 i ' II 41 ~4 dI )4c' blat I I11 I ()kI im1 \\ I 4 As pa tel 4I~ I144 v, s2t I he' rc I or 412. q11 I h

I[4I4i -;t i I Ia I444\4 i ( \ )k ii h t iawa I, note tiilv. I Iit he'l oiI .1 o 1 d i lie 41--a

ill n'II eni141i444 :411(1iwr Iit ' 1f. w44J114' 1111111111v4 ilt :1 41-c c lolrI .1i141I:411 P1441)11 I1\4

4111 4;I I 1 4411 441l -rf1..I. 41 Iii ': I" Ii 414 1 '111i4I if4ll iil I' -;:I . 1 Ito4

141'% '1 I111 14'i \if II I jI n w( .4'II. 41 V 4'11 11' 141IIIII 1 14 1 1 111 1 11 i. nJi44i'4 I I I le-

;'i'l1'1 1, 1

i'l'4I 144 1 1 41i j11 -o14 is I1'~~I44 I 44114 I II~'i.4 I' I111 14''414

hi~~~~iv- 1'4 41'4 4 1 I4i1i ' 1 i 4 fil IlIti I -,4111' I I '41 Ii , I~' I 44 it 111 -)''~4 ( ) 

Ill4 "Ch 441 :1 ii:1 1 n illll_ ho141 rv114 Ii 4\', m14:4 iddv pot4':141 44! 4114 hrlll\ ~ IiA.ii 
678 ACTIVITIES OF MEDICAL CONSULTANTS

Coccidioidomycosis

Since large numnbers of troops had been trained in the California-Arizona area

and had been exposed to this disease and since large nunbers hand come through

California and Arizona on the way to Oahu, it is remarkable that during the

war only a very few soldiers transferred to Honolulu were on arrival found

to have acquired coccidioidomycosis. No patient with generalized coccidioidomycosis was hospitalized in tile Central Pacific Area.

Dengue

Descriptions of epidemics of dengue in various parts of the world have

appeared in inedical literature since 1780. The vectors of dengue have b)een

reported from most of the islands in the CPA, and the disease is endemic in

Makin, Tarawa (Gilbert Islands), and the Ellice Islands. An epidemic of

dengue occurred in Honolulu in -July 1943; in 1944, there were two outbreaks,

the first starting in the Gilbert Islands and the second in the Marianas.

Epidemics of dengue in the Central Pacific

On 3 August 1943, the Board of Health of the Territory of Hawaii was

informed concerning three cases in which the diagnosis of dengue was suspected and, in further observations, was confirmed. Several days later,

another physician reported the same diagnosis in three other individuals who

became ill on 2 July 1943. These patients resided or were employed at the

Beach Walk Inn in the Waikiki district. Later, it was ascertained that three

flying personnel of the Pan-American Airlines arriving on Oahu from tle Soutlhw:est Pacific were ill on 4 July 1943 with what was then thought to be influenza.

These three new patients also resided in the Waikiki district. A review of

the case histories by board of health physicians and the attending physicians

resulted in the decision that the diagnosis probably should be dengue. These

cases were the first to be recognized as dengue in tile city of Honolulu and

were responsible for tie introduction of this disease into the Hawaiian Islands.

Whxen this knowledge came to the attention of other physicians, 17 new cases

were reported during the week of 28 July to 4 August 1943. All but two

of these patients lived or were employed in the Waikiki district. This area,

being primarily a resort frequented by transients, provided an ideal source

of dissenlination. By 15 September 1943, the disease wias diagnosed in a

total of 17 servicemen. It is of interest to note that 11 out of the first 14

cases of Navy personnel with dengue were sailors on leave and billeted at

the Royal Hawaiian Hotel in Waikiki. In Honolulu, the Aede.s albopictux

represents 60 percent of the mosquitoes found, ('ulex quinquf.axciatuI represents 36 percent, and A. aegypti represents 4 percent. The overall breeding

index of the city averages 10 percent. The epidemic of 1943 ended with

1,339 civilian and 56 military personnel with dengue reported after the onset

of the outbreak on 30 June 1943. This epidemic was brought under control

by screening of patients, curtailing interisland travel, eradicating mosquitoes

and their breeding places, and (leclaring certain places off linits.
CENTRAL PACIFIC AREA 679

The second epidemic outbreak of dengue occurred during 1944. This

time, the patients were among the military personnel in the CPA and were

evacuated to the hospitals on Oahu. In February 1944, 396 patients with

dengue were admitted to the hospitals on Oahu. The rate among troops

in the CPA for the month was 26.10 per annum per 1,000 average strength.

These patients came front the Gilbert Islands where the outbreak started.

The main artrhropod vectors proved to be A. aegypt% and A. albopictus. On

'Makin Island where dengue is endemic, the only vector detected was A.

r.enegjatus.

Again in July 1944, following the Saipan campaign, another dengue

outbreak occurred resulting in the admission of 774 patients to the hospitals

of the CPA, chiefly on the island of Saipan in the Marianas.

The clinical symptoms amuong the military personnel who had contracted

t he disease in 194"3 resembled the typical clinical features of dengue as it occurs

in garrison troops. The disease was much more severe in the patients seen

in 1944 following the military operations on the Marshall Islands and Saipan.

The onset was sudden with chilly sensations and headache. In the mild

cases, there were several days of vague body aches and malaise. The headache was most severe in the frontal region and was usually associated with

postorbital pain, which was aggravated by lateral deviation of the eyeballs.

Malaise, low back pain, and joint pains were also common complaints. Breakbone pain, which is considered a cardinal symptom of dengue, was not common

in the simaill groups of patients seen in 1943. However, those patients who

were admitted from Saipan and the Marshall Islands complained of having

had this pain in the bones, which in this disease is all but unendurable and

can hardly be exaggerated. The pain behind the eyeballs was much more

severe in this group also. A rash was seen in only a few patients.

Temperature curves varied, with elevations of from 1000 to 1040 F. In

many of the patients seen in 1943, the temperature reached 1010 F. daily and

failed to show the classical saddleback or dromedary curve. Many patients,

treated in the dispensary for several days, had temperatures that had begun

to decline on admission and never showed a secondary rise. In the patients

evacluated from the Marshall Islands and Saipan, the temperature graph in a

sinall percentage resembled the saddleback curve.

Enlargement of the lymph nodes was a striking physical finding. It was

not particularly prominent, early in the disease but. became more apparent

during the later course and often developed very rapidly. The enlarged nodes

seldom exceeded at maximum dimension of 2 cm. by 3 cm. Tenderness was

noticeable on firm pressure.

When there was a rash, it appeared suddenly and involved a definite area

of the body. The rash consisted of bright pink-colored macules, about 3 n11.

in diameter, which faded on pressure. Maculopapules were occasionally

observed, most often in the skin of the Negro patients. The eruption was discrete, the lesions did not coalesce and did not tend to form pat terns. The rash

was distributed evenly over the neck, thorax, upper abdomen, and arms. It
680 ACTIVITIES O1F MNEIICAL CONSULTANTS

persistedI tiflichmigedl for atbout 24 liours after defervescence, then falded rajliilly.

The white bl100( cotint ats at rulle vrieit(l betweeni :3,000 and 5,000 cells per

cuibic inillinieter. Monoc10ytes were present uip to fronm 4 to 6 p~ercent, and

miany irritation cells and ininat tire forms of nieutrophijis appeared.

Control of dengue on Saipan

It is of historic interest to show what methods wvere employed in the

eradicat ionl of Vectors of (elengue onl tilie islandl of Salipanl.

Following thle assault onl thins island on 15 June 1944, denigue made its,

atipearaiice amitong thle. troop~s. This wats exp)ected since it was. known thalt

(leliglie existe O'ilo Saipan (lurhing thle ~Ja1)aese occupa tion. The incidenice waislow duiring, thle first weeks, however, probably owving to tile fact thait the rainy:

seItisoli had1( not yet b~egmi and that. mosquitoes, alt hiugh presenit inl tilie %i-I

cinity of villaiges, wer'e not found in large numb~ers. By I1I Auigust 1944, inos-

(j nitoes were 111)11i(1111t , aind at denlgue ralte of :300 had been reachled almonig

garrison troop~s andl rap~idlyv miotinted to at rate of approximnately :3,500 by 8

Septemb er 1944. The early rates tire not considleredl enitirely correct-owinig

to lack of trained personnel and of adlequiite relport ing miet ho(Is--ailtare

b~elievedl to lbe below te lie ct intl inicidencve. After 1:3 'Sept embher 1944, accuratte

recordls were ltvalihi be conicerninig tilie inlcidenlce of denigue coverinig aill troops

(Naivyv Armyv attd Malirine Corps) onl the ishind. The recordls show thatt

be(t weent 8 Septeni her 1944 and (6 Octob~er 1944 thle dengue ratte hiad dIropped

from approximately :3,500 to 182.

Mosquito control problems.-At. the tinme of the occuipation of Saipan

onl 15 June 1944, t here wits anl unlbelievalble amiount of rub11ble resul1ting" fronm

the totall (lestrutct ion of scat teredl dwellinigs an1d villalges. A iuiult ittilde of

wells, cisterns, valts, trouighs, andl diverse facilities for the collect ion of rain

water, ats well ats anl inunenise quantity'A of suich itenms ats thims aid shell cases,

p~rovided suiitab~le locaitions for thle breeding of cert itn nuosqifitoes.

Onie plaitooni of the 743d M\edical Sauui- -v Company wits availaible for

satnit attion and mosquiito control. Thme prograliii wa-Is iiiinlelvit ely- begu wit Aid)

hle sprayving of wells anid cisterns withl kerosene midn with tilie removal of'

art ilacial Ibreedling containers in Cliarain Kanomi andl Isley Field. Wells ilild

cisternis were stockedl with small fishi, which fed on niosqtfito larvae. A large

part of the timie spent by this plhatoon had to be expended in flyA control. Wit Ii

lie lbegitmining of the rainly sealsonl, it wats evident tilhat the nuni ber of t raiined

personnel ava ila l~e wvould lbe insufficient for mide(1 uat e conit rol of mosquitoes

by these mlethodhs.

A supply of DDT wits received onl 3 September 1944. Plans were mtade

Unimediat ely to hit rodhice DDT into thle effort to conitrol mosquiitoes onl Sailpan.

No dlatal were avatilable on satisfatctor~ymnethiods of covering -large atreas of gr-olnd

by airplatne sprayinig. The following procedures were accordingly (levised anld

applied. A large quantity of at 5-percent solution of D)DT in kerosene wats

preparedl, and Army and Macine Air Force units were calledl upon to work out

the technical prolblents involved in sprayving large atreas of thle island. Ani
CENTRAL PACIFIC AREA 681

M-10 tank was attached to the underportion of the fuselage of a C-47 airplane

and used without detonators or glass shields as a coml)ination surge tank and

venturi tube. Seven 55-gallon oil barrels were placed on their sides ini the

fuselage, connected in series, and piped through a 1%2-inch pipe to the M-10

tank. A control valve was placed on the line from the fuselage tanks to the

M-10 wing tank, to be opened and closed by a soldier on signal from the pilot.

This arrangement permitted a flight of not less than 20 mimntes carrying over

:300 gallons of insecticide in contrast to a flight of 25 seconds if, its had been

suggested, four M-10 wing tanks were used. The equipment. as described

wits instailled in at C-47 airplane. As more wits learned about the weight and

balance capacity of the airplane, it was found possible to doul)le the amount

of insect wide carried into the air by standing t lie tanks on en! in a cradle, each

tank being equipped with an air vent and each series being attaehied to a 2-inch

pipeline through which the entire series could be filled. By this system, eaich

series of tanks could be reloaded simultaneously from both sides of the airplane

and approximately 45 minutes of spraying time could be accomplished during

each flight. A C-47 airplane so equipped can take off and fly approximately

800 miles without an overload.

During the first, test run on 12 September 1944, made with kerosene

insecticide, the airplane flew at a speed of about 140 miles per hour at an altitude of from 50 to 100 feet, covered a swath estimated at from 75 to 100 feet

wide, and applied somewhat less than 1 quart of insecticide per acre. Apphcation of' DDT insecticide by airplane began on 13 September 1944. Owing to

tei speed of the airplane, the roughness of t he terrain, and the unevenness of the

shomeline of the island, it, wits not considered practical for the pilot to attempt

to follow prearranged markers to identify swaths sprayed or to he sprayed. In

deternining each successive line of flight to prevent overlapping of swaths,

the pilot had to depend upon his ability to recall land markers.

The southern part of the island, desigiiated as Area I, is relatively flat

and consists of about 9,200 acres. It was sprayed by first circling the outer

border a,'id gradually working inward to the center. A total of 7 missions,

on 13 and 14 September 1944, were flown over this area, using 2,000 gallons

of 5 percent DDT in kerosene to cover it. This application was calculated

at less than 1 quart of the mixture per acre for the total acreage, indicating

that swatlis had been too widely separated in some places. Another application was therefore made on 17 and 20 September 1944, requiring 6 missions

and 1,800 gallons of spray and covering the area with a different. flight pattern.

The two applications totaled about 1.65 quarts per acre for the total acreage.

The populated portion of the west side of the island from Charan Kanoa

through Garapan to beyond Tanapag, desigriated as Area II, was sprayed on

15 September 1944 in 3 missions with 900 gallons of spray. A second coverage

of this area was made on 20 and 21 September 1944 in 5 missions with 1,330

gallons of spray. This area, lying along the coast, was sprayed by strip flying at

approximately from 50 to 75 yards apart. A total of about 3,000 acres was

covered with 2,230 gallons of spray, averaging 2.97 quarts.
682 -rIivItrii.:,s 4 w MEDIC(AL COI NSULTANTS

The popuilated'( port ion of the e~i~t0 side of tilie island arounid M iagicleliln(

Bay north to Initi Fahu and including Eatst Field, desigiliat ed ats Area IlI,

Wit' sprayied Oil 16 (" eptember 1944 inl 4 missions with 1 ,370 gallons of spray.N

A second application wats miade onl 22 Sept embher 1944 fin 4 fit issions with 1iI,200)

gallon Tfh~rn 'e totial a1crealge ill t his are~a wits al~proXinlat ely 3,45(1

aceres, and it was Sprayedl withI 2,570 gallons of insect icidle, anl average of 2.98

qularts p er acre.

The total airplane spraying during the period from 13 to 22 Selptemeilr

1944 covered approximately 15,650 aceres withI 8,60(0 gallons of spit ' y for the

two applicationis, averaging albiout 2.2 quiarts per acere, of- 1.1 (I iiart 5 per a lpllicat ioul per atcre. A h('avier app~licat ion of inlsect icile %Its Sp)ra *yedl upllj) Areat

II and Area Ill inl which t here was- the greatter density of trioop~s and ieaivier

miosquito breeding.

Residual spraying.-Aiiother import ant approach to the control of dengute

souight to reduice thle nuuit1ber. of allult m1osquitoes that alternately* hide anld

bite inside building"s anld temilts, sojltitiamong thlese leinig vectors of thle disealse.

This wats (lone by using- DDT ats at residuall Spray: for examlple, at wetting spraty

of DDT solu tion leaving at residue of DDTI ('rys;t is e'ffectivye inl killing mosquitoes-, which miight or- mighgt not lbe Vectors5 of (vleuigue.

Thle Ch~lemical Wartfaire Service t urnied over one of its truck-miounted chemnicall-deconltain 1inait Iionl Jower-spniav units for this work. A sJpecial spry 104)11

equi pped with a1i series of four nlozzles. elicli wit 11 a 60-gaige openling inl t Ilie sprayi

disk, wiis built by the 283d Ordna rce ( ompt jnau. Onl 14 Sept ember 1944,

residul tt spraly! ng wvi th this rig began in aill tenits. inrcludiing quar~ters., wards(l,

offices, anld lat rinies, of thle 148th General I lospi t al. This wats done inl abouti

half the hospitali area 2 days prior. to spray.6ing by alirphlane inl thle sauifie areal

Tile p~roceduire wit-, very effecb(tive, 1111( freedlomt frotil iliosqliitoes inlside all1

spriayed tents "aIs nloted (luring the nlights of 14 and 1.5 Sept ember 1944. After

airpilane sprainvlg Oril 16 September 1944, there wats freedom fromt this annioyance(

both Iout side aluld itisidle tilet tents.

1Foilowving the residtlual spratying of the 148th Genieral Hlospit al, nuiilerouls

ot her umiits, iricllidi(ing tilie 369thI St ationi Hospit al and thle 2d1 M aririe D)ivisioni

Ilositil, eresimilarly piyd

The 176th St at ion IHospital1 moved into their (designat ed area onl 22 Sept ember 1944. This area wats withi bnla edge of the areai of thel 148thI General I lospitai an td litiuu beein sprayed by aiirplane onf 16 Sept ember 1944. Onl 1S Septveinher 1944, af resid util spraHy wats applied to aill tents I lnit were to b~e occupjied by,

the 1 76thI St ationt H ospit al wit hiim the niext fewv days. There wats niot at s-ingle

caise of leniglie inl t his unit durhig thle sticceellirig 21 (Ilay*s, ats conltralsted wvithI

at very,% high incvidlence inl the personnel of thle 148th Genieral H ospital d11-i it

simnii r period of time after they occulpied this airea onl 10 August, 1944, before

sprayi rig.

Surveys of mosquito breeding before and after airplane spraying.-

Eleveni species of mlosqluit oes lire kriowvii to exist onl the islanil of Sai pam, a id thle

lireedinig Iliabits of sontie of thlese nia1de comit tol by nor.1mIal methlolls ext remniely
CEN'1RAIt, A('I FI C AREA (63 )

difficult. Of these, A. aeg?/pti and A. albopictu. have long been known to be

vectors of dengue. Two ad(lditional species, A. pandani and A. re.rans, have

been incrintinateed epideiniologically in the transmission of the disease in this

area. All four of these species were reared from larvae collecte(d in artificial

water containers, such as rain barrels, tin cans, turned-up helmets, and cisterns,

except A. rexans, which is found as larvae in fresh-water ground pools. The

majority of A. albopictus larvae are found in water contained ill rot holes of

trees, annd the larvae of A. pandani occur most frequently in water held by the

parndanus, although they' are often found in artificial water containers as well

as in tree holes. The greatest density of A. aegjypti occurred in the vicinity of

towns. A. albopictus occurre(d most frequently in areas of heavy tree growth,

which was also in the neighborhood of towns. A. vexans was found generally

o-er the entire island but most albundantly in flatlands or poorly drained areas.

A. pandani also occurre(d over much of tihe island, but it was most, frequently

found in tile imniediate vicinity of heavy tropical growth containing pan(lanus.

"M11aximurn albundance of mos,-'itoes about human beings occurred within

the first. hour of (darkness. However, A. aeyypti most frequently attacked man

during early morning or late afternoon hours, often in the deep shade of office

desks and sometimes at night in houses with electric lights of low intensity.

A. albopictus often attacked man in bright sunlight as well as during daylight

periods when tile sun was low. No specimens were ever collected late at night.

A. pandani attacked man at any tinie when the opportunity to suck blood wias

present. A. ve:rans was only seen biting man ati night. From 16 August to 10

September 1if.-, before the first application of DDT-kerosene insecticide was

inaide, it wias possible to collect as many as from 5 to 36 specimens of A. aegypti

from one human being during a single 10-minute period late in the afternoon

alniost anywhere in the vicinity of towns or villages. In addition to these

mosquitoes, from 2 to 16 females of A. albopictus, from 1 to 4 females of A.

rexanr, and sometimes as many as 3 specimens of A. pandani could be collected

during the same period from tile same individuual. Late at night, as many as

26 specimens of C. quinquefasciatus and 16 specimens of C. annulirostris could

be collected during one 10-minute period while biting a single individtual. In

addition, A. rexans and A. pandani were often taken in such night collections.

Between the dates of 5 September 1944 and 11 September 1944, just prior

to airplane spraying which began on 13 September, 6 areas, 200 yards square,

were chosen in various sections of the southern part of tie island as being

representative localities for mosquito breeding. Careful surveys were ma(le

before and after spraying. Some areas were in wartorn towns, where artificial

containers were albundant, others were typical field or woodland breeding places

although such containers as tin cans and shell cases were to be found alnost

everywhere over tile island. When tile surveys were begun, it was impossible

to determine the exact (late upon which spraying would be done. Some of the

areas were, therefore, checked as long as 9 d(ays prior to spraying. The prespray surveys were made following several days of relatively light rainfall, the

the postspray surveys following several (lays of heavy rainfall, which accounted
681 ACTIVITIES OF MEDICAL CO'NMLTANTS

for tile increased numnlbers of containers holding water, including ground pools.

Suurv'e*ys were nade by nen working side by side over an allotted strip. ReordIs were kept of" the total numnber of containers holding water found, tihe total

nIImnlber of sai1ples taken, the total number of larvae and pupae taken in each

sample, and the type of containers sampled. The contents of a small tin can

and a tree hole, for instance, were considered as one sample. In sonie areas

between the prespraying surveys and the postspraying surveys, some policing

and woods clearing were in progress. In others, more containers had been

added to the debris.

The postspray surveys were made on 15 and 16 September 1944; that is,

from 24 to 72 hours following the first application of the spray by airplane.

A summary of all prespray surveys indicates that 99 of 372 water-holding places,

which included ground pools, rot holes in trees, pandanus trees, wells, cisterns,

and miscellaneous artificial containers, produced 4,194 mosquito larvae and

pupae in 600 samples. The postspray surveys indicated that 80 of 815 waterholding places produced only 1,772 mosquito larvae and pupae in 1,423 samples.

"This was a reduction of from 7.0 larvae per prespray sample to 1.2 larvae per

postspray sample.

A total of 445 biting female mosquitoes was collected in 230 minutes,

divided into periods of 10 minutes each, spread over the 30-day period prior

to the application of DDT. From these data, the biting rate was estimated

to have been slightly less than two female mosquitoes per minute per individual.

The known and suspected vectors of dengue comprised 60 percent of the total

collections made during this 30-day period. Immediately following the application of DDT-kerosene insecticide by airplane, a total of 252 female mosquitoes bit ing man was collected during 1,260 minutes of the 20-day period. These

data indicated a biting rate of 0.2 such mosquitoes per minute. Of these 252

biting mosquitoes, only 38 percent were known or suspected vectors of dengue.

For the 10 critical (lays following the application of the insecticide, only

57 female mosquitoes were collected. A total of 595 minutes was spent making

these collections during this 10-day period. The biting rate was thus indicated

to be 0.09 mosquitoes per minute. Of these, only 40 percent were known or

suspected vectors of dengue. The reduction in these mosquitoes during the

10-day period was from 1.1 (prespray collections) to 0.042 (postspray collections) mosquitoes per minute. Only two specimens of A. aegypti were collected

during the entire 20-day period following the spray applications.

The total reduction in the mosquito population in the 10-day period following the insectiei(le application was thus from 2.0 to 0.09 biting female mosquitoes per minute. Since dengue patients are no longer capable of passing

the virus to mosquitoes after 5 days, the following data are presented to show

the reduction in vectors during this critical length of time following the spray

application. In 200 minutes during the 5-day postspray period, 14 specimens

were collected. Of these, there were 2 female specimens of A. aegypti, 2 of A.

vexan.s, 9 of A. albopictus, and 1 of 0. quinqu.fasciatus. Of these 14 specimens,

3 specimens of A. albopictus and the single specimen of C. quinquefasciatus
CENTRAL PACIFIC AREA 685

were collected in an inseetory and probably were protected from the spray.

But, even including these, there was only 0.07 mosquito per minute instead of

2 mosquitoes per minute, the average biting rate immediately before the spray

application.

Thus, evidence was obtained of the effectiveness of this newly originated

method of dengue control. Incidental testimony to the tremendous reduction

in the mosquito population was eloquently voiced by troops in every area

where spraying was done. Not a single comment was heard to the contrary.

All opinion was of one accord.

The incidence of dengue decreased steadily from 13 September to 3 October 1944. Spraying by airplane was begun on 13 September 1944 and completed on 22 September 1944. Residual spraying continued following that

time.

Tire effectiveness of spraying is illustrated by the incidence of dengue in

the 148th General Hospital and in the 176th Station Hospital during a period

of 21 days after their arrival on Saipan, the first having arrived on 10 August,

the second on 21 September. Both hospitals were located in the same part of

the island. The only significant difference between them was the date of arrival in relation to the date 13 September that spraying with DDT was begun.

The strength of the 148th General Hospital was 536; the strength of the 176th

Station Hospital was 318. Of the total personnel of the 148th General Hospital, 33 percent had dengue by the 21st day and 47 percent by the 38th day

after arrival on Saipan. By the 21st day after arrival, not a case of dengue

had occurred in the 176th Station Hospital, which had landed on Saipan 7 (lays

after spraying began. It is evident that the epidemic was broken. Careful

observations were made of 4,624 new troops arriving between 17 and 30 September 1944. Forty-one cases (0.88 percent) of dengue occurred, the rate for

this group being approximat1.iy 232 for this period, as compared with an approximate rate of 3,560 for the comrmand on 13 September 1944 and 182 for the

entire command on 4 October 944.

Conclusions.-A serious dengue epidemic can be effectively controlled

within a short time by the use of a DDT spray.

Mass coverage of large areas with DDT could not be done satisfactorily

with M-10 tanks andi small airplanes as previously recommended. Cargo

planes carrying a large volume of DDT solution are necessary. The method

of spraying indicated may he carried out in any combat area.

Residual spraying of such places as quarters and offices is an important

part of mosquito control with DDT. Airplane spraying has the advantage

of covering large areas in a short time, but work on the ground is also an

essential part of the whole program (fig. 238). It is believed that tentage,

mosquito bars, beds, and stools should be impregnated with DDT before

issue by the Quartermaster Corps to troops, especially during the assault

phase of operations.

Commonly used methods of mosquito control must be continued and

should not be considered unnecessary when DDT is being used.
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CENTRAL PACIFIC AREA 687

During the occupation of Pacific atolls, under tile conditions existing

for the first few (lays of contested action, large numbers of troops may be

expected to contract bacillary dysentery. The incubation perio(d is so short

that a recently landed force may have a large percentage of its men sick.

The troops also developed the disease in large numbers on two atolls where

there was no enemy opposition and in spite of what seemed to be a full understanding of tile danger involved. The greatest number of patients with

diarrheal diseases were hospitalized in 1944, following tile Kwajalein, Eniwetok,

Guam, Saipan, and Tinian operations. Patients from these islands were

evacuated to other hospitals of tie ('entral Pacific Area.

A large number of small epidemics and a few large epidemics of dysentery

were studied with considerable care. In the first epidemic, 34 carriers of

Shi geila paradysenteriae developed among 280 admissions for bacillary dysentery, a rate of 11 percent. None of these patients had received more than

7 gi. of sulfaguanidine daily nor was tile drug continued after the first negative

stool report. In contrast, in tle second epidemic, none of 69 proved cases of

bacillary dysentery became a carrier. This improvement of the carrier rate

was considered to be the result of the large daily dosage of the drug and the

longer duration of treatment.

In tle first epidemic, of 320 admissions for enteritis, 120 received only

symptomatic care, and 21 percent of these became carriers. In contrast,

only 13 carriers (6.5 percent) developed among the remaining 200 cases of

enteritis, even though these patients were treated with inadequate (loses of

sulfaguanidine. Substantiating this evidence of the drug's effectiveness is

the record of the second epidemic, in which no patients with active dysentery

became carriers and only 2 contact carriers recurred.

No relation was apparent between thle severity of the illness on admission,

the number of days of hospitalization, and the subsequent recurrence as a

carrier. A definite relation, however, existed between the total dose of

sulfaguanidine and the subsequent remission into a carrier state. This is

shown clearly when tile results of treatment in the first epidemic are compared

wit h the results after the larger doses used in tihe second epidemic.

In the control of acute symptoms, there was very little difference between

symptomatic therapy and specific drug therapy. Diarrhea, abdominal distress, and tenesmus yielded as readily to sulfaguanidine as to bismuth and

paregoric and in about tile same number of dlays. Sulfaguanidine was superior to symptomatic therapy in that patients so treated tolerated a full diet

sooner. In thel first series of cases in which diarrhea was very severe, combined

therapy was tried, but no advantage was noted when compared with the larger

(loses of sulfaguanidine in the second epidemnic.

One finding of great interest was the discovery of a large number of carriers in units with only moderate admission rates for diarrhea. In most organizations, the number of proved carriers found equaled or exceeded the

number of active cases of bacillary dysentery. The control of these epidemics

depended as much on the elimination of carriers as on rigid sanitation and the
688 ACTIVITIES OF MEI)ICAL CONSULTANTS

hospitalization of acute cases. The discovery and control of carriers can be

accomplished only by laboratory investigations. Stool studies must be

made on every man of an involved unit. To hospitalize and follow only itien

with acute symptoms is to overlook this reservoir of future outbreaks.

Practically all instances of dysentery among troops were proved to be

caused by nmicro-organisms that fall in the Sh. paradysenteriae groups. In

one outbreak, however, which consisted of 53 cases among the military police,

the micro-organism producing the dysentery was identified as Salmonella

newport in group C.

Amebic dysentery.-Before 1944, few cases of amebiasis were seen in the

Central Pacific. There were only 19 reported cases during the combined

years of 1942 and 1943. However, in the increasing number of patients hospitalized in the CPA from Saipan, Tinian, Leyte, and Okinawa, the number

with amebiasis increased fourfold in 1944 over the combined totals of 1942

and 1943.

The cases of acute amebiasis were few in number. The diagnosis was

made by finding the motile forms and cysts in the stools and by proctoscopic

evidence.

The bulk of the cases were classified as chronic amebiasis or as asymptomatic carriers. Many of the patients in this group never gave a history of

any diarrhea. Many were admitted with vague gastrointestinal complaints,

while others listed intermittent constipation, loose stools, or abdominal pain

relieved by defecation as their outstanding complaints.

Nonspecific diarrhea.-The occurrence of nonspecific diarrhea or common

diarrhea of unknown cause was frequent among Army personnel.

No specific statement of the etiology of these milder diarrheas as distinct

from the dysenteries is possible. Dietary indiscretions or, more frequently,

the character and condition of the only food available have been blamed in

some instances. However, in the latter case the actual cause of the diarrhea

may be considered with more probability to have been some bacterial infective

agents contained in the food. By no means has the last word been said on the

subject of the etiology of these diarrheal infections of unknown causation.

Filariasis

Although the only source of filariasis found within the Central Pacific

Area was the Apamama Atoll in the Gilbert Islands, the first cases seen on

Oahu were in 1943, several months before the Gilbert Islands operation. A

total of 199 patients were received in the Central Pacific Area from the

Air Transport Command in the South Pacific Area for evacuation to the

continental United States. These patients remained in the Central Pacific

for only a very short period so that careful survey was impossible. Suffice it

to say, the malady was mild, and its manifestations were ahlost subclinical.

The diagnosis was based upon a history of pain in lymph nodes and along

lymphatic channels, generalized or localized lyniphadenopat hy, occasional

localized swellings, eosinophilia or positive reactions to skin tests with Diro-
C'ENTRIL I'A('IFIC AREA 689

filaria immitis antigen, together with a history of residence in an area endemic

for filariasis. Microfilariae were not found in tihe blood.

Following the Gilbert and Marshall operations in 1944, the surgeon of one

of the searchlight battalions stationed at Apaniama reported that patients

were seen with an undiagnosed condition. The typical clinical picture follows:

The onset was sudden with chills lasting 5 minutes, recurring irregularly, followed by fever varying between 1000 and 1010 F., which was also irregular.

Heaidaclie and muscle and joint pains were conmmon. A few days later, there

was enlargement of the axillary lymph nodes and inguinal lymph nodes bilat- erally. Shortly afterward, red streaks, starting at a point 2 cm. below both

elbows and extending to the axillae, were noted on the Iiedial aspect of the

arms. There was no edema of soft tissues. There was some soreness of the

scrotum about the 10th day of illness.

Upon arrival of these patients at the Tripler General Hospital, the evidence of acute lymphangitis had subsided. There was slight to moderate

enlargement of tile nodes in the axillary and inguinal regions. They were freely movable and mildly tender on deep palpation. The left spermatic cord

was found to be thickened and tender in a number of instances.

The presence of filariasis in the CPA aroused sufficient interest to send

a group of investigators, consisting of internists, entomologists, laboratory

officers, and technicians, for clinical and laboratory survey of tile Gilbert

Islands.

A report of the clinical manifestations in the natives and in Army personnel and a report of the laboratory studies will be presented briefly.

Native population.-A total of 365 natives were examined on Apamama

by careful inspection and palpation of the scrotum and its contents. Sixtyfour (17.4 percent) were found positive for filariasis. The signs included

enlargement and hardness of one or both epididymides and/or testes. Frequently, the organs couhl not be differentiated since a single matted mass

was present. The largest. such mass found was about tihe size of a grapefruit.

Because of lack of time and facilities, it could not be ascertained if tuberculous or gonococcic epididymitis complicated this clinical picture. However,

it was felt that the genital findings were characteristic enough to warrant

a diagnosis of filariasis on clinical grounds alone. This diagnosis was further

substantiated by blood smears showing microfilariae in 13 (20.3 percent)

of the 64 natives. Of 201 natives examined on Makin, 7 (3.5 percent) showed

evidence of genital involvement. It is of interest that of 46 natives with positive smears for microfilariae, 24 were found free of clinical signs.

Army personnel.-Considerable reliance had to be placed upon the histories in suspected cases in t(ie Army. In all cases, the histories and initial

findings were corroborated by the attending medical officer. Out of 39 suspects, 27 were found to present a history and clinical findings consistent with

a d(iagnosis of early filariasis. Those eliminated either presented vague histories and findings or else showed localized infections that couhl have easily

accounted for the observed lymphadenitis. The earliest onset of symptoms

564.9701-- E1--6-46
690 ACTIVITIES OF MEDICAL CONVI.'TANTS

was 25 days after arrival on the island. This occurred in one patient only.

InI tihe ot hers, tile onset occurred from 1 to 2 months after exposure in a highly

endemie area.

The following clinical types of onset were noted in tliese cases:

1. Pain in one or more extremities, occasionally associated with a tender

localized cordlike structure under the skin.

2. Pain and often swelling in various hymph nodes, especially in the axillae.

3. Scrotal pain with an associated enlargement and tenderness of the

epidid 'ymis and/or the spermatic cord and its surrounding structure.

4. Low suprapubic, cramplike pain with radiation into the groins was

also an initial complaint of some patients.

5. A few had an onset with urticaria which was persistent and refractory

to treatment with adrenalin. In two such instances, t here was also angioneurotic edema of face, hands, and feet.

All of these patients had enlarged and often tender lymph nodes in one

or more sites. An unusual feature was the frequent enlargement of epitrochlear and posterior cervical nodes. At the time of survey, these enlargements were still present and could not be explained on the basis of local skin

infection or otlher systemic disease. Nearly all the patients had a low-grade

fever, between 99.6' and 1000 F., and symptoms of generalized aching and

malaise. Most of the patients were ill 10 days to a month. In brief, the

syndrome presented by these patients was highly suggestive of an infection

of the lymphatic system with marked allergic manifestations. These are

essentially the outstanding phenomena in the acute episodes of filariasis.

Laboratory findings.-On Apamama, a total of 365 natives were examined for the presence of microfilariae by the thick-smear technique and the

concentration method. From this group, a total of 46 natives (13 percent)

was found to have microfilariae of the species 11'. bancrofti ill the peripheral

blood. In a group of 100 native laborers in Tarawa, 6 were found to harbor

microfilariae. At Makin, out of 201 natives, 1.5 percent had microfilariae

in the circulating blood. No investigation was made periodically in the same

patient during a 24-hour cycle, but microfilariae were demonstrated in different

natives at all hours of the daY between 0800 hours and 2200 hours. Filariae

were found in the blood of natives who had come from the following islands:

Apamama, Nonouti, Tarawa, Makin, Marakei, Bern, Tabetauea, Abaiang,

and Nukunau.

Thirty-nine Arn;v sus ects at Apamama were examined by the thicksmear method as well as by the concentration method, but in no instance

could microfilariae be demonstrated.

Conclusions.-The evidence presented in this survey indicates that

filariasis is endemic throughout the Gilbert Islands. The disease undoubtedly

hias been spreading from the Ellice Islands. The investigations of tihese iatives suggested that their transportation to diff'erent islands for purposes

of labor had been factors in the spread of the disease to nonendiemic areas.
CENTRAL PACIFIC AREA 691

The epidemiologic study on Apamama led to the conclusion that filariasis

couhl be and had been transmitted to Army personnel on that island. It was

also apparent that knowledge of early phases of this disease needed to be revised

and extended. The lack of this knowledge was due to the fact that few careful

observations were ever made on largkt bers of susceptibles suddenly exposed

in highly endemic areas.

Of interest was the fact that this same group reported that a few adult

Aedes seutellaris pseudoscuteilaris and innumerable C. quinquefasciatus mosquiitoes were present on the Apamama Atoll. ('dulex mosquitoes, which were

raised from larvae, were allowed to feed on a native carrier of microfilariae, and

after 11 dlays numerous infectious larvae were found by dissection. The scarcity of Aedes mosquitoes was thought to have resulted from several weeks of

(Iry weather. Wild adult Aedes mosquitoes were caught after feeding on a

native carrier of microfilariae, but these survived only I or 2 (lays in captivity.

Some of theni were observed by immediate dissection to have taken up microfilariae. It was the conclusion of the epidemiologic team making the study that

the diagnosis of filariasis in the suspected cases was epidemiologically sound.

The Army Garrison Force, Apaniama Atoll, returned to Oali during late

October 1944. The returning group numbered 200 individuals, and they were

examined for evidences of filariasis. While lymphadenopathy was prevalent,

bot hi inguinal and axillary, there were no scrotal signs or lymuphangitis observed,

and none of the troops had suggestive symptoms. Twenty-one men with

moderately enlarged axillary lymph nodes were examined for the presence of

eosinophilia, microfilariae, and complement-fixing antibodies to D. immitis

antigen in the blood. These tests were all negative.

After 13 June 1945, approximately 4,563 prisoners of war arrived on Oahu

from Okinawa (p. 666). From 15 July to 18 August 1945, a survey of microfilariae in these prisoners of war was completed on the 4,563 individuals. These

blood smears were taken at night between 1900 hours and 2200 hours, stained

with Giemsa's stain and examined for mnicrofilariae. A second smear was

taken on 3,703 of t he prisoners whose smears were negative on t he first examination. M\icrofilariae were found in the blood of 728 individuals (16 percent) of

thie 4,563 examined. Six hundred and thirteen of the positive records were

found on the first smear and one hundred fifteen on the second.

Both It'. bancrofti and 11'. malayi were found, the former principally in the

Japanese prisoners and the latter in Koreans.

In the foregoing pages, some account has been given of the medical aspects

of thie war in the C(entral Pacific. Available for this great enterprise were the

resources of modern medicine and vast stores of materiel. Implicit throughout

this discussion has been the prime importance of the third factor, the mnedical

officer with his specialized skills confronting the special needs of the soldierpatient. It was apparent in all theaters that the excellence of medical service

varied as medical officers were, or were not, properly placed. Accordingly, it

seenis not inappropriate to conclude with a note on a subject that was a
692 ACTIVITIES OF MEIOICAL CONSULTANTS

particular concern of the medical consultant because of its essential bearing

oil the quality of medical service of the Army in wartime.

MILITARY OCCUPATIONAL SPECIALTY RATINGS

The medical consultant was appointed by The Surgeon General to inform

him concerning technical and professional aspects of medical services in the

Army. This, it may be notled parenthetically, was not an innovation in military

medicine. The German Army had professional consultants in the FrancoPrussian War, and Wilhelm His, Jr., was a medical consultant to the German

Army during World War I. Also, during that war, specialists from civilian

life were employed as professional consultants by the English, French, and U.S.

Armies. During Worlh War II, the U.S. Army Medical Corps was increased

from about 1,200 physicians in the peacetime Army to a peak of approximately

49,000. As these civilian physicians were entering the service at a rapid rate,

medical units were being formed and hospitals constructed as rapidly as possible. The first problem was, therefore, an adequate and comprehensive classification of medical officers. This was accomplished by a number of methods

with varying degrees of efficiency. The individual officer first gave his own

estimate of his professional qualifications; that is, whether he . was a qualified

specialist, a general practitioner, or possessed some proficiency not related to

medical practice. He was then directed to submit certain data relative to his

medical and premedical training, internships, residencies and teaching positions,

membership in learned societies, and whether or not he was a diplomate of one

of the specialty boards. This information together with certain other facts

published in directories of the American Medical Association and the specialty

boards was utilized to form a preliminary estimate of the medical officer's

capabilities and of his present professional ability.

The first duty of the medical consultant was to confer with the personnel

officer at the proper level and to request the assignment of individual medical

officers where their medical training could be used to best advantage. Owing

to the relatively small numbers of specialists in certain categories, assignments

have to be made at a high echelon in order to meet the overall needs of a comimand. Suitable assignments are the principal factor in determining the

efficiency of all medical installations. They should therefore be made only

on the advice of trained medical specialists and not left to the sole judgment of

personnel officers with inadequate knowledge of the technical problems involved.

Reassignments should be made on the advice of the theater or command surgeon with or without lower echelon or hospital commanders' concurrence. In

the latter part of the war, with the initiation and evolution of the MOS classifications, the assignment and reassignment of medical officers became more

realist ic.

In the future, it will be desirable to give a preliminary MOS classification

to every medical officer on admission to the military service, this classifi(cation

to be revised by the consultant and competent medicomilitary authority as
('ENTRAL PACIFIC AREA 693

soon as possible after the medical officer has been assigned to a permanent

post and at frequent intervals thereafter. The next logical step might well

be the revision of all units established according to tables of organizations to

require that certain positions be filled only by officers with certain MOS and

proficiency ratings. This would tend to block pronmotions based on considerations that are irrelevant, and often inimical, to good medical care.

It is unlikely that the present trend toward specialization will be reversed,

and it is certain that professional skill varies within every specialty and in

every group of consultants. The MOS is the result of a search for a method

of evaluating the capabilities of a medical officer in a special field of his profession. It is not a measure of efficiency, and, although average efficiency

may well be expressed by the MOS, it should not be used as a job rating, nor

should it be changed every time an officer is assigne(d to a different service.

It is a measure of his qualifications and attainments after careful comparison

with those of other specialists in the same field throughout the Nation. Authority to assign or change the MOS rating should therefore be delegated only

to the surgeons of major ('ommands. As a rule, the surgeon will obtain tle

necessary (iata from the professional consultants assigned to his headquarters.

The (care of the sick and wounded is above all a problem not soluble solely

in terms of numbers of men and amounts of materiel. It will be best (lone

only if the consultant is acquainted with the professional skill of each medical

officer and with the uses and efficiency of all apparatus. He should inform

himself also on various auxiliary services, which have large and useful functions

in the care of the sick, wounded, and convalescent soldier. He should make

frequent visits to all medical installations and make written reports on each

unit he visits. These reports together with the recominendations he makes

to the coniniand or theater surgeon should materially enhance the quality of

medical service. If these very important duties of the lnedical consultant

are adequately performed, each miedical officer in the theater will at all times

have an MOS rating that confornis with his professional ability and may be

quickly revised to reflect any change in his usefulness to the military service.

The MOS classification, as it evolved during the Second World War, was

very profitably used to fill a real need. In the future, when any rapid expansion

of tihe Army may be necessary, medical officers should be assigned MOS ratings

c'ommensurate with their ability and given rank commensurate with their

usefulness, as soon as they are ordered into military service.
CHAPTER VIII

India-Burma Theater of Operations

Herrman L. Blumgart, M.D., and George AL. Pike, M.D.

The problems confronting the U.S. Army Medical Department in USAFIBT (U.S. Army Forces, India-Burma Theater) can be understood only

in relation to the environment in which the personnel of this theater worked.

The climate, the lack of modern sanitation, the wild and primitive regions of

the Stilwell Road (formerly Ledo Road) country in which some units operated,

and the close proximity of the native Indian population in other areas created

peculiar, if not unique, medical problems. Few, if any, regions excel India and

Burma in the variety and profusion of disease. One million persons (lie annually of malaria while a hundred million suffer clinical attacks yearly, and

250,000 die of pulmonary tuberculosis, according to the most reliable estimates

available. Endemic foci of the three major plagues--smallpox, cholera, and

plague-constantly smolder in India and are among its principal niedical

exports. Each and every one of these factors posed particular medical problems

or influenced professional policies and must be appreciated in any review of

medical problems in this theater.

The China-Burma-India theater was established on 15 March 1942, and

U.S. troops on the Asiatic mainland were designated USAFCBI (U.S. Army

Forces in China-Burma-India). Lt. Gen. (later General) Joseph W. Stilwell,

USA, and Col. (later Brig. Gen.) Robert P. Williams, MC, were assigned as

Commanding General and Surgeon, USAFCBI, respectively. At that time,

only 3,000 U.S. military personnel, chiefly Army Air Forces, were stationed in

the theater, which included, generally, China, French Indochina, Thailand,

Burma, and eastern India. The theater expanded rapidly. In October 1944,

it was divided into the USAFCT (U.S. Army Forces, China Theater) and

USAFIBT. While, of necessity, this chapter includes observations concerning

activities in the USAFCBI theater, it deals primarily with USAFIBT.

When Lt. Col. (later Col.) Herrman L. Blumgart, MC (fig. 239) arrived

as Consultant in Medicine, USAFIBT, on 28 January 1945, the total bcd capacity of the general, station, field, and evacuation hospitals (maps 6 anti 7)

in the theater was 19,772, and 512 medical officurs were assigned the care of

9,819 patients. From a humble organization in 1942, the Medical Department in the theater had expanded to an organization of approximately 14,000

officers and men.'

I Report, lHeadquarters, USAFIBT, subject: Operational Data; Medical Department Facilities, IBT, 4-Week Period

Ending 26 Jan. 1945.

695
696 ACTI VITIES OF MED)ICAL C( NSVIATANT.S

FiC;URE 2 :39.-Coiisultatit in mnedicine, China, Burma, aid India. Col. Herrmnan L.

Blimngtirt, MC, Consultant in 'Medicine, Office of the Surgeon, Second Service Command;

Consultant in 'Medicine, Office of the Surgeon, USAFI BT; and Consultant in Medicine,

Office of the Surgeon, l'SAFCT.

SCOPE OF CONSULTANT ACTIVITIES

The primary miission of Colonel Blunigart inl this already estab~lished headquarters team (-iifl b~e simply statedl. It was to improve the' quality of professional mledIical care by recomm]Denladt ionls to the Surgeon, tSAFIBT. Generally speaking,, this mission was carr~iedl out by act ivit ies that fell into thle following( four groups: (1) Formulation for tile Surgeon's approval of general overall

policies aflfectinrg medical care, (2) formulation of specific recommendations to

thle Surgeon to correct dlefects inl medlical care commnon to various installations

Visitedl, (3) oni-thle-spot correct ion of irregularities and~ (deficiencies observed

d urintg visits to hospit als, and (4) consult at ion regardling local professional problenlis. Thlese four activities hardlly ever existed1 separately, one being almost

always influenced by another. Inl the matter of assignment of personnel, for

inst anice, the overall (list ribit ion of medic*al officers necessarilyv conformed to

the existing tables of organization andl the total number of officers inl various

(1t egOries availab~le ill tilie theat er. Oil tilie other l11111d, tile individual assignmlerit of suchl officers, and1( reassignments fromi one hospital to another when

necessary, were frequently (let erminied by observat ions, muade dlurinig the rued-
INI)IA-BUtM A T69Ii:.VrEII(

T I B E T

NEW DELHI,* 00 So /V A *7SR /t

" 81rGen A cra -- 72 Fd

*Korachi P ' Lolman'r-hot Gauhoti J IN +D.1o -- 9So Gaya .-- ~Sto ýI

-. Panogarh /, D•cca

Piradobia t 142 Gen ( - -7 -, i -K2mChoparo

Chokcul i ,v -. larBURMA

98 S,.

Bombay

Baong 0lore ci

0 Soo

MILES

CEYLON

131 Sft

Colombo jdy

MAP 6.-U.S. Army hospitals in India.

ical consultant's visits, on the qualifications of each officer and the needis of

each hospital.

Activities at Headquarters

Colonel Blumgart spent somewhat less than half of his time in the Office

of the Surgeon, headlquarters, USAFIBT. Here, many activitls clhimine(l his

attention as a member of the Surgeon's staff. Diseases cannot be compiartmentalized; formulation of many policies and action on many problems
698) AC'TI\VITIES O•F MEI.CAT.\, (*4)N.SII,TI'.NTS

'- -*, •

", 001" 000 2OGen p~ 000 III' Sta0 ___ 9Ge

.2" " ej234Gen 69 Gen

14 Evoc

000oo.

0006 + 73 Evoc 4-2 Ai

+72 FId \+ 24 Sto

000 "1N18Ge 2

1 Fid . .95 St";

,000' 0-,:o" ;l

I N D I A -f".-48Evoc

y)U 

N

, '..'> I-A- . .

MAP 7.-..S. Army hospitals in Assam, Indiai, and nortlhern Burma.

required coordination of the neuropsvchiat ric, surgical, andil medicail consult ants'

opiniioiis. . laity matt ers primarily the concern of the Preventive . ledicilie

Section or of the Personnel Section in the office were referred to Colonel Blumngart for comment and coordlinat ion. The preparation of the section on medicine in the ETNIrD (Essential Technical .Medical I)ata) reports; the review of

all pliblicat lolls Oil Illedical subjects submitted to the Surgeon, USAFIBTr; the

prepa ra tion of inm t erial on current medical problems for t he Surgeon's 10ond1l , y

Fielhd M[dical IBh'tinm; the preparation of t heat er circulars, Surgeon's circulars,

and memorandums oil professional medical subjects; the review of clinical record-s and post mort em findings in all deaths due to medical disease(-these activities claimnled most of Colonel Blumigart's time while at headquarters.

Coordination with neuropsychiatric consultant. --The professional problehms thit. concerned tlie neuropsychiaturic atid tile medical consult ants were

Iairticuhlarly closely related. In all iedical conlditions, for instanice, thlie .ignifican'ce of the sy toms t to the patient is important; a "stitch" in thle chest

if it occurs near the heart may lead to invahlidisni and days lost solely because

of the pittient's fear of heart disease or of pllihotiary tuberculosis. In other

conditions, such as dyspepsia with its manifold litiaiifestation4, the symptomiiatology may rel)resent "body langainge" expressing the patient's emiotional difficulties. Prolonged duty in this iolcoil hat theatter under the hiardshilps of
INI)IA-111IIMA THEATERA'699

thle extreniely variab~le cliniate of India proved to be emotionally wearing.

Because miedical officers tihem selves were not mi nilune to thlese stresses and

strains, they frequently were resentful of sucit reactions in their patients and

thleir ahdlitv to deal withl thleii symlpathieticallY wits re(iieced.

Time p;roposal to have simiultaneous visits b~y thle neuropsychiatric and

medlical consultants to thle variouis installations it) thie thieater in order to eniphiasize tile (lual approach miet with approval by the Surgeon, tTSAFIBT, and

provedI to be of inestimable value in proper treatment andi sa~lvage of mnany

patients. The edlucational value of joint, ward rounds, to the nienbers of thle

bo0slit1all staff inculcating of) i hemi tile significance of fpsycilosoinatic miedicine

and thle importance of inmni1ediate tlherap~y, wits evidlencedl ly tile lively (usemissions tliat were alniost always evoked. The major amiount of ealch conasulltant 's timie wats spent on tile niore specific inie(ical andl neuropsychiiatric

Jprohlenis. At, momt of +hie installations, conferenlces witih thle stalff were hleld

jointly by thle, two consultants to (delineate tile fundamnental concepts of (iagnosisi andi tilerapy in lpsycliosonilatic niedicine, always using ats a text specific

cases seen during wardl roundis.

This arrangemient wats found to be highly effective. It worked well

because the neuropsychiatric consultant wats firnily grounded in tile field of

internal niedlicine a1nd( tile Inedical consult ant hiad sommie knowledge of psychiiatry.

To elinminate loss of timie and energy on controversial points (luring conferences,

tile two consultamnts hlad achlieved at comummon approach 1111( general agreenlent.

In ad(ditionl, the miedical consultant, interested in the miore purely miedical

aspctsof iseseactivl participatedl in tile, comnferences, andl tile neuropsychiiatric consultanit utilizedl his extensive, specializedl experience ill answering

qluestionis at issue. All these factors hlelpedl to demionstrate to adlvanltage tile

interrelationshiip between thle two fields.

Coordination with preventive medicine officers.-Many of the preventive

medicine activities in the theater were closely related to internal miedicinle

problenis. Almost (alay, informial conferences were hield between Colonel

Blunigmirt, and( various officers in tile Preventive Medicine Section, Office of

the Surgeon, Headquarters, USAFIBT. Time statistical accuracy of tile incidence of (diseases depends in tile first instance onl thie accuracy* of clinical diagniosiS. Inl at tileater in whichl constant. watchlfulniesi hiad to ibe exercised for

diseases such ats smallpox, chiolera, scimistosoiniasis, filariasis, and kalai-azar,

particular caution iii differential diagnosis wats essential. Accordingly, Colon~el

Blunigart reviewedI numerous case recordIs andl rendieredi umany opinions. Tlme

initiat ion of Atabritne (quinacrine Itl'ydrociiloridle) suppressive treat mient for

mnalaria likewise raisedl miedical prolblemmis ill respect, to various mainifestations

of At abrine toxicity anl(l to tile incidIence, t reatmient, and ad(inministra tive d isposition of the affected indlividiuals. One of tile mlost pressing prolblemuis inl

thle timeater wits tile hiigh incidience of (liarrl-eial and (dysenlteric dhiseases, lparticularly amnebic (ly-sentery. As will lbe shiown latter, an integratedl approachi to

th~is entire prolbleni wats aceoumJplishied only by time closely c'oordinated1 efforts

of tile preventive mnedicine oflicers, 1111 tile, iiiedical consult ant.
700 ACTIVITIE*:S OF MEDICIAL C'ONSULTANTrS

Personnel management.-Baqic to all other consideratioins in achieving at

highst iuedicl ndad cre o as he uestiouol ersnne .U.S.rmy uiiedlical

officers its at group replresent at (ross s.,:,ct ion of thle. Nat ion's uiie(ical profession.

The nutiniber of highly trained specialists was dlecidedlly liiiiited, as well as thle

nun11ber of geiierall internists qualifiedl to be chiefs of' medical set-vices or hieadls,

of sect ions. The personneil recordIs of edtucat jotall t raining andI post graduatilte

niedicail exp~erience are lot at sure ind~ex of proficiency. For ilistaiice, certain

mnedical officers wvith at wide range of mnedical knowledge, somle of whom011 hadI

b~een qualified lbv an Amierican specialty board, lackedI soundl coniservat ive,

clinical ju(Igui miii; others lacked necessarY quialities of' leadlership). Conversely,

other niedical officers with little postgradluaite I raining, who nleverthieless had

iiiain1t ainledlian active interest in scienitific iuiattIers (luring Years5 of' general

pra~ct ice, were found fully quailified to be chiefs of iiuedical services at 250- or

500-bed Stat ion hospitals. Appraisal of the intrinsic qutalificat ions of thle inedical officers couldl be miadle onlY onl tile basis of personal ob~servat ion duriiuactual ward1 roundls. Colonel Bluingart Spent at least Otte or m~ore hour11s with

ea1ch officer oil thle Wardhs reviewing~ ill det ail physical findings, clinical recordls,

andh ti'eit ieleit andl~ adliiiillist ralt le (li,;posit ioul of p~at ients. Jnforuinal d iscuissions of related general sub~jects suich as, in fectious hepatitis, del unlue, ceuu miother:!py, and thle significance of various labora tory v l rocedhures formned part

of such visits. This personal evaluation by Colonel 13luumigrtan atrve

of each mnedical officer's Personal revordls servedl as t he basis for thle proper

assigniment it) veah officer of it classificat ion uiniibuier and rating and mnade

possib~le at full utilization of each officer's capab~ilities. lIn 5011W inst ances,

persoiiality ('laishes rendleredl an officer's services inieffective ait it particular

inst allat ion andl could be obviated by his assignmnent elsewhere. The( Surgeon,

USAFIBT, einpliasizedl the inplortauice of at Personal evaihuiatioii of eachl medical

offi cer by Colonel B1tllmgart and directed thatt tilie persoinniel officer coinsider

Colonel Bluting-art 's opinion before efl'ecting transfers andl assignmnents. This

appraisal of Officers b),y thle consul tanltt pr'oved helpful to tile personniel officer,

who0 was coiifronted constantly with shift ing needs consequent to thle (departuure

or arrival of niedical officers.

Editorial duties,.-Colonel Blunigart, was responsible for the preparat ion of

tile sect ion on miedicine Hi the ETM D replort., suibmit ted muuoiitlily to tilie Sliitgeonl Generall's Office. It was found ti at tlie( reports subim iut tedl 1) tile hiospita~ls

1111( lbecofmue rout ine and lacked mnaterial of mnedlcal interest. Tile Suirgeon1,

USAFIBT, adldressedl at (ouninitiication to till the installations ini thle theater

its well ats to the headquarters of sub~ordlinate coiuiniands, stating the type of

inforinat ion desired. During at visit of Colonel Blunigart to tile various inistallations, further effort was inade to stiniuilate studies of groups of unuitsual cases.,

such ats kala-azar, atypical pnuelnionia, and cereb~ral mnalairia. N~i\ ch1 valuable

niia terial was t hereby accum rilit ed. Colonel Bluingairtr reviewed aill inedliCal

articlesi subiniitted to thle Surgeon, USAFIBT, for publication.

Colonel Bluimgart was also responsible for articles or comments on current

medical problems in the Field M1edical Bulletin. Medical officers were encouir-
INI)IA-BIURMA THEATER 701

age(d to submit reports on their studies, and many of these were published.

Tlie Field .lfedical Bulletin also provided a valuable means of conveying

information regarding recent advances in medicine. Various irregularities or

deficiencies, such as failure to comply with certain directives or misunderstandings regarding the intent or meaning of others, were corrected by appropriate

brief notes. In some instances, where no suitable official guides or directives

were available, appropriate circulars or memorandums were submitted to the

Surgeon, USAFIBT, for approval and( then (listributed. A more detailed

account of such directives is included later in this chapter in discussions of

the various diseases of particular interest in this theater.

Review of clinical records and post mortem findings.-Soon after Colonel

Blumgart's arrival in the theater, the Surgeon, USAFIBT, approvc-d the

request that complete clinical records and results of post mortem examinations

for nonbattle casualties be submitted to headquarters for review. This

proved to be an exceptionally valuable procedure. By this means, theater

headquarters was kept informed of some of the most interesting cases, medical

care of the most seriously ill was reviewed, and occasional suggestions or

deficiencies were noted. These facts were made the subject of correspondence,

or, more often, a conference with the hospital staff was held on Colonel

Blunigart's next visit to the installation. It is believed that this procedure

also had anticipatory value as it was generally understood by medical officers

that the clinical record of any seriously ill patient would eventually be scrutinized

in the theater Surgeon's Office.

Other activities.-In addition to the main duties just outlined, many

miscellaneous activities occupied Colonel Blumgart's time while lie was at

headquarters. Many communications were received regar(ing me(Iical practice

and procedlure that req uired reply. In addition, the available current periodicals,

ETNID reports from other theaters, and other reports were constantly scanned

in order to maintain professional medical standards abreast of current advances.

Activities in the Field

Colonel Blumgart's activities in the field have been indicated as ramifying

from his activities and relationships at headquarters and will be described in

more detail here.

During tile 9 months lie spent in the India-Burma and China theaters,

the author spent somewhat more than half his time in traveling more than

40,000 miles in field visits to the various installations, although, as much as

possible, the visits were grouped to conserve time. M\any dispensaries were

visited, but only a few of those of the Army Air Forces could be seen during

his period of (luty.

The isolation arising from the wide dispersion of units and the poor lines

of communication made it the more important for Colonel Blumgart to be

regarded as a two-way ambassador between the theater surgeon and the

installations, interpreting theater policy locally and acquainting theater
70)2 ACTIVITIE'S OF MEDICAL. CONSULTANTS

headlquarters with the problems confronting thle officers in the field. For tile

most, part, medical officers hiad had no olpportlility'A to discuss professional

mnatters with all anone otlier t han their immnediate associates and had but lit tle

information regarding experience withI comparab~le p)rob~lems at other installations. The opport unity to display their own accomplishments was anl imp~ort anit.

morale factor. Colonel Blumngart himself had had1 little specializedl training

or experience inl the field of tropical medlicine, b~ut thie clinical experience

grained (luring initial visits to some of thle large inst allat ions togethter withI

collateral reading remfedlied t his def'icienlcy. At mnany inst allat ions, tilie

experience and ingeniuity of thle medical officers proVidled ('olst ructive Sulggpstions t hat. could1 be transmittedl to the officers at other inist allations. This,

function of Colonel Blumigart as a medium for exchange of ideas was lprolbalI ly

one of his chief contributions. The conifidlence of hospJital p~ersonneld inl Ils

helpful inlt ent. having b~een est ablishied, Colonel Blumigart 's suggest ions were

acceptedl without resentment.. Ill some installations, t here was a surplus of

mnedical talent ; 2 or :3 highly able internists were serving in a 200-bed hiospit al.

Inl others, 110 int ernist withi ext ensive knowledge an 111Sound, conserv-at ive,

clinical judgment had b~een assigned. These instances were, however, few

and were readil 'y rect ifiedl by personnel( reassignments.

Training and education.-The scarcitv of medical officers sufficiently

skilled 811( Personally qualified for posit ioiis of responsibilit v and leadership

mfadle it, imperative that. hospitals be considered as t raining centers. Thus,

p~ivotal personnel lost, through illness or rotation couldl Ie replacedl. It, was

found that maiiy young mledhical officers who were products of t he emergency

accelerat ed program of civilian medical educat ion had considerable infnate

ab~ilityv but, meager clinical knowledge or experience. Whenever possible,

Such officers were assigned to duities under thle immnediate supervision of mature,

seasoned clinicians andl, after varying periods of time, were qualified to l)C

chiefs of small station hospitals or heads of sections at general hospitals.

The criteria for (diagniosis of disease and the t herapeutic regimles that.

were emiployed vairiedl greatly from hospital to hospital and indeed from ward

to wardl. This was dule to tile facet, that thle nmedical officers -men wvithi widlely

(different typ)es of t raining, experience, 1111( per'sonial views- -had not receivedl

tlie filiundaientil1 directives and1( guidles issued by thle Surgeon CGenerid's Office.

Few, if any, TB N IED's (Warl IDepart uncut technical blillet iuis, uiiedical),

had been received, and1( b~ut, few overall profession al p~olicies ha1d beeui est ablislied

in the t heat er. To raise thle quality of mnedical catre to tilie highest poss5ible

level, each inst allation was dlirectedh to prepare at list, of tilie TB NI ED's it.

lacked, iund adhequatte (list ribution was effected. It. was fuurthter direct ed that.

a complllete file of such bulletins as well ats t heater surgeon 's circulars, be iniinainiled by thle Commiuanding officer and by the chiefs of uniedical and surgical

services. In thle instance of somne (liseases such as anie1bialsis, which constitultedl one of tile major problems ill tile area, at theater (directive wals issued,

Since none hiad been made available byv the Surgeon Greneral's Office. Every

effort. wits miade to encourage faithlfuul adlherenlce to a11l directives.
INDIA-BURMA THEATER 703

The consultant attempted to stimulate professional interest by recommending the estat)lishnent of a suitable reading and conference room in each

installation, even when a tent had to be erected for that purpose. Steps

were undertaken to supply each installation with its authorized allowance

of books and periodicals. Through the generosity of the Josiah Macy, Jr.

Foundation, New York, N.Y., reprints of outstanding articles appearing in

current medical periodicals were distributed to the medical officers in this

theater. By informal communication between the Surgeon, USAFIBT,

and the medical director of the foundation, Dr. Frank Fremont-Smith, material particularly relevant to the medical problems in India and Burma was

made available. By this means, medical officers were encouraged to keep

abreast of advancing medical knowledge.

In addition, medical officers were urged to review series of cases at their

own installations and to prepare reports summarizing their experiences. In

some instances, these reports were used solely as the basis for a talk ati one of

the medical conferences; at other times, they were found suitable for publication in the Field Medical Bulletin or even in current. leading periodicals

in the United States. A schedule of at least one medical conference a week

and one grand ward round for the discussion of the most interesting and perplexing cases was established at the various hospitals. The value of such an

educational program in improving medical care, in heightening the professional

interest of the medical officers, and consequently in raising morale was gratifyingly evident. The numerous reports received from these installations

were of invaluable assistance in obtaining a comprehensive knowledge of

diseases peculiar to this theater.

Visits to hospitals.-The major portion of the time spent at each hospital

by Colonel Blumigart was utilized in a careful review of medical practice on

each of the wards. In the smaller installations, each patient was examined,

the clinical records reviewed, and the clinical management discussed. In the

larger installations, with a census of approximately a thousand patients, this

was manifestly impossible. On each of the wards, however, at least five

cases were spot checked; all patients with a fever of 101' F. or more were

reviewed; and the seriously ill were examined, as well as any additional ones

requested by the medical officers.

In addition to the visits on the medical wards, an hour or more was usually

spent in the laboratories. In some installations, the nmonthily report of the

laboratory substantiated the impression on ward roun(ls that an excessive

amount of laboratory data had been requested. This practice tended toward

poor quality of laboratory work with occasionally misleading inaccuracies.

In other instances, laboratory tests necessary for diagnostic purposes were

omitted. General criticisms of such deficiencies were never expressed, however, until tie indications and contraindications for such tests in the individual

patient were pointed out at the bedside. Visits to the laboratories of the

hospitals by Lt. Col. (later Col.) Howard A. Van Auken, MC, Commanding
104 AC'TIYITIES OF ME1ICAL ('NSULTANTS

Officer, 9th Medical Laboratory, were of great value in heightening the quality

of lal)oratory work performed.

The inspection of the X-ray department properly fell within the province

of tile surgical consultant, but Colonel Blunigart, always made a visit in order

to coordinate the activities of this department with those of the medical service.

[During World War I I, the radiology service in an Army hospital was frequently under the overall jurisdiction of the chief of surgery.]

At a few installations, it was observed that there were too many consultation requests from one service to another, particularly at some of the

general hospitals where, at. times, such complaints as headache led to a request

for neurological consultation, backache for orthopedic consultation, and

precordial ache for a cardiac consultation. It, was emphasized that such

practice results in but little b)enefit to the patient when required of a specialist

deluged by impossible demands on his time. Time and effort were conserved

by the proper use of consultation forms. The necessity for explaining on

such forms the purpose of a consultation prevented the expenditure of mnuch

fruitless effort by Colonel Blumgart. The presence of the ward officer in

charge of the patient at the time of consultation was urged so that the medical

consultant could confine himself to the pertinent issues and resolve any differences of opinion with the medical officer in imuinediate charge

Clinical research.-The promotion of clinical investigation was considered

an important function of Colonel Blumgart. A study of disease may appear

at first somewhat remote from the primary mission of improving the quality

of medical care, but the novel nmedical problems peculiar to wartime, particularly in a theater such as India-Burma, raised many issues concerning which

there were no guideposts from prior experience. Clinical investigation had

to be undertaken to answer such questions in order to provide the best medical

care. The type of investigation that could be fostered was limited by certain

definite factors but was favored by the rich clinical opportunities that were

available. Any study had to be relatively simple and conform to the exigencies of time available to the medical officer from his immediate compelling

clinical responsibilities. Observations had to be made by means of techniques

readily at hand. The possibility of transfer of officers to another assignment

made it imperative that any investigation should be undertaken by a group

whenever possible. Sonic of the titme, Colonel Blumgart acted as instigator

in these research projects, while at other times he merely facilitated the progress of the study. Some investigations were initiated at the bedside whell,

during discussions on ward rounds, a question arose that required research

to provide the answer.

It was important that fruitless energy should not be dispelled in clinical

investigations. To this end, it was emphasized that no research project should

be undertaken without approval of the proper authority, that a definite

protocol of the proposed study should be sublmitted to the chief of service,

and(1 that the advice and assistance of the office of the theater surgeon should

be utilized.
INIDIA-IIU'IMA TIIEATER 705

Assisting to establish contacts between officers at the difTerent installations, making available technical assistanice from tile theater laboratories

an1d other sources, and guiding the progress of investigations were functions

that the medical consultant found interesting and gratifying.

Reports to headquarters.-At the conclusion of each field trip, Colonel

Blumgart submitted a report to the theater surgeon summarizing the conditions

at each installation and making recommendations for i provement. The procurementr of basic statistical and personnel data was facilitated by the use

of a form which was given to the conmanhding officer of each hospital on Colonel Blumgart's arrival and was returned completed to ('olonel Blumigart

within from 24 to 48 hours. The form provided space for information on

the number of medical personnel, by corps, on eac(h service in the hospital;

the number of patients in the hospital's reconditioning program, the number

sent to the Zone of Interior in a specified period of time, the number on the

medical service and the length of hospitalization, the number acted on by

the disposition board, transferred to other hospitals, and being retained in

the hosp)ital for otlher dispositions; the name, duties, and patient responsibility

of each officer on the medical service; the number of admissions to the hospital

anld the medical service for a specified period, including breakdowns for admissions for diarrhea diseases, fevers of undetermined origin, and venereal

diseases; and finally, tie number of deaths on the medical service for a specified

period, with a breakdown by date, diagnosis, and race (United States or Chinese).

CONSIDERATIONS IN DIAGNOSIS OF DISEASE

Medical practice in a tropical and subtropical theater such as IndiaBurma requires not only new knowledge but also a reorientation in processes

of reasoning in arriving at a diagnosis and presents novel considerations in

respect, to treatment.

1. Effects of c/imate.-The consistently high temperatures prevailing in

many parts of this theater, together with the meager recreational facilities

and tile isolation of many of the posts, had a profound effect on medical personnel (fig. 240). Even in the relatively brief experience of Colonel Blunigartsomewhat less than 1 vear-- it was striking to witness alert, energetic, enthusiastic medical officers gradually "flatten out" during the second nionsoon

of their stay. The same influences were apparent in many of the patients

hospitalized for psychosomatic complaints, such as headache, backache, and

dyspepsia.

Heat exhaustion and heat stroke were not prevalent and constituted a

relatively minor problem. During the hot humid months of the momisoon season.

oral afternoon temperatures as high as 1000 F. in apparently healthy males

and as high as 100.40 F. in females were observed in nonhospitalized personnel

engaged in routine activities. The subjects had been in the area 4 months

and therefore had had ample opportunity for acclimatization. Similar

564970-- C61o -47
ACTI\ ITII.S III, NIIAtIt \I, 4 , it\., ý 1 1, 1 ANTs

.-. C- SY

I'[-.I 1:r '2 1(1 N , cr, :iiim 1;:ill. 2111h i:tl H - pil:ti.

III the :111ýcllco 411, ;111 r\pIaltati(Ilk w 1wi. Alýnll Ow 4-ItIM11111. \Ntll'tl

The It lt-plv:ld li'l, Ill' /ilw. Ird Ill

IvfI:II c(Illiplic:11 lmiý 1114. lit'l (.I..\ off"l-I \\ ;1- 111:1411,

111 111('1114-:11 p l-1- 4111111.1 \\ it It I lit, 110CO- if.\ Ill I Ill;m Il :If]

I)III p III ro l Illr I ll:lfl ('111 I'll 2) A p ril I I

:iý- I)III)IL-d ic(I to I lll-ý ollccl 11 1 Ill- It( I lit, ý1111 I lond -

I 'SA I-A BT. 1 111114-11 ;1- :; (if. I liff-r- (0, 1111111 n 11:1.\ ,

11

'llch cm lqllllml-ý :I- l4will p:1111. T111. III- Ill

III* lit 1111tT C H IT I'llf \ 4)11111111.-r ;11141

2 . tl I If .4 if I 11,1 -;1 -1 -- If I I'l-I -(I Ill 'I I I IY I w I W \Ill'

11 1 Ill, I 'If 11 1 .4 1 1 :111 11 w f I I :I I I I m c (IIII- 11 it Ill 1 11 111 k 114 1 1 1'( 1 :111

I I I I I r I I I I I I Iý I I I c:1 I I I Z , I \V I I I

it I I r. 4 f-I :1 11 1 '1 r rv ;l, I I I I 1 -4 1

I I I I T I I -

r 1*1 111 nI.I.\ I k I I rn 1 14

o :I . I I I it I - I f, it I I I I I 1 1
INI)IA-131U ItMA THilEATER 7oT

stages of the war was presuimptive evidence of anileliasis in patients with

gast roint estinal sluiptolils.

The prevlencel'it of actute felbrile (lisealses p)osed par t icularly perpjlexinug

Prob~lemls in Patients entering hospitals wit 11 fever'. At t lie onset, one ('01111011 onv, 

was unable to make at diagnosis unless tilie bllood silteitP WIts p)ositive for idaii

A pattient with mnalaise, fever, andl( Synipt onis Similar to infiluenza inl tilie United

St ates might turn out to have anythling froin iniilait it to in fectious liepat itis,

scrub typhus, or kala-azar. The Problemi was not inade easier by thle great

variety of clinical mnanifest litt ionis of' dengue and1( sttndflv f'evei'.

In the Zone of' I nteriior, one is usually niore accuirate Inl asCribll(n all of

tile patient's signs and1( syiiiptonis to at single disease ent ityv. In tilie Ind~iaBurmia t heat er, however, at multip~licity 01* diagnoses, was, frequently indiicat ed.

A patilentI with atiny l'elrile illness couldl sudd~enly dlevelop) chills and fever repr'esent ing thle activation of SuIbcinicl( malarial infection. Vage gstrolintest inail comlplaiints, not at promlinent p~art of thle clinical pictutre, iiiiglit represent

clhronic aitebiasis. Laboratory (diagnost ic p)rocedutres were ai Iindi~sp~ensab~le

aid( and~ placed at prentiuint on a well-stafredi lalboratory department.

Tfle challenging aspect of internal inedicine in the I ndia-Burnia theater

was well dlescrib~ed in the following extract froil it personal commnunication

front Lt. (Col. Jamles E. Cottrell, NIC, Chief, Medical Service, 142d General

Hospital, Calcutta, Indlia:

We are always taught, in the United States, to hunt for a single diagnosis which will

explain ll .1thle feat ures of the ease. On the other hand, in this country, we miust always consider lt(e possibility*- that the patient has two or mnore diseases, and he on1 watch to finld the(

others that wve have not Yet diagnosed. I have mYself seen a1 inan lrotulght in froin the

lBurma~ jungle with the following combination: inalaria, scruib typ~hus, anioebiasis, hacillarv

dv etradmiiaiss Equally impressive combinations of dliseases are not tUncomumniot

in Chinese soldliers.

MILITARY IMPORTANCE OF DISEASES ENCOUNTERED

The ext remlely high incidlencee2 of tilie (liarrlleal and dy senteric (diseases

and mitlatria contributed heavily to the t heat er's nonleffect ive ritte. &Srub

typhus and~ cuanou liphitheria, thloughl less important statisticallyhmed

military operations b~ecauise of' their occurrence in conilbat areats and1 tle serious

dlisabtility ihey occ.isionec(l. Soilme dliseases, such-I Its inlfectijous hillepat it is, (eile

atnd siindfly fever, were under (constant scrutinly because of their possible

ep)ideleiicity, while O1thers, such ats polio] lveli tis, filari'asis, and kitla-azar, hiad(

a deleterious effect on miorade. C'ert am dliseases withI considerable incidence

in t he native pop~ulattion were never encounteredl in the p~ersoinnel of the U.S.

2 Statistical data presented in this chapter are preliminary and are subject to revision on thif lu-sts of final tabulations

of Iindividual mnedical records. staltistic b ave been derivedI from several sources but tnail, ly front the statistical health

r Isorts. Fromt the beginning of tihe war, through October 1444, data on V.S. Army troops in Tiurma-India were included

in the consolid~atedi reports for the China-Burma-India Theater of Operations. '1wInclutiiesion in tlit-ildata of the efxiitrielOS

of the troops In China (luring the early period doe5s not slgnifleantiy affect the validity of the anaiysis made in termq of

Biurros and India because, before November 19t441 tile Army str4 ngth in Burma and India represented nine-tenths of the

total strength In the China-Burma-indlIa theater.
Ak.

oi i 1.S t 1.Ariiiv t im S. H t~l di lo.NPi

Arml l 'or i isllS IS likel th I'tetr bil : holsifh Iihled li';Iilts ~~Im e iilhg Ilthi'lnth ihIlst

I1)1)111III l ht'ea iv I \\;Is'l~ 1111' IIltgv ; 'i lv j I ic ll I It I lit' Il'o~ we i Iow v r IIi con- Ie
INDIA-BUIMA TIIEATER 709

CHART 5.-Monthly admission rates, all causes, U.S. Army troops in India-Burma theater,

January 1943-August 1945 1

[Preliminary data based on sunmnarics of statistical health reports]

[Rate expressed as number of new admissions per annum per 1,000 average strength]

Rate

1,700

1,600"19AA

1,500

1,400

1,300

1,200

1,100 43

1,000 14

900 - -"

800

700

600 , ,

Jan. Feb. Mar. Aor. May June. July Aug. Sept. Oct. Nov. Dec.

I Includes 'ases admiltvl in China prior to November 1914.

and the necessary reliance on canned articles led to a monotonous diet and

increased tendency of solliers to frequent civilian establishments. Although

the low-caste Indians employed in Army Iiesses often lived in fairly favorable sanitary surroundings adjacent to the militry area, most of their insanitary

habits were unaffected by contact with U.S. Army personnel. The Indians

had spent their lives in an environment in which defecation was promiscuous,

usually taking place near bodies of water and wells. The use of toiler paper

is ob)jectionable to them, for they consider it an insanitary method of cleansing.

They perform anal ablution after defecation, washing themselves with the left,

hand and then rinsing the hand with any available water. Soap is rarely used,

not only because it is frequently out of their economic reach but also I)ecause it

is often made from animal fat, with which they avoid all contact for religious

reasons. Even those that can afford knives, spoons, and forks do not use themn,

preferring to eat with their fingers. The entire family eats from one or two

central dishes, all using their hands in place of tableware. The low-caste

Indian regards the presence of flies as inevitable as the monsoon rains; swarms

frequently can be seen resting on prepare(I food, which may l)e only a short

fly hop from excrement o(i ground near their (Iwellings.

The urgent military necessity of sending military personnel into this part

of the world did not permit the inauguration of adequate preventive measures

from tile outset, and it was almost itevitable that diarrheal( diseases would

constitute one of tile most serious medical problems (charts 5, 6, 7, 8, and 9).

The noneffective rate caused Iy tile diarrheal diseases in 1944 was very similar
"d I ACTIIVIT1IE'S OF MEDICA.L ('4 NSI'ITANTS

CHART 6.-Mlonthl admeiI~iss'ion ratIes, aill dI~'iscas, U.S. AIrmy Iroop.s in I udia-flurmpa theater

Janunary 1943.- - Igusl 1945 1

(Pirehinhw dl~r ata i tased on summarnries of stit istic:ii healthi reptortsi

(Ilatee \ ir-'st' itas mnonber oif new titlinfss~ioii per annumn per INKI average strvngtsh)

Rate

1,600 14

1,500

1,400

1,300

1,200

1,100 -14

1,000 -14

800

600

500

Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec.

IIncludes civws admii~twd. in ('hum prmior to Novenber 1U44.

to that. c'aused by nialariat (chart 9). Manly Patients With g'astrointestinal

dlisorder"Is und1(oubtedlyV (onint ifhed to serve~ oil active dluty, anid colis((l11('lltI

t he act ual incidence wits JprohablY even greater thanl tile statistics Would

inidicat e.

Types encountered

ANI EJUASIS

Of tilie diarrhelial and dlysenlteric diseases, aiielinasis p~resentted the( most,

seriouls problemi (chart 8). It wits so regardled not only beeause of its high

inicidlence buht allso b~ecause of its insidIious chatracter, the iiecessityv for early

dhiagniosis andl thloroughi treatimeiit to prevent infect ion from s'preading, tlie(

dliff'icult ies of lab~oratory (diagnosis, and thle seriousness of tlie( late coimiplica~tions.

"Thle solution to thlis Probleni wats 11long two (distinct lilies: Prophiylaxis

ea 'Vigorous .n~ act ion ill idleitify ing and treaigaral netdidvdas

The protect ion of nilitary personniel fromt infect ion with E'ndam~oeba h isqtolytwe

wats thle responisibilit y of thle preventive iInedicinle sect ion of tilie theater suirgeon 's office. 'I'le iieasure's unlilert akenl aire dlescribied elsewvhere. Ili b~rief,

these consisted of p~rovidhing a cleaut supplIy of water (fig. 242), fly 'ont rol,

eliminuiationi of native food handlers from Army messes ats far ats practicable,

periodhic examiination of aill food handlers ait sulitable iiitervak. inspect ion of

Civilian eating establhishmenits ui~ld placing un1sat isfactorvY onles out of bounds,

survey-ms of varliouls units to detect carriers, andl( the supervision of laborattory,
INIIIA I'l I.AlA 1,11 EATEN 711

it 1. 2 12 . ýi I ý-r o l I riti c:I I i., I 1 111:1111 :11 1 "ýl 11 ;1-Tw r:1 I I I ()-p il:1 I vA IT I- I I'l Ic I cd 1).\ 4)ýp ila I

P" -1.

I III speci.11 st ildle, Id* I liv p'-I I rv-qmll-ýIlllo fol I he

I-In"ll 41,1"'Ose'S.

Tlw 1111porkill(II, Of swile ()I, llw v I"Iclors \\,Is IIIIIS11"lled hY Ille c\1wrivilco

\,Irlwl-ý Illedic.11 llflll-ý III \0114-11 IIIv 1111.1dollf-c of '11111,16c ilifeclioll ,()()It offer

.1 ITI \ d III tills Olvalor \N.Is alormill'-dv Iwdt. V() r I list ;I lice, III (d It ) I I

()It ()I, olllvhln-ýIs hY MnA. (Inter I'l. C(d.) Nllx NIC, will

hl-ý n-( wlnloý, it Ow 241h Ilospit'll 11 Jorlint, III(IM, it \Xas found 111.11

-I ppnix I I In I cl v 15 percei I I td' I I it- I I I i I i I

I II.II* V p'l-solillel of Ille IlospilA 1111'ered from

zlllwhl.1,1-ý smm Iliv IIIS1,111,11iml iiperalions. To (.111-1) tills III,-II rn t r.

I*I-vSII veuclobles werv scrupillmlsk- prolml-ed

1111do.l. cmisinill sillw1wl"ý11)II, Olld 11,11,1Vvs Wel't, IMI nllm\(ýIl to vilter Ow lotcheli,

Mir p-l-IIIIII(.41 14) 11,111illo .111 v lifolisils offer sl(.I*Illzlll()Il. The clillre persolillel

Id' fill, III'lollollml \\.Is IIl-vvYvd, 11141 111 illi'vried pvr-ýmls \\vIv Irented. I it-

,11,114.1 Hill, III re--m-d 14) llwo-ýlllv'ý \\(1111 Issiled 'Ind cIII'm-col. Tllv IliI, -f - I I I' :I I I I I I I it m 1 -4 1 1 st ri k I I I,,-- v( -rvo so, I I I( I I I I I v not ;I slngdv coC

4)"111ITC41 III lilt- pcrý,milwl of I III., II)II 111 .1 pvriml ()I, III(Wo 111,111 G Illoill Its.

Ti., :I I I livid \\.IS I he pl-m-111cold, I liv 1114.411col cmIS1111 1111 . Al I lit- 1 11114, ()1()-

Hid BIIIIII.-,ort \\ Is I I I I I , ,-; .\ I " I I V I' . I he a va I In ble ovI( lom-1. 1111 11 11 ot I

Ih.-if imin- I li;m 25 1wrveW t4diol-l-livo III Ille reg"Iml \\.Is (lilt- Io .111wbic

VI'll, It, fill- 114),plink I-v\voled 111,11 If,-; 111,11111'estoliOlls \\cI*I1

11M op1wri-I'lloll. Brief, opl-ýmlv-4 ()f \\vro bvlll,_ý, dlwý:Ilovd 'l,
712 ACTI'ITIES, (F MEI)ICAL CONSULTANTS

CHART 7.-Mlonthdy incidence ratfes, diarrhea and dysentery, U.S. Army troops in India-Burmna

thea ter, Januar!) 1.943-11 I ugst 1945 1

(Preliminary data i'ase I on sufliuiaries of statistical hevalth reports]

IrRate expressed as number of rim admisinhlsh plus secondary dliagnosis cases per annum pe~r 1.000 average strengthl

Rate

400

1944

300

I *- 1943

o.

200

0/

Jan.Feb Ma. Ar. My Jne ulyAug Sep. Ot. ov.Dec

Includes. cae/ditdi hn ro oNvme M

simple~~~~~~~~~~~~~- ae dirha fcnchptts eebig igoe spylo

nerss an th stol of suc painsuuly-entbigeaie.I

was~~~~~-. eonzdta -o Dli el"an odpioigwr rqettigihn laatrsti fE. hitltc fotE oi n te o .aloei

Jnan. eb. Mar. Apr. Mlaslary Jundersod July Aug Sepett. Oct Nolv. Dec.

p nloy i( led trat idng thed pnatiena rto ovared nor 1944. i opta ohoptlbu rn

sierpe flirrquentl nelcases of, chronclheutiisn wereatbeint, dagnosd ase pchponeuronts, and t eoetully ofasucuate.iehetsiusuallycoeretiot ofeing epatinednts

was not recoguited tafterDelhiiBelly"oardefoodtpoisoninghwereefrequenletd

Sonelic patiens enery. oTher impotancei ofbecaursn pfroecurenstool speiniensctien

paond recotreatingtheviu patpietsariedatiol nl fere ot hospitablet. optl rn

were frequentlyoneglectedia atthek cnlson ofes trobeaments alng the followipno

three main approaches: (1) mitcreased accuracy in the dletection of cases of
INI)IA-BUILMA T1IEATER 713

CHART 8.-Noneffectiveness from all causes, from all diarrhea and dysentery, and from amebic

dysentery among U.S. Army troops in the India-Burma theater, January 1944-JulY 1945 1

[ Prelimniilry data based on sumnmaries of statistical health reports]

[Rate expressed as a\verage daily noneffeetivewiess per 1,(X0O average strength]

Rate

50

"THEATER - ALL CAUSES

DIARRHEA & DYSENTERY

AMEBIC DYSENTERY

40

30 - - - - - - -

20

10

0

J F M A M J J A S 0 N D J F M A M J 1

1944 1945

SInc.ludhes cases admittedI iln Ch"]it 1prior to November 1944.

clinical amebiasis and the ideiitification of all carriers who entered the hospital

because of other diseases, (2) imiproved treatnent in order to eliminate the

disease in the hidividual patient and prevent his becoming a carrier, and (3) followup observation of all patients in order to be certain that repeated tests of

cure wouhld be made and therapy instituted in the event of recurrence. By

encouraging reports of the results of the various measures undertaken, improved

methods of practice were hoped for.

The initial step in this program was the preparation of Circular No. 9,

which was issued on 2 April 1945 by the Office of the Surgeon, Headquarters,

i I- ll - - - - - - Illllllll - - - - - - - - - - - - - - - - - - --
714 ACTIVITIES OF MEIt'AIL C'ONSULTI'ANTS

CHART 9.-Noneffecliveness for diarrhea and dys/.entery and for malaria among U.S. lrmy

troops in the India-Burma theater, by month, 1944 I

(Preliminary data based on summaries of statistical health reports]

I[Rate expressed as average dally noneffectiveness per 1,000 average strength]

Rate

7

.Malaria

6

5

A Diarrhea &Dysentery, \

2

0. I I__ I__ I

Jan. Feb. Mar., Apr. May June July Aug. Sept. Oct. Nov. Dec.

1944

n Includes cases admitted in China prior to November 1944.

USAFIBT. This directive outlined the salient clinical diagnostic criteria for

the various forms of amebic infection. The pathology of amebiasis and the

technique of stool examinations were briefly reviewed. A section on preventive measures was included. The various complications and sequelae of

amebic dysentery were delineated. To achieve greater effectiveness and

uniformity in treatment, a conservative basic scheme of therapy was recommended for amebiasis in each of its various manifestations including complications and sequelae. This circular was the foundation of the entire

program. The following paragraphs elaborate on each of the three phases

of the clinical problem.

Diagnosis of the disease group.-The first. main approach to the problem was by increased accuracy in the detection of cases of clinical amebiasis

and of all carriers who entered the hospital because of other diseases. The

onset of amebic dysentery is frequently insidious and may be characterized

by only vague symptomatology with but slight constitutional reaction. Consequently, the disease was often not diagnosed. It was essential, therefore,

[ ~~~- --- - -- - ---- - --- ------- - -lJ~lel lm tdlw lt mi i dJ • • •
FiT B I, 243. -20th Gvn(eiral I [opjil al

to llincrease the indlex of suspicion of all mnedical Officers. Thle prevalence of

diarrhea ini military personnel, even ini the absenceIC of amiehic infect ion, only

adldedl to the (lifhcuty of dliagnosis. For eXmnlI)I, Capt. AIIwer MANhe, SnC,

init astud ti1 t the 20th1 General Ho0spital As Xsain, India11 (fig. 24.3), of thle carrier rate in 506 apparently hiealthyi Unit ed States soldliers who 11a1( spenlt 23

mnont is in Indlia, foYn that of 47 E. hi4o1hica. carriers only 11 (23 percent)

gave at paist history of diarrhea. In the 4.59 found free front infect~ion, 12. 61

percent gave a past. istoy of (Iial'rea This experience was simiflar to that

ob)servedI elsewhere in thle thea ter'.

Major FEllenberg andl his assoc'iates in their study likewvise observed t hat

of 4S6 patielits who eliterem the hiospital for conplaiiits dhirectly or indirectly

relat ed to aielbic infection, (hirriln was by v Ino mans I uIiliformlvl chiaract erist ic (liagnost ic syniptomi. Abdomlinal panis were by far thle mlost frequent

(onlplaiiit (70 percent) ; actunal dia rrhiea was, onily half as (.01111101. Moreover,

lie patients with dia( nrrh ea rarely haId nIarked Ifequency of bowel mlovemients.

Thie hiigh iniicidence of naulsea and vomnit inug (29) percent ) and1( anorexia (26

percent) oft emi led to .1ii erroneous (liagnosis of guistrit is or of pvp~v)thy ucr, as

shiowni in at study on pneummmop(''tonun'im iii the (diagniosis of (leformnities of thle

liver by Clark, Bercovit z, and -Jones at thle 69thI Greneral IlosJpit al, 5 mniles

northmeast of L edo, Assaiinm, Inidia. Ini t heir opinion, exanniinat ioul of thle abdonien elicit ed chairzact erist ic phy isical signs, leadn( ig to a1 hiighi perceiit age (if

correct cliniia enIiangoses prior to tie receipti of th laehibora t ory report . In
716 ACTiVVrrni*:; (F MEDICIAL CO(NSULTANTs

hIis st iidv. abd)(oninail examhinat ion t ,lyicall 'v revealedl a tenider, squashy~ cectin;

it le", teliider, palpabilIle, ropy2 sigmfoidl; right, tipper qtiiidrauit teniderniess; and

shock t endehrness over t ie( liepa tic area.-

Promnine'nce of somec of thlese 5VAfl1 tonifs and1 signs wits not uncommronly

(lilt' to amiebic colitis silitiilt ing acutet( aivpetidcit is. The Comnbinat ion or

abdol(iiiiiil paill, voimitingf", and tendlerness of the rirght lower qlia(rainlt fre-

(j11ilelt resultedl in thle admlission of Such pattient s to the surlgicall service.

Tile Slirgevoli alert to lineielsiisi w~itsno 1)0vratlily dleceivedI, for at luisto(WV of di1arrliheil, abdomonliill t enderniess over otther port ions of tlie( lairge bowel ats well,

and indutrat ed, tend(er sep-Iiients of I ie( lar1ge intestine ind~icated tilie a(Ivisabilit v of stool examflinatijons, p)Ioct os('oI), anid~ other dliagniost ic tests. Tlie(

p~resenice of amenii (coit is wvas, however, 11o guaranty that thle patient (fill not

also havi e acuite aplpenid icitis till([ recj iinre surgical inuterveit tion. The general

cfliiciil impressioni was, Indeed, t hat afliehic colitis predisposed tlie( pat ient to

aicutie applPld Iici tis. It was thlerefore adlvisedl that , wlieii a nv pat ieiits showed

coniivl lc ig signls of acuite a ppendicit is, delay inl surgical intIerveintion wvas, not

to be counit enanced. Whlen, however, thle evidence wits equivocal, symptomls

and1( signs, vague, and1( conlt inuedl observat ion considieredl safe, at short. course

of anit ta iuel ic t 1era py oft en resolved(l th d ileinnial

Ini tlie( generviall experienlce of muost observers', lhlivsial exaiminat ion Wats

en t irelyN liegaiv e ill fromt oiie-tIilirdl to onle-mialIf of tIit(' pittieii t hiospi talized

for a mel )iilsis. Wi uen phsial11-ls were present, t hey were feunl o

st rik Ig , and were cohliihi( I to (t( lie a)(lolien. Inicreased reliance onl stool exanliiiuat bus wa-Is, therefore, tieceSSiir..N

TIo il"Ilire atccuirat e laboraltol oiv diagnosis, it was es-sential to have wvelltraii ie perisonniiel anll to ma iiit ali iiClose lialison bet ween t ie( miedlical ward

ol licers an til e ab-lit oi'a ,rv. Few well-t ra i ied litbora t ory t echinica 115 were

availii IIal(isa os'itiewnci there wvere missed diagnoses or, equally deplor-able, falsel ,vPositive (il~igoses. This situiat ion wits correct ed in timle by

visits, of C olonel Van Auken of the( 9th MN edical I abora1torvY to thle laboratories

of tlie( hospitals in this t heat er. ILabor-atory, techiliiiianls wvere Sent to tile ()th

MIed(Iical I abora tor *v for at refresher course of several weeks. Stepsj) were

takenl to slipplYl dispenlsaries wvith ll nicroscolpe5 iand~ liecevstry e(j uipntent, to

perform) Suit aide stool exaiminat ions.

Ill thle larg-oer stat ion and1( grenerall hospitills (dysen tery wardls wvere orgitnized,

if t his had iiot alreaidy ,lveen (lone. A part of tile ward11 wats part it ioiied off

a id eq iiilppc Ifor hao-i oat orv St udies of' stool Spec imenis aluld Siguioidloscofpv.

This arrailglpmient favoredl prompilt (eleiver-Y or Sped cimes ; increased (1t1h in te(rest

and1( proti('iolcvN of tble iie(Iival oflicers in) thle iii1kilnVigeien t of thle various

(I I NSvillteric diseases ; I'l iii lifili rized ti( lixe t d Ne vard p~ersonnewl with riiolit lie techdlniq lies, wh ichi were (oiisequnl t ,ii v carriedI oult withI greater dhispaitc clin ai v fficienc .N aindI facilitalted ciii ploviu lent of tite Inc(evssary precaulitn t iagil in5t

illfect ion (fig. 244). Suich anl arranigeentvi h ad been in operat tion ait tIit('

20thI Genieral I ospit al midi was fullY describied by 1st Lt. (liter Capt.) Arthur
FXit~J;va -l. 1 2 1. 4ii114'(Ii f~irt-pzlc,ý 111 i(4' 1 :;itii 69 1114 lllal .hl-4'41141ill ratlll. i o f wank1114.

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INIIA-BURMA THEATER 11)

and treatment of amebiasis. In analyzing 62 of his cases, he found they fell

into four distinct groups, which were readily differentiated clinically, as follows:

Acute amebic liver abscess, acute amel)ic hepatitis, subacute amebic hepatitis,

and chronic amebie hepatitis. Major Klatskin stated:

The acute abseess cases were characterized by liver pain, high fever and frequently

by cough. A definite mass was demonstrauble in the liver either by palpation or by X-ray

examination in every instance. The right lobe of the liver was generally enlarged and

exhibited compression tenderness. Abnormal pulmonary findings were frequent. Marked

leukocytosis with only slight increase in the percentage of polymorphonuclears was the rule.

The acute hepatitis cases resembled the abscess cases except that no mass could be

demonstrated in the liver, liver pain and cough were less common, diarrhea and cramps

were more common and lei|kocytosis was less marked.

The subacute hepatitis cases differed markedly from the others. Only half of them

complained of liver pain. Many were admitted because of diarrhea and cramps and were

found to have enlarged tender livers. Fever was inconstant and when present was low

grade in chalracter and intermittent. Cough and abnormal pulmonary findings were unusual.

Leukocytosis occurre(d infrequently and when present was usually mild.

In contra:wt to the first three groups of cases, in which symptoms were usually present

for less than ten days, the chronic hepatitis cases were adnmitted with liver pain of long

duration, ranging from two to twelve months. As in the case of subacute hepatitis, fever

and leukocytosis were inconsistent. Diarrhea was fairly common and cough and abnormal

pulmonary findings occurred occasionally. * * * It must be remembered that cases in

one group may advance or regress to another, either as a result of treatment or spontaneously under the influence of factors already discussed.

In this series of cases, the most characteristic symptom common to all

groups was liver pain. This pain had a number of distinct features. It was

usually localized in the right upper quadrant of the abdomen beneath the costal

margin and less coinnionly in the left upper quadrant, in the epigastriumn, and

in the right lower chest. It was usually described as a constant ache or an

intermittent sharp pain and, as a rule, was only moderate in severity. Major

Klatskin noted:

Aggravation of the pain by movements and change in position was a prominent feature

and was of great diagnostic significance. The principal aggravating factors were deep

breathing and cough, bending and twisting, lying on either or both sides in bed and jarring.

Frequently the patient spontaneously offered the information that these l)roduced or ageravated his pain, but in many instances it was necessary to inquire specifically about their

effect. The effect of jarring, especially on riding over rough terrain, probably occurred

more frequently than indicated, as many of our patients were not asked about it.

Radiation of the pain was very common, especially on movement or change in position.

In several instances, the first complaint was pain at the site of radiation, and only later was

pain noted in tl:., liver. This led to a wiumber of diagnostic errors, especially when radiation

was to the chest. The common sites of radiation were the shoulder, chest and lumbar

region. On one occasion, it radiated to the neck. Radiation was always to the right,

except in the three patients with involvement of the left lobe of the liver in whom radiation

occurred to the left.

The compression test proved to be of great help in differential diagnosis. It clearly

demonstrated the hepatic origin of the pain and differentiated it from that arising in other

structures above and below the diaphragm. The test was tried in a great variety of conditions inelllhling pneumonia. pleurisy, renal colic, pyvlilis, acute dysentery, peptic ulcer and

malaria with enlarginent of the liver and was invariably negative. It was also of some value
720 ACTIVITrIES OF 31 II CAL CO NSULTANTS

ill differentiating anioebic from infectious hiepat itis. in it large series of infectious hiepatitis

case's, inl which tile test wits tried, it wats negative int all but, at few. Thet only other conditionl

inl which thle test wats inivariably positive was acuite cholveyst it is. No doubt there are other

conditions, such as siffphrenic abscess, ill which the test. may he p)ositive.

Compression tenderness is 1) no means to be consid(lred pat hogimomonic of hepatic

amoebiatsis, but it bas proved its worth as at confirmiatory finding, and in a few instances it

has made anJ early diagnosis possible ili the absecelC of other fiuidimigs.

Therapy.-The second main approach inl clinical attack was lby iniproved1

treatm~ient inl order to elinunate thle disease inl thle indlividual patienits- and prevent.

thieir becoming carriers. The importance of early adlequate treatmnent of

amlebic dysentery, well recognizedl iy those familiar with the disease, wats not

fully appreciated by most U.S. Armny mtedical officers. Inl thet ais-elice of prior

(directives, the therapy of the vairiouis clinical manifestations wits variable 1an1d

characterized tit times by practically sole relianee onl earlbarsont, or one of thle

iodline comnpounds. The treatmaent outlined inl tie theater dlirect ive onl amnebiasis (Circular No. 9, April 1945) wats similar to that. advocated inl paragraph

7 of Circular Letter No. 33, 2 F'ebruary 1943, Office of the Surgeon General,

United States Army, entitled ''Treatment, and Control of C1ertaini Tropical

Diseases." This therapeutifc regimie will be evaluiated whten the results of treat.-

inent ats recordled ill the aniehiasis registers tire~ finally available and analyzedl.

It is of interest that at similar regimne wats employed independently by

Major Ellenberg, andhi s associates and 1)y' Captain Rogers andl C olonel Elsom

with apparent success. Inl their study of 8.33 cases, Major Ellenherg

employed three types of treatment., all of which were similar inl that emietine

and carll-arsonle were administered (luring thle first, 10 days, one of thle oxyqui noline derivatives such ats chiniofon, Vioform (iodlochilor-olydrioxylquinolinle),

or Diodoquin (diiodlohydrloxyquintoliie,) from the 11Ith to thle 19th day, wvith

either carbarsone or chliniofoni enemtas onl alternate (lays (luring this latter

period. The average timie of disappearance of signs and symp~tomms wats 8 (lays.

The investigators dlescrib~ed a not infrequent reaction to treatment onl or ab~out

the 4th (lay, which closely simulated thet original symptomls aind usulally canisisted of cramnps, diarrhea, at moderate rise inl t emi pent ttire, andl general ma'1laise.

They stated: ''* * * one must considler thle possibility of this representing at

'lerxheiimer' type of therapeutic response and not necessarily* at toxic reaction

* * *."l At the conclusion of treatment, at proc tosigi oidosco pic examination

was performed inl every case and wats followved by stool examiinations after

at salinie purge. Of the 833 cases, thie stools were found to be negative in aill

lbut 10; these responded to at second course of treatment. Thle results did ]lot.

indlicate the relative superiority of any of thle three oxyquiniolinle drlugs used.

There were 9 recurrences inl the series of 833 cases. Of the 9, 3 recurredl within

3 monfths following completion of therapy. Thle other six recurred from 3 to 6

nionthis after conmpletion of treatment and may have been reinfections. Thus,

there wats anl overall cure rate of 99 percent. These successful results miay be

attributed inl part to early diagniosis and treatment of the cases: approximmately

75 percent, had had synmptomus for less titan 1 nionthi and only 7 percent longer

thian 3 months.
INDIA-BURIMA THEATER 721

Toxic effects from the drugs in the dosages recommended were infrequent

and never serious. Subcutaneous instead of intramuscular administration of

emetine was less painful and had no ill effects. In a few patients, two injections

of ý grain daily, instead of the customary single injection of 1 grain, obviated

the attendant nausea.

Major Klatskin analyzed the effectiveness of treatment in 69 cases of

amebic abscess and hepatitis. He employed the following criteria for cure:

(1) Complete absence of pain and fever, (2) absence of liver enlargement, (3)

absence of subcostal and compression tenderness, (4) normal white blood cell

count and sedimentation rate, and (5) absence of E. histolytica from tile stools.

The treatment consisted of repeated courses of emetine until the criteria of

cure were observed. Thereafter, emnetine was supplemented with one or more

courses of Diodoquin or chiniofon, followed by carbarsone, to eradicate the

associated colonic amebiasis presumed to exist in all cases. The schedule of

treatment consisted of a first course of 12 grains of emetine given over a 15-day

period; then a course of 1 grain daily, given with a 3-day rest period after

the 6th or 9th dose, depending on the patient's reaction to the drug. Most

patients tolerated 9 grains, but occasionally patients complained of weakness

and exhibited a fall in blood pressure after 6 grains. After a 3-day rest period,

Major Klatskin found they were able to complete the 12-grain course with no

ill effects. He wrote:

The first course is followed by a two-week rest period, at the end of which emetine

therapy is resumed. Courses of six grains each are then alternated with two-week rest

periods until the criteria of cure are met. A rest period of two weeks was chosen because

it proved to be sufficiently long to prevent the cumulative toxic effects of the drug. Also

it was noted that considerable improvement often occurred up to two weeks after the drug

was stopped, so that the total dosage of emetine could be kept down to a minimum. Where

the rest periods were prolonged beyond two weeks in the face of liver tenderness, leukocytosis

or an increased sedimentation rate, a clinical recrudescence frequently occurred. In a few

of the more acute cases the second and third courses of emetine were given at eight to ten

day intervals with no untoward effects. It may be necessary to shorten the rest periods

in this manner if a recrudescence with fever occurs.

Except for the occasional weakness and fall in blood pressure during the

first course of emetine, no toxic effects were seen.

The total emetine dose required to effect cure varied with the type of hepatic amoebiasis.

The abscess cases required the largest doses (average 21.9 grains in 47.6 days), the acute

hepatitis somewhat less (average 14.4 grains in 33.4 days), and the subacute and chronic

cases the least (average 11.2 and 12.4 grains respectively in 16.1 days).

The largest dose of emetine administered to any patient was 27 grains, the smallest 6

grains.

The response to emetine usually was so dramatic that it was considered

diagnostic of the disease. Of the 69 patients treated, 68 were cured. One

patient, though afebrile and greatly improved clinically, had a persistently

enlarged and tender liver.

Relatively few cases of hepatic abscess requiring aspiration or drainage

were seen in the theater. Captain Rogers and Colonel Elsom, in their study

of 444 cases of aniebiasis, at the 20th General Hospital, observed only 4 patients

5649701- 61-48
722 ACTIVl'ITIES (IF MEIC:DAL ('0NSUILrANTIS

withI liver abscess. IIn tile localization of Such lesionis, the( possible usefulness

ol p)ieutioperitoiieuin wa-s Stutdied by C oloniel Bercovitz and his associates ait

be 69t Iimi General i lospjitial. Thiri ol)Servalt iolls Were tIot conclusive buti

I indicatedl thle p~ossible vallue of this techniique ats at diagniost ic ad(junlct. III the

bheater ET.NID for August 1945, C ol. HIarry C . II till, M( , and his associates

ait the 142(1 Genieral H ospitali relportedl it contrilbuition, of conisidlerablle mierit,

to thleralpv of lhepat ic abs)cesses. Fliese oflicers t reate(l two pittieuits wit Ii

amiebic abscess of tlie( liver by closedl drainiage aftfer visuitlizat ion withI diodlratst

BothI paittients were( gravely ill (des pit e emi lloYii en t of all1 accep~te m'I easuires.

uinctliuding rep~eaited' asp~irat ion. Und~er local a it'estiliesia , a1 catibet er was inisertedl

int o tlie( abscess clitvi tv, closed drai lagelo with iSuict ion wiis inst itutted, andi~

penicillin inject ed (liil ,v into tile ab~scess cavity and1( allso int raveiiously. Bot 11

pa11t ieiit s iiialde ftill irecoVei.v.

'lo ap pjraise thle plain of t reiatmient inl use and to elaborate imiprovedl

iiethlods of t herap l 1, programii of' cliniical inivest iga tion of' tilie (lilt rlleivll dliseases

wats p~lannhed 1ii1d p~ut into op~erat ion tit, thle 142(d General H ospitalt. Tile

re~lative valule Of thle OXvu WliliolPn drugý,s, tlie( evitlua t ioul Of eii iet i ii and tilie

possibility.N of either omlitting it froii the treattmieiit or acuite dv3seiiterv or

suibstituiting ant Oral p~repiarat ion, the( ellicaceY of tilie oxyquiniolijie dlerivattives

il t reiatiient of iisviiiptonliat Ic cairiers, atnd~ tilie possible valuep of chieiiothlerapy,

Such ats ulse of tilie stilfotia iliiies lii~ld/or penicillin, inl affecting thle secondary11%

bacterial invalders ill thle bowel wvere Soiie of tilie problemis thaiit were' lpropose(l

for investigation. The end of hostilities interfered with the complete fulfillmnent

of this programi.

Followup observations.-Tlie thIiird imed ical approach wits thIirou glh followu p

Ob~serviat ions of till patients ill Order to be cert aml thaiit repeat ed tests of cutre

be iii in e anud t berapv inst itut ed inl event of recurrences. Post treatmeneut. examii- mlitt ions iiitist b~e Viewed ats part of tilie nianiigeiliet, of thle p~atient its well ats

part of tilie control of thle Spread of these (diseases. Tlte necessary* transfer of

u)erso)niel withlin the thbeater led to minsat isfactory followvup of pattients withI

anieliiasis. Tests of patienits' stools onl ret urn t'o (liit 'v after hospit alizittion

usuially were not p~erformied. Wien paittieiits reportedl to dlisp~ensaries or were

readiii itt ed to liospita its beca use of glist roint est inal coinplatints, recordls of previouis liospit alizat ion wvere not itvailable. Restilts of p~reviouis cliiiicitl findings,

lie( prior diagnoses iand~ response to t reidtment wvere unknown. It wits believed

inl tilie O ffice of tilie Surgeon, moreover, t hat thle inad~equaittely t reatedl miilit ary

p)erson nel miiighit, Onl t heir ret urn to thle Zone of In terior, prese:nt it p~ublic htealthI

p~rob~lem it. casirriers. To rem edy lvIiis Sit ua tion, it wits decided tha tll Itanniiebialsis

register analilogouis to tilie s *yphilis reitrShudbiniadfo le pint

This register coniitinedl it sumnimary of till p~ert inent clinicitl (hitt it, restilts, of exa iiii it t ilis, and a ii iii in itrv1 of t li treatmiient. lrev iotislv enpi loYed . The register was begtin bY thle niedical officer iiaking (t(li original (diagnosis, wits mailtitaitled bY ti( ledui~ical Officers curreuitlv inl ch arge of treittiment of the citse, anid

wits forwarded to thle surgeon of thle pittient 's new St at ion or coimimantid. When

at satisfactory remult hand [)evil attitined or w~hien the piatient wats transferred outi
INIDIA-BURMA THIEATER 723

of tile theater, the register was forwarded to the Office of the Surgeon, Headquarters, USAFIBT. Besides the purposes of this register just mentioned,

evaluation of the therapeutic regimes employed was made possible. When the

registers were forwarded to the Surgeon General's Office at the conclusion of

the war, they were studied and were made available on subsequent hospitalization of the patient in the Zone of Interior.

Only meager information was generally available regarding followup of

patients hospitalized for amebiasis. Major Ellenberg and his associates, however, performed a 1-month followup stool examination in each of their 833

cases, a 3-month followup examination in 60 percent, and some were followed

for varying periods up to 11 months.

Of particular interest were the results of their followup in 101 cases in the

personnel of their own unit whoni they were able to study with especial care.

Twenty-six had beel) hospitalized because of clinical manifestations; the remaining 75 were asymptomatic carriers. All had a mnnimum followup period of

6 months, and 81 were followed monthly for 11 months. There were only 2

recurrences in this group of 101 cases; one a symptomatic and the other an

asymnptomatic case. As previously stated, the remarkable cure rate of 99 percent in the entire series is to be attributed in part to early diagnosis and effective treatment.

Of the 444 patients with amebic dysentery studied by Rogers and Elsom

at the 20th General Hospital, 162 followups were requested and 84 (35 acute,

20 subacute, and 29 chronic) were obtained. The total followup period was

from 3 to 6 months for 25 patients, 6 to 12 months for 24, and 12 to 23 months

for 35. A summary of the findings in the 84 patients follows.

Number

Hlistory: Findings of cases

Abnormal bowel habits --------------------------------------------------- 9

Periods of diarrhea ---------------------------------------------------- 36

Abdominal pain- -1------------------------19

Sick call attendance_ 7---------------------

Weight loss ---- ------------------------------------------------ 66---- 

Weight gain_-- ------------------------------------------------------ 45

Physical examination:

Liver palpable ---------------------------------------------------------- 3

Liver tender ------------------------------------------------------------ 1

Colon tender ----------------------------------------------------------- 10

Stool examination:

Trophozoites ------------------------------------------------------------ 0

Cysts ------------------------------------------------------------------ 2

Sigmoidoscopic examination:

Active lesions ---------------------------------------------------------- 0

Healed scars, definite ----------------------------------------------------- 3

Healed scars, possible ---------------------------------------------------- 3

Total with history of findings suggesting a recurrence of amebic dysentery or chronic

dysentery during followup period ------------------------------------.------ 0

At the various hospitals, readmission for amebiasis was not uncommon.

In a theater where repeated exposure to infection was inevitable, one could not
724 ACTIVITIES OF MEI)ICAL CONSULTANTS

confidently distinguish between recurrence and reinfection. Disposition to the

Zone of Interior of patients with persistent disability despite therapy and of

patients with persistent organic intestinal damage limited clinical experience

with this important group of cases.

BACILLARY AND OTHER FORMS OF DYSENTERY

The numerous cases of dysentery l)revailing in the India-Burnla theater

and the limited hlaboratory facilities generally prohibited detailed laboratory

diagnostic study except in special instances. However, the Sub-Commission on Dysentery of the Army Epidemiological Board reported in Noveiimber 1944 that, of 369 cases admitted to the 20th General Hospital because

of (liarrhea and of 175 cases seen in dispensaries, stools were positive for ba- cillary dysentery in 24 percent and 16 percent, respectively. As Colonel

Blumgart advocated examination of stools for E. hi.tolytica in every case and

reconiniended equipuient of the smaller installations and dispensaries with

micros(opes and the necessary laboratory supplies, this was done to an increasing extent. Except in field, station, evacuation, and general hospitals,

mild cases of diarrhea usually were treated symptomatically and the more

severe or protracted cases with cheniotherapy. Patients treated on an aimbulatory basis usually were given sulfaguanidine, whiich, although therapeutically

inferior to sulfadiazine, was not attended l)y the dangers inherent in sulfadiazine. The hot climate in this theater during inuch of the year predisposed

patients to dehydration and renal complicat ions, particularly those patients

with diarrhea whose fluid intake could not be supervised. Un(ler the more

favorable conditions of hospitalization, sulfadiazine was administered with

excellent results in accord with TB MED 119, November 1944, entitled "Bacillary Dysentery." Most cases of "Delhii Belly" cleared rapidly regardless

of the regime employed. Even in proved acute bacillary dysentery, the efficiency of chemotherapy was not always evident. Thus, in 300 C(hinese patients studied by Major Elson, Maj. (later Lt. Col.) Dickinson S. Pepper, MC,

and Lt. Col. (later ('ol.) James S. Forrester, \1C, neither sulfaguanidine nor

sulfadiazine shortened the course of disease or ameliorated the symptoms

in comparison with the group of controls. However, the value of clieneotherapy in the treatment of bacillary dysentery and in the prevention of the

carrier state was generally impressive.

Differential diagnosis

The differential diagnosis of the diarrheal and dysenteric diseases in

the India-Burma theater presented no unique or peculiar problems. As in

other tropical and subtropical regions, the following possible diagnoses required consideration: Amebic dysentery; bacillary dysentery; simple diarrhea,

including food poisoning; and parasitic infestations, such as hookworm and

strongyloidiasis. The acute form of amebic dysentery could not be distinguished from bacillary dysentery with absolute confidence on clinical grounds

alone. Concurrent bacillary and amebic infection was frequent; indeed,
[NDLIA-iIURIMA THIEATEI*R 72Ž5

accordling to vairious estimantes, fromt 10 to 25 percent of patients with blacilliarv

dlysentery fldIikl niebiasis ats well. lIn generil, however, certnin i(lilgost i(

considlerait ions servedl as guides for (lifferentijation. litn iiebic (lysentery.

thle onset wats uisually less violent, the symnptoms wvere alpt to halve existed

for weeks ratther I hin for hours, mnid thle naxini mu number of' bowel movemients per (lay wats characteristically front 5 to 10 rat her than front 15 to 20

its in liteillarv (lysentery. hligh lever, l)1'0t rattion, a~nd intense abdOminnal

pain were less frequent in aimelbic dlysent ery; tilie leukocyte count wais more

likely to be normml or only slightl ,y elevated ; and tilie stools consisted priniar11ilv of feces (containing blood, whereats in bacillatry (1% setnteIy they often

consisted only of at very Sm1111all mount of' odlorless ldoodlv mutcus. Bacillarv

dyvsent ery tendedl to sublsidle e'veni when not t reat ed withI stiltonaittides, whereas

il n~elic (lvsen t ry cont inuedl unalbatted or implrovedl only slightly until specific

treatm iet wats inlstitultedl.

Simplle diairrheat could he (list inguished in the manjority of cases by its

more explosive onset, lby its tendency to affect simutltanieoutsly at nuimber' of

mien inl thle salnte orglinizat ion, by thle albsence of blood( inl thle stools, an1d by

its rapid subsidence wit hin1 fromt 24 to 48 hours. Malat'iat wats oc('asionahll

alssoCiatedl with bloody (dysentery, lbut tilie abrupt onset of' (chills, it remittent

typ~e of fever of 1040 F. or ab)ove, healachie, mnid genleralizedl bonle, joint, andl

muscle pains were so highly chatraicteristic of it andl so aitylpical otf amebic or

bacillary (dysentery thatt the different ilt ion wats uisually not (difficult.

Hook worm disense a ind slrmong~yloidiiisis Frequently gave rise to low-grade,

generalized 0i)(lomiiniil paiins and~ diarrhea. The two (hiseases dIid not cause

bloody stools, aind thle Abdoninal symptomis prodlucedl by them were usua~lly

less ceaerly colonic in origin, consisting rat her of generalized or upper abdominal

(discomflort with indiges~tion. Finailly, an tinporti ant dialgnosti(' considlerat ion

wats tile fact thatt certaitin locailities in I ndii mnid Burnita were known to be highly

end~emi ic centers of amebic infection, and personnel fronit t hese alreals were

allways to be susp~ected.

CJonchisions

The ef'e('tive treatment of patients by preventing their becomiing carriers aind by (let ect ing andl elimiinat ing thle caririer st atte in ot hers, unidoubhtedly

wats partly responsible for thle redluced1 noneff'ectivye ratte for thle dia rrheidal i(Id

(dysenteric diseases in 1945 (chart 8). 01f equal if not. greatter importance

wats thle improved satnitaition throughout tile theatter.

Malaria

In at lec'ture on the inilortance of malatria in Indlia, Lt. (i'ol. (latter Ma1j.

Gen. -Sir) Gordon C ovell, Director, Malariai institute of Indlia, statted: ''Although * * * the case niort ality fromt malatriai is probably less thanl one( per

cent, it hats been est iniated t hat inl India allone tilie disease is (direct ly resp~onsible for more thain one million (featthis per aitiunut init atormtall yeair, whilst in

yeairs of greait epidemics this figure maiy be greatly exceedled."13

3 ('uvi,I G, Lictuires on Malnar ia. li aiti, null. No. 5, New DOWfi :( overmnexnt of Indih Pi'es~. 191I.
726 A(CTIVITIES OF MI.)IC'AL ('ONSULTANTS

This indicated the occurrence of malaria in approximately 100 million

people in India each year, or in I of every 4 of the population. Into this situiation U.S. Army troops were sent in 1942, many of them going to the Province of Assam, which was described in the 1943 annual report of the 20th

General Hospital, as follows:

* * * a malaria infested area, one that is continually epidemic, as bad as any in the

world * * * From the best statisties available, the malaria infection rates of the native

population were as high as 3,000 per 1,000 per annum, or 300 percent during the malarious

season. The rate dropped to about 70 percent during the winter months or the so-called

"non-malarious" season.

Lest it be thought that malaria was confined to the jungle regions such as

Assam, one of the very first letters in the medical files may be cited, reporting

an outbreak of nialaria in a detachment of 20 men who travele(d bv rail from

Karachi to Dinjan. Of the 20 Inen, 7 (35 percent) contracted malaria on the

trip. This report, was only the first or many to come to the theater surgeon's

office. Any train trip that involvedl night travel, andt all but the verj shortest

did, almost invariably resulted in new cases of malaria. In spite of control

efforts, this situation still prevailed1 as late as August 1944. The 843d AAA

Automatic Weapons Battalion, mobile, left Bombay for Teok on 7 August,

arriving on 18 August. Of tile 726 men in the battalion, 98 developed malaria

within a month of arrival; as far as could be ascertained, 85 of the 98 contracted

the malaria on that tripl)

Malaria control was grossly inadequate in nmost areas. Occasionally,

as in New Delhi, moderately effective measures had been initiated: in August

of 1942, only 12 cases occurred in U.S. military personnel stationed there.

However, during 1943 and 1944, most of the troops were in the parts of

India where the malarial rate was highest and where there had been no control

prior to their arrival. A highly effective malaria control program was inmiediately instituted by the Preventive Medicine Section, Office of the Surgeon,

Headquarters, USAFCBI, in areas where United States troops were stationed

(fig. 246). A description of the control program is available elsewhere. The

following pages are concerned with the disease as encountered by the medical

officers of tile India-Burma theater.

Statistical observations

In all, 39,906 cases of malaria among U.S. troops were treated in the several

years of the theater's existence. Knowledge of the disease was furthered, and

valuable contributions to therapy were malde. The great majority of the cases

were seen in the 20th General and in the 48th and 73d Evacuation Hospitals in

the Assanm-Burmna region along the beginning of the Ledo Road. Later, the

69th General Hospital and the 14th Evacuation Hospital also came into tile

Ledo area. Many reports and scientific papers were submitted fromn these

4 lAtter, Col. John M. ramraz, Mc, Surgeon, U.S. Army Forces In India, Burma, and China, to Chief of Staff,

Services of Supply, 30 July 1942, subject: Malaria Contracted by Troops Traveling on Railhays.

S IAtter, Maj. Mason Trupp, MC, Assistant Surgeon, headqunarters, 10th Air Force, to Commanding General. 10th

Air Force, 21 Oct. 1944, subject: Report of Excessive Number of Malaria Cases Within theM 43 AAA AW Battalion.
INI)IA-BUR31A THI'ATER 727

installations, all stemming from the thousands of cases seen during the monsoon

seasons of 1943 and 1944.

The material available for this review did not, lend itself to a chronologic

study in the sense that at day-by-day development of the malaria problem and

its solution in the theater could easily be presented. Ideas conceived in 1943

frequently could not be completely developed until 1944, and in many instances

the final report did not reach the theater surgeon until late in 1944 or early

1945. Consequently, it seelied best to present the material by subject, including under each heading all the ideas that were developed in sequence as

nearly chronologically as the material permitted.

INCIDENCE

U.S. soldiers.-From 1 September 1942 to 30 June 1945, a total of 39,906

cases of malaria were reported in this theater. This figure included recurrences

as well as original cases. Table 5 shows the total nuniber of cases and the rates

for each year. Chart 10 shows the attack rate by month for January 1943

through August 1945.

TABLE 5.-Total cases (including recurrences) and attack rate for malaria in U.S. Army troops

in India-Burrma theater, 1 Sept. 1942-30 June 1915 1

[A ttack rate expressed aIs number of new admissions, plus stcondary eas:s, plhs recurrent cases per annum per I .0(X) average

strewCnth]

Year Total cases Attack rate

1942 (1 Sept.-31 Dec.) ------------------------------------ 911 167

1943 ---------------------------------------------------- 8,316 183

1944 --------.-------------------------------.------------ 27, 458 166

1945 (1 Jan.-30 June) ------------- :3, 221 2 32

Total --- ----------------------------------------------- 9,06

I Inehli s casts admitted in China prior to November 1944.

2 This striking red ucetion of the malaria attack rate was due to the institution of the Smilppressive Atabrine prograin,

Ferlruary 1945, in the most highly ma larious districts.

source: Bttumgart, Iherrinan L., and Pike, (George NI.: History of Internal Medicine in India-Burma Theati-r

[Official record.1

Table 6 shows the malaria statistics of the two most active hospitals in tile

Assam-Burma area for tile part of 1943 that these hospitals were functioning.

The 20th General Hospital received patients beginning 3 April 1943 and the

73d Evacuation Hospital beginning 26 April 1943. The figures for thie 73(1

Evacuation Hospital are incomplete in that the breakdown for the month of

Novemnber wits not availab)le. However, these figures suffice to show that in a

period less than tihe full year these two hospitals alone treated approximately

45 percent of all the cases of malaria in U.S. soldiers seen in 1943. The figures

for tilie Chinese soldiers are of interest ; cases were not included in tile U.S. Army

statistics, but are shown in table 6, as they formed a part of the experience of

these hospitals.
T12S -111"IlICAL C(IN.SVIA-ANT.S

XT

L

it 1 2 1 G. N 1 1: i: 1. A . ili:lfl (.11111 rm .im - 1114)-411lio) prim fing, m -111v

illýt:111:11ifill \0 11 Ile-iall ChOll :11141 flmýfjllitql 11. N:itkc wnmý to DDTill N ivillitY of itIS1:111:16 111s,
Att

de 1:1 t di cc rc nha 11.111.1a v12 the ca7;2¶1 2v.

T \131 vt1 6. - (I, 19ip tho2 Pith G.il.l H;l // , II/'/I/Il1,8Ilfi~ lt

I~~~ 1iI I I i i ~ P. 

2 .\11 /i~l 11 ~ lt 19 111S I BI l

1: 1112 c I~ .i9I I1 5 1 G I 12:1 1. I 79ls 
730 ACTIVITIES OF MEI)ICAL CONSULTANTS

CHART 10.-Monthly attack rate for malaria in U.S. Army troops in India-Burma theater,

Janiary 1•.114-Augynst 1I4.ý5 I

[Preliminary data based on snilniarics of statistFial health rcports]

[Hate expressed as number of new admissions phis secondary diasnosis cases plus recurrent (cases per annum per 1.00I

average strengthi]

Rate

400

1943

300.-

200

100

•" 1945

Jan. Feb. Mar. Apr. May Jun.q July Aug. Sept. Oct. Nov. Dec. cases admitted in China SIncludes prior to November 1944.

Chinese soldiers.---The prevalence of malaria in the Chinese was due to

many factors, the chief of which was the almost complete lack of interest in

atitimalaria precautions on the part of the Chinese. This was only another

manifestation of the general lack of concern about health principles of any sort,

and, indeed, lack of concern for life itself. It was also thought by some medical

officers that the Chinese were inherently more susceptible to malaria, but

whether this was a matter of racial susceptibility or a secondary result of the

poor physical condition of all thie Chinese troops flown to India from China was

questionable. In any event, in the Chinese the incidence of infection from

Plasmodium.falciparum was much higher thian in the Americans, the condition

of patients on admission usually much worse, and deaths more frequent.

TYPES OF INFECTION

In U.S. personnel at the 20th General Hospital, during the period April

1943 through Marci 1944, there were approximately as many infections from

P. rivaxi as from P..falciparusm, whereas infect ions from P. mnalariae were uncom-
INDIA-BURMA THEATER 731

mon. Figures differed somewhat. in the following year, when there was no

apprecial)le change in the number of infections from P. vivax rbut a pronounced

decrease in the number of infections from P. falciparum (table 7). The

decrease in the latter reflected the decreased malaria rate; the high figure for

malaria caused by P. vicax represented its tendency to recur. Infections with

P. malariae remained relatively rare.

Mixed infections were considered much more common than the figures

indicated. Under the pressure of a caseload so great that surgeons as well as

internists were caring for malaria patients, a laboratory could do very little

more than a single nmalaria smear, and, once a parasite was seen and the diagnosis established, the luxury of a continued search for other forms was not always

possible. Mixed infections always showed P. falciparum; P. vivax was usually

the other parasite. As far as can l)e determined from the available material,

a mixed infection did not necessarily present added difficulties in treatment.

TABLE 7.-Types of malaria observed in U.S. Arrmy troops at the 20th General Hospital, April

19.;3-MIarch 1945

Estivo- Quartan I Only diagHioslpital autuinal T'rtian 1P. ma Ia- \Mixed Unelassi- nosed elin- Total

(1'. falcipa- (W'. rirar) riae) fled ically

ru mn)

3 Apr. 43-31 Mar. 44 .... 951 1,317 33 25 755 215 3, 296

1 Apr. 44-21 'Mar. 45 ----- 1 460 1,225 18 13 154 189 2,059

Source: Blumgart, Ilerrmnan L., and Pike, George M.: hlistory of Internal Medicine in India-Burma Theater. [Official record.]

The unclassified group included all cases in which parasites were seen

but the specific type not identified. It will be seen from table 6 that in 1943

approximately 25 percent of all the malaria cases seen at the 20th General

Hospital and 21 percent of the cases seen at the 73d Evacuation Hospital fell

into the unclassified group. Table 7 shows a pronounced drop in this figure

at the 20th General Hospital in the following year. This difference representedi a change in laboratory conditions. In 1943, with limited time and laboratory facilities, prolonged efforts to make an absolute identification were

not justified. In 1944, with better laboratory facilities and more time, it was

possible to make a reduction in the unclassified group. Capt. (later Maj.)

Calvin F. Kay, MC, of the 20th General Hospital, reported on primary infections, reinfections, and relapses in the highly malarious district of Assam.

In the unclassified infections in his study, Captain Kay reported that, when

further smears were obtained and identification was possible, almost without

exception the previously unidentified parasite proved to be P. tivax. From

this finding and from the similarity of the relapse rates in this group to those in

patients with malaria caused by P. vivax, Captain Kay was of the opinion

that infections caused by P. Vivax constituted the b)ulk of unclassified infections. In discussing this question, Captain Kay nmade the following statement:
73-ý ACTIVI'rIEMS OF %ilMEIV~AL C'ONSULT1ANTIS

" We had at first expectedl the reverse to be the calse inasmuch ats thle

later formis of P. rilax are More easily identified thban those of P". fillciparum.1In

However, withI thei t hick bloo0( smevars emliplo* ved, ill nia1nv inlst ances, large

nuimbers of P., vriax t rophozoites were present With nione of tilie readily

(list igliimlisatble later forms ill evidenice.''

Onl thte othter hand1(, this opinlionl apparenitly * was niot unliversally tieldl att

that hospital, because Lt. Col. (later Col.) Thomas Fitz-Ilugh, JTr., MC, M~aj.

(later UA. Cot.) llenr ,y U. IHopkins, MIC, and1 M~ajor P~epper, inl thlier report

on) cerebiral malaria, stated: "WXe have also good grolindis for believing, t hat t lie

majority of Itile 'Type U ndet erminiiedl andl 'Clinical Only' groups are actunalty

caused1 by P. falciparumi infect ion.'' Thie medIical officers ait thle 73d Evil(--

uiat ion 1Hospital were of thle opinion that it large proportion of til lie uclass"ified

CiscIs 'were causedl by P. falciparam., -since this was tlie( more commnonily, seen

parasite inl that regrion. Thle * atso) felt that, inastmulch as al ii uiiclas-.itived case

signiifiedl insufficient parasites inl tilie p)eriphieral blood for a1 lefinlite dIiagnosis

anld since tile findling of few parasites inl thle p)eriptheral blood( Was, USua11 vtllya

ind~icationl of anl infect ion from P. falciparuin, t his was further evidlenc'e that.

hie unclassified group11 largevly rep~resenited infect ions from P. falciparumi.

Thle tast subgroup ill table 6 ilicicdeol patients ill Whom tile (liii.iiosis

was made sotel~v onl clinical evidten(ce withioiit hiboratorY confirmat ion. Inl

miall, vjist ances, t reidtment had1( been startedl b)efore thte pat ienit reachdti thle

thospitail. Althloughi some of thtese cases und(outbt edl'v were not malaria, thle

sulbsequient volursk and response to treatment. of most of them and the known

fact that several factors cont rilbuited to tilie difficiilt y of obtaining positive

smuears5 made it evidlent that inl the large majority tile (diagnosis wats ('01,r1e0

Capt aiii Kay,1 basinig his olpinion onl recurrence rates, and later irechlecks, onl

smeiars, ('oii('tlded t hat 66 p~er(cent of his group of un(lahs'sifiedl cases Were duie

to infect ions fromt P. ritar and 33 percent to infections from P. filcipari'ui.

RELAPSE' RATES

M\alar'ia relap~ses gave rise to the saime p~roblems- in thle India-Burmia

theater as elsewhere. N\lajol' Kay st udied t hree organlizat ions and( catlcultat ed

relapse irat es inl 499 indiv'idluals, of whom 407 wvere followed for tat least 4

m1ont tls. Ill I ndiv'iduaiils withI one previous (cIiniical attack of malaria, the relap~se rat e wa-is 25 percent for Itie entire gr'oup), inc(lud~ilig. patients Wit h uiiiolassifiell infect ions antd t hose withI infectionis cau~sedl byV P. rirai' and 21'.1 . fiah'ipaium.

Those pt~ietn'its who had0 maltariai calused by' infect ion froml f). falcipa ruim shiowedl

less I his 5-percvnti relaipse rate, andl t ho;se withI infect ions cVaulsed by P. rr~

showed 34-p'i''enlt rela pse rate. Iit ml ivid tials who hadu alreadyN h adI one

r'elap)se, tble rate rose to 75 percent. 'I'lie figuire of :34 percent, apprecviably

lower thanl t Ii( uisliitl -v acc'(epted' figulres for malairiia r'eha pse ili (other par its of

1the world, litriglit ha I'e beenI greaiter had tlie( CaiSVS beenl St nldied long1er. Tleo

stuid isof tli 73d E'aicua ti HonI sp~ital1 ill at 61)-Iolitil pieriodl shiowedl at relaipse

raite of 9.7 percent following t ie( iniit ial attaci(k.
iNIIIA-BURMA THE1~ATE~R73

Thle well-known fact that traumlla, operatiolns, and( aeicite illiwsse" (can1

pt0(ltivte t r'ecurr~ence of a lat ent itlaia infet loll was, 1i52l~letvla 'ly demlonlStl'atedl ill the experience of this theater andl ledi to tilie us'e of Sullppressive

Atabrine t herapy inl patients hiospit alized for tiny% medlical or surgical reason

Who gave at lust orV of hiaving had at Previous attack. of mnalatria.

clinical aspects

T[le word ''protean"' has often beenl us'ed inl lescril~ing malaria mnanifestat ions; however, its- frequent use (does not make it an 'y thle less applhicable.

M edical ofliceris who camev to this theater fromt the United States had ha~d

very lit tie experience With mnalaria b~eforec th~eir arrival. Thoughi textbhooks

anid eotlrlses oil t ropical medicine have alway' s eml)Ipialsized that this (lisease.,

like syphIilis, canil be at gre-at limtitator, a1 toctor whose tralining and eXperivn('e

hanve aiwal A-s- associat ed diarrlhea With I)I (aillarl.v or ainehic infect ion is not

likely to con1sitler malaria as a cause of waterY stools. The dtifficulties inl

diagn1osis alre Well (les(r1ilbed int thle following" extracet from at personal columnilnicat ion from (C0l. LFraltis C. Wood.. NC, Chief, Medical Service, 20th Gener-al H ospit al:

we saw the abd(ominail imla1.rias, often in (list higngisbable fromi acute appendicitis, the

(hvsellteric nialarias, t hat looked somewhat like lIacillary d 'vse-iite-rv excelw that tlie( patienits

Avere muore apt to have chills aund a higher fever. We saw thev post ohierative and post tratiluat ic inalairiw:i anyv fever was malarira till p~roved otherwis-e. We saw somie verN queer :ualaria pictuires; our Chaqdain had a typical alttack of aeuite cholveyst it is that tuirned out, to

lbe malaria.

Cerebral malaria.-Cerel ral malaria was thle major cliii i al p~rob~lem.

Ill the early tlavs, whlen malarIIIia cases Were p~ouring ill, filling both imedic-al

and~ srgclWards, tilie Various muanifestalt ions of Cereb~ral mlalaria 'were not

fully appIreciat edi

'The fimures- for incileuice wvere somewhat Variable. largely leecalse of tilie

Variedl 0Jpi thou as to what conistit ut ed cer-ebral malaria. Wh'lereas ait fir-st

only t hose cases WithI convulsions, comla * or ot her severe cer-ehral s *vmlpt 01115

wvere inicliuded inl thle classificat ion. it hit er becamile apparent that1 d rowsi ness

or mildl behavior chiaiiges were earl-Y maniifest at ions antd such patients had1(

to be t reaited accorthi ugly. Colonel Wood, Whose letter was jutst referred to,

dlescribled thle situaition inl these wordls: '"At first we didn'it know w hat to

look for. W~e dhidni't know how tlrowsv a pat icitl 11ad( to he to be suspect ed

of earl-y cerebr-al malaria. Eventiualhv A we foun id on t liait if. when awa keined,

a pat ieiit was not fully' awake a id able to t ell vonl his iiamie prhitI that

Patient uIeedled careful wuitchluiit

At (the three hiospit als t hat saw Jprlctwially till the cases of cereb~ral malaria,

the aiveraige incidencee of t his mniiifestat ion inl relat ion to thle total nitumbler

of malarIIia CaIses was 2.3 p~er'enlt tit the( 20t hi General I los-pitalii 2.3 percent ait

the 4StIi Evaicuati Hol ospit al. and 1 .1 percenit ait thle 73d1 Evartiatio HollIspit al

(fig. 247). wit I ilan overall average of 1.9) p~ercenit. These figures cinviuded

( *hiuieme as Well as; U.S. t roop)s. For U.S. personnel alonie, the incidence att
I

frP~ s
1114 2DO ( '4'114I:4 1h44'litil \\;is 2.2 pr -elm'i. A~ll4th -i tiii Ii,4Il'4 \w:Iý imi)

114 h 4I 1: 1). ( '4141 41 l'Ided~ II~I :111c 1 romi 44' 1i\4I- h- I9:114h1'44 4li 7141:; I;

I

1

414ta. \,ii4il I4pe 4'io 14.i1'il (1 i111 .14''-4 ' 1)~lI- (1.' h441'i 4 I:) j))4'I'4 li 11164111H

it \ i Nk 1 1 .1 '11,41 114 417 :4 ii' IIi I I'~ )1 "4141 -1 14 III. '.\ 1114' 144i'i444 : 6-114(11 .\14 1 l mI¶ .I

144 If \I r )7 ;ll4' I¶4 II)c il-inii I o iia\ Iti 27\4111144 1144-lit:4i. 1 I(I( III 4414 en i" .il 

441441: t~:111ia d 27h4' d 44411! it-cmn 44)II~ nnl A'4'e4icni44i. Fr' m Il 144 \I;W 'l.,.14n4

Ill( Iii~'~' 4411I'I'. lt l4IIL114 pe-4' I Il III" 444 i1:144t i . I 44\ 'l i 'jtill' V\:11,11'' 14 11441
73 ACTIVITIES OF MEDIICAL CONSULTANTS

Thle etiolog-ic agent, in cerebral mialaria has genlerally b~eent accepted ats

P. falclparwki and in rare inistancees ias P. vriax. Practically aill tile (lata that

were collected1 sulpported this con~ep~tioni. Although Colonel Fitz-llugh and

associates IInade thle statemlent that. ''cerebral Iinalaria is (hieflv if not excinsivelv at result of P. falciparuin infestation * 'at table tin their paper

reveals 5 cases of cereb~ral nialaria attribunted to P. i'irax~ -1 case inl anl Amnericanl

and 4 in Chinese. The 14th Evacuation Hospital staff enliplasizel thle fact

that P. vu'ax canl be at cause of cerebral mialaria. Although thle 1)ossibilitY

of at dlouble infection in which P~jalciparuin wats overlooked titlst lbe contsidleredl,

the clintical imipressions of' these iniie toget her withI lalboratory findings cannot

be dhisregarded.

"iThe clinical p~icture of cerebral mialaria has been dlescrib~ed 1) m nany

authors and has b~eeni particuhtrlv well p~resenlted by Colonel Fitz-Hugh and

his associates. All variat ions of cer'ebral mianifesta tions were seeni, friont tinild

(dizzintess or slight, drowsiness to severe lheadlache, coina, and convulsions.

Temtperatutre charts showed no constant, pattern, and at norital or slightly

elevated tenliperat nrc didl not. necessarily ind~icate imiprovemient. Soitie cases

that, were adhtlutteI ats ordinary mialaria and seemied to be responding properly

to treatmnent shtowedI severe cerebral s *vni ptonis several days after adlltissionl.

No adlequate explanation for this wats found, but it wats observedl that hv~poglyceinia wats occasionally at factor onl prolonging cerebral symniptoninatologvy.

Ani interesting clinical observation, mnade ait thle 20th General Hospital

in June 1945, wits brought, to the attentioii of this author by Colonel Woodl.

When at group of Chinese patients with mnalaria received no treatment for a

periodl of several (lay*s prepatratory to the use of at new drug, fraxine, all thle

Patients with infection due to P. virax becamie symlptolni free in 4 (lays without

therapy, but the infections front P. falciparun dlid not subside spontaneously. Colonel W~oodl believedl that this experience suggested why miore

infections front P. riraxr were seen in Amierican and miore infect ions front P.

falciparuminii Chinese patients; the Chinese with infections fromt P. vivax

recoveredl spontaneously and dlid not collie to thle hospital, leaving at relatively

high prop~ortion of patients wvith mnalaria due to P.falciparurn to be hospitalized.

Treatment

The CBI theater wats established in Mairch 1942. As far ats can be dleterniinedl, the first publication onl the subject of treatment of mialaria appeared

in first theater Field Medical Bulletin, punblishted in August 1942, and wats at

siumntarY of at lpamlphllet, issued by thle British War Office. Thle treatmlent

reconi mtendled wats different front that reconitnended by Circular Letter No. 56,

Office of the Surgeon General, U.S. Armny, 9 June 1941, entitled "Notes onl the

Treatmnent, and Control of Certain Tropical Diseases,'' which wats still in

effect. fIn the Novemiber 1942 issue of thle. CBJ Field Mledical Bulletin, another

article onl therapy appearedh by Maj. (latter Lt. (Col.) Sydney P. Waud, ýM(

and Maj. (later Lt. (Col.) Robert S. C rew, M(', of the 159thl Stationl Hospital.

These ant hors ittent ionedl that the article in the August issue reconinniended a
INI)IA-BUR1MA THEATER 737

treatment not in line with Circular Letter No. 56, and they went oil to present

several changes in the treatment of malaria gleaned from the School of Tropical

Medicine in Calcutta, India. These also were different from the recommendations of The Surgeon General.

Finally, in the January 1943 issue of the theater Field Medical Bulletin,

The Surgeon General's authority was recognized by reprinting Circular Letter

No. 135, Office of the Surgeon General, U.S. Army, 21 October 1942, subject:

The Treatment and Clinical Prophylaxis of -Malaria. By January 1943, Circular Letter No. 135 had received complete distribution in the theater, and in

the February 1943 issue of the Field Medical Bulletin, Lt. ('ol. Gordon S. Seagrave, MC, expressed doubts regarding the efficacy of Atabrine. He also presented his own views on the therapy of malaria, which included the use of

liquor arsenicalis and neoarsphenamine.

The theater as a whole continued to use the plan of treatment outlined

in Circular Letter No. 135 (October 1942) and in Circular Letter No. 33 (Office

of the Surgeon General, February 1943), changing to Circular Letter No. 153,

Office of the Surgeon General, U.S. Army, 19 August 1943, subject: The

Drug Treatment of Malaria, Suppressive and Clinical, when this was received.

By the end of 1943, installations in the heavily infested areas had sufficient

experience to reach their own conclusions about the efficacy of the different

methods of treatment. In the special report on malaria by Colonel Ware

and his associates at the 73d Evacuation Hospital, it was concluded that all

methods currently in use at that hospital were equally effective insofar as end

results were concerned but that the treatment recommended by Circular

Letter No. 153 (lid not reduce the temperature as rapidly as methods employing

quinine and Atabrine in comnbimntion. This was very nicely demonstrated

by a graph which accompanied the special report. The same conclusion was

reached by the 20th General Hospital in the nmonthly sanitary report, dated

December 1943, which states:

In accordance with instructions received from The Surgeon General (Circular Letter

#153) quinine was withheld from all patients save those particularly ill, and the entire

treatment carried on with Atabrine. The results have not been statistically analyzed, but

there seems no doubt that the patients thus treated have a longer and more severe course

and several cases of cerebral malaria have developed after some days of this therapy.

The 48th Evacuation Hospital evidently was also somewhat concerned

about the effectiveness of the therapy recommended by The Surgeon General,

because, in addition to the recommended plan of treatment, LAt. Col. (later

(Col.) Hernman A. Lawson, MC, and Capt. (later Maj.) John A. Dillon, MC,

treated a group of Chinese patients with a somewhat larger total dose. They

reported the results in the April 1944 issue of the Field Medical Bulletin. The

conclusion was that the treatment recommended by Circular Letter No. 153

was satisfactory and no clear-cut advantage was demonstrated in the use of

larger (loses of Atabrine. The experience of the theater with Circular Letter

No. 153 was summarized in the theater ETMD dated 30 July 1944. The

general opinion was that the results were satisfactory and that only in the

564970-- 61-- -49
7T38 ACTIVITIES OF MEIDICAL CONSULTANTS

very sick patients was it necessary to supplement Atabrine treatment with

quinine, usually intravenously. This will be taken up later under the treatment

of cerebral malaria.

STUDIES WITH VARIOUS DRUGS AND COMBINATIONS

During this period when Circular Letters No. 135 (for 1942) and No. 33

and No. 153 (for 1943) were in effect, which included all of 1943 and most of

the malaria season of 1944, occasional investigations were carried on, particularly at the 20th General Hospital, to determine the effectiveness of other

drugs or combinations other than those recommended in Circular Letter No.

153. Observations were also made on the usefulness and side effects of tile

commonly used drugs. The following paragraphs summarize these observations.

Plasmoquin (pamaquine naphthoate).-The hospitals in the Assam-Burma

region, in which Negro troops were stationed, soon discovered that Plasmoquin,

always recognized as a moderately toxic drug, was particularly dangerous in

Negroes, producing a severe hemolytic reaction. Because of the frequency

and severity of the reaction, this drug was eliminated from the therapy program

in all the hospitals in that area and eventually in the theater.

Fraxine.-TThis drug, of unknown composition, was tried at the 20th

General Hospital on Chinese troops and reported on in that hospital's sanitary

report, dated December 1943. It had been sent by the Chinese for testing as

an antimalaria agent. It was completely ineffective in malignant tertian

malaria, and its value in benign tertian malaria was open to question, since it

was during this study that it was found that Chinese with malaria caused by

P. vitax recovered spontaneously if untreated.

Arsenicals.-Arsenicals had long been recommended in the treatment of

malaria. Although it had already been established that alone they had no

effect in preventing relapse or, for that matter, in preventing initial infection

by the malaria parasites, Major Kay, at the 20th General Hospital, undertook

a study of the treatment of benign tertian relapses with a combination of

Atabrine and .Mapharsen (oxophenarsine hydrochloride). No beneficial effects

were observed in the use of the combination of drugs; relapses occurre(d with

the same frequency in the Atabrine-Mapharsen group as they did in the

group treated with Atabrine alone.

Atabrine.-Problems occasionally arose in the hospitals of the Assani-Burma region that were peculiar to that locality and required special solutions.

This was owing to the large number of Chinese troops in tie area for whomi tile

U.S. Army hospitals provided medical care. Although the problenis were precipitated by the Chinese, the solutions frequently had a more general value and

contributed interesting and useful information. One such problemn was the

difficultv in keeping Chinese patients in the hospital long enough to be given

full antimalarial courses of treatment. As soon as the patients felt well, they

left the hospital or were taken out by their conimanding officers. In an effort

to circunivent this, Maj. Thonias E. Machella, M•[C, Capt. Roger A. Lewis, MC,
INI)IA-BURMA THlEATER 739

and T/3 L. J. Kimmelnan, of the 20th General HIospital, worked out a plan

to give almost the complete week's (lose of Atabrine in the first 24 hours of

treatment. It was felt that, if this method proved to be safe and effective, it

would insure adequate dosage and at the same time shorten the hospital stay

legitimately. The dosage used was 0.3 gramns of Atabrine every 3 hours for

8 doses. Patients so treated were compared with other groups treated on different schedules. The final result compared favorably with other plans of

treatment. In fact, the duration of fever and of parasitemia was less than

usually observed in patients treated according to Circular Letter No. 153.

Because 2 of 80 patients developed signs of stimulation of the central nervous

system, the authors reduced the dosage to 0.2 grams every 3 hours for 8 doses.

This seemed to be as effective as the original dose.

At various times, new drugs were sent into the theater for trial. One such

drug was called SN 6911 Bisulfate. This drug was tested at the 20th General

Hospital by iMajor Machella and Sergeant Kininuelman. It was given as a

single intravenous infusion and compared with a corresponding (lose of Atabrine, also given as a single intravenous (lose. The drug wias found to be effective but to have no advantages over Atabrine.

Major Machella, with 2d Lt. David F. Burgoon, SnC, and T/3 R. Fine,

also studied the effects of the two drugs on the liver. Concerned primarily

with the effect of a single intravenous dose of Atabrine or SN 6911, Major

Machella limited the study to determination of Bromsulphalein (sulfobronioph.-

thalein so(ium) excretion before, during, and after an attack of malaria. He

found a definite impairment of the ability of the liver to excrete tile dye during

the period of fever; this impairment disappeared in the majority of cases within

96 hours after the institution of therapy and usually within from 48 to 72

hours after subsidence of fever. In general, the more prolonged the fever,

the greater the dye retention; but in all but four cases the retention was only

temporary. Those four cases all showed slight jaundice on admission. That

the (lye retention was related to the fever rather than to the (disease per se

was demonstrated by normal controls with artificially induced fever (typhoid

vaccine) showing a similar degree of dye retention. It wias imposible to de(monstrate any effect of Atabrine or SN 6911 on the ability of tile liver to excrete

Bromsulphalein.

Failure to respond to oral administration of Atabrine was not common but

did occur on a few occasions. Lt. Col. Frank B. Cutts, MC, and Capt. (later

Maj.) Irving A. Beck, MC, of the 48th Evacuation Hospital reported in the

April 1945 India-Burma theater Field M1ledical Bulletin on 8 cases, out of approximately 4,500, that did not show a typical response to oral administration

of Atabrine. In 3 of the 8, the therapeutic response was delayed but eventually appeared. In the remaining five cases, there was no response. Atabrine

was not found in the urine of any of these patients, and, since it was believed

that they were taking the tablets, it was comcluded that there was no absorption of the drug. Intramuscular Atabrine produced a prompt response and the

appearance of the drug in the urine.
740 ACTIVITIES OF MEIIICAL CONSULTANTS

DRUG REACTIONS

Plasmoquin.-All three drugs used in the treatment of malaria produced

reactions. Plasinoquin had always been known as a toxic drug and proved to

be particularly toxic in Negro soldiers. Both the 73d Evacuation Hospital

and the 20th General Hospital had occasion to treat Negro troops since many

Negro units were working along the Ledo Road. A severe type of heniolytic

reaction was the most serious difficulty associated with Plasinoquin therapy.

The 20"h General Hospital, in its annual report for 1943, reported on appro..lnmtely 20 instances of this reaction, all in Negro troops. The 73d Evacuation

Hospital witnessed 10 such reactions-9 in Negroes and 1 in a Chinese soldier.

All patients developed a moderately severe anemia; in 6 of the 10 patients at

the 73d Evacuation Hospital the red blood cell count fell below two million.

Because of the severity of these reactions, Plasnioquin was omitted from routine antinialaria therapy. There were also lesser reactions to Plasmnoquin,

such as gastrointestinal disturbances, cyanosis, hepatitis, and drug fever.

Quinine.-TThis drug had long been known to produce toxic effects, but,

because the alue of the drug as an ant imalaria agent outweighed the disadvantages of its !oxic reactions, its use was continued. It was administered intri•-

venously in all cases of cerebral malaria prior to the availability of parenteral

Atabrine and was generally considered to be a life-saving procedure. On the

other hand, in the experience of the 48th Evacuation Hospital, as reported in

the theater ETMD for June 1945, intravenous administration of quinine was

very dangerous. Eight Chinese patients (lied in convulsions very shortly

after the injection of quinine. Although it was admitted that a definite cause

and effect relationship could not he proved, the clinical impression was so

strong that the investigators at this hospital felt that any reasonable alternative

was preferable to intravenous injection of quinine.

Atabrine.-React-ions to Atabrine constitute a history in themselves. This

theater saw all of the reactions commonly attributed to Atabrine, including

atypical lichen planuis and various other skin reactions (p. 776), toxic psychoses, and the usual gastrointestinal disturbances. When Atabrine suppressive treatment was instituted in February 1945, there was apprehension in

many groups regarding its toxic potentialities. Many symptoms were attril)-

ute(d to Atal)rine without definite proof of a causal relationship. There

were, however, occasional instances of unusual manifestations that were

reasonal)ly attributed to Atai)rine. Col. Edward A. Abbey, MC, and Maj.

Edgar A. Lawrence, MC, Surgeon, and Chief, Preventive Medicine Section,

of the India-(China Division, Air Transport Command, respectively, reported

a study of the effects of continued dloses of Atabrine (0.1 grain daily) on visual

acuity of pilots. They concluded that Atabrine in the t(ose used had no effect

on visual acuity except in rare, highly sensitive individuaL. Their report

included ;t single case of ocular sensitivity to Atabrine characterized by blurring of vision and change in visual acuity in both eyes from 20/30 to 20/50.

Discontinuance of Atabrine resulted in relief of symptoms; readmuinistration of

the drug rssulted in a recurrence, relieved by cessation of suppressive therapy.
xiNDIA-BURM0A TilE A'rER 741

CEREBRAL MALARIA

Whereas At abrine given orally p)ract ically always produlced goodl results

in the usuial case, it wits frequently ineffective lin cerebral malaria, and ot her

measures had to be instituited. T11his wa1s largely owing' to the filet that pittients withI cerebral malaria were unable to take oral medication andl requiredl

imore intensive treatment. Patients withI cereb~ral malaria who were respondlit)g, favorabl)y to oral treat ment frequent ly stiffredV~ relapse after 3 or 4 days.

lit the early diays of t he theater when pam'enteral Atabrine was not availab~le,

practically aill inst alla t iolls uised intravenous quinine. Later, intranmuscular

anl int ra venous inject ions of At alrine were used withI excellent result s.

lIn thle ETM D for Jlune 1945, Major Machella summarized the results

inl five cases' ol cerebrial imalaria treated1 w~ithlia single intravenous infusion of

Atabrine. The dlose varied fromt 0.61 gramt to 1.0 gramt, adminuistered in 1,000

ce. of p)hysiologic Saline. One patient. in comia onl admiission. expired inl 31

hiours; hie had received 0.S grami of Atabrine intravenously. Two p~atient,-

who received the infusion too rapidly had brief psychotic episodes which lasted(

less than 24 hours. When tim infusion was g'ivenl slowly. 110 toxic nian11ifestations were not ed. N-o conclusions regarding the relative merits of parenteral

quinine and Atabrine wvere dlrawvn fromt this very smiall series of cases; however,

Major Machella felt that Atabrine was ait leaist as effective as quinine and

that 0.8 grami of Atabrine admlinisteredl in at slow intravenous drip providled in

effective methodl of clearing the bloo0d of parasites.

Aside fromt the specific dIrug t herapy of cereb~ral malaria, certain gene1ral

measures were t riedl. Some appeared to be of b~enefit ; others were discarded.

Thiey were as follows:

1. Spinial tap.-There were no consistent results fromt this procedlure.

The group ait the 20th General Hospital found it extremely ulseful and felt

that ani initial spinal tilp wats always advisable, whereas ait the 73d Evacuation

Hosp1ital Only inl occasional cases did lumbar p~uncture, with reduct ion of the

spinal-fluid pressure, have ainy appreciable effects. In mosst cases, it wats of

110 avail.

2. T,'ansfu.ximi of irhole blood.-The medical Officer-s ait the 20th General

Hospital felt that w~hole blood trans-fus'ion wats, ait timies, at life-saving prIoceduire.

p~articularly in catses withI pulmlIonariy edlemna.

3. Intrart'(nou. Adreinalint (epmiiphrinC ).-Thiis dIrug was used by the 20thI

General Hospital and the 73d Evacuation Hiospit al. It wits considlered to be

of value in some cases; however, b~ecause of untowvard reactions, its routiiie

Ilse wats not adlvisedl.

4. Sedathmn.-This mecasure was, usedl univers-ally in excited or convulsive

cases. lIntravenous Sodiumi Amvt al (aniollarbita sodiu5(m) and intravenous

paraldlehvyde were used most often.

5. 0th er mn as~ures.-Various ot her nieasures were t riedl, part icularly ait

the 20thi General Hlospit al. These includedl oxygen therapy, Benizedrine

(amphetamine), eplhiedli'iie, aminiiolplylline intravenously and by intracarotid
742) ACTIVITIES OF MEDICIAL CONSU'LTANTS

injection, an(I also nit roglycerin into the carotidI. No striking resuilts were

ob~tainled fronit t iese iiieastires.

A stiggestion thudt restilt('( inl nituchi correspondence wits suilnitted by

Capt. (litter 'MIaj.) m~ason Trrtpp, MC,' an Army Air Force stirgeon. Ile

recommliend~edl the combined uise of nicotinic acid and oxygen, the nicotinic

acidl to increase thle Cerelbral 1b100( flow and the oxygen to relieve the anoxennaii

Iprodluce(1 by the plugging of the cereb~ral capillaries by parasites and pigment.

For some reason, the suiggestion receivedl only at limited trial. A few cases

were t reated1 at thle 234t1 General Hospital in (liabua, India, and occasional

calses elsewhiere, 1)11 110 adlequate clinlical trial wits ever given.

Evacuation policy

In general, the resuilts of malaria treatment recommlendedI in tie dlirect ives

fromt Thle Suirgeon General were excellent, and( ver~y fewv Patients, mostly cases

of lblakwater fever andi several cereb~ral cases, required evacuiation to thle

zone of' Interior.

Scrub Typhus

At least since 19:32, typlius fever-louiseborne, tickborne, fleabornie, and

mnit eborne-hlas b~een known to exist in Burmna. Interest ingly enouigh, hlowever, the first reported case of scruib typhuts in the Indlia-Butrnla theater camne

not from Burnia b)ta fromn Indhia whiere at civilian technical representative

lilt([ been admitted to thle 1000i Station Hospital at Delhi, India, on 2 October

194:3, wit ii fever an(1 mild1 nieningeal signs. Aggluitination of OXKi strain of

Prot~e?i.,* to 1/2500 wats found on tite I 0tht daiy of hospitalization, and comnplemuent-fixat ion tests (lone latter in Washiington likewise indicatedl that the

(lisease wats scrtl) typlihus. Thle history in thiis case revealde~ that thle patient

biadi jtst retturned from Kuinning, ('itina, where several other cases of typhuts

hiad been reportedi. Tile othier cases were provedl latter to be of the epidemic

vatriety; only tilie one case wats provedl to hbe scrub typhus.

"The (hiief focuis of scruib typhuns in the India-Butrni~a theater wats Buirma.

In -November 194:3, Chinese troop~s, stationed in ('hinglowv and Shiing-bwivang,

in Buirmia began to develop at disease that, ait first wats thiought, to be mneasles

buit later wats dliagnosed ats at formi of typhuts fever." In one company of thle

114th Infantryv, 28 cases occuirredl with 4 deathts. At the end of November

194:3, two U.S. soldiers suispected of hatving t his dhisease were hospitalized

ait t lie 20t hi General Hospital, and shiortly afterwards Maj. Walter S. Jones,

MIC, whto hiadl been assignedh to thle Chiinese as liaison officer and hiad also made a

trip) to Shiingbwiyaing, (developed ain acuite illness wvhich, following the appearan1ce of at rashl onl the fifthi (ilay, wats dliagnosed ats mnite typhuts. His own suibjectiwe reactions to thlis (disease aire described in detail in his 1 Auigust 1945

rep~ort to the theater surgeon on his activities wvitti the Chiinese.

Le'tter, Col. F.Ilas E. Cooley, MC, Medical Iumsxwetor, to Theater Stirgc~o, ('111, 13 D~ee. 1943, subtject: Report of

Ouitbrea k of Rficket tsiai-lik DkiIsease Io Chiitoes Troop~s.
Ne

A

I 1 2 111

;III'l III :141flill" ll Ir;I,,r I(-J d im ll l1w k 4l;III If) H I\ 11-1 1111 ;If

411 1111r c lif)II ;II'M I1111

\\ 1111 N 1;11. 1:111. 1- 1 '1 . ( " d . \\ 1111:1111 L . oil 1,111,11f. I h -:111 It

Ill, ýI- owl I I],- 111:11 ;1 111111, \\ ;I- I h r Illf" I 111\41 r - fill,

-. I IW O, \\ I'l 1, 1 h r \ .,-I It'll ('111% 1 1w r'. If,- ;I III- fill :ItIII

I it .,I 11:1 11d . kk\ I )IlIf I l l,ý I f ) 11111 1 :1 11. 1 \\ . -IJI( I II( ,I

I III Ill- 11,10401 1 4111 III\ 1- 1 P-1:11 H ill- Ill, If Ill. - 111,11111 11,41

-li-clifill I"-p p .l. ( fill

" ".11 1 I'llh Ill O ff, I."kill Ix" ;I41 -1ý- 1,14,11 it! A - ;m l :111.1 Ill fit,-

i f 1\ ;I I 1''. 1, ;1 1111 111 Ill 11111 ,A )" I llf, wkw, 111, If I III- , 1\

If 111111- 111, I.\ oil' > 111w ill;l.

,ct [Ilk 11.\ Phil- 4*11". 111 11". hlIT:IllIII..-

( :fill IIIIII, :11r d 1 11ý11 I Ill- 1,111-111.16 \\ :I - I'llIf

14)
744 ACTIVITIES O F MEICi(AL cCONSULTANTS

rvrfever (Tsiitsiigaii' shi disease). Their reluictanice toC ieleit ifv it specifi itl s'Isit tsuga ini isli d fisease wvas a pparenlt .v NI .de to( t heir filuihare to fiiitl

the typical ulcler ill itiost of' tilie cases. Ili one group) of 29 p~atieints, oiil 2

showed tilie chiaracteristi( esehiarl. Tile (descript ions presented IllI tie capturtire

rep~ort s leave no0 tlouht thfat thIns wits thle sanie (hiseuse thlit wits thlen ap~pearing

ill Chinlese and U.S. troops.

The British Were having their own dlifficulties with this infection. Report

No. 433 of thle Joint Inutelligence C ollect ing Agrency, ( hiina-Buarina-l udial

theat er, (dated 24 F~ebruary 1944, dlescrib~ed an out break in tlie 1st Devon

Reg'imient, which occurred betwneen 21 October and 17 November 1943. Of

part icuilarI iiiterest ill thisl. rep~ort is at graph showing tile numiber of cases that

developed day by day andl their relationship) to tie tiune thle grouip entered

and left the infectedl ro(*Us.

The init ial out break of inite typhus amionig L.troop)s was of relat ively

b~rier duirationi. TIhe first (-Ises appeared in Novemiber 19431 and at considerable

numuber inl Decemiber 194:3, but lwY Januatry 1944 the incidence had fallen

sharply. C

1ol. Elias E. C ooley, MC ' Medical Inspector, USAF( BI, submiit ted

at prelinilatry ireport oil scrubl typ~hus luinoug U.S. and C hiinese troops inl IndiaBlurjlil, inl which he included a1 report oil tilie clinical alspects of the dlisease

b~V M\ajor Pepper and at report oii possible vectors, by Capt. (la ter Maj. ) Virgil

I. ýMiles, SitC, entomiologist of tile I 8th Malaria Survey Unit. Maj. (latter

Lt. Col.) John TP. Siiuilev, M(CI Surgeon, Base Section No. 3, then p)rep~aredl

at fuind report, dlatedI 20 April 1944, summinarizing thle Situation. htis finlding"s

colifirinle( t hose already* arrived at by Major P~epp~er. Inl addition, Major

Sinlilev Caine to tilie following conclusioiis ''It is highlY likely t lint sporadic

(altses occurred t brouighouit thle year: however, thes-e have beenl recorded ats

fever of unknown origin inasiuiuch as- nio se(rologic st tdies, were done, but there

sceems to be at definite seasonal inicrease ini thle (disease (hirilig November andl(

December.''

The concept of seasonal ineidhenlce dhevelopedl support ats tunle p~assedl.

However, t hei e was good realsonl to believe that this factor wats niore apparent

than real (p). 746).

A second outbreak of the (hiseatse begain in April 1944 and lasted thlroughi

July 1944. These cases were limited almost entirely to troops taking p)art ill

tile battle around My* itk kyinat, Burma, chiefly to thle group) known as Merrill's

Marauders (5307th IiCohiposite Unit (Prov. )) (fig. 249). TIhere were 148 cases

withi 17 deathIs. W~riting abhout this out break to tilie Surgeon, USAF( BI.

onl 23 August 1944, ýMaj. (later Lt. (Col.) Kirk T. ýMosley, the t heater

epidlemiologist , saiCid

The ouitbreak of seraz typhims fever occurredI while this force was engaged onl a combat.

missiona to clear tile enemyv oult of North Minniria, esp(cia~lly in the general regionl of the

route of the LC(I() Road. The area covered by the 530O7th Comaposiite Unit, (Prov) (hiring

this period was in thle lower ranges and foothills of the North Burmia miountains where the

head-waters and~ tributaries (If thle Mograiin, Tinai, and Irrawaddy rivers are located

These streams or dheir tributaries were crossed a numnber of t intes an( site-salong their banks
INDI IA-HE ICN A 'Fl EATERt 7 4.5

Fi(;Ilml. 219. --Brig. Geti. Franik Merrill, U SA, ('rinialiIilig ( *iieraI. 5307111 (Compolsite Unhit, lProvisioiii.iI, MIerrill*. Nlaraih(Itts, With itil4'rjir(crs.

were freqiieitlY iisei1 as hivoun~c airiIs. flie estnbisim.iietii (f hiivouii:Is (ii thei tiaiiks of

Owsv ttfihinii ma1( ,i~ vtbe (li~tji imp itiii feitr Iini l cui;)idilt(endliehi of Owc ou~itbrak ioi (fig.25))

Ca'ses coillitii lI('( to appea~t'r (111-11" Auhg us an 111sept(Jiber. but1 not ill excessiv numbersi )'l. Ili Oc)toberIII, N ovineiilIr, and1 D 1ecembi1 er of 1944 and1( ill

.JanitarY 1945, thle number1)CI of1 caises rose shrlY~ JI. liiere wats . lower dleathI

rate ill I lie third outbr)eakI(, .1 It11d Ow disease wats ill (relleflhl]lot so Se'vere as

ill the Iprevious v'p' IIidmICS. Thes 45'cases caiii la I;rgely Iro]l trop I O5St at ioned~

at caiip I aili is w ho had ta;keii pairt ill thle last Stages of the 13111-111, camipaign.

E-Nevllent I (escri pt lons ofI Scrub I , phius have beenl prepared by* the( Iiiedical

Officers wit h considuerabl e jpersonual expe)(rienice wvithi t his, disease. Ma hjor NIa-

(liella Iatd ('1)1 o ('1e Forrest er, of' I lhe 20t It (hiiendn I lospi tal, report el onl 64

Cases sveen ill thte first 4)11t break. C apt. ( 'a renice NI. A-ress, N I (, and1( Capt.

Edward It. Ev-ans, N I( ', of tiel 7341 11 viiciIiloll I 105jpitai, rep~ort ed oil a1 SliWCve

of 86 (11545seei n tl hii fI st a I seconoil~ I h)1i tvraks. At t lve29 .aiuiar v 1945 Brit ish

Army Miedi cal (Congress, ( olotiel W~4ood, 1st U . (later. ( apt ) John .J. Sa~veiiý

INic, and C apt. I lar-ol(I S. Pl'oi4, MC( Suibmiit ted .t paper that l)r.ieflv i-Suilliiiirized I 1114' filldiliizS ill Somhe 600 cases seen : ttl i 0 iGeirl op1 l Finally,

tiese hallIer I Iir4'e off icers, ahotig with Co( lionel For'rester', p~repaUredI at. comiiIIlietisiv c( linicalaI re'view of th (ief(;l case's seen1 at I tiv 20t hi (reieral H ospi tal.
At, T I \ , 1 \11 .

I.'2 II I)I, ".S 12\ I.' rmll) I l- l.1 I IýIl!,2 II o1112 1 \ f -I I.-). I I . - ;12 . :1 .241

I l .-II1. A i di :1 1- 1F - 2d1141.I Wit,, '2I \ H V . 1 -.-

1' 111 ;1112. i 1 111, 1- 11-11,1 HilII 21 211 ,I .,h;h 1l
INDIA-I3'I1MA THEATER 747

CHART 1l.-Incidence anid deaths due to scrub typhus fever in U.S. Army troops in IndiaBurma theater, 1 December 1943-S1 July 15945 1

[Preliminary data based on summaries of statistical health reports]

Number

120

Cctses(No deaths)

100 ' Deaths

80

60

40

20

D J F M A M J J A S O N D J F M A M J J

1943 1944 1945

1 Includes cases admitted in China prior to November 1g,4.

troops when they acquired the infection. The 1943 American victims were supply or liaison

troops in relative sound health. The present group is composed of exhausted, malnourished

men; often not evacuated from the battle front until several days after the onset of typhus.

Not infrequently the patients suffer from simultaneous diseases, particularly amoebiasis and

malaria. The importance of early evacuation, institution of bed-rest, nursing care and

proper nutrition, as well as the treatment of concomitant diseases for which specific

therapy is available cannot be overestimated.

Clinical aspects

There is nothing characteristic of the early syniptonis that distinguishes

this disease from any other acute infectious process.

Incubation period.-TThe incubation period is always difficult to determine in diseases with grdiilual onset atii indefinite time of exposure. In two

mnedical officers, who were in a known typhus focus for onl)y 4 days, it was from

9 to 13 days in one and fromn 10 to 14 days in the other. One had a typical skin

lesion 2 days, the other 4 days, before the onset of fever. The incubation

period for the fever in these two cases corresponded closely with the one deterinined by tle British, which was froin 9 to 17 days for 121 cases.

Signs.-Three physical findings were found sufficiently characteristic to

make them of considerable diagnostic importance. These were the typical

eschar, generalized lymnphadenitis, and the rash.

The following tabulation shows the incidence of these signs in the series

of 600 cases reported on b)y Colonel Wood and Captains Sayen and Pond from
lhe 20 111 ( i'iendi I l4)~liltl ;iild ill thle S6) (**is reported (Ioil by\ Captains Xri

Mid~ Ev111iii Iioili thle ;:"l Evacuiat ion I lospit ;il

781 lKo:(*pi till ¶11 1,/ its ?S.

TIi e suliar. Shiowin In ligiiie 251, was the miost pathloimioiioniii physiV~cal

fi lil Ii , althloili- it N\as Sven less, Ireqiieiinty h ha Iv i lii n ianleit is. Althloili-1

lte lesioti was fouiid oil111 palrits of, I lie lod ',N ill Iiost cases it occiii-red oil the

I iiii1lk or Ill tIlie axihlae. Ulisliial sites weIre thle e~veld.ls, lie pewiis.; '1ind thle

Ipeii1i ii,1l regioni. M ore t han onle eschiar was VverV I'are; C oloniel W~ood andl C apTtaiiis Sa ~veli and lPoiid lIm-elil1oW oeCalse. Thev imiport ance o1, thle eschla as

a dia.1noshe sC 5Wti Inv ill tihe f.et thai~t 11,11.111v this JiiI~iv leioli wns presenlt

for several (hil vs before t lhe act 11al oniset of siiton. Ifr thle lesionslal" hadeehi

(Iljseoveredl and~ 1 lie si&-iiificiiicv eioilnize I, t lie nifb'eted inividvjliinil iiiinzIll

lii ve sharted t heir ;irliioiis trip ic)h k it) a hiospital 2 or 3~ (lnys 1l(ehwe ti ole 015(

of hllv dIsea1se inlstead of iiioviii&r deep~er inito thle J1iile sthyUlt1es onal

did l ii vioiips su~ch as N errll's NIaTher e'Fu best dlescriptionls of thle eschla
IND IA-IIURIIA THEATER 749

were foundl ill Lietit ellant Sa ven's p~reliminilary rep~ort of 28 MIay 1944 and inl tile

11rticle oil 616 cases, of Captains" Savenl an1d Pond and C olonels Forrester and(

Wood, the latter containing the following~ commitent:

A typical primary ulcer, or esehar, of Scrub Typhus begins as an inflamed, ;)ainles-s

papule which soon ulcerates, forming a central crater over which a dlark, redldish-ibl:Ik

scab) formis. In moist areas, or when the scali is pulled off a deep uilcer with raised edges

and thin yellowish-white exudate is seen. An essential characteristic is that it does nlot

heal, possibly not un1til miany days after thle patient has recovered1 from his systenmic

symiptoms. Although resembling other typ)es, of bijtes in its early phlase, the mite uilcer

shortly becomes so distinctive that it can scarcely fail to he recogniz~ed if seen. ItI is a

raisedl lesion about. the size of a dimie wvith a black scab) at the center k2 to 8 mmn. in (lianmeter)

and a red, angry flare surrounding it for a distance of a centimeter or more. One or more

regionial lymph nodes soon become enlarged and tender and it. is these rather than the symptomless ulcer which may at tract the attention of the soldier. Since the eschar may occuir

anywNhere on the body, common101ly in moist, p~rotected areas suich as thle axillae and the

genital or perianial regions, a thorouigh search miust. be imade of every suspected case. 'Medical

corpsmen and line officers could probably be taught to recognize such lesions in addition to

members of thbe Medical Corps.

Lesions on moist intertriginotis surfaces (axillae, scrotuim, perianal regioni) app~earedl

as shiallow, yellow-based uilcers without much surrounding hyperemia and without the black

crust.; consequently they wvere easy to overlook. IesionIs oni the hands anid those below the

popliteal space wvere often indlistinguishabile from the many cutaneous erosions and leech

bites sustained by troops traversing the jungle * * *. Tle vast majority of patients dlid

not report feelingr any ''bite.'' Secondary infection was rare * * *. The presence or

character of the uilcer appearedl to have no relation to any other manifestation of thle (disease,

including the OX K titer and thme severity.

The lymphandeniopathv wits the( most. frequent. singgle physical findin~g.

Generalized lviiiphadlenit is wats the rule, but it wats common to finld enirg.1-ed

tendler lyinpilih nlodes draining, tite site of the p~rimnary ulver a (hay or two previous

to the appearance of the generalizedl adenlopathIy. Because of thle wide varialbilit v inl lie( site of thle esehar, careful search wits necessair , in ordler not to

overlook tilie regional lymplli nodles. The nodles were uIsuall1Y large and rubb~hery

Fever,- Ant irreguilar spiking type of temtperatutre cuirve with dt(oublie

daily rises wits regrardled ats chatract erist ic or scrubl typhus by Captain Savenl

and his associates. It wats exhib~it ed 1li'v 70) percent of tilie p~atients at someW

time (luring thle course of the dlisease. This characteristic type of cuirve wats

uisuimdl *v not persist ent but was suppla~nt ed bY lon,_r or short periods of remit tent,

Or slust aiiied fever.

Laboratory findings

AgIlut mat ionls of tilie Prott us- OX K ant igeni were found to h~e of ft( lie reat eSt

d imn oiist ic value. A (let ect aile titer wvas not tisumilly found uint il thle I (t0I

(121v oif tlie( ilisealse or hat er. Opinions varied as- toi what conistit ut ed at (hiagnost ic

ti t er. ( )servers at tilie 20th Gieneral H ospit al, Ilsimig / 100 ats tilie dialgnostic.

(lillit ion, found only 55 percent of their 60(0 catses withI this titer or at higher onle.

At the 73Id Evacualtionl 1Hospit al, observers considered at titer of 1/50 w; strong

evidlence of scrub typhus; 70 percenit (if their 86; cases showed t his or higher.
.41.

li( 4)f the dii'ase.

(i..252), whichl iuIi ;ppvI'I*(,,l bet'weeii lhe .3d andi 7th day of the disease

Mi lximm n 061-41of Ole pn)vifils. The fate ~sInivolved 111 15 l)&ice lit.. It.

q I1se stil11 t t I1hlsl firoim alily otther severe !eirVIIitzIezd jold'vctm alouk-v

levver for at1jittruuiittllev 8wv'tks. aitti It \\*Is fi theii1rii w- 2d ;indt :')d W('tk that
IN1DIA-BU'RMA THEATFR 751

serious diagnostic and therapeutic prol)lems; there were other less significant

features, such as tender toes, colijunctivitis, deaffless, visual (list urbances, and

edema of the face, hands, an(i feet.

Respiratory manifestations.-Ihvolvement of the respiratory system was

very common; almost every patient had bronchitis, and pneumonia was seen

frequently. Colonel Wood and Captains Sayen and Pond concluded that the

following points were most important in establishing the diagnosis of typhus

pneumonia:

a. The most important sign to look for is tachypnea, :35 or more per minute. When

this persists for 2 or 3 days, a fairly extensive typhus ineulhnonia is probably l)resent whether

or not physical or roentgenologic signs confirm this suspicion.

b. Less extensive typhus pneumonia is often indicated by persistent rales, iml)airment, and restricted breath sounds, in the absence of marked tachypnea.

e. The ordinary roentgenologic signs of pulmonary consolidation are rarely seen.

The chest film often shows nothing hut prominent hiluim and trunk shadows in a patient

with extensive typhus pneumonia. Occasionally there is diffuse mottling. Typhus )neuimonia is a lesion which is not adequately demonstrated by x-ray of the chest. When abnormalities are found they usually fail to indicate the true extent of the lesion. The

occasional ease will die Nxith extensive typhus pneumonia without having had the degree

of taehypnea indicated in (a), but this is rare. In conclusion, then, the most important

clinical indicator of the condition of the lungs in scrub typhus is the respirator ratechart.

It rarely fails to show a rate above 35 per minute for at least 2 days when the lesion is extensive

enough to be of major clinical significance.

Cardiovascular findings.--In the cases observed at the 20th General

Hospital, cardiovascular findiings were summarized by Colonel Wood in the

theater ETAID for M1arch 1945. In 500 cases, no true congestive heart

failure was seen. Cardiac enlargement deternined by percussion and the

position of the apical impulse was found in 28 percent. of 200 cases; however,

Colonel Wood questioned whether X-ray findings would corroborate such a

high percentage. In the same 200 cases, 24 percent had a gallop rhythm

mnd 33 percent a soft fiirst heart, sound. Electrocardiographic tracings were

taken on 42 patients in the 2(1 and 3d week of the disease. In 30 of this group,

the tracing was taken b)eeause a car(liac complication was suspected; 8 showed

P-R interval prolongation of 0.22 seconds or more, 18 showed minor and 3

showed definite abnormalities of the Q.R.S. and/or T segments. In the

remaining 12 cases, the tracings were taken merely to determine the incidence

in unselected cases of scrub typhus. Although the series was too small for

conclusions, 3 cases showed P-R intervals prolonged to 0.22 seconds or longer,

and 2 showed nmarked RST segment deflections and/or T wave inversion.

Colonel Wood concluded his report on the cardiovascular findings, as

follows:

These cardiac plhenomena rarely occur in the first week. They appear from the 7th

to the 1ith day. We do not as yet have the figures for the duration of enlargement, gallop,

etc. Moreover the correlation between pathologic and clinical findings is not yet available.

The patients with the largest hearts did not all (lie, by any means. In fact most of them

recovered. As they got well, their hearts returned to normal size. None of them showed

congestive failure. A few pativiits who died showed mild to moderate degrees of right

sided eardiac dilatation at antopsy. Pericardial effusion was not seen.
752 ACTIVITIES (OF MEI)ICAL CONSULTANTS

e. Conclusion.-Although our data are as yet incomplete, it is our impression that

these cardiac signs all disappear during convalescence, and that the "effort syndrome"

picture seen in some convalescent typlitis patients is not due to heart disease per se.

Ocular changes.-Maj. Harold G. Scheie, MIC, studie(d the eyes of the

patients at the 20th General Hospital at weekly intervals during the course

of the disease, consolidating the results of his studies in a brief but comprehensive report. He stated as follows:

* * * The first and most uniform change found in the fundi of the patients with scrub

typhus was progressive venous engorgement with onset late in the first or during the second

week, continuing until the veins are two to two and one half times the diameter of the arteries. Accompanying this change the veins b)ecome more tortuous, irregular and salllsage

like in caliber, most marked near the disc. The outlines of the venous walls become indistinct while the arteries remain ANell defined. Apparent compression of the veins occurs at

the arteriovenous crossings where the veins frequently appear interrupted by the arteries,

which at these points have a diffuse veil along their walls. As these latter changes progress, the disc and retina become edematous and the posterior pole of the eye appears somewhat veiled particularly in the region of the disc. The disc and surrounding retina appear

pale and more opaque than normal. In a few cases retinal hemorrhages and cotton wool

exudates occur when the retinal changes are at their height.

Conjunctival injection occurred in 38 percent; subconjunctival hemorrhages in 6.5 percent. Retinopathy, when present, was of diagnostic significance inasmuch as lesions of this type were not seen in other febrile diseases.

Edema of the disc and retina was noted in 36 percent, was always bilateral,

and was preceded by engorgement of the veins. Retinal hemorrhages occurred in 16.6 percent. They were usually superficial and flame shaped but

occasionally deep and punctate. Retinal exuldates, usually of the cottonwool type, occurred in 4.9 percent. Major Seheie failed to find evidence in

the retinal vessels of the perivasculitis mentioned in TB MED 31; he felt that

the changes were rather those of at true vasculitis.

Neurological manifestations.-Involvement of the central nervous s*-stem was evident in practically all cases. A nerve type of deafness was seen

in the majority of patients during the 2d or 3d week. Tinnittis was usually

an accompaniment. Peripheral nerve symptomatology, such as paresthesias,

numbness, and weakness, was seen in a few. These phenomena generally

disappeared with deferveseenee. Meningoencephalitis was evident att post

mortem exanilnation in all fatal cases. Clinically, ilvolvement of the central

nervous system was reflected by apathy and drowsiness in the early stages

of the illness and, in tile 2() and 3d week, by confusion, delirium, restlessness,

convulsions, and coma. Captail)s Sayen and Pond and Colonels Forrester

and Wood described the restlessness in their 616 cases as follows:

Twenty-six p)atients developed a peculiar, persistent restlessness. Such individuals

would not lie quietly, but constantly thrashed about, sat ul), or tried to get out of bed.

They wvoild not tolerate an oxygen tnask, or an intravenous infusion. They required coltstant nursing supervision and sedation. They were all gravely ill and wore themselves out

at a time when their physical reserves were precariously low.

Malignanit restlessness or convulsions were among tile most ominous developments, and coma was usually followed by exitus. In 200 cases at the 20th
!NDIA-BURMA THEATER 753

General Hospital, only 12 patients had convulsions; coma occurred in 14 cases.

Hemorrhagic phenomena.- To a variable extent, hemorrhagic phenomena

were seen at the different hospitals. In the theater ETMD for June 1945, the

73d Evacuation Hospital reported that at that hospital relatively few patients

showed a bleeding tendency except as a terminal event; whereas, in the theater

ETMD for April 1945, Capt. (later Maj.) Horace H. Hodges, MC, at the 20th

General Hospital, found the reverse to be true, as follows:

It was concluded that, in a considerable proportion of patients with scrub typhus, there

is an abnormality of the clotting mechanism. A lowered prothrombin content seems to be

frequently associated with prolonged clotting. An actual purpura, with platelet deficiency,

was encountered twice with long clotting and low prothrombin. The significance or cause

of this is unknown. In itself, prothrombin in the range of 50 percent normal is not enough

to prolong clotting. Other unknown factors must be operating.

Also in the June ETMD, the 14th Evacuation Hospital in reporting on a

gross pathologic study revealed the following incidence of vascular or hemorrhagic manifestations:

1. Of 16 autopsies performed on U.S. soldiers, there was 1 case of acute

infarction of liver, 2 cases of acute infarction of spleen, 1 case of acute military

Jmlyocardial infarction with perirenal hemorrhage, 2 cases of adrenal medullary

hemorrhage, 1 case of massive hemorrhage into psoas muscles and retroperitoneal tissue, 1 case of massive hemorrhage into small and large intestines,

and 1 case of acute infarction of kidney.

2. Of 7 autopsies performed on Chinese soldiers, there were 3 cases of massive hemorrhage into psoas muscles and retroperitoneal tissues; 1 case of

massive hemorrhage from nasopharynyx; 1 case of acute infarction of kidney;

and 1 case of massive aspiration of )0ood into lungs, source undetermined.

These were all post mortem findings. No mention was made in the report

of the incidence of hemorrhagic phenomena in nonfatal cases.

Treatment

Therapy was primarily supportive and symptomatic. Strict bed rest was

essential, and it was generally agreed that nursing care was of the utmost importance. At the 20th General Hospital, it was the consensus that the care a

patient received in the first week of the disease might be decisive in determining

ultimate survival.

Sufficient fluids to insure an adequate intake were essential, particularly

during the monsoon season; at times it was necessary to administer fluids parenterally. In the theater ETMD for May 1945, medical staffs of the 20th

General and the 48th and the 73d Evacuation Hospitals agreed that slow and

cautious administration of intravenous fluids did not constitute a serious hazard; however, the medical staff of the 14th Evacuation Hospital expressed the

following opinion:

b. Fluids: We are strongly of the opinion that the interference with fluid balance by

means of intravenous fluids in this disease is hazardous and, at best, not as beneficial as the

frequent administration of fluid, even in small amounts, by mouth. An intravenous infusion,

564970'--- 01 --- 50
.42

An iir 2 :. \ro11 i ' c 1 11 i 0 1 .V Irw iw
(-II-1UI )idvTE i 0 i nta npta i mteso 7nepljitw~-e'ia 

\\lii if tIl li 4It1' (ill . ltVml d ll.'( c~vllt li iiit he I lei niea lji off lt ell):0 ! ( m %llee Off li

h in 1,,h fi n h I:iii ill li (0f1(h it 4)1 :If&d ( i: . 2 :1ti lieýi t)) \f1ý. 11lewiols Wai s l I i

)111 vi on ii'ii i vi 4Ii ii v fin ie nt the4 20as COiiollten' HosIaplil. i)t ( \\ ) ffll lioth a Iadit v .,oiii IT pof- l ut11d toH jil4(it . l Iielo produced, alt ldve~l-s effW ct. esiill f

l)4-Iielt-i fiat acItl [o)ili I~fll a i iih( h(I' tle doe,\ats'i v'fee l .1 fio re reoil tiles aml gfi nt! 

,dlII ilil1e \\Is a-ibj eet e le11i~ bv .11 le Wa1h1.1di se fa I lifec dopf III(

fa T het ileS,1,11l fI oat( ;itii II, it el 14) 1114' nt 24-53)it't ti h\t I e v ite m. (i(' olt lithe

belle\ v iIlh t I- oll I il lo if~ I lose 'ho (I hie pal ilii fi hg 11ore ('II fort ýlt(4k We 'Il1' '\
.W''II'I~4 ( i)ii.i C ('XSI'.TIANTS

trol bleediiig 1 t'iitliicies. I igitIallis -als not ulsed ill tilie varldiovitsclilaltr .ol ii phvit~ti ios 0t t ie 20t Ii ( Gtield 1 lOSpi It ad! lecittist of t he i II I I) re'5l~i Or ot I st atfr littII

tmtiie N111 w1its1 lit helpful ill aculte febl wlt' tisvalst-'s. Oji t he 0 it'i her hand, th 1tI41 It

lEvitmiiit ion Iiospii tii stiUfr niiiithl Ile followving staUt emlent '' Di'i ti bs lilts

Urvl uitiost valtlultb' tNvige ~~lt ist'tl calII wUtS~ith 1111 11iiv uiiatstattioiis or

Citi'diovitstilcill piti imaret'll f 1' (I iv5hiiict iou , its well Uts ill ('ast's with ob iviouis

cvi'idiac fnilure.'' Tile 4StIli E'vacuiattionl Hospitad wvas allso of tlie opinlionl

I hatt digitaldis wats heileficiald.

P~rolonigedt colivalescenit care was thle ruie. Tile ulia1jority'N of patients

withI scrub tvlN-)lIIuS were returnied to dilt Nvwithliinit period of friouii :1 to 4 mlonithIs.

A compi 1 lette jrogrlil for recond it ioning of such paitieiut s, based onl t ie( progr1-uln

iii utse, at thle 20 thI Gvetiet I lospi tail, wits publlished inl ( irculdir No. 11 , Offlice

of t lie Surge--on, I laitdqjuart ers, USAFI] 11T, 231 Decembi er I1944, subject : Scrub

'lvphlts Rveouidit iollilig. Th'le conivalescenit p~eriodl required fromn 3 to 4 miotitlis

for pat ienits who were to ret urn to colinbait (it *t v. Becitlise of thle seven t N. of

lie illniess atnd tilie p~roloniged coni vatdesceele, t here wits it t endency forl patt ielt

to (developl)ilti eff'ort svlildrolie if tilie physicall recond~it ioninig wit pushed too

hiarld. Pitt ieiits who iliid bieei severely Ill, lisiiidll with :Ii coiiijplicitt ion suich

its pliieiilionill, iiivocatr'ditis ieiigecplitis, or* seVerVe Iieunlorrhagme, Nvere

t'vitcuiit e( to tilie Zoiie of Inteit 'or.

Cuitaneouis Diphitheria

(Chlronic 1ilcerat ive skiii lesions or-ig.iiiat iil igli Illvtin(I liall'eed , etel airatlsiouis

or. hit I's Illt' commoni~l (Iitrililie dw iolisooui Seatsoli ill t ie( Assitiiilliiruiiii11 jung~le.

l~litv tre g('vi ierldlv t'illetl I ropit'iul uIclct'r or, palr i-Iilatlzl v ill t his region, Nitgat

Soi'es,, (fig. 254). (ConisequtenitI'y, whiein ili June antI.1i k 1944, U'.S. soildtiers ill

tlet nieighboi~rhiood o Nitvltdeve'loped slugg~ish nie'crot ic ulcers onl t heir

ext remiitit's, tilie le'sionis were ('01nsidelred to he at forili of t ropicali ulcer. Undi(er

silowetd stilii( degreev of leivilliig of tili( uuluc'rs; Oi leu returini to (hIllY, hiowever,

resuiltetd ill almiost imiul('lidittt' relillist'.

Tlhe' mire severe a1in1d persisten'ut caises wt're evatcliat ed back to geiierid

liospitI adls. Whlti soiie of thle pat ielits onl th l leiuttolog-v vit' service itt thle 20thI

Geiieral 1 Ilospilald dt'vt'loped neuritis aunld cartdiace s~*iiltt)1i1 iii August widit

earlI v S epteimber 1944, C oltonel' Wtitd, cliitf of lt'e iiaediciil service, 11d ta( j

(IntIei. I' . C ol.)1 ( 'lareiict' S. I vitugood , NI ( , of Iit'e teleiiiiit ologv- service, biothi

sluhlitniIted re'port s onl 15 Sept emiber 1944 to lit' ctiii miiiiaitig offitcer of t it'

liospit til , sluggest i ig thait t hese skiii uIlct'rs were ciit il~leolis dipI t lieriit.

As it resullt of thiest' reports, 'NI atj. (lit ei let. C ol.) JTohin L. Arliogalst , NI1(,

Of tilit 9th NIi diCadl 1,11ithiorYtr, iii ide ani epidv lenioltigic an~d biactetriologic surlVe V*Vof tilit Nivit kviiia atreit, sending ill a pt'luiir reptirt to tilit coniiiititntliiing

Ollicer. of til lt al orail orv on It OI( ctobe'r 1944 sii laiitimre tcoiiiplet'te rteptirt onl
P; N"ovembiler 1944. Thel surve v shOwed t hat tIlelv I i iu.,IIvtOlvvd III tie Outbreak wevrve 4xl)sedl to1 lvin-iL (Thli~ll i4s t hat were severe e'veni I'm c4)Iiil)

.In addit lOll t0 tile' hardrslip,~ oh lO.\llOle thltuiIlese iieui 5u1114rv4'( l 'Oiii ]IIIiiei(ouiS 111l110l' ;ll1fllsioils 141 tile lhick jiiiigle uIuldlti.-I4)wtIil, froiii leech .1l(d

Inisect lbit es, '11dilOl I thei I lieljtelse heat aIIIt1 1 iuiilYl tvOf IlIe( B1u1.11i. iiioiiSOOui

season01. Voor per-sona i zeueWas uiiiuVOnlabldt' batilung. facilities were~

r,1rel1v .1valiable. ( lot hiiuii .a1d vquiipmneut were lw sdiii.1;uid, Slince

III ticli of lie ffligt lug. took place tilirolighi ri1ce fields, it was IIlipIO.sible( for tilie

Ilien 10) keep thleir feet dry. v

Thit SOirtev o tilelt iilr'tt ii'o nlileio-()''l-aiisiiWll was .in m tter of £rirelt inte(rest

.11i1d was iiit('lsiveiv stuitied. Thie mi b Metlic'h Laboratory s111d jes" iiichlidet

cultuire's frmi (hle ri1ce paddies; thlese weie 1iuliormulll ,v uIeIive-It~ . ire1- cases of

faluciald (illithleria were relpOrt ('( aullioug theit I roops frouiu1 timue to timue, blui

129) nose aiid thlroat cult uies frmii a gm )of thle 475thI Infant 1w showed OIllY

One' positIivt' fOr* ( 'wqit (bqt~r/Ul dip hp//I ;ur ; It pr )ved to 1be a vi Ill eu t No

definlite relationishiip couild be4 tracedt letweeli rauicial (hillitleia'i andiiL

livoiti tliphitleii'ia. It is or interest tilat tI~ liJ.tit ]Intelhligenuce ( Olectilui

Ageuitv, ill Its, reimrt N\o. 207S, dthied 14 Novemiber 1944, obSI1seVet t hat (i11.1i1(

tlit samiie 1iiouitlils tilit Brit isli hospit als ill India were also seeiui(. a 1iiiuiiil.t~

of cast's Of ciii auieoiis diplit ienia.il

( 'it.1iieous dipht hueia was otItl r oi epotedi ut il S'ept embe~tr whlcu tile tliWghioSsVIs wsfir.st est abli shied at Ilt' 20t li ( reuieral I IOsjpit a I ii a groupo41'pa Iieh Is

W\itl II Iiivo('a rtial andh ii'ui-i li' compiJhcat Iions. Earh-it'r cases uiuidoubht edl*v laid

Occuirredl. 011v soldier, athriltit t' tto auitot hie hlOsjit.a! because or uilters of,

the leg., devt'lOpetl III Ocardihi is miut died iii ctongesti ye heart faiiluire 12 do vs

a ft er athdiissioii. .No ~ihi~ris41- 0lc c1IiI lint's weire Iii~lt'd. At p)ost
758 ACTIVITIES OF MEDICAL CONSULTANTS

Inortem examination, inflammatory changes consistent with diphtheritic nivocarditis were evident.

Once cutaneous diphtheria became established as a disease entity, patients

were diagnosed early and hospitalized. A more comlplete report on 9 October

1944 from Major Livingood of the 20th General Hospital to his comnianding

officer followed the original brief reports, and in October the 69th General

Hospital reported on 30 cases. Additional reports were subntit ted in 1945. In

the theater ETNID for April 1945, ('apt. (later Maj.) Harvey Blank, NMC,

of the 69th General Hospital, reporte(d on anot her 40 cases frontl that hospital,

and Maj. Herbert S. Gaskill, CI(, of the 20thi General Hospital, reported on

neurological coinplications. In the May 1945 ETMID, Captain Blank reported

on 3 cases from the 69tht General Hospital enlisted detachment. Major Kay

of the 20th General Hospital submitted a report on the cardiac comuplicat ions.

Clinical manifestations

The clinical findings have been described in many textbooks and in TB

MED's on the subject. It was apparent from the histories of these cases that,

like tropical ulcers, the diphtlheritic ulcers arose from minor cuts, abrasions,

and mosquito bites which failed to heal. Multiple ulcers were the rule, in

most cases located on the lower extremities, usually below the knees. The

hands and the forearms were the next most frequent sites; other parts of the

body, such as thie scalp, trunk, axillae, and perianal regions, were less commonly

involved.

Major Livingood, in his preliminary report of 15 September 1944, stressed

the following three diagnostic features:

1. An ulcer with a black adherent crust; this was the most important

clinical finding.

2. A grevish, yellowish, or brownish-grey membrane in a superficial or

deep ulcer.

3. An ulcer surrounded by an inflammatory reaction out of proportion

to that usually seen in eczematous ulcers of a similar size.

Captain Blank, in his analysis of 40 cases at the 69th General Hospital,

described the lesions as punched-out, ulcers with a black or brownish-black

eschar or, in the absence of an eschar, a greyish muemnbrane. T[ihe scars were

" deep, very e(lst ructive, and atrophic, withi a violaceous tan color." Darkening

of the skin around the ulcers was described by all observers, and anesthesia

of the skill ininiediately surrounding the ulcer was common. Pain was not a

prominent feature except when an attempt was inade to remove the eschar or

membrane.

Under local treatment, the ulcers healed slowly fronm the periphery towards

the center. The scar did not contract when healing was complete, and the final

scar was an atrophic circular spot the size of the original ulcer.

The healed ulcers, frequently broke down. The process was usually

preceded by the formation of a bulla or vesicle in the center of the healed scar.
INDIA-BURMA THEATER 759

When this ruptured, the rest of the ulcer soon broke down completely. Healing generally took place fairly rapidly after such a breakdown, but because of

the frequency of such occurrences hospitalization was usually prolonged.

In a final report on the cases seen at the 20th General Hospital, Capt. Daniel

J. Perry, M', of the dermatology and syphilology section, wrote to the consultant in dermatology in the Surgeon General's Office, as follows:

This tendency of diphtheritic ulcers to break down is perhaps explained by the microscopic picture which shows massive fibrous tissue formation enclosing small vessels and

capillaries surrounded by a round cell exudate. Tile process extends peripherally into the

normal skin beyond the ulcer and also downward into the subcutaneous fat. The histologic

picture suggests that a local toxic agent has p)roduced severe cutaneous and subcutaneous

changes. The destruction of nerve endings probably accounts for anesthesia present in

the scars of cutaneous diphtheritic lesions.

Cultures from the recurrent ulcers did not show virulent ('. diphtheriae.

Complications

The 7 cases with cardiac complications (in the 141 cases reported on by

Major Kay of the 20th General Hospital) constituted only 5 percent. of the

total group. Only 4 of the 7 cases had definite myocarditis; the others were

listed as probable. One of the four died. [here was no "typical picture" of

car(diovascular complications. The one fairly consistent finding was an inversion of the 'r wave in lea(d CR3 ; this was present in all cases of nivocarditis

except the one with fatal termination. Interestingly, no instv• •ces of intraventricular conduction defects were noted in the cutaneous diphtheria group, although two patients wit hi faucial (liphtheria who developed inyocardit is showed

this type of lesion. Cardiac manifestations usually developed b)etween the

3d and the 7th weeks. At the 69th General Hospital, only two cases with

cardiac involvement were seen.

Neurological complications were much more common. At the 20th

General Hospital, 43.5 percent of the cases showed neuritic involvement. At

the 69th General Hospital, in a group of 40 cases, 48 percent developed neuritis.

The important neurological complications seen at the 20th General Hospital

were summarized in the theater ETMD, diated 10 May 1945. These coniplications were discussed, in general, as follows:

Neuritis appeared in the average case 70 days after the onset of cutaneous diphtheria

(the extremes were from 23 to 158 days). The clinical course of the neuritis proceeded in

regular sequence through certain definite steps, which were in some cases partially superimposed and in others quite separate. The steps in order of their appearance were (1)

cranial-nerve ini\volvenment, (2) peripheral-nerve involvement (sensory), and (3) peripheralnerve involvement (motor). In the majority of cases, cranial-nerve involvement failed to

ap)pear, but tile stated sequence in peripheral-nerve involvement was maintained. In m'ny c-s•,s

the peripheral motor symptoms did not occur, the patient showing only sensory phenomena.

The manifestations of these three types were as follows:

1. Cranial nerte involvement (duration from 10 to 30 days).-The most common symptom

was blurred vision due to loss of accommodation. Other less frequent signs were wea.kness

of the pharynx and palate, loss of taste, and numbness of the lips and tongue.

2. Peripheral nerve involvement, sensory (duration fromn 28 to 56 days).-This always
7 60 ATIv1'1'IEs OF MED)ICAL CONSULTANTS

mwgan with paresthesia (numbness and tinjgling of hland(s or feet or both). Later, there was

a dimijeiitiote il pe'rception of light touceh and paine.

:3. Pcriphcral nerl'e in rolre'men!, Pnotor (du ration * from 80 If) 90 daqs) .- This aelways b~egani

withi the subljeet ive symptonm of weakness of armls or legs, accomnpanied by d eiminisheed or

lost, t eniC~Oi reflexes. fit severe case's, at ropjih y ectirred. A verY few inividu~IIals shiowed

posterior volitimie signs, loss of posit ion aind vibraticon plus muild aetaxia.

Craniial nerve inv~olvemneut wa:s ustially' followed by neoulrate or verv severe neulrit is.

Couese(etieeuet I' , it seeiuiede to bce a jerogueosti indc'uejat ion. The ehiret ioni of nuteirit is was eliretl't Iv

relatede to its severity. Tile average ease laestedl l(t) daYs, (extrenlees fromu 21I to ISI dayvs).

Tilt- site (of thev cutaueouts lesion bore' no relat ion to Ilii locat ion of thet neurological involvement. Se've'ritY~ of c'letaneoiis lesions u'oehld not he vorrehuted \vithI se'verityv of neeuerit is, butt

it did ecrreliete wvit h freiuieueeY (if neunritis. Thel( spina~l flutid proteins we're' focuid to b~e

elevate-d inl ne':rl *v e've'ryvease of neucriit is. lin geueeral. tilte elevat ion ma:s proorionalI to the

severit 'v of thet nee'urit is aned persisti-d muti iit)( heneureological jplue'lonieiem elisaep,:ire'd. Comlplete' recovery from neutrit is oecturred ('vetlt iallv, evene ill tile mnost severe case's.

Treatment

Anttitoxin, ilit dos(-, of firomi 20,0(0) to 40,000) unlits lilt rainutscularl *v ats early

ill tilie 'ouirse of tilie dttitseas its possibule, \\It" tilie mtost impIort anit Itteasitre.

lInjec'tiont of tieIitalitittoxili ili thit ieiglitorlioot of thle lesioni had 1no apparent

adIvalit Iaor( cover hit ri'l Ini tiscduti' inijectiolt Into lie buttoctks.

Nonslpecific therai'ipy conisiste ciof jpi't'51iit driessinigs after'i cle'ansiing wvithI

vai'iotis antIisept ic's suchi as peniicillini solut ions, pot assium i petit atigaliate(,

liner('ii'.v livililoritle, anid suilfontamiides. C od liver oil oiiitiiielt undi~er at firiti

itressiigl.it WAS s sed itfrt'cti vt'l VIn several inistances'(', andi Zinct per'oxidIe also was

uisedl withI belueificial result s. Parelt eral peniicillin %%-.is iii('ff('(Iive.

"thle uilcers of tw~elve cases lit tile 20thI Genteral H ospit at were treated't

surgvica liv, antd rep~ortedl oil lbY Maj. (lateir Ltt. C ol.) Itn- . Roystt'r MC.

It was tilet opilticolt of M Iajor Ro * st er t hat itiore frequtent use of surgery, wouild

have resulte(d( ill at larger proport ion o~f Itelt retutrnted to hitY V 111( wouild have

r('(licedl thle lenigthl of hiospitalhizat itn. Ilet coincludled that surger- shouild be

considjered( ill every, case' whetn thle ltesioni fails to lit'al after front 60 to 70 (lays;

excision of tilie ullcet dining thle actit e st agte is coit raindicat ed. Excision of

the tilcer and1( a sitnalt cuff of skin followed by *ivtpplicat ion of at split skin graft.

apparently vel t het le h ltst results. Tile itutrlit ioual state of tilie pai~zent seelliedl

to e'xert at profound inllueni'ice oPit lthe healing pr'ocess. lit 9it patient withI aiteittia

and Ilipoprot eilitt'iitia tssociatted wvithi hookworm inifestat ion, th liw~oundit failed

to heat Iout ii thlese factors were taken inito a('comiit anid corrected'(. Adlequiat e

feedinig of' prote(iii anid t rantsfuusioin of blood andt plasimai were't lit'('try'i inl sonie

Cases. No mtainifest ationis of vitaittilc (m'teicieticy we(re' app1arenit.

Bacteriology

nhe first initenisive iacteriologic studies were iweguut by" thle Oth IiMedical

Laboratory iii October 1944 101(1 report ed oii to ttile Coniittnlitidig officer of thle

laboratory, by Ist L4t. (later Capt.) Charles C ox, Sn( , onl 14 November 1944.

lit addlit ion to ('lilt ures fromt thle ullcers-, tIlie sttildy' also itichuided cult tilres from

(lie soldhiers of coine of thle orgivtizations locatedh near MIvitkvinia. Nose and

thiroat cultures ft'oltt thle 475th Iinfaiitry, oite of thle units iutost affectedl. showed
INI)IA-BUIIMA THEATER 761

128 negattive cultures andl I miorphologically positive, but avirudlent, culiture.

Cultures froin thle rice paddlies, considered at possible source of inifection, were

uniformdy negative.

Of .53 cultures taken front leg ulcers, 10 showed miorphologic characteristics

typical of (C. diphtheriae-9 were avirulent, andl 1 wits positive to virullence test.

Later cases showed a higher percentage of virulent cultures. Of the 10 positives, the siiigle virulent culture canie from at patient whose ulcers were only

of 6 (lays' dluration and wvho had at Schick positive reaction, whereas in the

other 9 patients the lesions were fromt 23 to 110 (lays 01(1 and the Schick reactions were nlegative.

Schiuck negaitivit 'y, however, did not inlealti protect ionl agalinst thle dlisease.

In 'Major L~ivingood's rep~ort of (9 October 1944, one paitient, ii medical officer

treaitedl at the 20th Generail Hospitail, liail dlefinite kniowledge of haivinig a

negaitive Schiick react ion, for 6 yearis. This ind~ividuall not oidlY developed

cliniical cutii eous Ii plih teria lbut. also neurological comiplica t ionis. A soldier

in thle 69t i Genierail Hlospitail enlisted (letach iitent , reporti-l onl by Captain

Balank, (developed tv picail cli iical cutii neolis (Ii 1)1t liria :3 weeks after at negative

Schick test htad been founid inl thle course of at routine survey of his uniit.9

Althouigh nio cultutres were taiken ini this caise, it resenitded inl every respect,

the otlher caises of cutaneous (ilipthieriai. A second caise ait the 69th Genleral

Ilospit al developed t ' Jpicail skin di pittheriat witht at positive viruletit culitutre

for C. diphtheriae in Mlarchi 1945; this pattient, also hiad had a Schick negative

reaction iii October 1944 wheii the uniit wvas surveyed.

Comment

Cutaineous diphitheria proved serious in niany respects. Two deaths

were dlirectly attributaible to it. A tremnendous nimiiuer of inlarl-avs were

lost to the Armny because of thle slow hiealinig of the ulcers and thle high inicidenice of neurologic coiti llicatiionts requirinig prolonged hiospittalizaition and

conivalescenice. The totail itnumber of hospital (lays of 140 paitienits ait thle

20th Genierail Hospital wats 18,783. Mainy of thle patients lost, a, total of 5

mnonths front (liitY, and1 severail lost ais ittuc i as 7 tuonths. The aiveraige healing

timie of thle ulcers for the whole group ait the 20thi Geiterail Hospitail wits tipproxiiiiiately 42 daiys, withI extretues of froin 12 to 128 (lays. Sixty percent

of thle paitienits ait thte 20tht General Hospital returited to full dliltty after an

average periodl of hospitalization of 8.5 (lays, atid 18 percenit retiurnted to limiited type of' duty.

Thle ntost. iinportant lessoit learnted from this epidleitici wats that these

paitienits 1111( to be recognlizetl in tite eairly staiges by t lie lorwatrd itiedical units

and evacuated initniedhiattelv. The eairlier specific treatnment wats instituted,

the shorter wits the staty in the hiospitail anid the lower the incidence of

coil)phicalt ions.

9The question of the potency of the testing materials may be raised in these last two eases, or for that matter In aimost

any mwL~ testedi with Schick material and found negative, unless, It Is known whether others testedI from the same vial

were Schick positive. The diphitheria toxin Is heat labile, andi, with the high temperatures reached In India, it Is conceivable thai the testing mate~rial may hiave been rendered uiseless.
T62VIIE m-r%*mi O MEDICI(AL C1INSULT1ANTS

Fever of U li(eterinhi i d ( rigizi

Diagnostic probldem

The liiie(Iiial offlicer IIl-ivitll" if) I 11(11 or. ruii roiil thle tempijerate Zonie

ot, the Uniited Stiitt's I-. stirtlet l)v tlie( tillillipreselit (fill"Iglost ic problIemi ol'

lie( patienit whot presn'S ts liiiiisell a ti sl511)t'lsa, N of. liosjitaiI soleIlv leealuse of

fever with iat tel idaii t iii ala se, hleladache. antd genlerallized pai uls a11d atches.

A catrefuil phYsical ('xt~iminat loll s0011 litter t li olset k~its to reveal anly dinghlost itli fi ldigs. th'le ii ied vla oftficer s0011 len Pu is thalt refpcn t (' cairefiil phi * sica I

e.Xl In n t1111 ll 2111d1 12lo11) toprv stilithes hgtle t111 siicceettiiig (121,vs l1111% reVeVI

finding"s thalt will declakre tlie( dialgnosis oh* ma211-laria dengigu, saiidtll fever.

inrect iots hiepat it is, kalai-atziar. 51112111 1ox, t j~I pOid fever, pohiounvelit is, typillius

Iouselorie. uchorielteahorle(, or miiiebortie ),2ailiellic hepatitis, or oie oif

the lvs'ii cries. Thien, too. i1i1a 1i, pait enit s will reveall tOlw prese'uict of disealses

11i0or1 iistild ill thle preyvious jproressioiall eXperielcev of thle Ileiiet j21 oflicer, such.I

25it, sjll r g piS.1)1121Y iy t V Iical I ~iu nlillil 1012~of ii lred toi~s ii ioioiiiicteosis.

Th'le hIitt thl~t the 1)211ieiits Nv'ier iii11ilyl at voting vig-orols, grlolij) hu'oiii Which

t it', sit'kl viuhtd beeli stret' it't. littcoiiitC(I for thle few tinstanlces oh, flietilh~otic

of. tlegei era1 Ii vt'e disvi25t', such I1s dtli bet es. niephiri tis, uibverulosis, or chironiic

rliemi 211 lienirt tIisealse'.

Statistical fallacy

The iiicideince ralt' per I .000 perl 2111111lili of pait tents w~ithi liiiiliagnlosedl

feverls, 01r ld() kever of iilte'intdorigin') iii the I ndini-Burnia theatevr wits

not) equllaldt ill 2llti* othter thealter of' oper'at ions. It is lnifort ifialte I lint Ilthe

termi ' fevt'r of' 1111knowni orig-in ii s uisetd iii t ie( statist icili repjort s carlries tlit'-

coilimit llit lol that suichi paltienits iiiauiiirtsted fever t hat could iiot be diagiilos'tl

1) x the( Ileivit'I ca officers. Ill p)oinit of* faclt, t Iiis a ppliedt252 its it ul ilve01% whleu t it('

1)211elit first pret'5it'it't1 Illit'iills ~ tilt lf tis~t'isi~ir y o- P ohier locatl inst 2111211ion

S0ooi ii t ' lthe offset whl t'ii I Wt' weiert to (21(.1 ilelt erist it t1i2lgllost ic finidinigs.

Tit'lse iiist alliut iolis wvere fiot 211w-IV5 equlipped wit I thle Il bora tor ,Vfacvili t 's

to imiake tIt(' reqhuisitedl(Y'lls stde.Th 11joiyo such "'inswe

observedt ttiiiiiig their'i c'ilnicail t'oiit'se, rT('et(t50111'e ttt' dfiulit ' (tjst'215t f s1 %-iidu'ouiie ent itV 'Indi weu'e lippropriiately' repor't ed. Smitli ani~t individul a11ppeared't

sa idll)IvI feveir iuliPl, of. wh'loi tevrl dtiignosis %%-its fiiatlyv imiiute. TIhe exIt'uitt

to whichtl Iit', officitlt ld() ratt' or this hit'att'r ieflectttedthit iniitiail perplexity

of' I lit llei('telt officerrti'P hierI' 11121 t lie finuld tiui lllOSiS is ho0t 215tt'i't 2111121 Ide. ( tiil It

12 show, 1 he I heatter mont hly~ incideiwt' rait frtlomi .lmaiiia' I943 t iroligh I

.Jutil 1945.

Dengue and sandfiy fever group. MaknY patients e'xhiibitedtlit febrile

('Olli'5t' of fi'oiui I to 10(lith V-s w~ith citlinicicl t'hiiui'ut' trist ivs c'onsist enit wit hi tit hit'

S111141d tv fe'vtei or. dtt'igiit. ( ertaitil pat it'llts, to lit Snure, Shmowedt it l'2lShl, blood(

finidtings, or, teliilletu'at ilre cur11e wholl , Ohiu't n ~t'rist iv of lilt' one ou' lt' otheitr.

F~orth I lt i 1)5 pli1t , hiowe'ver, cliniictal oh servi'vlioli )ll iirit te I1 f sucthi tIifreu'entit -

aktilou. The' fact. thlit sauittflits aret p)Ievilvit'lt ill Kuirl-iut'ii I 1lidil, 2111)(I thit.'i h Iv
INDIA-BURMA THEATER 763

CHART 12.-Mlonth1lj incidence rates, undiagnosed 'fev~er, (7.S. Army troops in ludj'i-Buirma

theater, JIanuary 1943-Aigust 19451

[Preliminary data based oii summaries of statistical health reports]

Il Hate, expressed as nurrber of new admissions plus secondary i I iagnosis eases per aintnum per 1,OM) average stretigthj

Rate

400

300

200

100

~ 1945

_____________mI I________

Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec.

hic uine s cases admitted hin Chinia prior to November 1944.

aegypti in Calcutta.. India, led to diagnoses of sandfly fever in the. formier andl

dIeng1ue in the latter on epidemniologic grounds, although the clinical findings

mlight, be identical. Elsewhere in Burmia and India, knowledge of insect.

vectors is rather incomplete.

Throughout the India-Burmal theater generally, the problem of diagnosis

of these two diseases wats confused iy several factors. There is no conclusive

evidence that Phiebotomus papatasi is the only competent vector of salldtly

or that A. aegypti is the only insect that. can transmit dlengue in India or Burmna.

Moreover, no accurate entomologic surveys of India or Burmia had colle to

the attention of the U.S. Army M\edical Department. The medical officer

was Ctcaught in a further clileminia. Only the following three official dliagnoses

were permissible under the reporting procediures in effect: Dengue, sandfly

fever, or fever of undIeterminedl origin. Unable to make at lefinite dingniosis of

either of the first two, hie retreated to the comiparative safety of tile third

classification. Tilis prob~lem of diagnoses wats nlot peculiar to tile Medical

Department of thle U.S. Arnmy stationed ill this theater. Outbreaks of febrile
T104 ACTrIVITI ES OF MEDiCtAI. ('(NSILTrANTS

illntess of short d1ur'at ion w ithi pl'a t i(al * v nio in oi't ali I are ralther extenlsive! .

referr'ed to inl thle Indlian a1BritIishi will ii iedicall litera'llt ure bv suclh vagule t (''llis

Its ' N ildri'i5fk er 'fi i1 N v e-T',- 01' Or 111 i fsa Ieer."

It was nlot munusual litt thle t i iii of' visit of t lie medical consultant to

enlcolinit er group~s of pa tivi its f romt 1t pairtictular untlit withI surprisinll".y uni lforml

(.1111 act erist ics suich ats fever lastilng fromi 5~ to 6) (las, sevvi'e miodlera te pi'ostrintioii, painls l111( aheis, inl the iiitist'les, phlotflpllohia., headachle, Ilotlerate

lviipliadviiopatlivh but no i'asli, letikopeiiia, or secolidarY rise of teiliheralt tire.

Stlll-rolp, o elsv Neefrquetl giensuc(hi thiigiiosvs it. ''En1giFinviier ss ot 

fev'er", "61'II0 ( rdhna lice Amiimunit ion Co. feve1r.' an1d ''Signall C'orps ('onst md Ili-jl

Bat talioii fever."' This phenloinlenou of a disealse exhibit ing striking tiiiiforiliit v

duriiing telill)0l'at'V out lhreaks is simiilar to t hakt wit iiessetl inl man1y ot her coIni-I

tionls. E'ven thle ('OMil11 (01(1 Cllitt (('t a in t imies ilia v adrect almo11st allt vict mis

wit il sin ilsi tis, of r gast ioi lit ('St ma sn S 1)lt olils mayl% akssiunet sI iiking promi nence.

On occalsionl, this priedomiiliance of' a1 single feaitutre of t lie illness wa-Is

p~erp~lexing, At severth inst allat tions inl t his thlea ter Itingthle spring imiomit us

of 194.5, in terestinug grotups of cas~es were oIbservedl wit i syni 1 t ollus and1( signs

coliisist ('lt with viteiter (lelurueor sandlflV fever but, inl add it ion, str-lilkin viec

of ineiitiiige'l itnfltammation. From thle 1Stiil Gvenerall H ospital, M ,vitkvina,

Btirina, Capt. Frank IV Kibbille, M\ C, reported 22 cases. H e stulmlairizeth his

obser-vat ions ais follows:

These 22 pat ie'nts were admiit ted to th le1th Gi(envral Ii (iji ta dt1hirinig thle mlonithl of

.liie W-915. lt is not eworthyi that, the patient-l t are not all from a single grotip or outfit,

hut t hat fouir of the patients are from one group, and1( that thire'e others not onuly cana' fromi

lt'W Salilt ou1t it, hult. IiVe~l ill t~n' saine tent. IiT'eir fourthi te'lt iiate was not admituteitd Ito

lilt- hotspiital, hut had mild( symIlptomis for one dat at t he eoipnpyi. (Iuest lolling of patien'lts

ill aitl eittrt to discover a mode of inf'ect io comonliltoit all has1 1liuis far prove'd tunsticcessfuill.

The pa~tit'11 were aidiiit ted to thet hospital %\ith a vari('t * of sv 'up w on s, t he mon st

couist alit (of whIichi was severe fronital hevadaceli. This was n(':rly alw:uvs at'coiiijaliii't by

paulls ill tin' ('~*s. Six tof Ilt'w weny-t~wo via pal itnts had (l'ttiit(' protlromazl s *iijitoiiis of a

miildll it'ad cold or slight lv soret'hirtoat . Four ot hers had inijid diarrhea, onel( se've're' enough

ito suililate all Iclitt(.( d-vitll'r v. ''l'here was nio historyv of bite ill alll tiit' and no l~t oc'al paptilles

or whetals as dt'scruibet iii palpthlIitti ft'vtr. At Ilt'e height of the (lisenst', the sintgle striking

sv tptounk was tilit' inlteut' frontal ln'atlache, over and inl thle (p'V(. ( il JINhsical e'xaminuat iton

I hey' showed not Simitis t'iidvi'rtess, hilt imarkted ve'yeball teitdevrliess hoth oil pressure and

wititt loitotio. Evtr'rv pal ieut had smal~tl cetrvical iioites altong tin' ptstt'rior chain. Onldy

hirtev of liltt' group showevd e've'n tdittth'att' vuiclil rigidity anti ili nieairly half the Cast's it was

a:tset'ial ttoget'tenr. Allf the' patIit'nls had imiltd f'vt'r ranging froimi 100

' to 1(13'. The elevation

lasted( fromi twt oto five' tlavs anid tdid not1 rvetur ill zttY uinstanee.

Every patienit. had a routinit e'xamlinlat ion of i lit' Ilitlnogtlobin, whlitt' ilitloo-C('l Colillit,,

tlifft're'itiai, anid lirilne. Thit whiti' ('titits vai'itd fromn abouit 5,0001 to 12,000 with niormial

tlviiht'tnt ials wiiilt' otheir laboratory studies wt'r' iu'gat ive. 'F'lit' spinazl Iiluiits showed vairied

react ions, the whlite eil ctults ranguing froml 0 cells ipl ito 490, ailmiost all of which were

lyvinjilitwvtes ill all Cast's. Thet proitein coltet'itral ioni rangt't fromnltorinul to 70 lIiigliis. per

10 c.t vc. Ini thlrt't tf jt'w reptrt ed cases5, till l th li'tlevated '( proteinl was lirsen(it with no illcrease over itiorilial of tilt white eil ('olilt. I'l tto tilt preset'ut itiine varitills other stuidit's

have beenl negative includitnig occasinutal protelis ant I litettrolplile ftgglitil~tit itots, Kaliuts

and1( spinial fltuid chltritdts. No latet stiuldits have beit''t Comlplete'd as the tdisease is not. sutli-
INDIA-BURMA THEATER 765

ciently long lasting. Throat cultures, where indicated, showed no diphtheria (K-L)

organisms.

Because of the suspicion of lymphocytic choriomeningitis, ten mice were given intracerebral inoculations. Our limited supply of aninmals did not allow us to (to this procedure

on all patients so characteristic ones were picked, some from the high cell count group, others

from the increased protein group, etc. Three of the mice were injected with the patient's

blood, (3/100ths c.c.'s I.C.) taken at the height of the illness. The other seven were all

injected with spinal fluid. None of the mice showed the typical leg symptoms and convulsions of lymnphocytic choriomeningitis. Two of the mice died violently (crushed by the case)

on the eighth day, while all the rest survived showing no symptoms at all at any time. The

two crushed mice were autopsied and showed no evidence of disease.

The majority of the 1)atients were over their acute symptoms b)y the end of six days,

and were discharged from the hospital by their fourth week. At the time of discharge none

of the patients showed any gross abnormalities. No residua were noted at this time.

Similar cases were observed at the 234th General Hospital in Chabua,

100th Station Hospital in Delhi, and the 99th Station Hospital in Gaya. Appropriate tests of the sera in two of the cases at the 234th General Hospital

were negative for lymphocytic choriomeningitis. Occurring at the time when

instances ot poliomyelitis and of lymphocytic choriomeningitis were et tcountered,

these cases raised an important clinical problem. Were medical officers dealing with lymphocytic choriomeningitis, abortive poliomyelitis, or were the

findings merely expressions of the inflammatory reaction of the meninges to

a virus similar to or identical with that which causes dengue or sandfly fever?

None of these patients gave evidence of other diseases in which meningeal

irritation is recognized; namely, acute infectious molonucleosis, mumps, acute

infectious hepatitis, primary atypical pneumonia, bacterial pneumonia, or

influenza. It was believed that, although further virus studies would be

helpful and additional complement-fixation studies for lymphocytic choriomeningitis would be desirable, the clinical evidence permitte(d a diagnosis of

the (iengue-sandfly group of fevers, probably pappataci fever. It was of

considerable interest to note that in the extensive experience of the Mediterranean (formerly North African) theater, sandfly fever with a similar benign,

lymphocytic meningitis was observed.'O Napier, likewise, states that sandfly

fever may simulate benign lymphocytic meningitis."

Hookworm Infestation

Although hookworm infestation was prevalent in the native population

of India and Burma, it was not a problem of great moment in U.S. troops

except in certain areas under particular circumstances. In a survey on the

incidence of intestinal parasitism in Assam, by Capt. (later Maj.) Franklin

Carter, M[C, of the 9th Medical Laboratory, single stool examinations were

done in 6,422 U.S. soldiers; only 13 were positive for aneylostomiasis. Similarly, only 9 hookworm infestations were found in a survey by Captain Ehrlich

10 Circular Letter No. 40, Oficer of the Surgeon, hleadquarters, North African Theater of O ,mations, 29 July 1944,

subject: Saodfly Fever (Pappataci Fever).

If Napier, L. E.: The Principles and Practice of Tropical Medicine. London: W. Thacker & Co., 1943, p. 318.
766 ACTIVITIES OF 31EDICM. CONSULTANTS

of 506 personnel of thle medical detachmient. of thle 20th1 General Hospital. This

is in contrast wvith the finding of 280 positive stools front I,000 inldiaiI civilianls.

These st udies, although iiot. highly accurate because of tilie inevit~alle handicaps

inciden~t, to wartime conditions, neverthieless, provided1 at general estimate of tihe

incidence of infestation.

The extent. to which hookworm disease was resp~onsib~le for liospitalizalion is not known since report of the dhiseaise wvas not required oil Form 82 ab1,

Statistical Health Report,. The experience of th lm ledicatl conisultant Onl his,

visit's to thle Various installa tions was in) genleral accord wvithI the low inlcidence

of infes-tation fouind inl thle suirvey' s just menitionled, except, however, that, tilie

(disease was farl more Common thanl hiad beenl suspected ill tilie patIients hiospitalized in Ledlo anid along the Stilwell Road. These patients had wvorked inl

maintenance and~ couist ruct~ioii units, had bathIedl in streams, occasionally' had

walked barefooted along river baniks, or iii fields, and had had ample opportunit -vfor infect ion. SimlilarlY, early in the wair, combat units were not infrequiently' affected. It is prob~able that. almost. aill of these patients Cont racted

hlookworml inlfestation in this theat~er. Onldy about, 20 percent had lived inl tile

hiookwormi belt inl the U..nitedh States, and AncYlo.sto-ma dmuldeiale, a specie-,

encountered inl thle United St'ates, wvas recovered inl at high percenltage'.

The experience wvith hookworm infestation in comblat, troops was excellen tly described by Capt-ain Rogers and Lt. Col. Gustave J. Damimin, 'MC,

inl their report based onl 50) consecutifve cases adlmit ted or transferred to thle

gaist roin test inal andl (lsenterv wvards, of thie 20thi General Hospital. Several

liundiredl additional cases- b)0th with mid1( without, s ' mftonis were seen on the

general medical Wvardls duiring the Samle Period of time. The authdors, stressing

pairticulharly tilie syndrome of act e onlset o mdrtel seee gastroinitestinial

symptoms associated with eosinopliilic leuikocvtosis, and stated:

It. differs from the tradlitional clinical picture of hookworm disease chelnte abruptIless of onset, the p~rominiience of aculte andi sometimes dlisab~ling digestive symfptomis and the

lack of anemia * * *. In many, a smidlen onset, of nausea, Vomiting, abdominal pain and

diarrhea occuirred. In others, a more gradual onset. of cramping and burning ahdominal

pains after meals was the initial manifestation. The nauisea, vomiting and diarrhea tended

to subside and to becomie initermiittenit.

These auithors described pain ats the most, prominent aind persistent of

thie gast roin t e~t inal symlptomis. It, was usually eJpigastric but sometimes,

periuimhilical, and it. tenmled to be (diffuse. Inl many 'lv atienits, thle painl appeared

imnmedhiately after meals. The frequency' of the various s,'ymptomis of tile

hookworm iinfes;tation found inl tile patients inl this stuldy is shlown in table &S

IPhy Asical thindiiNgs wNere not. st rikinig except, for the almost. universal loss

of fromt 10 to 40 Ilbs. in weighit. Tile definite (diagnlosis of hookwormn infestation

(leJeii(led onl the (demonis tria ion of thle ova ill the stools. Inl accord withi

ext ensive exp~erienice elsewhere, Ca pta in Rogers and C olonel Daumnmi found

that. (direct examinat ion of the stools, evenl whenl repeatedl several tiules, wNIts

not it sat isfactorY procoilure. Repeated exit minail t ions hby tilie direct, iletihod

established thle diagnosis inl oiily a pproximately 60 percenit of tile patients;
INDIA-IW]RMA THEATER 767

only 20 percent had positive stools on the initial examination. On the other

hand, when the zinc sulfate flotation method was utilized, hookworm ova

were consistently found after not more than 3 stool examinations, and in 85

percent of the patie,,'s they were demonstrated on the initial examination.

In iccord with general experience, one of the most striking features was the

prt, -alence of eosinophilia.

T •E 8.-Symptoms observed among consecutive cases of hookworm infestation at the 20th

Greaeral Hospital, U.S. Army troops, 1b45

Symptoms Total cases I Number with Percent

symiptoms

History of ground itch ------------------------ 42 12 29

Respiratory symptoms ------------------------ 41 29 71

Abdominal pain ------------------------------ 49 42 86

Vomiting ------------------------------------ 46 27 59

Diarrhea ------------------------------------ 48 25 52

Abdominal tenderness ------------------------- 48 32 67

Weight loss ---------------------------------- 36 29 81

I Number of cases In which a reliable history could be obtained.

Source: Blumgart, lHerrman L., and Pike, George M.: History of Internal Medicine in India-Burma Theater.

[Official reeord.1

Gastrointestinal X-ray studies in these patients was the subject of a

report in which the so-called cogwheel pattern was described. This abnormality in the pattern of the small intestine was considered a characteristic

finding in many cases and was due to deep broad indentations in the colurmu

of barium made by the thickened rugai tolds of the jejunum and distal

duodenum.

Colonel Blumgart visited the various installations only late in the course

of the war, at which time the clinical manifestations of hookworm infestation

(lid not present the acute fulminating syndrome described in the report by

Captain Carter of the 9th Medical Laboratory but were rather those commonly

recognized as indicative of chronic infection. Malaise, anorexia, upper abdominal discomfort or pain with insidious onset and accompanied by psychoneurotic disturbances were frequent. The clinical diagnosis of hookworm

disease was rendered difficult, since practically each of the symptoms of this

disease was prevalent throughout the theater regardless of the presence or

absence of hookworm infestation. Thus, "Ground Itch" was simulated by

foot infections or dermatitis and respiratory symptoms by nasopharyngitis,

while abdominal pains, vomiting, and diarrhea occurred in practically all

military personnel at one time or another during their stay in India and Burma.

Detection of cases, therefore, rested largely on suspecting the condition in

all patients with any of these symptoms, insisting on a differential colnt of

the leukocytes in all suspected patients, alld examining the stools by con-
768 ACTIVITIES OF MEDICAL CONSULTANTS

centration techniques. Not a few diagnostic mysteries, temporarily residing

under the designation of dyspepsia or psychoneurosis, were classified by carrying out these simple measures.

Filariasis

Occasional cases of filariasis contracted elsewhere were seen in the IndiaBurma theater from time to time, but no outbreaks occurred in U.S. Army

personnel. Nevertheless, the presence of endemic foci of infection among

the congested native population in close proximity to some of the Army encampments and the prevalence of one of the chief vectors of the disease, Culex

fatigans, raised important problems.

During .May 1945, three cases of filariasis were reported from the Hastings

Air Base near Calcutta. They were referred for study to the 142d General

Hospital in Calcutta. Eighteen additional cases were under observation at

this time at the Hastings air station.

An epidcmiologic survey of the problem was made by preventive medicine

personnel of the theater surgeon's office and reported in the theater ETMD

for August 1945. The Hastings Air Base was adjacent to the community of

Rishra, a slum district, in which there were many cases of elephantiasis. No

factual data regarding the epidemiology of filariasis in this community were

available. It was clear, however, that transmission of the disease occurred in

this population and that living conditions and sanitation at the air base during the first few months after opening of the station were such that it would

have been possible for transmission of filariasis to occur. A well-organized

and vigorous mosquito-control program plus a successful sanitary cleanup program resulted in the control of the chief vector. It was believed that these

measures greatly reduced or eliminated the possibility of contracting the disease at Hastings Air Base.

When seen at the 142d General Hospital, the three cases referred from the

air base showed no positive evidence of filariasis. Orchitis had completely subsided, and, in the opinion of the chief of the genitourinary section, little or no

residual changes were present. The chief of the surgical service, who had extensive experience in the Southwest Pacific Area in an endemic area of filariasis, was of the same opinion. The chief of the medical service, who had seen

many cases of filariasis returned to the Zone of Interior, was in agreement.

It was acknowledged that many infections remain asymptomatic for years, or

even for their duration, and that the cases examined might have been filariasis.

It was believed, therefore, that the three patients should be classified as suspects,

their clinical status checked monthly, and, if further evidence of filariasis appeared, they should be returned to the Zone of Interior.

A conference was held in Calcutta attended by the Surgeon, Base 2; by

representatives of the Air Forces and of the 142(1 General Hospital; by a memiber of the Preventive Medicine Section, Office of the Surgeon, Headquarters,

LTSAFIBT, and by the consultant in medicine. This conference concerned itself mainly with the development of a common policy in respect to the dispo-
INI)IA-IVIUIMA THIEATER 769

sition of patients suspected of harboring the infection. It was generally agreed

that patients with a definite diagnosis of filariasis should be evacuated to the

Zone of Interior. The chief differences of opinion revolved about the disposition of the filariasis suspect, in whom there was insufficient evidence to warrant

a definite diagnosis but in whont, on the other hand, the possibility of harboring infection (0ould not be confidently excluded. The various views were re-

(luced to writing and communicated to the theater surgeon. After careful

study, the theater policy was laid down in Circular No. 21, 29 July 1945, Office

of the Surgeon, Headquarters, USAFIBT, on the diagnosis and disposition of

cases of filariasis. It was recommended that any patient in whom the diagnosis

was seriously entertained should be transferred to a general hospital and that,

so far as feasible, such cases should l)e transferred early while still showing

acute manifestations. It was further stated that:

It is imperative that a definite diagnosis of filariasis be made only when reasonab)le

clinical evidence exists. This is particularly important because of the serious emotional

imp)act on the individual concerned, and the adverse effect on the morale of troops in the

area, as demonstrated by experience with the disease in the Pacific theater. The imlpossibility of making an absolute diagnosis early in the course of the disease by detection of microfilaria in the blood or by biopsy of affected regional lymph nodes makes reliance on sound,

conservative clinical judgment essential. If a reasonal)le basis for the diagnosis is established in a general hospital by a thorough and careful review of the case, the patient is to

be evacuated to the Zone of the Interior in accord with War Department policy.

The criteria which must be exercised in establishing the clinical diagnosis in the early

stages of the disease are outlined in paragraphs 3 and 4, TB Med 142. In some patients the

available evidence will not justify a clinical diagnosis of filariasis; on the other hand, its

possible presence cannot be confidently excluded. Such suspects should be returned to

their organization and the unit medical officer be informed of the status of the case so he

can make periodic examinations at monthly intervals or oftener if considered necessary, for

at least four months.

Particular caution must be exercised in basing the diagnosis on a single finding, particularly when such a finding frequently occurs unrelated to filariasis. A single recurrence of

epididymitis or orchitis, without other evidence of filariasis and with only equivocal residual

changes, is not considered to be sufficient basis for the diagnosis of filariasis. The diagnosis

should, however, be suspected. In the physical examination of the scrotal contents, it

should be remembered that there is a considerable range of normal variation. In order to

evaluate correctly the earliest changes in the scrotal contents extensive experience in the

palpation of the normal and abnormal is necessary.

If an individual is a noneffective repeatedly because of unexplained recurring inflammation of the scrotal contents which cannot be arrested or cured by appropriate medical or

surgical management, he should be evacuated to the Zone of Interior because of inabilitv to render consistent and effective service in the theater. Such cases, without any other

evidence of filariasis however, should not be evacuated as filariasis, although the clinical

records should indicate that such a diagnosis has been considered.

Lead Poisoning

The diversity of clinical problems encountered in the India-Burmft theater is

illustrated by the occ'urrence of lead poisoning in petrolatum pipeline companies.

One of the major missions of this theater was the construction and maintenance

of the pipelines to China. Jungle and mountainous terrain presented

,564970- 61-_ - 51
! Ficl in.;' 255. l eall doi thtim piii)T -l'a Inf' i n l 4i 7eue ihe F11944wc Piiia dI eit;llm iitit tll tol

the 111I~ (ieiral lopitY almielII, Alii Tuiitliat [HuhaY itia. A51\' UStli

iliall4 [,I(,( hi diff.culate (c slict as heia v. iii l rarlli) (e v v i I o fi c ll n'XI)0e1.oi.. oft

il.1the1V0111( paivc to wliile ai t hisat elit heloir e 14 S;lieu l, Oigr 255)I ) .uta Tlv I

lpeib iotni o[ ~Ille 4 ltipciiliihi Nvstilu & it we- Ii Decembe re~~ 194: T i. iv firset cnil of'

#Ill 20111i Cenall Hospilit al 4 tilioii oI*lldr1v i aJill) . Aitl surve, evewale theni

I e l.2 1),vIsti Ll .tt (I'llll) 'a t)Bei~ Itl) -. (Ti. l o'1i x o ed p roiZ

ilrIii imallealwhich t) hi;s pl Wl~t' belonged ulIG ; mcill thip aparoimatel Ii (I2.cil I,.1 exaterlde wit Ii Iies, dvraw loutr Itou sthowa l tagnificant dv4) : oijleei

lit for~el 111i11, I'apoa111

1. Norml~fi'i Fa"lilue toI -vasofin lui lll l ufort' ea t o (1-1ii'ls. Mel.o
INI)IA-BURMA THEATER 771

7. Pumping units refuelled every 6 hours with gasoline carried over from

storage tanks in 5 gallon cans.

8. Heavy concentration of furoes around leaks being repaired.

9. Common practice of standing in pool of gasoline either barelegged or

with legs covered with grease.

The following measures were put into effect to minimize exposure:

1. Construction of an olbservation and control tower 50 ft. front the pumps

to afford adequate supervision and minimize exposure.

2. Use of nonleaded gasoline for washing hands annd for cleaning pumlping

units.

3. Frequent showers.

4. Change of clothing after work.

5. Periodic rotation of personnel.

6. Careful washing of hands before eating.

7. Use of high rubber boots and rubber gloves.

8. Prompt washing with soap and water after exposure of skin to liquid

gasoline.

All personnel with signs of lead absorption were rotated and removed from

exposure for a minimum of 6 months. Pipeline-company personnel who were

exposed to gasoline were required to have blood-smear examinations every

3 months. During the entire survey, 475 exposed individuals were examined;

14 (2.9 percent) showed basophilic stippling of erythrocytes.

Skin Diseases

The incidence of diseases of the skin in the India-Burma theater, as in all

tropical climates, was high. The 20th General Hospital reported that skin

diseases constituted 10 percent of all dispositions from the hospital in the first

year of operation and 8.6 percent in the second, approximately the same as the

figures for diarrheal diseases. In addition to the patients that required hospitalization, many were seen as outpatients.

Disorders of the skin, more than any other group of diseases, reflected

thie effects of the climate of India and Burma on U.S. military personnel. Capt.

Neal Phillips, MIC, of the 18th General Hospital, writing on skin diseases in

Burma, nmde the following observation on the climate and its relation to the

various dermatologic manifestations; the remarks apply equally to India:

In Burma, as in some parts of India, there are roughly three seasons of the year, the

months of May, June and October, the hot dry period; November through April, when it

is fairly comfortable; and the monsoons of July, August and September, when it rains daily,

usually in the morning until noon. During the latter period the sky is overcast and it is

fairly cool but humid. At the time of the hottest months preceding and following the monsoons, the temperature reaches 1 IO-120 degrees daily with correspondingly hot nights * * *

Dermatologically, then, it is obvious that the monsoon period with its dampness encourages the growth of molds, yeasts and fungi while the hot dry season promotes disturbances in the coil glands and pilosebaceous system. * * * with the body continuously

bathed in sweat, such diseases as contact dernmatitis, eczematous dermatitis, miliaria,
772 ACT'IVITIES 1W .MEDICtAL CE )NSI'LTANTS

folliciulit is, infect ious (CezCiattoid (ltrniatitis and1( possibly (lerma~tolhyt idfs are tile problem'i

coiifroniting til dethrmatologist dhiring the hotter period, while (luring the monsoons, fuingus

dliseaises flouirish.

Not onlY were fungus infect ions anti ecZematiltOtis and infectilouts eczeiftatoid skill cotidit ions mtore frequlent. an d mtore se'vere' 0111t1 ill the Unit ed States

butt t here were also skinl disorders peculiar to thle t rop~ics t Itouight not due to

tile chum it e per* se. fIliese included tropical uilcer, (~itolie-ltiark (lermtat itis,

andt( selisitivit y to exotic p~lantts. Atypical lichien plaitis also was of ininportattee ilt t his t hvtezi tt and wtis st udiedh ext etsivelA, part icuilarly tit, lte 201 I

Genier I Hosp5Jit al.

Prickly heat.-In India, prickly hteat, also known as miliaria, miliaria

1111(l an sudamilla, was uttdoubt edly thIe tmost ptrevaletnt skitn disorder, and

it atlecte til Ie vast majority of U.S. Arm ttv petsontnel. Discomfort andI interfertentce( wit hi sleep frequentt ly loweredI vftcivncv in miiiit ary pers-onnel. Aliotgltl"1 rarely (Iisablittg. ext ensive case's occasiottally hectante seconidarilY

iiftect ed andt( requuiredl liospit alizat lol. 'FItel hliaract erist ic featuores of stmall

redl papjille5 or vesicles, w~iilit appeared principally ott thle t rtunk and~ upper

extretIt eIMs and were associatedi with itntentse itching~," presenttted Ito diagnostic

difjlictiltiet'. A p~owder' contatiining sutlfur, boric aicid, statii'c, and zitic Oxidle

was t itt mtost comtmontly used therapeutic aigent, bult tliere, were almost as manty

otliteu met htodh of treattmettt as tltet'e werte doctors treatinig p~atients withi

jpricklY hat. Soume adhvisedl a. (leep) tallt ot hers Ad~visedl Stlavinl" out of tll.i

sltil. Both ttintet andh tuntannedi' intdi'viduals hiad prickly heat. Very little

cirei-t was notitced with Ii a of tdi(e met hods recoutuimuendv ; whentilte weat her

cooled , t lie JprickY livitat d (isappea(ttred.l

Dhobie-mark dermatitis. '

2-- This was one of the surprising medical expvtrit'ittts of U..S. tr~oops int this theater. Tle (lholbie, the I udjait latundryntann

tmarked clot lies withI tilit intetselty' irritating juice of til hiebilti ttut.3 A'lten

best' mnarks camie in contact withi a sensit ivte skint, a localizedt contact (lertiatitis resulted. Whien thit(, source of ir'ritationlt was remtoved, thev derlttatitis

dhisappieared i itt ftw days. Colonel F'itz-llughli, Matjor L~ivinlgood, andtt Lieulteutit R~ogers, as we'll its M\ ajor Waitd antdi C apt. H etnry Fe in, Nl(', publishevd

rteports oln this t 'ype of diermtatitis itt thile Pidd Mefdical fBui/ettti for Jlune 1943.

Tropical ulcer.- Necrotic, sluggish skin ulcers are found in mtiost tropical

cu('Oi s mid altl-11(1 ir kntownt by different nameslt(' in vachu count li v whier' di('v occ'ur.

Ill India, particiularly intit(th Provtttce of Assami, andit iii BuriEtt, thut'Y Were'

referred to ats tropical uilcer, Naga sort', or Assaum ulcer. They werel( 'olituiiouilvy seeti duirintg thit( mtonsoont seaison antd frequently foutnd in individuals

sufferitig front somte systemtic disease or chtrontic tmalntutritioni. The uilcers

Origititit ('( itt infect ed cuts, abrasionis, or itnsect, bites and utsually developed

tito rapidly progresstve, painful lesionts with a ntecrotic b~ase, utnde'rmined

Ilecrot ic ediges, and a blut'-grey border. In time', tie lesions becamte citronic,

I 2 %o to lii' confl,4q %% wItl 1ii ~ Itcihi,'i Whichit I., filaigns Infeei lol.

13 Mite c11(11 o isiOII2t~ v~lf regairilig th evic.,' t Wetncto of iii, mit tisvid Il tim ThoiS. le term "hiiciii mitit

.4-1S 10t 1)4 tiIV miiost go-neralm vinv to pio
INDIA-BURMA THEATER 773

pain disappeared, and progress was slower; the base of the ulcer then generally showed some granulations, and the border was raised, indurated, and

red. Bacteriologic examinations showed fusiform bacilli and spirochetes.

Except among Merrill's Marauders, there were very few instances of

tropical ulcer among U.S. personnel. Merrill's unit, fighting during the

monsoon season under highly insanitary and exhausting conditions in the

country where Naga sore was endemic, inevitably developed cases of tropical

ulcer. The major part of the experience of U.S. hospitals with this disease

camie through care of the Chinese troops who, malnourished and insanitarv,

were fertile soil for this type of lesion. Several reports on treatment were

published; these were largely based on the experience with Chinese troops.

Lt. Col. Clarence J. Berne, MC, of the 73(d Evacuation Hospital appended

a preliminary report on therapy of tropical ulcers to the annual report of

the hospital for 1942. He was of the following opinion: "Treatment of tropical ulcer should consist of two phases; an initial phase during which the septic

factor is eliminated, utilizing chemotherapy, if helpful, and a secon(lary phase

initiated when the ulcer becomes free of significant infection." Skin grafting

was not done in his series, which was in its initial stages at the time of the

report. No definite conclusions were (Irawn.

In the Field Mtedical Bulletin for October 1943, Maj. (later Lt. Col.)

James M. Beardsley, MC, of the 48th Evacuation Hospital reported on the

treatment of 21 cases of tropical ulcer by a more radical surgical approach.

This group showed large ulcers with a sloughing necrotic base. He concluded

that the best treatment for such large tropical ulcers was immediate excision

followed by skin grafting and that prolonged conservative therapy resulted

in a loss of valuable t ime. Small ulcers were treated conservatively with

sulfanilamnide powder and pressure bandage.

Maj. (later Lt. Col.) John H. Grindlay, MC, who had been in Colonel

Seagrave's unit "' and who had had occasion to treat many tropical ulcers

in tlie men forced out of BurMna in 1942, published his experiences with this

Condition in the January 1944 issue of the Field AMedical Bulletin, (fig. 256).

He recommended, in the early stages of the ulcer, excision of necrotic tissue

and use of magnesium sulfate and glycerine dressings daily. In cases where

tlie ulcer had progressed to deep tissue involvemnent, complete excision of

the ulcer and all necrotic material was recommended. After the application

of sulfanilanide crystals to the tissues, the cavity was packed with petrolatuniimpregnated gauze and the entire limb placed in a cast. In 3 weeks, the

cast was removed, revealing fresh granulation tissue. A fresh cast was applied

and again removed in 3 weeks. The procedure was repeated until the crater

was filled with granulating tissue, at which tinie pinch grafts were applied.

Contact dermatitis.-AMajor Livingood of the 20th General Hospital

made an extensive study of a type of contact dermatitis seen in the Assam14 A hospital of the American Baptist M ission at Namkham, Burma, at the start of World War II; later served with

the British Army In Burma and the Vnited States, British, and Chinese Armies in India, Burma, and China. Its commander was Lt. Col. Gordon S. Seagrave, MC, who i,-d tben in Burma since 1922.
Iih1i2 siin tnI'iiý 256 '. . B cI4 ri-i- nur-v4 h;ii 44111 oiwi ( 1 I41441ibi Ch 1(f iiw '14Il t lii

\lajo o-hIon IJ i _-i 2 574I t4'I4. T 44 i elsloI14, I14' I'4I.44 4 li' -IN SlIoNNII'41i~4'4'he

Ow s i p 441' of14 :14 1i4 ViS" s I~l'es ofiai~4 ills" This41 t skiill cm d l\l ( willi. 44' Iiv.~iI
Fwi lip 257. MIaj. ( 1ar4';ev S. Livinirood, NIC, ,ttitidving flora,~ inear 2011 Gv( neral

H os.pitalI. bclieved to be soiirce of contlact dermatiiitis.

ypohidrosis syndrome. Eliglit eit casit" or' all1 tItitISti.d s.Niidroiiie pectillala to hot ('liHl tes and n11 ot deCscribed~ Ini most text books WICseeni at tilie

20th ('etieral IIosIpt lla and~ reported byV Major Liviiigood Inii t(e Fich/

.Mtid icrl B11/it1in for Ma aN' 1945. Thiese Waes ee VverY Sli iiilar to t hose re-v

port ed byV Wolkiti, ('oodiiiaii, and~ Kel~ev.'" III his rep~ort , Major. Livilwood

(I ItoI eil I IeI cl i II ica I(lescriptIot Io oft Ilie SYv(0I IdrIie described 1) t hcese I lireve atut hlors.

lBecat use featuiires (describled bY th lem are so (cialract erist ic, tile qu totat ioni

use bN Mjor I vii igood Iis presviit ed h ere. ats follows:

Ili general dinvY all1 prieneited a tIpicaIi(:l liistor% , viz. at rat her smiideii onset of geiieralized wvt-akiess, stibilj ive w:irmith midai discomifort , dlizziness "aill-iii feeling, llead~wlie anld

ýliakhiiv's. 'litese sympumt(is ()ccllrreul durinig ('x1)(sitre to sctimigtit, either with or wilhtoilt

lricli'ewrtiozi. 1,e1 oiisot of Ow li ilijptoill.s was a.'soiaitrle withI or jplectiled hy a ce~-

ý,kaol (uof ýIvvat ing ill each case. This wa":s in I nirn often p~recededl l) . a rhdi.rinc period of

lprofuime Elll poring of swevat from au fewi daYs upl to several weck< rltirat ioni. The loss oif

Sweatinug was liuilti-d nilliforiailvY to the body regrion below lie neck inl proiioiunced conitrast

lipE thei ow11potring ojf sweat fromi the face and iieck. Thie objective fininigs wevi'' characiteri/frI iiiEE~ of all1 by a warml, drY skiii froii the neck down, whereas Owli face aiid neck showed

W~Ii~. .,(~x~iiiIi. I I.,nu IKý11.-\-.\ E.: Falijit r-j ( ijvS%,~i\v ~ h-hanis ial iniithe iDvsrt..T. . NIA. 124:
77e6 ACTIVlITIES OF' MEIC:)(AL, ('XSVA'rAN'rS

profuse droplets of sweat. The( skin of t he entire hodY below the level of thle iteek had1(

the appearancee of goose flesh. H owever, this fine papiihir erupt ion (lid not appJeair anid

dlisap~pear in a maltter (of minutes like goose flesh. The pajpiilar erupt ion was uliffiise andi(

uniifornm, each paptile beiog about the size oif a largre pinhtead. III cases of Ilonger standingy

there, was a fine, lbraunn'y desquanat ion. As this voiidit ion iimiproved, the fine paptilar

eruplt ion dlisappearedl and t ie( skini resumed its normal appearalice.

M\ ajor Livitlg~oodl's group iniclud~ed Will1 wh~ite and( Neg-ro soldliers ; 6, or

tlie, Patients liad litvjical liclieti Jliknims and :3 were recoverinig fromi t.%l. film

fever whien tile s *vliptin~~s appearedl. All caises gave at histor ,y of' excessive

sweating atlid generalizedI prilrittus prior to onlset of tilie s , i~lrollie ; nilost oft ilie

pait enits ''tend(edl towards at selborriloeic hmiatit s.' As inl thle cases previously'

dlescrib~ed, failture of tile sweatiIng mieeliitnisiii was ilote( limost frequentl*y onl

the trunk and limbs1), with at (Irv skin andl at ''fine branntY desquitinittion' inl tile

inivolvedl areals. The pairts of tilie lbodlv tisuallyv not affected bY thle (list trirnee

Were tilie lace, l)aIIIIIS, soles, inild axillte; those regions generally slioweti hiyperbitirosis. Ast henlia ittiti Weakniess Were at constant. featutre; hv~perpvrexiat did

not occuri.

Seven of the group improved spontaineously' , and their sweating fund cion

retutrlied to norma illt i fromi 2 wveeks to 4 mont lis. The rel Dliindlelr co01nt inuied

to shlow Ihvpoliidrosis, itittltat tilie t imie of tlie( report. 4 iouit lis and eliapsed

wvitiliont evidence of imiiprovemlenit. Inl this respect, M\ ajor Livinlgood's calses

differed fromi sinmilar cases described byv ot liet' aititors whio found that, sweatinig

ret wirnet to normial ini pract icall 'v M1l eatses witliin at few weeks."7 Anothler

point of (hfference wvits the gradual otiset inl Major Livingood's patitents ats

comnpaired withl tilie rapid onset, wvit Ii evidence of heat exhatistion rep~orted by

tlie( otiler anithors.

AltiliouglithIle niumbier of cases showinig livpoliidrosis wais smaiill , lie

svnldromie Was of' conisideraible interest iand of sonie military significance: inl

severatl instances, evactiat ionl to tlie( Zone of Ilit erior wats conltemnplaitedl eca use

at teficieiicv ili normial swventting conistit uted ia serious hazard inl t his t heater.

Atypical lichen planus. Ill ia let ter' da~ted :30 October 1944 to tilie Surgeon,

USAFCB I, Thle Surgeon General re(jl tiStetl a r~stmii6 of tilie exp~erienice inl tilie

tieaiter wvit Ii tilie cliniiicatl sYnitroiie kntownt its atvypicitl lichien phatnus (fig. 258).

The( letter iiiclidditeta brief dlescript ion of t ile s *vndromie and1( statted tihat it wais

seeni with striking frequency inl the 'Southwest Pacific Areat. A copy of the

letter wits forwarded to 2t11 miiedicatl i list 11ti2at ionls.

As fair as canl he det ermiinedh, thle diatgnosis of ait picidl lichlell hl~lauts wVas

not imilde ill this tfheat er prior to Novemiber 1944. Onl 1.5 Novembi er 1944 inl

at letter to t lie (

1 omnmnadimtg Officer. 20th Generail Hospital, Major Livingood,

tin repl *y to Thle Surgeoni Generatl's request, reported thtree cases andit imiade tilie

followinig stitte ilelit:

Abouit five weeks ago, I receivedl a personal letter from a dermiatologist of myl aequ ainit-

:uit(( uinformuing tile tim hat(!h had seen aI group of cases from the Soul hwesl Pacific Area

' Ii)Se PK4 E ot 1 5,t)i p..P.774. 42) A114.1. . D'. ;111.1in O 'iril-u,, .. P.: Tropicail knidroirci kt.mbetnixi A P'reliminary

16-mw. \14-t I.1. Aistraia i 2: :335 336a'. 23 sept . M ~4.
INDIA-BURMA THlEATER 777

%

Fimx-RE 258.- 't, ,ical lichen planus of foot, U.S. Army captain, observed by Major

Livingood at 20th General Hospital.

presenting signs and symptoms suggesting an atypical form of I lypertrophic Lichen Planushe (id not include a detailed description of the syndrome. At that time I reviewed all of

ILky cases of llypertrophic Lichen Planus as well as other chronic recurrent dermatoses and

came to the conclusion that I had not seen the syndrome in this hospital. Therefore, it

seemed an amazing coincidence to see three cases which probably fall into this group in the

past four weeks, one of them a General Officer. We forwarded biopsy specimens to the

Army Medical Museum on one case about 10/26/44 and on the other two cases a few days

ago. In the clinical protocol, I referred to the fact that I thought that these patients had

an atypical form of llypertrophic Lichen Planus which had been seen in the Southwest

Pacific Area and asked for information on the pathology of the lesions as it had been noted

in those cases.

In his comments on the disease, Major Liviogood said: "I have found no

clues as to etiology except in two patients particularly there seemed to be a

questionable light sensitivity factor. All three of these patients had been

living under field conditions at the tinle of onset."

The 234th General Hospital reported a single case that was thought to

fit the description in The Surgeon General's letter.1 8 Although the description

'•A 1,tter, Col. Bennett (. Owens, MC, Commanding Officer, 234th General Hospital, to Surgeon, Headquarters,

Services of Supply, I'SA FIBT, 2 D)ec. 1944, subject: Information on Occurrence of an Unusual Skin Disease.

-- -- -- ---- - ----- ------ -- -
t78 k (,ri v rITi., OF MiEiiiCAL CONSULTANTS

stronly-1 siigrcrestel atylpicad lihenll plantils, the Ilistory revealed that thle (lisealse

had its onset IS1 uiontit s earlier, while tilie patitenlt was still III tilie United St altes.

Ini Janiiar ,v 1945, at coimn iiiicat ion froin thle 18thI General H ospit al relporte(l

two calses of at skill dIisordler ('Oiisidei'ed to he alt~piiciI liietie phiaitis. 19 Bot ii

patients had beeni taking sulppressive At albrine, itat cl tests withI thins drug1

were negative. One of thle two p~atijents was found sensitive to SKiAT, develOpilg al posit we pat cl te(st with lthis liosqutito l'(pelleiit but1 wit IinclOot her.

Onl 23 February 194.5, Major LI viiigood submiit ted at followuip report Onl the(

3 original cases and ill adl(it iofl rep)ort ed 6Iiore fuill-b~lown cases of t lie (lisealse;

3 Ot hers were Iii en Iionled ill which tilie (diagnlosis was not defin it el ,v est ablished.

TIlins rep~ort Was very'% Coiiiprelieiisive, 1111(1 tile fili(Iili-S Iiiav be stil llIarized ats

follows:

Tlhiese cases were chairaicterized by: CIombinat ion of eczemaiatoidl (eritiat itis,

('cZelliilit oils p~laquies, and~ violaceous lCsioli5 or various, Iliorplies, ideintical with

those seen ill ait pical I ichieti pla ntis; genieralized(ldist riibii tionl withi predlilect ion

for certainI sit es ;severe pm ili t I s; lonI g course; tillt rked resi (It it1

I cl ia uges inl thIe sk IuII

includilmi loss of' hair and marked (list Aiirliance or sw('Zit jug funict ion.

All patienits wh-[o wvere seeni with the (disease had1( hiad ilitiniate conitact

withi the jutngle. All patijents, emcept onle lhad beenl Oil Suppressive At abrinle

p~rior to oniset. Most p~atijents hiditl alt ecedlelit vezemiiat oils lesions.

Thle probal~ie tim n1t iple et iologic b~ackgroundi~ was Possibly at comibinat ion of

exposuire to jutngzle anid a drug allergen - At a brinle inl tilie iiajori t yof cases. One

patlient had never t aken At abrine ait tnivtIN time but haid had arsenicals, for early

syphilis. i ghit selisit ivi.N t was 11 possibile p)redhisposinig fact or. Exacerbat 10on

was5 seeni aift er the following: At abritie t herapy for miialaria, sulfatbliazol,

typhoid vaccinle, tilt raviolet lighlt, suiiligh , anld Possibly food allergens.

It wals suggest e thlait inii 'i who wvork a 11/or live inl thliejtingle miiigh t acquire

at COintact senisi tiza tio 107 l('iiittit is front tilie sapl aliid leavyes of trees alnil shrubs

whtichi occtir on lY ill t ropical1 and semt itrolpical1 Zonies of thle wvorld lind( thlait thei(se

sensi tized i nl i viduldtls in igh t (develop I I'itt' yliil-il(ilit lns yiil ioiiie whenl

anl enllogeliots allerg-en (At abrine inl iiiost itist anlces) is aldtIm ittist eredl

There wa-is ev~idelice t hat thle pat ienits ill t his series, hald dist ilbirhaces of

glucose mitetaibolislmi, and of gaist roinl t est illial anld liver fuitict iou, mnanifesteli

by flat ghalcose-t oleraulice curves, X-ray chianiges inl thle gast roinite(stinal tract,

lui(1 dlecreaisedli iver funict ion with Ii roluimsllplialleinl excret loll te(st.

A t imird report, diated 19 M Iarch 1945, by M ajor i vingood, brought the

tota nimit Ilet'ofcs's seen ait thle 2th Greneral Ho[sp1 itali to 1.5. Iii t hisreporl)it, lie

emiiphaisizedl tilie J)05ilil it *v t hat exp)osurie to tlie( iirit liiit black sill) of certain

r1ollical triees iiiiglit be lilt e'tiologic fact or. Mao I ij iI viiig.od~ wrote:

Wbe have not accIihlmIate(I anyu n1ew iniformuat ion. All of thevse newv patijents had beeni

ill the .jlitigle ill forvward areas, and haid been ill contact with tree-sap)i Iandpntis eitherd(irectIN

or as thle r smilt of exposure to wood fires. Againu I wish to emIIphasize that thus far all of our

'' It-ter, ILu. Col. Alexandier .J. Seiofi-r,r NiC(, ('hief. Ni--dicai S-ervice, Isiil (ienrai i iwspitA. to De.pu~ty I'ivatier

tiurivii.,u i IIe'i'umlrters,i I'SA Ftii. llT 0.i1mi. i190~. Siui'j.ect :0Cs teoio f. yiei y.rrith lit~iiiOis
INL)IA-BURMA THEATER 779

patients with this disease had been in contact with the jungle with exposure to potentially

allergenic contact ageents-tree-sap, various plants, etc. I consider this a possible important

predisposing factor; also dietary deficiencies, and multiple insect bites are possible predisposing factors.

To facilitate study, it was decided to concentrate all cases of this disease in a

few hospitals. The 20th General Hospital was designated as the center in the

Advance Section, the 234th General Hospital in the Intermediate Section,

and the 142d1 General Hospital in the Base Section. The 20thi General Hospital

prepared a form for the study of the cases, and, in July, Maj. (later It. Col.)

James M. Flood, MC, who succeeded Major Livingood at the 20th General

Hospital, submitted a report on 19 cases seen between 14 March and 1 July

1945. The report opened: "'The experience in this theater leaves little doubt

tiat atabrine is the main causative factor of atypical lichen plamus as seen in

thtis area. Wietlher there is an associated factor still remains a question, but

it, must now be assinned that atabrine is the principal etiologic agent.."

This report was accompanied by a paper by Major Machella and coworkers

on liver-function studies. Although the stu(lies suggested the possibility of

hepatic damage, no patients with atypical lichen planus showed any clinical

evidence of liver (list urbance.

The 234th General Hospital reported tlat 11 patients with the disease

were being observed but no data were submitted in this preliminary report.20

Other cutaneous eruptions.--In addition to atypical licthen planius,

there were other skin eruptions that were attributed to Atabrine. Major

Livingood rel)orted a numbler of skin reactions seen at the 20th General Hospital. T'liese included an extensive maculopapular eruption with a violent

systemic reaction in a dental officer and a pruritic maculopapular toxic erythema

in two nurses, 14 days and 4 (lays after tie suppressive Atabrine program had

b)een initiated. Tie eruption reappeared in both nurses wien the drug was

again administeredt at a later (late. Two individuals developed a flareup of

an lold eezeniatoid derniatitis shortly after the Atabrine regime was instituted.

In the theater ETMD for August 1945, Captain Blank of the 69th General

Hospital reported on 12 cases of an urticaria-like syndrome that he attril)ute(l

to Atabrine sensitivity, and in at communication dated 23 July 1945 to the

theater surgeon's office, he later reported 2 additional cases. In 12 patients,

wlho gave no previous history of Atabrine ingestion, the eruption did not appear

until 2 or 3 weeks after the institution of the suppressive Atabrine program.

In 2 patients, botlh of whom had previously taken Atabrine, the eruption appeared within : d(lays; in both, the symptoms disappeared spontaneously withiout discontinuance of the drug. In the other patients, the urticaria disappeared wlien the drug was stopped and reappeared briefly in 4 patients when

Atabrine was again administered. All 14 patients eventually were able to

take suppressive Atabrine treatment without difficulty. Skin tests with pure

20 Letter, Capt. Joseph A. J. Farrinuton, Chief of D)ermatology Section, 234th G(eral I lospital, to OfMet, of the Surgeon, Ileadquarters. USA FI BT, 6 J.uly 1945, subject:
68o ACrI VITIES OP 3MEIUCAL C( INSULTANTS

C'HART 13. -. 1fonthliy incidence rates of common respiratory disease (including influenza) in

U.S. Army~ troops in India-Mirma theater, January 9 -Au'419415

W rt-imin ary datai based on stiminrnries of stati.stical hi dlh reportsJ

IlRatt eprt-ssed as numb~r ofnew admiss,,ions 1Pius seconidary di~ignosi.s casLes p-r annum per 1,M~)average strnetbi

Rate

400

300

200 ~~~1943___ ___

200

Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec.

1niieti~le; ease'.irniitted in China prior to Nowinitwr 1q44.

powdlered1 Atatbtine were (biie ill six catSeS, wit Ii resuilts lietraltive to l)otl pitch

and jlt raideral-1 tests.

One case of uirticariat thoughlt to be due to Ataibritie wits reported from the

234thI General Hospital1. 2' A paltchI test ill thjis cISe WaIs stroglyrl positive.

Respiratory Diseases

U pper respiratory infections

'The niewcomier to hidia, pairt icularlv if lie had recenitly endlured the snow

and sleet of northern Unfited States and had arrived inl hIdia during thie suinn v

monthis of March thbrough Junte, withail temperatutres of 8Oo-1OOo F., wa,.s

stairt led by the prevalencee of tipper respiratory hifect ions. This fact is reflected inl t he high incidenice raite for t his condhit ion inl thle hintia-Burnia theater

(chart ':3 mid table 9). The acti nal inlcidence wats fmuchl higher since onlY thle

V1 latter. Capt. iosepim A.]3. Farrington, NMC. CiniefoffDermatology and Syphilology Section. .134th General Hlospital,

to Offlo, (of the Stirgeon, iteadquzirter, USAMF IT, sub-ect: Suppressive Atabrine as it i'o~siblb Cause of Urtik-ria.
INI)IA-BUIRMA THEATER 781

disabled were admitted to hospitals or kept in quarters. The extent to which

these infections contributed to the total noneffective rate was, however, small

(charts 13 and 14 and table 9).

TABI.E 9.-Total cases, incidence rates, and noneffective rates of diseases of the respiratory tract

in U.S. Army troops in India-Burma theater, by month and year, 1944-194451

[Preliminary data based on summaries of statistical health reports]

[Rate expressed q- number of cases per annum per 1,000 average strength]

Common respiratory diseases Primary atypical Tuberculosis, all forms

and influenza pneumonia

Year Total Inci- Nonef- Total Inci- Nonef- Total Inci- Nonef- cases dence fective cases fective Cases (ence eence feetive rate 2 rate 3 rate 2 rate 3 rate 2 rate 3

1944 Number Percent Percent Number Percent Percent Number Percent Percent

January 1, 635 215 3. 3 53 7.0 0.33 18 2. 4 0. 16

February -------- 1,331 165 3.6 44 5.4 .27 14 1.7 . 19

March ----------- 1,739 149 2. 8 19 1.6 . 17 20 1. 7 15

April ------------ 1,453 145 2. 7 29 2. 8 .22 26 2.5 16

May ------- 2, 117 180 2.7 42 3. 5 .21 19 1.6 14

June -------.. 3, 250 208 2.8 60 3. 9 . 18 30 1.09 18

July ------------- 3,221 238 2. 8 28 2. 2 . 13 26 2.0 17

August. ---------- 2,643 210 2. 4 33 2.4 .09 13 .9 11

September ------- 3,089 172 1. 9 70 3.9 .14 14 .8 .08

October ---------- 2,534 173 2.0 55 3. 6 . 11 18 1.2 .09

November ------- 1,916 138 1.8 59 4.4 .25 12 .9 .12

December -------- 2,222 125 1. 7 66 3.8 . 19 18 1. .09

1945

January _- 1,855 119 1. 7 68 4.6 .20 6 .4 .08

February -------- 1,854 113 1.6 157 10.0 .28 9 .6 .03

March ----------- 2,286 108 1.4 175 & 9 . 24 11 .6 .04

April ------------ 1,777 110 1.2 74 4.5 .14 26 1.6 .09

May ------------- 1,866 125 1.4 34 2.1 . 07 15 .9 .09

June ------------ 3,021 155 1.9 71 3.8 .019 20 1.1 . 10

July ------------- 2,760 179 2.0 70 4.9 23 19 1.3 .16

1 Includes cases admitted in China prior to November 1944.

2 Incidence rate was calculated from the following formula:

C-CXI,OOOXF: C=number of cases; S=strength; and F=time factor for period of time involved.

8

3 Noneffective rate was calculated from the following formula:

Number of patients remaining in given period

Strength

Source: Blumgart, Herrman I.., and Pike, (leorge M.: History of Internal Medicine in India-Burma Theater.

[Official record.]

The clinical characteristics of nasopharyngitis in India were astonishingly

similar to those seen in the United States; the complications of chronic sinusitis,

middle ear infections, and the not infrequent association of tonsillitis and

bronchopneumonia were apparently as frequent. Bacterial pneumonia was

relatively uncommon, and but few deaths occurred.
T182 ACTI VITIEI'S OF!. MEDICIAL CO(NSU'LTANTrS

CHART 14.-Noneffective rates for common respiratoryl diij.ses in U .S.. trini troops in Indialurmna theater, January 19.43-July l19.151

[Preliminary dtha ha-4-41 on stimlmaries of statistical heI lt II relorts]

[Rate expresed as average daily nonttfehliveness ;per annum lP'r 1,0(X)0 average strengthl

Rate

4

3

2

11945

0 I A I I 11_1_1_1___1 _1 

Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec.

I Includes cases admlitted in China prior to Novemher 1944.

Primary atypical pneumonia

With the onset of warm weather in this theater, the increased prevalence

of respiratory infections was striking. This increased incidence was particularly noticeable in Delhi and occurred during uninterrupted sunshine and

equable temperature. Actual observation of many of these cases by the consultant. in medicine revealed that the clinical characteristics and X-ray and

laboratory findings were in the main identical with those observed during

epidemics in the United States. The increased incidence could not be ascribed

to any discernible factors. Among other possibilities, ornithosis was considered since, at the time of increased prevalence of prinmry a typical pneumonia,

swarms of migratory birds made their appearance---a single tree, for instance,

often being occupied by at least several hundred parakeets. Inquiry by the

consultant in medicine, however, failed to uncover any supporting evidence

for this possibility. Attention was directed to this condition by the publication of notes in the Field Medical Bulletin, discussions with the staffs of the

various hospitals, and requests for reports from the representative group of

hospitals. The subject was summarized in the theater ETMD report, dated

1 June 1945.

Incidence.-In general, there was an increased incidence of atypical

pneumonia for the first 3 months of 1945 as compared with the corresponding

period in 1944 (table 9 and chart 15). At the 100th Station Hospital, there

were 96 cases in the first, quarter of 1945, whereas only 14 cases were reported

for the same period in 1944. The 234th General Hospital and the 73d Evactiation Hospital treated approximately twice as many cases of atypical pneumonia

in 1945 as in 1944. In all instances, the hospital census was roughly the same
INI)IA-BURMA THEATER 783

CHART 15.-MIlonthly incidence rates for primary atypical pneumonia in U.S. Army troops

in India-Burma theater, January 1944-July 1945 1

[Preliminary data based on summaries of statistical health reports]

[Rate expressed as number of new admissions plus secondary diagnosis cases per annum per 1,000 average strength]

Rate

10

/

86 ,,,-j1945

4 " \ 1944"\.

2

0 I I I_1 _I I I

Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec.

I Includes cases admitted in China prior to November 1944.

for both periods. Two reports indicated that the increase in respiratory

infection was coincidental with movement of new troops into the area. The

rotation of personnel, with the arrival of replacements from the United States,

also began at the same time the increase in disease was noted.

Epidemiology.-Although atypical pneumonia is apparently transmitted

by contact and is usually associated with an increase in upper respiratory

infections, the disease was not highly communicable. Certain other factors

were involved in addition to simple exposure. In this connection, the following paragraphs are quoted from an excellent comprehensive analysis of 96

cases prepared by Capt. Abraham Gootnick, MC, Chief, Medical Service,

100th Station Hospital:

In considering the epidemiology of this outbreak, it should be mentioned that the usual

criterion for admitting a patient to the hospital was the finding of a temperature above 1000

at the dispensary. A great many of the milder cases of upper respiratory infection were

thus screened out-at least as many as were hospitalized. But this screening did not apply

to the more severe upper respiratory infections, and even less to the pneumonias. One check

on the incidence of unrecognized pneumonia was provided by one organization, consisting

of 34 personnel, 13 members of which were in the hospital with respiratory infections at

one time. All remaining members were called in for mass x-ray check-up. All chests were

clear.

The experience with this organization is also illustrative of the mode of transmission

of the infection, which appeared to be by contact, contact with co-workers or barracks neighbors. From the few patients with atypical pneumonia, whose infective contact could be

determined with some certainty, the incubation period ranged from 9 to 16 days. An incidental finding of interest was the apparent immunity of medical officers, nurses, and ward
784 ACTrIVITIES OF' MEICALi CONSULTANTS

attendants-personnel whlose contact with r('sjirattor.N infections was close; anid the conlsidIerable stlsCejptilbility of hospital personnel whose con tact with patients N-as taiigeaitiaI.

Enlistedl men working in the laboratory, in thle x-ray (departmient, and iii the admitting office

came dlowni with respiratory infections of varyinig severitN .

Clinical characteristics.~- TIhe chiitcal1 cha ract(1erist ics of primiary a typical

pneumionia iii the Ittdia-Burnia theater coincided closel * with those reported in

outb~reaks of the dlisease in the Uniited States. The majority of the caises

were t roubledl iitjaill %vwith an a ppaireitt upper respira tory* infect ion, which

rangedI from a mlildI iasopharyngitis to a severe b~ronchit~is. A dIry, hacking

couigh wats a1 conspicuiouslY disturbing sym nptomi in many of thle patients. Two

symptomis frequently mentioned ats rare in primiary a typical pneumonia were

found rather commnoatly in thle p~atientts in this theater. lit Captain Gootitick's.

report just menttioned, lie stated as follows: "'(1) Repeated shaking chills

lasting 15 to 45 minutes were recorded in 25 of thle 96 patients. (2) Achting

in the chest. (apart. fromn the usuial substernal soreness), referred to the involved

sidle, occurredI in 19 patientts. lin nine of these, sharp stabbing pain in thle

chest, on uinspirationt was thle chief complaint leadintg to hospitalization."

Examtination of the chest onl admltissiont often revealed inconstant. physical

signs of pateh consolidation. X-ray , of the chiest., at.t this stage of thle, disease.

frequently Yieldled diagntostic evidence of the characteristic changes of primary

atyvpical pneumonia. The white blood counts aitd differentijal smtears showedl

the uisual fintdings, ats (hid examination of the sputuim. Blood cultures performed ill represent ltative patieitts were uniuformuly sterile. Thle 100th Station

Hosp1ital reportedl that: ''A spot check for the presence. of cold agglutinins

wats donle inl at total of nine cases. lIn 3, cold aggluitinins were not p~resent Inl

lie( one( samplle of serum examined; in 6, the serumn wats positive for cold

algglultintins aitd shtowed anl intcreasing titer after the second week of illness,

reaching at titer of 256 in 2 ait the end of thle third week.''

Reports front other hospitals were essenttially in agreement with Captain

Gootnick's ob~servationts. Ani intterestintg finding wats the occurrence of pleural

reactions, at feature contsidleredl by sonic observers to be rare inl this dlisease.

Captain Gootnick rep~ortedl 4 cases with pleural rub. The 73d Evacuation

H~oslpital rep~orted 6 lpletiral reactioits-2 in Amnericaits and 4 in Chinese. Of

these, 1 American an( I1 Chintese patient had sntall effusionts. The 99t1 Station Hospital rep~ortedl onl 24 cases, of which 2 shtowedI pleural rubs. Anuot her

feature noted in all reports and also observed in previous reports onl atypical

pnieumonia, wats thle high proportion of cases that were afebrile or shiowed

only at low-grade teitperatutre.

Sequelae.-Vcry fewv signtifican t coittphlica tionts or sequelale were reported

fronti this theater. The 99th Station Hospital ohbservedl one case of extension

front one lung field to the other. Thle 234th General Hospital reportedl one

miltd case of puruilent. bronchitis following thle, pneumnonia, and the 73d Evacuation Hospital fountd one case with suggestive finding's of bronchliectalsis.

There wats ito followup rep~ort onl these cases.
INDIA-BURMA THEATER 785

Bronchial asthma

Little statistical information is available regarding the incidence of bronchial asthma in the India-Burma theater. The condition was more frequent

than might be anticipated and was prone to recur even after bospitalization

induced temporary improvement. If returned to duty, the patients contributed little of military value and were almost always finally sent to the

Zone of Interior. Twenty-three such patients were sent to the United States

during 1944 from the 142(1 General Hospital, 68 from the 181st General Hospital, Karachi, India, and 76 from the 20th General Hospital. In this connection, a personal communication from Colonel Cottrell of the 142d General

Hospital is of interest:

India is a bad country for allergic conditions. Many persons who had had allergic

symptoms find that they are much worse than in the U.S., or that new manifestations appeare.g. a person who had hay-fever in childhood develops asthma in India. Sometimes, one

can return a mild asthmatic to duty for a time, but I have never seen one that lasted long.

In general, if a soldier has been seen to have an unequivocal, moderately severe, asthmatic

attack, it is useless to return him to duty in this country. I suspect that molds are important

as allergens here, but I do not know.

Not infrequently, individuals who had never had allergic manifestations

prior to service in the theater were affected with disabling allergic conditions.

In general, skin testing was not performed and when performed was of little

assistance in diagnosis or therapy. Climate, allergens, and psychologic stress

and strain were presumnably etiologic factors, but the extent to which each or

all were contributory cannot be stated.

Pulmonary tuberculosis

The incidence of pulmonary tuberculosis among the military personnel

in the theater was low (table 9). Among the Chinese, however, tuberculosis

was prevalent. An ETM*D report, dated 3 May 1945, from the 48th Evacuation Hospital stressed this high incidence of tuberculosis in Chinese patients

who constituted the bulk of the hospital census. Tile average Chinese soldier

neither understood the American interest in sanitation nor was he particularly

interested in practicing its precepts. The Chinese used no precautions in

the disposition of their sputum, the floor being most convenient forexpectoration.

The personnel of the 48th Evacuation Hospital were, therefore, extensively

exposed to the disease. Frequent, routine checks were made on the personnel

and, up to the time of the report, no cases of tuberculosis were discovered

that could be attributed to contact with the Chinese. The commanding

officer of the hospital suggested that members of the hospital staff be observed

carefully for some time after return to the United States.

Homologous Serum Jaundice and Infectious Hepatitis

Infectious hepatitis was under continuous surveillance by the theater

surgeon from the very beginning of the establishment of the USAFCBI

564970'- 61--52
78S6 ACTFIVITI'lES 0VF MEDCL ' l.(4INSULTANTl'

liea ter inl M archi 1942. ()it :0 NIz %, 1 942, at cnable w%:As receivedI fromi the

Surgeonl ( ieiieralls OffIice aleriting" tile t heater to jillilidce or liiikiiowvii etiology

followilo hg tdiiii iiistraItio 1)1 of yellow fevter vle'ci tie. Alinong" thle first calses to

he reportedl fromt thle h idia-Btirnia theater were seven inistanices of j aitnd ice

following Yellow fever vaccila t ionl ilUn i itedl States troops. ( enlerial Stillwell liiiisell' developedI jaiundice oil 31 June 1942, hiavinig rece'iveti vaccinle fromi

lot No. 334 oin 2 FebruariY 1942.

F'romi tlie( alvakilable scat tered l 111( incomiplete reports" it is pparenit thlit

i111aii% calses of' jaulndice of unknown etiology were observed inl 1942 and (ithata

sitrnificalit numbiietr of' t hese lpat jents hadit had vaccine friomi lot Nos. 334, 33.5,

33:8. and :367. lIn at report 1)*y thle Surgu lit, U SA F'('B , 17 October 1942, to

The ,-;1rgeonl (eiieral, comp llet e quest ionl liltires oil 80 catses orf jillitllict' Withbout

kniowntims 'iiUE' tre t ra 115thitt ed . nllirt.Nv-six of t Ins series hadi re('ei vei yellow

f'ev'er vaccine fr'om lot Nos. 3:11, 3:15, anid :171 . Of the ot her cases. 19 had

had (conltact w%-ilt Iiljan wdicem patientits. ()i 28 N ovemuiber 1942. anlot her report

of 35 p~atienits was submiit ted(l most of' w%-loll iii111 received Yellow rev-t'i vaccinle

fr'omi lot-, of tit'( :100 sert's. C ompillete inf'ormiiation regard11ing tilt niuimber

anld (list rihu t ionl of' ti( hc (lis's lollowitig, yellowv feveir ilotioclat ion wats not alvailaible. but it wats, appalrent that t he( nuniher 'onst it uted at seriouls problem'n.

Thle only .ivalila a ibe coin prelietisive report was subniit ted frionti tihe 7:13d

IEvaciilatio Hosp115it al by C olonel Valre, ('apt. (la1ter N111j.) ( oh'nianki B. Hlle-

(Iricks, MC, ' anud C aplt . Tlionins 11. Breni, N I( . The 405 patienits who -onlstit~t('te thle basis; Of the studyv hdlim ti'eceived Yellow fever vaccine ait approxiath elyM ajettile. lie I uiforuiia1t ioul conicerningl tilie lot nuumbers auild tilie exacet

dlate' of i lio('lit ionl was recorded il :305 c'ases,. The report i'eawd, i11 part, as

follows:

For ill lots of ye'llow fever vaccine, ti1w imajorityv of patit'lits lwecalaw ill be(twee'n 70

mid1( 110 days after inoctiiktion, t11w peak beinug re'achedI het weei !to and 100) days. ExNtreme'

variations were 46 mid 170 (I:Es .. Alhongl i IS differenut lots of va(ceiln are ilnclidedI

twEo particutlar lots acEoulhit for 222 of I ii lEiv 30 CL. si5 bi vai''l of thlese t wo major lots of

vaeeiuo' the peaks of inciht'int lol j'riodl oveiii- at such dist inctly (differenut timecs as it) hv' highlyl

silgge-st li%'-- liit No. :367 at 70 da vs and lot No. 3318 at 1(14 days, while the peak of tit .1 g-9

gregate of all cases falls at apjiroxiniati'Iv 90 days.

The clinical course, including tilie syiiptonlatologv and physical sign~s, WitaS

that obiservedh inlt ili' ext ensive series of' casies observed( 'lsewlit'rv inl thle U.S.

ArmY. No dentlis occurred.

The ('nt'rget iC Ikt iou in it in td t'bYi The Surgeon ('enieral was effective inl

sn ml (iiing thle out breaks orf)~ l(c jIii Jl l ildiC't ill tili( U..S. Aru1iiy. Ill a1

le't ter daited 21 D ecembi er 1942 from i( o01. (liiier Brig. ( en .) Stait hope BaynleJonles. NI( . Office of, t(le Slrge'onl Geiierall, to) thle Stirgeoui. the opinlion Wats

exprt'ssedl thaiit Ilit' cases Tort'jem' fr om thle ( 'iina-Bu mn-I iitia thlenter inl

ilit' last tuoitItls of' 1942 were probahvy lunre'latedt to tl( ladmiliiiiist rationl of'

yt'llow% levtr VAC'l((IVtE. Thie ('liVtS Of inifect'i'tus1 lie'pa tit is occiirriiig- ili 1943

a tid Itherea ftetr we'ret comist'qli~ith'iit to he Col1insit IEilEl Int Si in ila i- lighlit
INDIA-BURNIA THEATER 787

CHART 16.-Incidence of infectious hepatitis in U.S. Army troops in India-Burina theater,

January 1943-Auguist 194512

I Preliminary data based on summaries of stat istical health rep~orts)

Cases

500

400

300

200

100

0

JFMAMJ JASONDJ FMAMJ JASONDJ FMAMJ JA

1943 19A4 1945 IIncludt-s cases admitted in China prior to November 1944.

STwo deaths occurred in 1944: 1 in Septemnber and I in November.

The incidence or infectious hepatitis during 1943, 1944, and 1945 is

graphically presentedI in chart 16 and table 10. In accordance with experience in the North African theater and in the Northern Hemisphere, a sealsonall

increase (luring the late sininier mionthis, particularly in September and Octolber, was apparent. This increasedl incidence reflected an increasedl number

of cases occurring sporadically* throughout. the theater and also occasional

outbreaks. The clinical characteristics observed in these cases of infectious

hepatitis coincided with those witnessedl elsewvhere in the U.S. Armny.
788 ACTIVITIES OF MEICIt'AL CONSULTANTS

TABLE 10.-Incidence of infectious hepatitis in U.S. Army troops in India-Burma theater,

by month and year, January 1943-July 1945 1

Infe~ctions |epatitI6

Month

1943 1944 1945

Nn inber of cases Nu inher of cages Nn tuber of cases

January ------------------------------------ 38 56 70

February ---------------- ------------------ 24 49 87

March ------------------------------------- 22 83 114

April --------------------------------------- 2 95 95

May -------------------------------------- 17 95 53

June ---- ---------- ----------------------- 13 108 73

July_ - -------------------------------- 41 163 47

August- ------------------------------ 28 230

September ---------------------------------- 74 2 439

October ------------------------------------ 94 265

November ---------------------------------- 35 294

1)eceinber .. 44 157

I Includes eases admitted in China prior to November 1944.

2 Two deaths occurre•d in 1944: 1 in september and I in November.

source: Bllumgart, Herrmnan L., and Pike, George M.: History of Internal Medicine In India-Burma Tbeater.

[Official record.)

Occasional sporadic groups of cases were observed from time to time.

During August 1944, 122 patients with infectious hepatitis were admitted to

the 98th Station Hospital, Chakulia, India, from 14 units in the theater. As

in other outbreaks, the source of infection was undetermined. These cases

were considered to be unrelated to the administration of yellow fever vaccine.

A similar increased incidence had been noted 1 year previously. The fact

that a considerable proportion of these cases originated in two of the 14 units

is of epidemiologic interest. It was evident that the increased incidence of

infectious hepatitis in the two units was not related to troop strength.

Poliomyelitis

No statistics concerning the incidence of poliomyelitis among the native

population could be uncovered. Clinical observation on casual visits ill the

congested districts of Karachi, Delhi, and Calcutta impressed the visitor

with the rather frequently observed residual flaccid paralyses. It, is of interest,

however, that experience in the British Army in India reveals a low incidence

in Indian troops as compared with British troops.

Polioinvelitis was seen only sporadically in the military personnel of

the India-Burma theater. The case fatality ratio, between 20 and 25 percent,

the ever-present possibility of an epideilic, and the effect oil imorale when

sporadic cases appeared inade the disease one that commanded continuous

consideration (table I I and chart 17).
INDIA-BURMA THEATER 789

CHART 17.-Incidence and deaths due to poliomyelitis in U.S. Army troops in India-Burma

theater, Jan uary 19.;3-August 1.945'

[Preliminary data based on summnaries of statistical health reports]

Number

10

Casjs ~(No deaths)

Deaths

5

0

JFMAMJ JASONDJ FMAMJJASONDJ FMAMJ J A

1943 1944 1945

1 Includes cases admitted in China prior to November 1944.

There were no major outbreaks of polioniyelitis; a focus of three cases,

however, occurred in Agra, India, during September 1945, and this area was

accordingly placed out of bounds to all personnel except, those on official mnilitary business. In the British Army, a seasonal increased incidence was evident

from March to October for the years 1942-44. The data of table 11 are too

small to be of statistical significance in this connection. The incidence of

respiratory and(/or bulbar involvement in U.S. military personnel was apparently high although no compilation of experience was available. In a group

of 10 cases at the 263d General Hospital, Calcutta, India, in August and

Septemiber 1944, there were 7 cases of respiratory paralysis or bulbar paralysis

or both; 4 of the 10 patients died because of respiratory paralysis.

The clinical characteristics of poliomyelitis in the India-Burmna theater

were identical with those seen in the United States. The principal probleni

was the supply and maintenance of the respirators. With sporadic cases

occurring at installations thousands of miles apart and often in relatively

sechlded places, it was imperative to maintain respirators at. certain key

points in usable condition ready for imiinediate air transport. One DrinkerCollins respirator was kept in readiness at Ledo and one at. Karachi, and two

were stationed in Calcutta. Arrangements were mnade with the British for

the loan of niechanical respirators. Several of these were used but were

unsatisfactory. They were subject to nmechanical breakdown, and the bellows

almost invariably developed leaks. Byv maintaining comnpetent technicians

constantly on duty, however, these respirators were invaluable in emergencies.

"Savalife" respirators, eniploved at several inst allat ions, were useful in emergencies and during air transport of patients. They were found impracticable
790 ACTIVITIES OF MEDICIAL CO, )NSILTANTS

for prolonged use, as indicated in a letter to the Surgeon General's Office from

the Surgeon, USAFIBT:

Even with the best nursing care the machine was extremely uncomfortable with pressure

from the metal and intense itching and maceration of the body tissties from constant contact

with the rubber. As a result there were many maccrated and blistered areas around the

neck, trunk and arms.

The apparatus is sufficiently difficult to remove and replace as to make it impossible

(because of the time element involved) 1st, to give the skin proper care and 2d, to allow

the patient to have periods out of the machine so that he can begin using his own respiratory

nmuscles as tolerated.

There were numerous mechanical difficulties. One death was attributed

to mechanical failure of one of the British respirators, and on another occasion

a hand bellows was used for 9 hours while the respirator was being repaired.

In general, however, the use of the British respirators, with the splendid cooperation of the Air Transport Command in rushing a respirator to any installation immediately on call, proved adequate in the treatment of emergencies.

T i.nLE ll.-Incidence of poliomyelitis in U.S. Army troops, India-Burma theater, by month

and year, 1942-45 1

Poliomyelitis Month

1942 2 1943 1944 1945

Number of cases Ni rnber of cases .umber of cases Number of cases

January - - 2 1 4

February 3 0 5

March ------------------------ --------- 1 0 0

April ----------------------- 0 1 1

May -------------------------.----------- 0 2 1

June ------------------------------------- 0 4 3

July -------------------------- - 0 0 4

August ----------------------- ----------- 5 5

September --------------------- 0 1 9

October ---- ----------------- 1 0 1

November ---------------------. 1 1 5

December ---------------------- -- 2 7

Total ------------------ 2 14 3 35 4 23

I Includes •segs admitted in China prior to November 1.44.

2 No statistics for the first 8 months of 1942.

3 Includes 8 deaths: 1 In May, 3 in Aumstt, and 4 In September.

4 Includes 6 death1S: 1 in February, 1 in June, 3 In July, aln I i] August.

Source: Blunmgart, Hlerrman L., and Pike, (h'orge M.: Hlistory of Internal Medicine in India-Burma Theater.

[Oflicial record.]
INDIA-BURMA T111:A'ER 791

Typhoid and Paratyphoid Fevers

Although the. statistics for t 'yphoid and paratyphoid fever in the native

population were grossly inaccurate, it was evidlent from the available informnation that enteric fever was widlespread. Statistics in India always err on

the low side because of the impossibility of obtaining accurate health reports.

I n one towvn, an epidemic was recognized by the medical staff of the local hospital only because of the unusual number of cases of fever that were beilig

treated as outpatients at a time when malaria was not prevalent. In the

1940 annual report of the Health Commissioner of India, there were 1,738

(deaths recorded in Delhi Province as due. to enteric fever. Delhi City contributed 683 t~o this figure, and New Delhi, the capital of British India and

certainly one of the best controlled cities in India from a public health standpoint, was responlsilble for 72. The res6 came from the rural areas.

No epidemics occurred in U.S. Army personnel, but sporadic cases wvere

reported throughout the 3%2 years of the theater's existence. Table 12

shows the number of cases of typhoid fever; table 13 shows the cases of paratyphoid fever (A and B are not differentiated).

TABLE 12.-Incidence of typhoid fever in U.S. Army, troops in India-Burmpa theater, by month

and year, 19!j2-451

TyphoFid fever

Month________ ___ ___ ___________

19422 1943 1944 1945

Nu inber of cases Nn inber of cases Nu mber of cases Noi mber of cases

January ------------------------------------------ 1 22

February ----------------------- ------------------ 0 6 4

March ------------------------------------------- 0 1 0

April -------------------------- ------------------ 1 6 1

May --------------------------- ------------------ 1 6 1

.J1tle --------------------------- ------------------ 4 70

.filly --------------------------------------------- 0 5 0

Auigust ------------------------------------------ 1 41

September --------------------------- 1 0 6

October ----------------------------- 2 2 3

No~vezber --------------------------- 2 5 0

D~ecembher --- ------------------------ 2 6 2

Total - - - - - - - - - -721 48

IIncludes cases ad mit ted ini China prior to November 1944.

Figures may be higher than the actual incidences. In reviewine somne of the clinical summaries, i~t wasL obvious

that certain cases were diiagnosed as typhoid or paratyphoiod solely otn the basis of aggiutinal ions of a relatively low titer,

andl these may have been of the anlaninest ic type'.

2.\No statistics reported until September 1912.

Source: Itluingart, Herrman, L, and Pike, George NM.: History of Internal Medicinte in India-Burma Theater.

lollicial record .]
792 ACTIVITIES OF MEDICAL CO NSILTANTS

TABLE 13.-incidence of paratyphoid fever in U.S. Army troops in India-Burma theater, by

month and year, 1942-451

Paratyphoid fever

Month

1942 1943 1944 1945

N. mlber of cases Number of cases Nuambsr of cases Number of cases

January ------------------------.---------- 0 6 1

February ---.--.---------------- ------------ 1 0 1

March ------------------------------------ 0 0 4

April --------------------- ----------------- 0 3 4

May -------------------------- 0 4 1

June------------------------- 0 6 5

July ---------------------------.------------ 0 2 0

August ------------------------------------ 0 6 2

September -------------------- 1 0 6

October --- ------------------- 0 1 5

November ---------------------- 0 4 2

December ---------------------- 0 1 5

Total- -------------- 7 45 18

I Includes cases admitted in China prior to November 1944.

Figures may be higher than the actual incidences. In reviewine some of the clinical summaries, it was obvious

that certain "ses were diagnosed as typhoid or paraityphoid solely on the basis of agolutinations of a relatively low titer,

and these mam have been of the anamnestic type.

2 No statistics reported until September 1942.

Source: Blumgart, Hcrrman L., and Pike, George M.: History of Internal Medicine in India-Burma Theater.

lofficial record.)

The first case of typhoid fever, reported in September 1942, was in a

soldier stationed in Delhi. He was treated at the British Military Hospital,

Delhi Cantonment, where the diagnosis was established by positive blood

culture. One week later a case of paratyphoid A developed, which was also

treated by the British. In October 1942, a soldier from the Delhi area was

admitted to the 100th Station Hospital and proved to have typhoid fever; in the

following month, a fourth patient was admitted and the case was diagnosed

as typhoid fever. Three of these patients were from the headquarters squadron of the Tenth Air Force, but no common source of infection was found.

As a consequence of these cases, it was suspected that the antityphoid

vaccine prepared in the United States was not highly effective against Indian

strains, and it was directed that U.S. military personnel in China, Burma,

and India be required to take a stimulating dose of Indian-type typhoid

vaccine. This policy was also adopted by the British Army, whose experience was similar to that of the U.S. Army. Although this program was carried out for a brief period, it was later discontinued, apparently on advice

from the Surgeon General's Office. It is impossible to say whether the incidence of typhoid and paratyphoid fever was affected.

No unusual clinical problems were encountered; in general, diagnoses

were arrived at more slowly because of the lack of laboratory facilities. There
INDIA-lI1'WIIA '1THEATER -,!):

wereQ onyv thrlee (featlis froin typhoid fever. This low miortality rate ill a

country where the typhoid mnicro-organismis have lost none of thejir virulence,

ait least for thle nlative population, (Ieniioist rates tihe efficacy of antitvphoid

inununtilizat ionl.

Smallpox

The 19:39 annual report of the Public Health Commiissioner of India onl

sniallpox b~egins as follows: '"Thle epideiniological statistics published by thle

Leaguie of Nations shows that British Indlia ranllks higher t han aill ot her count~ries

in its ralte of incidlence of smlallpox.'' The (disease is etideinie inl JIniai, withI

localizedl miinor epilemiicis occurring att all tinies (luring thle year with a seasonal

peak airouiiNlMarch, April, and May. A cyclic increase inl incidlence oeccurs

every 5 or 6 years. This is attributed to the increasedl proportion of susceptib~le children, a result of the inefficient enforcemient of vaccination. Ani epideinic year was expect ed in 1942 or 1943; act ually it occurred in 1944 and 1945.

NO Cases Of smiallpox were reported inl U.S. mnilitary personnel inl 1942 and

1943. Table 14 shows the cases andl leathts by mionths, for 1944 and 1945.

Tile first case was adlmitted to the 111thi Station Hospital ait Chabua and, as

far as could be (letermiinedl, was acquired fromn Chinese soldiers inl thle nearby

staging area. Subsequent cases resulted fromn contacts with both the native

Indian Population and thle Chinese troops.

TABLE 14.-Incidence of smzallpoxr in U.S. Ariny troops kq India-Burnia theater, by mnonth

and year, 1944--45

MonthSmallpox

1944 1945

Number of cases Nitmber of cases

January --------------------------------------------------- 10

February ---------------------------------------------------------- 2

March ---------------------------------------------------- 14 8

April ----------------------------------------------------- 3 7

May ------------------------------------------------------ 2 0

June1C------------------------------------------------------0 0

July ------------------------------------------------------ 1 0

Auigust------------------------------------------------- 0 0

Septeimber ------------------------------------------------ (

October------------------------------------------------ 0

Novembiler ------------------------------------------------ (

December -------------------------------------------------

Total ---------------------------------------- 22 -)1317

I nclud~es easse uiint ted In C'hin iou rior to Noveniher R944.

2 Includes 6~ deathis: 2 in February. 3 in Nl arch, and I in July.

3 Includes 4 (14eathis: 2 In February and 2 in Aprril.

Source: jiiomgart, llirrnan L., and Pike, George NI.: History of InternaliNiedicine in India-Burmia Theater.

(Official record.]
7-94 ACTIVITIES OF 0MEDICAL CONSULTANTS

Although the incidence of sliall)ox in U.S. Army v troops was not high,

the fact that it occurredl at all was of great concern to tihe Preventive Medicine

Section of the theater surgeon's office, andl many investigations were carried

out, as reported by that section. Tile essential finding thlt enenrged from

most of these studies was that either vaccination had 111 t been a cconiplished

recently or, if it haid been, an immune reaction was recorded on the immunization register without sufficiently careful observation to distinguish between an

imniune reaction and an unsuccessful vaccination.

The disease was frequently severe and the case fatadity ratio high. Sulfonaniides an(d penicillin were used to combat secomi hy infection. The only

ulusual clinical problem that atrose was the differentiation between generalized

vaccinia and s-nallpox in 4 cases seen at the 18th Field Hospital and reported

on by Major Mosley. These 4 cases, 1 of which was fatal, were originally

reporte(i as generalized vaccinia, because the patients haid been vaccinated 5,

7, :3, aind 4 days before the onset of their illness. However, investigations by

the theater epidemiologist, Major Mosley, revealed exposure in each case to

the native population at either Bombay or Calcutta at a time when smallpox

was at its peak incidence. Major Mosley concluded that these cases of generalized vaccimlia were actually instances of smallpox.

In view of the prevalence of smallpox, the theater policy was vaccination

every 12 months; in addition, whenever a diagnosis of smallpox was made.

all units in the vicinity of the suspected source were revaccinated. When the

a(itual number of cases of smallpox among U.S. Army troops is considered in

rehltion to the possibilities of exposure to this extremely virulent disease, the

immunization program may be regarded as highly successful.

Cholera

Cholera is endemic in India and constituted a constant potential threat

to U.S. military personnel. Its prevalence in lower Bengal and other localities

in close proximity to Army installations provoked energetic preventive measures, as (describ)ed elsewhere.

Despite particularly heavy outbreaks in 1945, such as that in Calcutta,

an area where many troops were stationed and were on leave, not a single case

occurred in military personnel in the India-Burma theater from 1942 to October

1945. On 20 July 1945, the theater surgeon addressed a letter to the surgeons

of the base, intermediate and advance sections, alerting all me(dical officers to

the possible occurrence of cholera and advising certain modifications in the

treatment outlined in TB Med 138, February 1945, subject: Cholera. One

mild case was observed in a Red Cross worker who had been repeatedly vaccinated in accordance with theater policy. At the 181st General Hospital

where she was hospitalized, Vibrio cholerae was isolated from the stools, and

the finding was confirmed at the 9th Medical Laboratory. The patient made

ati uneventful recovery.
IN! IIA-B1'RMA ThIEATER g95

This remarkable record of no mnorbidity in military personnel in the theater

is to be attributed to the close supervision of water supplies, tile sanitation of

the messes, the educational programs, the continued inspection of civilian

restaurants, quarantine of native areas and establishments when indicated,

and the strict enforcement of the cholera-vaccination program.

Melioidosis

Cases of melioidosis are recorded, mostly from Burma, predominantly

in males. Although only about 100 cases have been recorded in the past 30

years since the disease was first described, there is reason to believe it is more

widespread than the diagnosis would indicate. In Rangoon, the estimated

incidence is 4.5 per million. It is of interest that a case of this (lisease was

diagnosed ini a U.S. soldier and verified by recovery of the micro-organism

from skin pustules and blood culture while the patient was alive and from

post mortem abscesses from the lung, blood, liver, md spleen, by the 9th Medical Laboratory. Identification of the micro-organism of melioidosis was

confirmed by tile Army Medical School, Washington, D.C.

The disease is extremely varied in its manifestations and readily escapes

diagnosis. The condition may simulate cholera, pneumonia, pyemia, plague,

or typhoid fever. The case reported in the April 1945 Field 11Medical Bulletin,

by Lieutenant Cox and Major Arbogast, exhibited the pyemia syndrome.

The patient had been ill 24 hours before admission with headache; fever and

chills, accompanied by nausea and vomiting; and pain in the chest, the lower

back, and the joints of the lower extremities. He had been a mule skinner,

and some of his mules had died of the illness. During the 7 days in hospital

before death, lie developed scattered pustules over the entire body with a

septic temperature ranging as high as 1030 and 105' F. and the appearance of

pneumonic consolidation of the base of the left lung. Laboratory studies

revealed a white count of 7,000-9,000 and a red count of from 2.5 to 3.5

million; the causative micro-organism was recovered from cultures of the

blood and contents of the skin pustules. During the last 2 days of tie patient's

life, 40,000 units of penicillin were administered intramuscularly every 4 hours

but without (liscernible effect. Post mortem examination revealed the characteristic findings of this disease.

The disease has been recorded as uniformly fatal, but with earlier diagnosis

and newer modes of chemotherapy the course of the disease may be favorably

affected.

Schistosomiasis

No cases of schistosomiasis originated in the India-Burma theater. Twelve

cases caused by Schi.sto.oma haematobium were reported in a letter, dated 11

January 1945. from the Surgeon, 329th Air Service Group, to the Surgeon,

U.S. Army Air Forces, IBT. In all of these cases, the disease was acquired

when the group bathed in a pon(d while traveling across Africa. All the
796 ACTIVITIES OF MEDICAL CONSULTANTS

patients had symptoms of pyelitis or cystitis and 60 percent had hematuria.

Two patients were evacuated to the United States; the remainder eventually

became free of symptoms following several courses of treatment with Fuadin

(stibophen).

Leishmaniasis

Cutaneous leishmaniasis or kala-azar was seen but rarely in this theater.

Reliable statistics were not available, but it appears that only 1 case

was reported in U.S. military personnel in the theater in 1944 and 13 cases in

the first 5 months of 1945. Kala-azar is especially prevalent among the native

population of Bengal and Assam, but relatively unconunon among the white

people in those areas. The low incidence among those enjoying better living

conditions and among military personnel is probably to be attributed in part

to protective measures against insects, which are particularly effective against

the Phlebotomrus vector of the disease with its flight range of not more than a

few hundred yards.

A few cases of kala-azar were seen at the 48th Evacuation Hospital and

other installations caring for Chinese military personnel. Of the 14 cases

reported among U.S. military personnel, 8 were studied at the 142d General

Hospital. All had evidently contracted the disease in India, and Leishmania

were demonstrated in 7 of the 8 cases; in the remaining 1 case, the diagnosis

was established by the clinical course and response to treatment, in spite of

3 negative sternal punctures. The experience of the 142d General Hospital

with these cases was summarized in the theater ETMD report dated 1 July

1945, which reads, in part, as follows:

The average time elapsing from apparent onset of illness until the diagnosis was established was about two months; the longest time was one hundred and twenty-one days and

shortest (in a case diagnosed before transfer here) was twelve days. This wide variation

suggests that Medical Officers' "index of suspicion" of kala-azar has been too low, and it is

noteworthy that this "index", in the staff of this Service, has risen sharply. The remittent

and recurring nature of the fever has, in many cases, led to diagnoses such as typhoid fever,

paratyphoid fever, birucellosis, amehic abscess of liver or spleen, malaria, and dengue at one

time or another. The matter is further complicated by the not infrequent coincidental

occurrence of malaria or amebiasis. One patient had had several hospitalizations for

undiagnosed febrile illnesses which, in retrospect, were exacerbations and remissions of

kala-azar.

The clinical findings and the course of the disease in these patients were

in accord with common experience as described in TB MED 183, July 1945,

subject: Visceral Leishmaniasis-Kala-azar. The diagnosis was suspected by

reason of unexplained fever for several weeks, comparative well-being of the

patient, and gradual enlargement of the spleen and liver together with the

characteristic. blood changes. The definitive diagnosis was established by

sternal puncture. Splenic puncture was not practiced. Since the cases were

relatively recent in origin, the forniol-gel reaction and the distilled-water tests

were of little help.
INDIA-BURMA THEATER 797

Response to treatment. was generally satisfactory. Fuadin (trivalent

antimony) given to 2 patients appeared to be entirely ineffective and in 1 case

was followed by an alarming febrile episode of several days' duration.

The ET*MD report states:

The pentavalent antimony preparation Neostam was given to three of these patients, and

Neostibosan to five. Both have proved effective, but Neostibosan appears to be distinctly

the better of the two. The total dosage of Neostam has been from 4.0 to 4.7 gin., and

of Neostibosan from 3.0 to 3.6 gin. One of the eight patients is now under treatment.

The other seven have made apparently complete clinical recovery.

Every effort was made to emphasize the necessity of considering kala-azar

in the differential diagnosis of fevers of undetermined origin. The increased

number of cases reported in 1945 was possibly in part attributable to raising

t hie level of suspicion in the medical officers of this theater. It is not improbable,

however, that in some instances of this infection the diagnosis was missed.

EVALUATION OF CONSULTANT SYSTEM

Detailed descriptions of the educational and editorial activities of Colonel

Blumgart, his role in furthering clinical research, and his relationships with

other consultants have been delineated. Further comments have been made

on these activities in relation to the problems posed by specific diseases. The

following comments concern an evaluation of the consultant system as it

operated in the theater.

On the basis of 3 years of experience as consultant in medicine (2 years in

the Zone of Interior and 1 year in the India-Burma and the China theaters)

the author considers the consultant system to be invaluable in enhancing the

quality of medical care.

In the India-Burma theater, the role of the consultant as a two-way

ambassador between the theater surgeon in Delhi and the installations in the

field facilitated the interpretation of higher policy and directives of headquarters to those engaged in caring for the soldiers and conversely permitted bringing

to the attention of higher authority some of the problems in the field, inportant knowledge and experience gained in some of the installations could be

transmitted to other installations having only fragmentary experience with

certain diseases and conditions of medical practice.

The isolation in this theater arising from wide dispersion of units and

poor lines of communication frequently resulted in medical officers having no

opportunity to discuss professional matters with anyone other than their

immediate associates. Colonel Blumgart's visits established a line of professional communication with theater headquarters. The improvement in morale

was one of the most gratifying consequences of the consultant system.
CHAPTER IX

Field Armies

Garfield G. Duncan, M.D.

Field armies were the last major commands to which consultants were

assigned in World War II. The first assignment was to the Sixth U.S. Army

operating in the Southwest Pacific Area. In some field armies, the army

surgeons were reluctant to receive or assign consultants. Misgivings as to

their usefulness delayed appointments and prevented immediate adoption of

the plan on all fronts. However, as medical consultants to field armies proved

their worth, they were welcomed by all.

The various consultants and the armies in which they functioned are

presented in appendix A (p. 829).

From the medical point of view, there was no more satisfying assignment

than that of consultant. At its best, it afforded an effective combination of

clinical, research, supervisory, and administrative activities, which carried

responsibility sufficient not only to satisfy but to tax the medical officer

best qualified for the appointment. There could be no greater challenge and

stimulus than grappling with new medical problems involving large bodies of

men and the effectiveness of the military effort.

Officially, there was no clear definition of the duties of the medical consultants. They were confronted by a great variety of problems under widely

varying conditions in many parts of the globe. Furthermore, owing to existing

staff organization, the Surgeon General's Office exercised no direct control

over medical activities overseas. Consequently, in the field armies, the capabilities of the consultants were utilized wisely, or not so wisely, according to the

vision of the army surgeon.

The consultants themselves were quick to recognize the great opportunity

to salvage sick and wounded in forward areas of a combat zone. Mlost of them

had seen such patients as they proceeded back through the chain of medical

evacuation (fig. 259) to the general hospitals and had been impressed with

the wastage in manpower and its overall effect on fighting strength at the front.

They were aware, as some apparently were not, that it was possible to provide

excellent medical service to troops in the frontlines (fig. 260).

The account in this chapter is drawn largely from the reports of consultants to the Ninth and Fifteenth U.S. Armies in the European theater and

from the reports of consultants to the Sixth, Eighth, and Tenth Ut.S. Armies

799
ACTI\ 1IF MV1111CAL "INSI-11''iNTS

Fr I M I -1

Vi(;i In-1 2-9. Li I I (-I1915.

Ill Ille P.Icific., Tllv expol-lelices Off Ille cm1,1111,1111, of Ille Flrý,l .11111 Third

ill ille 1-:111-ope:111 1114"11cl. .11-v hi-14,11Y dI!wII,-wd Ill clinplel. IV.

rvrvwN m Nirmcim.: vr 'rm.: i.,itow

linical Problem-,

"I'llo varlol.v alld Iml Ilre (d, I lic 111.1jol. pr(ddcfil,-ý Ill 110 modiellic N\ it If

which lo I he held arfniv-ý NN (Tv collf,11111 1014 'Ire 11111-o rol ed bY experivilces Ill 1111, SIXIII, Sovellill, NIIIIII, and Fiftevioll

TlIv Sixth A1.111Y, Ill Ille l"Icific, had pr(d4vills collo-vilill'..

delio-Ile, 'wrilb llep,11111s, schi'l(fsmill'Isis, polimm elifis, (k-svilten

will .1111vb1c), will vellere'll discost's.

Tllv A1.111Y, III "I'llillsio oild h.-Il V,

11-cm-116tillf, helmlilis, :111d I * vpIllis (epildvillic].

Ninill ['.S. ArIlIv, ill Fr;l1we and Ificrimmv Hi-. 21M, oncomitervil

111,1jor prohlems collcvrllmý* 11,1111111mic -Amck, 11-ollchfoot, vvilvivol 11,111WZ11ý1(l,

M .,11'"I ý<. Pill

19 11 2.1 1.% P IV'. i, 4; 'Ifii H ill. , .,1 11'. \1. .11, :1 C .q:,!lIt lit W !Th ?I,- -I\fl,

A rin . . , \11-11,1 , \1 , , \ J!'ll. i I 1- f-L I 1, ýhflll. 1.1, C ýil. 11 '111- 11 1.. F q -, Ii. Tl,ý , ''I li" C io;,Illf .111 fit

M vd i..ill. . ýINO , I \im .\, Ill!]. 11ý1.', fit 11. .. till-, I 191,_. IfUll, I I w .t.) 1, It. 1.1 it

4 th, M . h. I C ý41,11lt 1;T l'' ill, \lm .k. I lllltý *2 [)ý I I lilt I I F

1 1, if I ''I \ 11. '11. .1 ( " o l-.1 If .1, 1 W it 1, 11, , 1 11 rill.\ filk
I. \i

-• ., ,

l ~ ~T kwt' F~l , ] + . ,~ : . , i • • } , ti i ,: r ,tl.,, r L ! t ll r i l :, ~ l . '+ . 1 iltlll ll,' •

"tl, " + ,,! t • I F .+ \ "I-. r r, r : ll! (,. l I~i :,, : • : ,l'' r,, , i t

,It,. , + F t i]f i,, I ii ii' l + ,~ I , " , . f l ,, , , i -, r jl+ - I,. Ir l l l - + It '+ t~t l Ii

: T , .• ,. t ' i~t - , , 1 1 -I ,+1+- • ,.-; t,- ~ l' l' l , I I: - 't l' ' I ('l , f l ; , l l I ' I : I l ' , l • • l t • : t :

14 , , .r ,; il. I I I I I I II 

i I t ,'t 111 , 1I I I I, t :t t

' , : l ' , IIl: I i,.\ . .! .I .~ I) 1 jt , ! l l ~ l : l • ' , 1 I•, ; ! lI T I I, ' I.1111 t l1\ I t -l.'

- , ,.+ . I• \ I+ ,t- t I' .. I ) ',I t, • (', I (': r ; .~ I• l r : , ;I ~ I. 1
F it. 111." 261. 1 111th IK\:c'iuti)i l1o..jpitAh. Ninti It V.. Army, Kamnp, (scrlinnnYI, 21

(f~.2C4). ( OslhlllIlt ill NlvdivIIie. SI.\tIl U.S. Arm.1Y Nva, ass~Zl!'-w- to) 1lt'

'Sl.\tII AIin1V TI-nrilliv~. ( (liter. at Rm04'kllll 1 llt ori"rdlli/4'4 I() lI-labiIilat'1 I IW'-;Vi

a 11(1 1(1 I)1('iil ril dIvIel i. a 'I4'lli. nI-) ImCiliii. mll hat (oi, dnv . aind lwttI II ('O1lZ4 '1 lif' ~ ~II, II Itli t 1,441 in (mJ4r l ll l)II\ l~I~'1 iliZ 'l 4~l4i 4

Ill1)4,114'i I 114''-1 p 4) illic :11141 lsla! 114) J)4'l s~v - :llll4 4)l4 i (f4'l, )4 1111,~li liii' m (fll ,.r I'4lll
FUL AME
-4 11A

404

W l :1, 9!0 ;. I. I k- iw '111 P. M .
CId1 I ;I f-iq' 011(-11 NW\i CfI11 B. Ni.., .1C

\111 ill. ( l-dici of. Hlict 40f, Ow i)I illt Mil-dicil. 4 irly o 4 il,- II FII ifth

Nidclet 4 . Mi ceii~iI 4~ ill e icii~.. cl (i Il.t

rcl
sot; ~~ACTIVIT~IES OF MED:ICAL C('1NV1 'I'N\'I'"

E.

F14.1 RE. 265.--tth Casualt (ozupaiii, ConavI(Sccllt B:Ltt:Itlio,3:2(1 D ivision, mar~ichling to4 IneiCh

for supetrvisedI swVimm~inlg, Po4i~it Finigal, NewV Smi4thI Walues, Ausitraliai, 20) April P113.

Par'allel st lildiv: Aveie ('1(1 i('t ed so as to reveal unfa Cvorab~le as wvell as

favora ble i'esiit s f'01owino-vi the several1 regimies of suppr~iessive treat menit. Tile

('0omparait ive stilidles Were basedl onl (1) tilie average (lady' at tendlance at sick

call froiui tile resp~ectivye com lpailjes, (2) admiiissionis to the hospit al for all ca uses,

:111d (3) admiiiissioins to tile lhospi tal for proveti irecti irenit attacks of iari

(los('lv ob)served I weie patijelnts wltb Iita ('Icar-dia, 5Jplel1OloievgaIv, ('ii jre1(111ogrlobl~ii vallue, loss of' weighlt, abd(ominital pa iii, d iarrhlea , yo iti irg, fever, art erial

IhvpertenI sion, albiimiiiiiiia, blood( smiears positive for mnalar'ia Iilli('lo-orgalli~sllis,

and( incr'ieasedl 'Atabrl~lie tijut ' ill skir lliand sclei'ae. lPait i('il-ar. ('oisidleiat loll

W.11 (riveli to ('Ia11ge., ill l)0(v Aveilrlit, to tilie ('oII('('t r t loll ol, Atalwiiie ill tile

blood~ luilel' (hei sever'Ial r-iligiies, 111d to i'eclassifi'a t iou) of soIldier's to ligh.It

Results. -'I'lllie fol Iowin iigrestil ts ý\vrie ob se've( I:

I. Eunli one of' several Ataln'iuie sliu)Jpiessive u'eiriuua's was flIoti(I effectivye

inl abrla'pt ly and comnpletely eliuji ua t iuig rec1rrr'i'ir~ tak of' .rla 11aan it.

\\a:s ('oni('llu1l('( t1, patJoor' .1dlrrirristrat ion of' thle (hg rievioulslv laid permuittedl

a hgh erc ntageof' t lle linenI to av-oidtjl ui it.

2. lInte'nsive' rilitar'v tr'ainini g for' 4 weeks, inirni 2 inl whiich the ex-

(1'4ise p~eriod., ('X('P('h(' SO) hour, pei' wee(k, did not preip((Jit at e ;n'itv at tac(ks,

of' 11i,1li1ia ill anY of thle soldiersl oilI'l snppessi ve .tabr'iru' 1hlarapY (fig. 266~).
FIEi.I A) .IMIES ( )87

4L4

FIwlt'RE 2(6.6-Ihtensi've milit'arv training for 3d Casial Company, Convalescent Battalitn,

32d I)ivision, Point Fingal, New Soith \Wades, Australia, 29 April 1943.

3. Recurrent attacks reappeared from '2 to 4 weeks after disconmtinuing

suppressive th era py.

Outbhreaks of malaria occurring subsequently were invariab)ly traced

to failure to comply with instructions issued from Sixth U.S. Army Headquarters regarding the procedures for administering Atlabrine. A notlable

outbreak occurred in the 127th Infantry of the 32d Infantry Division at

Finschlafen on New Guinea. The break in discipline was detected by the consultant, and, within 1 week after its correction, the malarial rate fell to zero.

As a result of adIhering to the regimes of suppressive treatment institute(d

at the Sixth Army Training Center, the 32d and 41st Divisions were rehabilitated and returned to combat. Greater details of this enterprise have

been pulblished elsewhere. 2

Clinical Investigations

It is of course not, so easy to carry on carelullyv coitrolhle( clinical observations in a fieldh army as in the more stalae (ircumuistam,'es of tihe (.ommuinicatioiis zolne or the Zone of Interior. Noteithieless, important problems arise

2 Ij) ui;iTi, . . (Jimierin. Ilylirochloride as a Malaria SIIppressive ALent for Combat Troops. War Med.
-,•'26-1 hdmT N."11' M ill. ., I \NIC' l \• .I' \ .

P" (I

I"1,,111:1.2 T . ( , I 1 J ,I 1- t m .I IO w 1 m. 111%. .,r . \ < ,, l - A (,, ' 11. :11 rI.• t•t ' .I ,. , , rl: ti ,

, 1"''-Ito i : m ' itt L , I it ,, l •1 I• •l ": 1 l• I, .:•'l• d p\i- mm'\ li i :I > n l -l| •l* ',Iltll.\ :•, ;11 :111h .;

21,4 1c 1. 14 111~I h i l i li h -: ] o 1)1(.1 1

tl l l ;i 11)!, k h . 1' 1!': tl 111 t <. , 1 -:1 1. ,1,\ 1 1 ;ll\ I -I Z111.1.1' 14)ll•] ; l t t i 11 , .i'-11 , .,I '4k I , •: - l ,, l

.\ + It i•t'i I I•r '• ~ I \ IIII • + l I l 1f .1'4l 111til • ; r~ 11 1 1 11 11 S \ ( )!, . _." i . ), II : I .- z 

,,I ~ ~ ~ ,• ~ ~ +"l i , IJ• I~- I,I , I I ,I .I .•, 11l,,4 (t ,.l II, f],,t I- ,'1l:••- A••

;•I •l ;,l .•l":• i l', :•< • l' .l: lU l• i~ l 1, ,\, 1, iI•_" ll• , • ,.l l,, i, • • " v t,. •I• I, l,,11 ',

• , ., ; l, ,oiv_" u f•- -, , l I I.I I ,,,riIt'1 , 11', l.1 1 1i •, , .:~ l I: i , f I1 ,11 1f I- v; l. 1 11.. ,.1 ~ i 1

+\ •, i: ~ • 'i t l, . . .+ • r ,r , ,l iz . l. \ ilJ l I ', - l l l ,, , t \ l . , i ; _' i l , + l ,

lllc ll tll11 ,'+ ,-:1 1'• vi 11 m 1 <fII 11 lI 1 1 ['1 1 1 4 1 1 1;11 I III.
"I'i Ri' 269,. -Shock tent in a forward medical unit of the Fifth U.S..Army, Italy, 1944.

In the future, it, shouhld I) possible to expedite assignment. of experienedI

investigators to tiiidertake appropriate problems in forward areas. This

lived was wvell fillehd (dring the later stages of tile War.

Treatment of Shock

The umblwr of patients passing I through tihe preoperative and postoperative shock wards was very large during tile active phaIse of operations

(fig. 268). The surgeons being fully occupied in the operating rooms, tile

internists, incl.udiiig the medical consultants, became interested in tile shock

proleihm. In general, teanis had not been organized or instructed it shock

tliera1. ' or iil tile proper ph'Iysical setup of shock wards. Considerable confusion and iiefficiencv resulted. Although tile rate of recovery from battle

wounds was extremely good, it could have been improved. The use of large

(llalt ities of blood and blood substitutes in conibatimg shock was an invaluable

aid, Ibut whien not prolpe~rlty directed it was capable of great harm (fig. 269).
'IiitiE 26.-s of 1)10( 1 :1ud blood slbtIIMj it($. in field armuies. A. PlIasma adlministered (luring difficult, over-water VV~ICIIal jioll if' Phililppilles. B1. Blood (listril)Ititon t ruck

with 9h Exicuilat ioln Hospital, FifthI U8 Army., ('edna, Italy, Mlay 19¶114.
Flt;Iu;- 270). ( liic~il ILdwr~itur 4r Slth IVvICli:itiflhI l1o-tit:1t, l'it ii V.S 1.51 ii, It:1lY,

Lalbora*ol~lv ali(1 wer'e n ite((';il1v U(Idj lliti to( a (r0ood shock service. TIII lhe

v. 11i * period of a1 *uii vr ; tawical operat [of). t lhe sul-icn jeal(ll~ilidIs weelt ui-.iaiIY

liecivier I hait the Iliedlic,11 loadl. Thei jplivsiolo-Ic lroIblvilis, iiivolvetl aliu Ilie

fre(Jlileic ,v of' hliest coilIjthieal ions d (1(1, lit fact, iuimke thle t real mcii of shock

primailyaI a1 prlobleml for I lie Initernist.......ordlinly~I, (licitli(lv would~ laive

beeji priomioted l)V plilttill-. tw Aloec10k wards undier thle lledlical serivce of a1

iiellvical I reaItleiitt faitlit V. Thie chie~f of illedicitie would t livi'i be Ievspl)OIlsI('v

for1 thle ol.2"Iliiz~lt loll1, I rliliilu2: ald i list ruct loll of shock teallas a~iid for I lie properi

tiile-rIit~o jol f~ 1v lioiritorv "el.Vlce niid shock service. This ,4iolild have

T[le Ill' ica I colli-l Ialit sl wel' I llevitiY con)1V('lcernied also wit IiI lie work

la'rileice Ill labilaiitl'\ st'rvic' anii oftell hadi lilttle jinter'st Ill It. T11ier1 is

vviteltice iil thle talbles oh orlZnilliiat oll, esplecillV11 for field liospit alsý and Ilnedical

ce~ariiw et llipi)lliies. alid ill tile iiidfividim~ls, selected to performl laiboal"or,,v

wor'k t hat it-, imiporhlt lle to chjiticall Ileiielitii \\'I* 1101 allways recoguiizetl.

DpI)peiaIdel~ J)llasil olozgic work wasI a p rele quisit to sIt)1iperior proftessional~ calre

ill I lie P~acific. The wriiter. as a Illledl lea coiisllltiil.1 1 believed that I ilie Iabornitor ,v

-WlV ice Ill illobile iliedictal iiistaIllatit bu shiouhld have bveei iliatle a sI11)elViS0orV
812 ACTIVITIES OF MEDIIAL CONSULTANTS

responsibility of tie chief of the medical service who was dependent upon this

service for accurate assistance. The consultant in medicine repeatedly encouraged as close an approximation as possible to such a relationship (p. 825).

A specialized laboratory unit under the direction of Lt. (later Maj.)

Frederik B. Bang, MC, was of great assistance in determining the concentrations of Atabrine in the blood that followed the various malaria-suppressive

regimes being evaluatedl at the Sixth Army Training Center. Such highly

specialized units proved of outstanding value in dealing with major medical

problems.

Evacuation

During the war, in t he Pacific particularly, disease condlitions greatlyexceedc(e the number of surgical cases. At least 70 percent of medical cases in the

field can be treated and returned to their units in a relatively short time, so

also can 70 percent of the less seriously wounded. The medical evacuation

of experience(d soldiers over long lines of communications and their replacenment by unseasoned recruits is aa expensive and wasteful procedure, unjustified if medical facilities for the care of such casualties can be made available

near the front. NMany thousands of minor medical and surgical casualties

were so evacuated in World War II. This practice was unfortunate because

such casualties clog the lines of communication and crowd the hospitals to

the rear (fig. 271). They absorbed the attention of personnel much needed

forward. Furthermore, their disabilities tend to become fixed in their minds,

particularly in the case of psychoneurotic patients. It was the experience of

the Army in all theaters, and especially in the Pacific, that, patients once

evacuated from field army areas returned to the fighting front only after long

delays, if at all. Their permanent loss from their units served to exaggerate

in the minds of the remaining soldiers the severity of the unit's casualty rate.

The value of better medical treatment facilities near the front-better equipnient and properly trained personnel-thus becomes evident. In short,

excellent me(lical care yields its highest return to the fighting strength of an

army if it is brought to bear upon disease problems as near as possible to the

point where they originate.

MEDICAL SERVICE IN FORWARD AREAS

In World War II, advances in the science of medicine and improvements

in equipment, communications, and transportation had made possible a forward movement of good medical service to the frontlines. This, apparently,

was not fully realized or accepted by some officers seemingly obsessed with a

concept of evacuation to fixed hospitals. The attitude of these officers was

reflected in the lack of emphasis placed on the professional efficiency of field

medical units and on the competency of pivotal medical officers.

It wis fully recognized in the Office of the Surgeon General that in a rapidly

expanding medical service with most of the officers drawn from civil life, the
27i.i- lreowdlv Ci( hitifteitee toe 4thlit eGii(erllloswit ath i M 'anil Jofk C lb, siMania

Wot t i d ed. Evalutittion of' lrof~essiolltI jpersl5()iel, thlii isU~~ieir t.;i(-0ilivill lo)

prloh-e5ioiiaI (11lialifica t lolls, profevssioial tr-aiiuiipr of, tillits, estiiiatit lo ()I Owli

(ittruterandt (flizlit itY of' itl~iziteriul livededl iald of' the overall ituethical serviceI(t

rqiredlii( to iiiect the (Ieltli(Ids of, iiiifelildiiu taictic.1l o1eratioiis-.ilI wevei

matitter-, refli~rilig. eXfert ineit'(l('ladie

DI~IIriig thle piamiiiiiig, pha~se of* operatijolts, Itowever', the seI-viet' of* tw lie iedWcal volislltilltiki were not alwas fu1111vlltitilizedl. fit soliti illstalices they ltv ad

110 defillite p'Jlace or. fixedl ieslpollsilliltvii the office of, t1 lie ,rit1V 5uIII*('liI.

IThe ('vahtiztiolt of th flivpofesSioll;Il ca~pabilities of' tw leitedical tiIIitS befoit'

vi'leil ('i Oil '111 ii)Ofral jolt miakes Jpossilble thle coti''c t ioul of' i11a1i vdeet. I

was5 .1ti1)ip'v fprovvd(. as the war progressed, thfat, whlte thte coitsuiltaits vjsjtcd

1111 ;i~rl(rttd to or ca ituI tI1kv I'm for jut,1ols nil" thv* (1jupI itls. properlyk Illu) lelhient ed, weehtj-zltv efl'ect ive ill ittcren:silt5r thle Sttandardls of,

Ittt'(lcatl s'vrjct' jIII thlese unitts. I uimteqiiltcjes iill the (1li.tlj1Y of, fperso.(tuii(ll jillt('

Iin jinii hg of' shtock tvait s, U iii Il (ihtle (f 1nt1lj 1Y of' I zboiziloty 5e1*\*jet iioti't (1111-111(r
A I IT I I ýs III' N11:1014 SI LFAVI*.,ý

IL

NIF

.22 19 1 1.

1*11-ýIllfcd I'l-4,111 L ic k 44 :11lo illitill 14) (IIII-IlItz ille

III\ 1ý14)11;11 Im-dif-:11 ýwl-\,ICV- ý,IIPPIWIC(l b\

ll'-' lield 111),I)i I nk -wn I w-'n- Imspil:1 1,

:111d pI-I-\vIIIIIILIII-li.-\r1l 111:11 1114. climco modic;11:11141 1wrý411111cl ý,Ilmlhl be

114),I)IIA 11-\ok 272). Dijrill,.ý

(Iporollml-ý. 1111cl-chwo Ow III'\\ millI I pen ird ý,lmvk \\()I.I\ :11141 :141\ Fwll 1111, ;IrIII\ s1IP-r11()II (III OW

)I 11'-ýf )I 1 114 1 p , rl-f -;I I o r )o rt I I I )I )-ýl I :I I I I

I I I I I lit, mvillo-n I I I I, 1 114 wk ;I ri k; I n ( I I

I 1 1*( 1

:I I If 4 1 11 1. 111 ; I I I -I. I I 1 1:11 it 1 4 w I [I I lif- Ilso 111, 1 111" c 111:11 c rin

t I h -4 11 111 - 1 -1 if I - 1111 1 111 - 14 w I I I , F, lud I I I I . I I I . T 4 I I I I . :1114

I i 2 -, I ýIwrl cfill] I I I -_- I I I t I I
i~iijj I.\H\JJ*; M14

sc6

m.i~: 273~. IE\trenwlYe hius' 211 tliviu Hos1I pitalI at Iveap1 ttin-ed I-')jt ~ut-ihtg

Iluniol, I'lliliptpiliv e ns A.~iuI Cuuasltitis :uilive b'. jeep aid :uuuiblitlace. BI. Cas-ualtites,
Cmi~.zt~iiult ill MIelivilie, Office (if the Siir-

*4)1-111 ntill MIeuliciclf, ( Mive if ilie SIr--

9cii, Iifiveeul U .S.iv

Si iniei ut, Eighth UiL.S. Aiiv.

I ii~t nim 27 1. uuliusuidal:t it, Ieuliclin, field arniuies.
FlELI) ARMIE1S 817

niedicid service of field units, criticizing, pairticuilarly thle hack of professionail

training of iiiaiiv of tile officers in chairge or tilie iie~liald all(l Iallora ttor ' services. The iV51)OiisiIbilit tv for this lII 1)v othI wit hini anid without the field III-III v.

Officer nssigmitnents beinig usually miiide (luring tilie orgainiza ttion ail(1 plaimling

periodl, field untixs often cailne to thle armily m 1)1poPerly 'vstalfred. W ithin thle

field airmies, not enough aittention wits paiid to evailuakting. tile units onl thle

baIsis- of professionall organiza ttion amid thle conipeteciic of t heir personnel.

When such surveys were imade and i'ecommendattjons. submit ted, they were,

ill not at few iinstalinces, i-niore(I. For examiple, repea ed reconinendaitions for

the trainsfer of wvell-i raiiiied officers front suibordhiiatte positions where they w ere

lnalahssignedl to posit ions of grealter responsibility invil keeping withl their lnedicill

trainiing, and experience aind in the interest of better muedical catre were repeiited Ily refusedl. In some caises, thme problem wats mnet by having at professionally* competent junior officer taike over thle work mid1 responsib~ility without tile

correspondling raink, play, or recognition. This sit nation wats in pairt, hut Ily

no0 mleans wholly, (Ilue to at shlortagce of internists. Experience silows thalt

Promotions of temporary officers shouldl be conditioned p~rincipally by professional efficiency aind not by lenigth of service or age.

W~it hin tilie Sixthi L'%S. Army atreai, there wats an inadequate numiber of

well-trained internists for thle proper staiffing of thle medical units wit hiii thle

comnmandl. It is believed that each field hospital midl eatch evacuiation hospital

should have as chief of its miedhical service it Medical C orp)s officer withI qualificat ions equivalent to thle requirements for cert ificat ion by thle American Board

of Int ernal Medicine. Pile few installat ions in thle sixthi U.S. Army that haid

well-qualified chiefs of medical service wvere withiout exceptioni thle units thalt

providledl iedical service of superior quality. When Ciol. hatrrison .1. S1111l1,

MC, reported on duty ats C'onsultanit ill Medicine, Sixth U.S. Armiy, there was

little evidlence that any careful, systematic review of professional quailifications

of internists in thle Sixth U.S. Arnmy niedicail units had been carried out, t here

haiving been no medicail consultatnt aissignedl to thle Sixth U.S. Army for more

than at year. Such an evaluation wa-is indlertaiken mid, upon completioin, real,-

signent as recommnended for several nedical officers who were obviously*

nialaissigned. Not one of the recomminendled chainges wats effected, al1though

five of the officers, recoimmendedll( for reaissignnen t 1121( quaiiificait ions equivalent

to the requirements of the Amierican Board of Internal Medicine or the Amneriean Boaird of Pediattrics.

D~eference to thle reluctance of lower echelon commanders, to release wvellqualified mledlical officers who had b~eenl nalassigned, all too frequenltly prohulbited such ohbvioulsly needled cihanges. InI add~ition, tile absolute shortag-e of

specialists in ixlterntal medicine, andl indeed of young Medical Corps officers

without specialty tramining, further iincreased tile (hiffictilt v of ('xcuii mgiug ti11(

t~ranlsferrinlg personnel. As a result, officers on~ce p~la~ced in anl assiglnmenlt

frequently were fixed t here for long periods, even thiough there iiiighit be general

agreemilentitas to tile ti(Ivisahbility of their transfer. No more implortant problemi

5i649D701-61--5~4
S18 ACTIVITIES OFI MEODICAL CONSULTANTS

faces, the Army M edical Service inl fututire operatimis thimi to provide til adequate

mletihod of ('valua21ting- andl properly assigninig its officer personnlel.

Tfle ilidoct inmat ion of tile newly coin iissiouiedl civilian 1)Iivsician in Armyi

procedlures, need take relatively* lit tie t ine. It would S(eeni that services of

muedlical officers in units atwait ing act ive field service couild, anid sliotil(, bw

uitiiized hbv temporary assigunments to hiospitals inl the( Zonte of Interior and the

coin) IIutiicat ions zone or uisedl to augitiment units of a snimiar type alreamly cotil -

tintted to combllat. A Iinuitedl iliniler of offl.(icer wit Ii nulls, assignedl to thle laltter

eclielotis were lbrolgll t forward early, and tile%- gainled invaluable experience,

which add~edl g-ealt lv to tilie effect iveliess of thleir owl) ullits whenl tile units enlteredl into active operat loll.

The tables of orgalizat ion of both tile evacuatioli midl field hospitals, but

especially field hospitals, did not permit the assignment of specialists in inlternal nmedicine of the higher calib~er that mnedical prob~lems of these hospitals

(enmaid. There should be further considleration of thle tables of organlizationl

of these hospitals with upward revisions to assure officiatl approval of the type

of professional officers needled ili these inistallations.

SCOPE OF CONSULTANT ACTIVITIES

InI thle precedhing pages, tilie cOli~it ions tui([ opportunities peculiar to consultaii assignmlents to field armies liave been b~riefly sketched and~ illustratedl

b~y some pairticular examiples. InI whlat. followvs, there is somewhat more emiphasis onl thle prinvples that emiergedl as a result of these experiences.

The consultanit inl mledicine in a fieldl army is the representative of time army

surgeon ili the field of internal medicine. He is aim advisor to thle armiy surgeon

on general mid1 special prolblemns pertaining to time treatmient of (disease among

thle troops. It is his duty to keep thle army surgeon informied ats to tile quality

of mledicall care bleing furnished by medical unmits of the commnand and to iatke

suich recommnendations to Lile su~rgeon and, upon approval of the surgeon, to the

units if) lower echielon of tilie colmmiandl, as tile ('onsuliltnt b~elieves indicated for

impllrovedl care of patients. XWithini the arimy surgeoni's office, there should be

the closest relat ionship b~etweenl the miedlical conisultant and other umembers of

thle surgeoni's staff to thle enld that the (onstiltaint may miake appropriate recoinIllenlatiolls colicerIiting thle proper assignmiient of Medical Corps officers wtitthi

sp~ecial traininig in internal niedhiciie, the procurement. of special drugs and

equiipmient , 1an1d such chalnges in] hospitallization policy as mlay lbe necessary for

adIequate care of the sick. The consultant shiould hiave knowliedge of thle plans

for impending tactical operations inl order that hie may lbe prepared to offer

professional advice. Furtherniore, inl the army surgeon's office, he is the

represemitaltive of thle initerests of 21ll initernIists in mledical installations of the

comiiimand and his reh t ionshiip wvithI t lien ,ilca be, and often is, of great importance inl mlain tuiliing mlorale. 'I'l( consultant can also serve ats anl extremely

valua11ble mledium of exchanllge, of i nforniation hietweeni units wvitlIiri the field army

and b~etwveen sources outsidle thle field aIIm-1v and l nedhical officers withilii thle corn1-

unand. He also has anl oplportunity for stimulating excellence of professionail
FIELD ARMIES 819

performance and interest in) clinical observations and in continuing self-education among nlledical officers.

It was unfortunate that a clear-cut, official statement of the duties of

professional consultants (lid not appear in an apl)ropriate War Department

publication during the war. Such an official statement woulil have made it

easier for tile army surgeon to utilize appropriately the consultants' capabilities

and would have mnade more uniform their activities in all organizations. It

would have assisted the consultant greatly in making his way among Medical

Department and line officers who frequently are not cognizant of tile contributions the consultant is in a position to make.

Since field armies were the last of the major commnuands to receive consultants, it is not surprising perhaps that certain aspects of consultant activities were not readilv accepted in ariny coniniands as fully as they had come to

l)e accepted in the Office of the Surgeon General and in service commands in

the Zone of Interior. When Sixth U.S. Army Headquarters was first organized

in the Zone of Interior, no professional consultants were assigned. Ab)sence of

these officers during tile early days of the army's operations subsequently

handicapped the surgeon by a shortage of position vacancies when consultants

became available. Furthermore, it made it more difficult for the consultant,

when he was later assigned, to integrate his activity appropriately into the

operating plan of the army surgeon's office. The surgeon's office should be,

in fact, a team of officers making their best collective contrib)ution to the accomplishnient of the surgeon's duties (fig. 275). It is important, therefore,

that the place of the professional consultant on this team be clearly defined and

that a professional consultant in internal medicine should function from the

beginning and continuously in order that his part in the team play may be

utilized to the fullest. Tile consultant in nedicine should be assigned to each

field army well before it starts on its oversea mission, and, when changes in

assigned individuals become necessary, the vacancies created should be filled

promptly.

Visits to Field Installations

General activities.-No other function of the consultant in a field army

is more important than that of making regular visits to field medical facilities.

His activities there may be described briefly, as performed, typically, in the

Sixth U.S. Army.

Approximately 75 percent of the medical consultant's time was spent

with medical personnel of the forward medical units. Systematic visits were

made to each unit caring for patients; that is. field, evacuation, and portable

surgical hospitals and clearing stations. In addition, visits were made to

division surgeons and corps surgeons and their assistants in venereal disease

control and to tile division medical inspector. In the Philippines and in

Japan, transportation for such visits to readily accessible units was by motor,

usually jeeps, while imore distant, less accessible units were visited by plane

or, in soime instances, by boat. Often, the hmedical and surgical consultants
I: 1 ,1V V M 1:1l( .44 ! 1 ' V '

4k iyjI
VIVID I lie iiitlci iE i'I4J5\lntltUI~i~~tsIivldIittir t

f ied illi 275 Cml)imtichlai 1ia. Mell:1 iedct it) of, ricer.inhul-es Veiit'ut feel hAtY ill 1the

othttlttw effot prve 111111'11 tireofpa elpit. The li leatocalp Weci'le, Ioht'i (41 wuer

iiid exto v'-11l1ii oflie ('fletr i thei's ofi belie ' voisiile alitbile to alwork.r ald

ilt" ea' 1v pesoalrebleas 11 tak en iao oisiter anthvdua ptet coser s trelwardoshi

Wibe lwee ' ill('(iti pro l's ite iii olsillifis o'. there .-it w l S1 p4rossil toffcealnat flit'1

thia11,il th fied t units. Eaver v effrtiv was, l stot tlist'uissio nis. s i ll~s itnis

f uvirt111 l lii1ii l' -5(it(iit a , .1d.15 itnhic 1 itl, c ould 11', Iiitll ta'tfulhv. h'e i whas silith

weit) l ]it aols hi~i 1111 v h aof it't'rs' offti'iiticeral strv1e a prol ssoldt1 ' -le tt with uh .1 k tll

Interesit 11 hi.i , pelit' u d p)t)55 l vlt flit's, h vl's thll".1*1.(. for lalo t1io\ ;il %.r

At1(1( '4Vt'it aktt u it, W.I l)r'en to vihst. it'e ind ifviduali ll ht'lsit'l thist'iisward.

4tt-itt'ruOwi. l)itvic1 ofuts ) i I n cll ar1 etý'xv tttiidv, itlliiia p sible~ iito ekluof t e theiil
2 2 ACTIVITIES "11, MEDICAL C"N'SIA"YANT.14

A* if

ft U-0 I

Fi4.i m.; 276. ArmY hradqti;lrlcrý Si\111 V.S. Arm v. S;ill

Liumi, Philippint- JA;m(k. 20 1915.

Observ,111mis ()If fliv proh--ýlmml (d 111dividli'll illedic,11 tfliirvl-ý4

\\()111(1 he l!Sed ns a --lilde ill llinkifl", 1() the ,Il*lii\' SllI*,_1(,q)Il--ý

liv,141(pl,111 ers cowvi'll Ill,- approPlAah, "IS,*41--milvill., (fi-,,. 271')).

Sil ppl , v problems 11 local ifislall'itiolls were 111,() 1-4,\ W\\vd .1-4 IlwY

to Illv (4 poill-Ills, Ill to obinill 11 .11,111Y lleýldcorro-lillp, It-ficiviwic-4 (ii--,. 211

Exchange of ideas. The mm-on will (4 Ille cmisill 1,111 Iz 1,1-mll mw

ill .11141ther Served zl-ý -,I vnill"lilic lllvzlll-ý (fl, ;md MI'm-Imill"ll.

Evvl- v ull'(wi wns Illmle 1) v lllrnll-ý (fl, lvall'ible pliblivollmls. d1I*v(-llv(-. bllllellil-ý.

;111(1 bv f-mlvel-Saliml lo brill". 1() vach fill- 1,114-1 1111*4wili'lliml

I(w hill(Ille ()I* pvIlivillill ill

I 1w výl 1-1 N. (1.1 (fl, Its liv. BY rrn-ým l (d, I licir 41,111Y 4-m il:14-1 \\ fill all (fl, I Ill. Illedl-

("ll (.1-\ Wes '111 1 he nrcn, I Ill- \\cro nble to kvcp ill(- sm--cmi MI'm-mcd

;1-ý Ill I he cal),lbilille., (01' 1 he vnrlmls mills ;[fill lilt, palicill ImId Ille v "wild v.

Ill :Idd illo ll, till, Ill .1111 :11111*1 ;fill(. to lm -ý-ý (m 1() :11-1-1ved

fillils till, v.XPcIIcIIVqS 0[ 11mr-4 all-cadv vilu:w-rcd Ill ()PTMIMI-ý. Oftoll.

11-1-1ved 1114-dic.11 (M icri-S :1ý-ýlulllrd to 111v 1,1-m ll 1() alluvilli'llf .1clixf,

111111S. T ill. vm l,1111:1111, I() 11"llil Ille"v

put Hill) ()per:1 I'll
B IA

I )j~-ji, 1 ,I\.All,~ , Ii 
824 ACTIVITIES OF NIEIICAL CONSULTANTS

Dissemination of Professional Information

O(ne of the unfilled needs of field armies during World War II was the

provision of' adequnte professional informnation to meldical officers Witlli forward

units. The farther forward in the tcomnbat area tihe metdical officer was assigned,

the more difficult it wats for him to get help from mnedical literature and(l Medical Departnient publications concerning professional practices. Thus, the

bat talion surgeon in his aidI station frequently had little or no available reference

material. Although technical hulletins of the Medical Department are intended to reach nie(hical officers in the forward areas, these bulletins frequently

failed to arrive. The facilities for (listribution of the War Department technical bulletins were not adequate to place these publications in the hands of

the medical officers with comlbat trool)s. Nor indeed were these bulletins

delivered with suflicient regularity ait! promptness into the hands of medical

officý's, of' moi)ile hospital units. The (listril)ution of the BuTletin (f the U.S.

Army M Jedical Departmend, which wats mailed by APO numl)er to individual

mleedical officers wherever possible, wAas received wvith greater regularity and

more promptly. lirary facilities in tihe form of textbooks were generally availatble in the inoo)ile mnedieal units. Current journals were received from tijume to

time but usually several mont hs late. It wats, therefore, nee(lful for the medical

consultant to interest himself in tile (iisseminattion of medical information.

He wats sometimes able to assist in ob)taining textbooks antl journals. Becatuse

of the special value and importannce of MIedical Departmnent te('chnical bulletins,

it was arranged to have published for all the hospitals of' tile commanids an

up-to-date list of the bulletins and instructions ais to how the missing issues

might be secure(d. The btimonthly Sixth U.S. Army Medical Bulletin served

for timely comment concerning nmatters of importance. Also, as has been

noted, tile consultant transmitted verbally pertinent information obtained

at one installation to others throughout the command.

Training and Refresher Programs

Opportunity for continued training, professional refreshment, and selfeducation should be provided in niaxilnum amount in Army installat ions.

Encouragemnent of' meli'cal meetings, formal ward rounds, journal clubs, and

similar educational exercises in field armies during times of' action did not,

however, meet witli mu.ch success. Often, there wis lacking in these hospitals

the type of professional lea(dership that mnakes regular rounds on the mneedical

services and between the mnedical and surgi('al services ý stimulating experience.

In addition, the niobile character of the unit, with fluctuating patient loads

under colnbat condlitions, frequently 1made organized rounds and, especially,

formal medical meetings difficult to maintain. Except in isolated instances,

encouragement of these activities met withi little enthusiasmn. Withl improvemnent of the quality of professional personnel in mobile units by the addition

of meedical officers Wit i interest and training in teaching l)roce(hires, it should

I)e possible to stimulate greater interest in local exercises for self-educ'ation.
FIE~LD ARMIES82-

After the close of the Luzon campaign, three Plans were inst it uted1 with

the purpose of prolessional ret reshilment. One of' these had its its aim tile

fumrt her trainingo of' lab~oratory t echinicians, withI the hope of' cont inuially uniprovinig the quality of' labor-atory' techinical work in forward inst allat ions. It

wits 1ai1,ai1(ed to senid select ed lalboratory t echinicians fromi each army niedicial

inst allation to the 26th Medical Laboratory (Sixth U.S. Army) for a period

of refreshier tr.a'Iining.3 A secondI educiational plain wats tilie hioiding of clinics

ait select ed forward mnedical inst allat ions- for memibers of their st affs and M\edical

( or-ps Officers in the adljacent area on professional prolblenis arising in forward

ar-eas. One series of' such clinics wats concernedl with djermiiatologic. con(hitiofls. 4

To supervise 21ind(l condICt. these clinics, the Sixth U.S. Army headquarters

wats fort unate in having assigned Lt.. Col. Charles L. Schmidt, I\IC, ats Consultant in Dermatology, Sixth U.S. Army. The clinics in dermatology were

receivedl with enit ilusialsml.

The third typ~e of refresher training was inauguratedl and conducted

tinder the auspices of' Armiy Forces Western P~acific in fixed installations of the

commuitnications zone. Refresher work of 4 weeks' duration wats offered inl

tropical dhiseases amid lalboratoirv lrocedl~ires, ats well Its ini generiti imiternl-1

mnedicine. This programn wats hardly uinder way when hostilities ceased, flnd

tile courses were abaniloned.

Cooperative Relationships

The iilCdical c'onsuilt ant main tained the closest professional relationships

with thle surgical anll tilie netirolpsych ia tric consuilt ants, to t heir muttual benefit.

Although in the Sixth U.S. Ariny the neuiropsycliiatrie consultant wats assigned

officially a is assistant to tile iinedical consuiltamit, lie wits requested by the inedical

conlsultanit to carry on) his activities freely, and dhirectly with thle Army surgeon.

It is believed that tile neulropsvchiiatrnc conisultant should hold an assignment in

the armyv suirgeon's oflice colipar-alle to that. of the niedical and surgical

consultants. Relationships with the mnedical inspector (preventive miedicinie

ofllcer) were likewise (close and helpful. Although at satisfactory working

enetin relation tothe army medical laboratory wisas re uo

withi the ni~edical inspector, whereby the inedicah consult ant. was expected

to interest himself in laboratory procedures ats they relate to the care of patients

ini armny Iiospit als, IL shoul1d again be pointedI ouit that clinical laboratory

ltrocedhures are most in-timately the concern of the internists in the armny area.

Lablorat ory examni at ions related to preventivye niedlicine, such ats food and1(

water analysis, constituite at relatively very smnall part. of the work of the army

laboratory. Furthermore, the internist is by official and professional interest

and training miore closely associated with the professional problemis that

3(i) Memorandian, Consultant lin Medicine, Sixth U .S. Army, to Acting Surgeon, 23 Juiy 194.5, subject: ItefrvShcr

Courst in Labtoratory P'rocediures. (2) Letter, Office of the Surgeon, hevadquarters, Sixth U.S. Army, to ('onsuitant

in Nivdiecane, 27 July W145, suibject: Refresher Couirse' in Laboratory Procedures.

4 Nl "morandulu, C'onutiiiant in D ermatology, Sixth IT.S. Artiy, to Consultant lin Medicine, 25 Juiy 1945, subject:

Instructions in Common D~ermatological Problems and Outline of Instruction Course lin Dermatology.
826 ACTIVITIES OF MEI)iCAL C( NSULTANTS

concern the labtoratory pel'sonnel than is Ilhe iiedical inspector. Experienice

indicates that tile consultanlt in IiiediCiine rather than the l)reventive e(li(.inle

officer shouhl have supervisory responsibility over laboratory procedures

within tilie ariy area.

Liaison with the statistical section of the surgeon's office was close and

satisfactory, as it was also with the supply section.

In order to serve most effectively, the consultant should have a broad

general knowledge of the plans for an operation as they are advanced. Hie

should be informed as to anticipated conditions of the objective, the terrain,

sanitation, water supply, density of civil population, disease prevalence, and

expected resistance. He should have knowledge as to troop strength and as

to the number and character of supporting medical units and the echeloning

of such units. In some instances, the rather curious attitude was taken that

mature, highly trained officers accustonied to dealing with confidential matters

were not to be entrusted with secret material freely shared by young officers

in other branches with little background of experience or training. The

niedical consultant is the adviser to the army surgeon in all matters that

fall within the field of his special knowledge and should deal freely with the

sections on plans, training and operation, personnel, preventive mnedicine, and

supply.

The consultant in medicine in the Sixth U.S. Army made a special effort

to maintain closest relationship and frequently to exchange information with

the consultants of medicine in the Eighth U.S. Army in Army Forces, Western

Pacific and in Army Forces, Pacific. On more than one occasion, arrangements were made to have one of these consultants visit installations within

the Sixth U.S. Army area and to assist in the handling of professional problems

existing there.

SUMMARY AND COMMENT

The experience of medical consultants with the field armies was similar

to that of medical consultants generally in the Second World War. It was

their particular mission to activate the principle that it is now possible to

bring good medical care to the frontlines. The policy of evacuation to fixed

hospitals is wasteful from every point of view; some 70 percent of nmedical

cases and of the less severely wounded, can be treated in forward areas and

returned promptly to their units. The consultants were therefore basically

(oncerned with the proper evaluation and full use of tile professional capabilities of all medical officers and with the equipment and organization of all

field inst allations. It is here, indeed, that the best in miedical care can make

its most direct contrib)ution to maintaining the fighting strength of the Army.

The medical consultants were directly concerned with training medical

units, before a tactical operation when possible, and with the dissenination

of ideas and medical information. By tlie logic of experience, clinical laboratory procedures in the field and the treatment of shock became their special

interests. They were concerned with clinical studies which, in spite of dif-
FIEL) ARMIES 827

ficulties in forward areas, yielded some results of great immediacy, as in the

use of new drugs and antibiotics, and new therapeutic techniques.

The ain of this chapter has been to present, in a general way, the duties

of medical consultants assigned to field armnies, the difiliclties they encountered,

and the conditions they thought miight be improved. A disproportionate

amount of attention has perhaps been paid to these considerations and not

enough to the excellence of the performance of the field army medical units.

There is ample statistical proof that never before had such units reached such

a high degree of efficiency as they did (luring World War II.
APPENDIX A

Consultants in Medicine in the Various Commands of the

U.S. Ariny in World War 11

Service Commands: E'uropean T[heater of Operat ions Continued

First: Base Sect ions -Continued

Col. George P1. Denny, MIC O)ise:

Second: Col. Richard M. .McKean, M. IC

Col. H errman L. Blumigart, 'MC Lt. Cot. Put man C. Lloyd, MC

Cot. Garfield G. D~uncan, MIC United Kingdom:

Third: Col. Yale Kneeland, Jr., MIC

Cot. Thomas Fitz-llugh, Jr., NIC Lt. Col. Lauirence B. Ellis, MC

Col. .John *NMinor, MIC Hospital Centers:

Cot. Roy 11. Tfurner, NIC 12t h:

Fouirt h: It. Cot. Arthur D. Nichol, MC

Col. F . IDennette Adams, NIC 15th:

Cot. Henry N~l. Thomas, Jr., ).IC Lt. Col. Linn F. Cooper, MC

Lt. Col. Richard 1P. Stetson, M.\C Lt. Col. D)onald T. Chamberlain, MNC

Fifth: 801st:

Cot. F. IDennette Adams, MC It. Cot. ElIton R. Blaisdell, M.\C

Col. W~alter B. Martin, NIC 802d:

Cot. Johnson McGuire, NIC Lt. Col. hfenry P. Colmore, NIC

Sixth: 803d:

Col. Irving S. Wright, MIC Lt. Col. D~onald T. Chamberlain, NIC

Col. Alexander Marble, MIC It. Cot. Carl Rt. Wise, NIC

Ia. Col. Myles P. Baker, MIC 804th-.

Seventh: Lt. Col. Frederick Kellogg, MIC

Cot. Edgar van Nuys Allen, MC It. Cot. Herbert W. Rathie, NIC

EighthI: 805t h:

Col. Walter Batier, NIC Lt. Cot. Laurence B. Ellis, M.\C

Cotl. Alexander Marble, MIC Lt. Col. Carl It. Fortune, 'MC

Ninthl: It. Cot. Elbert L. Pers~ons, M.\C

Cot. Roger 0. Egeberg, MIC 807t h:

Cot. Verne It. Mason, MIC It. Cot. Bernard A. Wat-son, NIC

Col. Irving S. Wright, MIC 809t h:

Mediterranean Theater of Operations: Capt. Phillip WV. 'Morgan, M.%C

Col. P~errin IL. Long, M.\C 813:th:

European Theater of Operations: Lt. Cot. Robert S. Baldwin, MIC

Col. William S. Middleton, MC, Chief It. Col. James S. Strang, MC

Medical Consultant 814th:

Cot. Yale Kneelanid, *Jr., MIC IA. Cot. Stanley C. WV. Fahilst rom, '.IC

Cot. Donald M. P~illsbury, NIC 815t h:

Cot. Lloyd J. Thompson, MIC It. Cot. Benjamin I. Ashe, MC

It. Cot. Theodore L. Badger, NIC 818th:

Lt. Cot. G;ordon E. IHein, NIC LA. Cot. Benjamin 11. Rutledge, MC'

Base Sections: 819th:

Brittany: Lt. Col. James S. Strang, M.\C

Col. 0. Currier MeE'wen, \IC 820th:

D~elta: Lt. Cot. Putnam C. Lloyd, MIC

Lt. Col. Frederick A%. Fitz, NlC Southwest Pacific Area:

Normandy: Cot. Maurice C. Pincoffs,, MC

It. Cot. Theodore L. Badger, NIC Cot. Benjamin M. Baker, MC

829
S:1)( ACTIVITIES OF MED)ICAL CONSULTANTS

Southwest Pacific .Area -Continuied Thbird U.S. Army, LI-'roJ)(aUI t heater:

Col. I leny M\. Thomas, .Jr., MC It. Col. Nathan Weil, .Jr., NIC

Col. Roy If. Turner, MIC Fifth U.S. .Army, Mediterranean theater:

Col. Eugene C. I'ppinger, MIC It. Col. Douglas D~onald, MIC

Col. *Josep~h M. Ilayman, .Jr., MIC Sixthi U.S. Army,' Pacific:

Li. Cot. John V. Ambler, MIC Col. Gmarfield G. D)uncan, NIC

Lt. Col . Myles P. Baker, NMIC, Col. Hlarrisoni J. Shiull, MIC

Lt. Col. Frederick T. Billings, Jr., MC Seventh U.S. Army, Mediterranean and

Lt. C'ot. Maurice A. Schnitker, MIC Eliropean theaters:

Souzth Psacific Area: Li. Col. Guy~ If. Gowen, MIC

Cot. Benjamin M. Baker, MIC Eighth U.S. Army, Pacific:

C'ot. E'dward G. Billings, MC Cot. Worth B. D~aniels, MIC

Central Pacific Area: Lt. Col. Robert C. Kiniuroughi, Jr., MIC

Cot. Verne It. Mfason, MIC Ninthi U.S. Army, European theater:

India-Burma theater: It. Col. .John B. Mc Kee, MNC

Cot. I [errman L. Btunmgart, MC TenthI U.S. Army, Pacific:

Field Armies: Cot. Walter B. Martin, MIC

First U.S. Army, European theater: Fifteenith U.S. ArmY, European t heate-r

Col. Neil L. Crone, MIC Lt. Col. Carter Smith, MIC

' Col. ItnyM hms .r, ,o p ernianent duty with U.S. Army iiiV,~O~~~ Poac.Sricsu i I'iCjl

Aria, as Consultant in Medicine, spent much time on a temnporary dluty status servinL' Nith the Sixth t.S.Army bhet%%i en

the tenures of Colonels Duncan and Sliull.
APPENDIX B

Programs of Conferences of Medical Consultants in the

Zone of Interior 1943, 1944, and 1945

MEETING OF SERVICE COMMAND CONSIULTANTS IN MEDICINE AND NEUROPSYCHIATRY, OFFICE OF TilE SURGEON GENERAL, WASHINGTON, D.C.

25 and 26 October 1943

AGENDA

MONDAY, 25 OCTOBER 1943

9:00 a.m., joint meeting, room 826

1. Meeting opened by ----- Brig. Gen. Hugh J. Morgan, Chief Consultant in Medicine,

presiding

2. Greetings ------------- Maj. Gen. Norman T. Kirk, The Surgeon General

3. Introduction of -------- Maj. Gen. George F. Lull, the Deputy Surgeon General

Maj. Gen. David N. W. Grant, the Air Surgeon

Maj. Gen. Albert W. Kenner, Assistant to The Surgeon General

Brig. Gen. Charles C. Hillman, Chief, Professional Service

Brig. Gen. Fred W. Rankin, Chief Consultant in Surgery

Brig. Gen. James S. Simmons, Director, Preventive Medicine

Division

Brig. Gen. Raymond W. Bliss, Chief, Operations Service

Col. James R. Hludnall, MC, Chief, Personnel Service

Col. William E. Shambora, MC, Surgeon, Army Ground Forces

Col. Arden Freer, MC, Director, Medical Division

10:30 a.m.

The first 5 minutes of discussion of each of the following special topics will be devoted

to a general statement, after which free discussion by members of the group is invited.

4. Reconditioning of patients

Discussion ------ Maj. Walter E. Barton, MC, Director, Reconditioning Division

Lt. Col. Howard A. Rusk, MC, Chief, Convalescent and Rehabilitation Branch, Office of the Air Surgeon

Col. Derrick T. Vail, MC, Chief Consuiltant in Ophthalmology,

European Theater of Operations

Col. Rex L. Diveley, MC, Chief Consultant in Orthopedic Surgery,

European Theater of Operations

5. Psychological preparation of the patient for return to duty or for discharge to civil life

Discussion ------- Col. Franklin G. Ebaugh, MC, Consultant in Neuropsychiatry,

Eighth Service Command

12:00 noon, adjournmertt for lunch

1:30 p.m. to 5:00 pJ.m.-separate meetings

Meeting of consultants in medicine, room 826

Meeting of consultants in neuropsychiatry, room 1125

831
8:12 AC'TIVITIES OIF MED)ICAL CO)NSULTANTS

TUESDAY, 26 OCTOBER 1943

9:00 a.mn. to 12:00 noon, separate mneetings

Meeting of consultants in medicine, room 826

Meeting of consuiltants in netiropsychiatry, room 1125

12:00 noon, adjournmnent for lunch

1:30 p.m. to .5:00 p.mt., joint meeting, roomn 826

1. Meeting op~ened by- - -- Col. Roy D. Ilolloran, NC, Chief Consultant in Neuropsvchiatry, presiding

The first 5 minunttes of discussion of each of the following special topics wvill be devoted

to a general statement, after which free dliscussion by members of the group is invited.

2. Functions of the servpice commnand consultant; his relationsh ip to the Nurgeon General's Office,

to tlie Ground Forces, to the Air Forces, antd to the ports of einh'zrkation

Discuission -------- Brig. Geni. Charles C. Hillman, Chief Professional Service

3. Disposition of p~atients

Discuission ------- Col. Arden Freer, MC, Director, Medical Division

a. Retuirn to duty

1). Retirement

c. Certificate of Disability for Discharge

d. Siection VIII

e. Section X

4. Medical Departmnent p~ersonnel

IDiscuission -------- Lt. Col. William C. Menninger, MC, Chief Consultant in Neuiropsychiatry, Fourth Service Command

a. Relationship of consuiltants to assignment of medical officer personnel

1). Camtp surgeons

c. Assignment of p~ersonnel to oversea units

d. 'Medical officers; chiefs of services and sections

e. Enlisted men

f. Nurses

g. MNAC officers and civilian secretaries

ht. Promotions

i. Duty hours for medical personnel

5. Edluc,7tion

IDisciission ------- Col. Walter Batier, INC, Consultant in Medicine, Eighth Service

Command

a. Libraries

1). Educational exercises

c. Ward rounds

d. Clinical pathological conferences

e. .Journal clubs

f. X-ray and laboratory conferences

6. Coller'fion and exchange of miedical informnation within the Mledical Departmient

I)iscuission-------ILt. Col. Haurrison J1. Shull, MIC, Medicine Branch, Office of the

Suirgeon General

a. Formal and informal rep~orts of consultants

b. Overseas re~ports

c. Surgeon General's Office circular letters and War D~epartmenut Circulars

di. The Bulletin of the U.S. Army Medical D~epartment

v. Meetin~g of chiefs of services wvithin service commnandls

f. Medical statistics and nomenclat tire of diseases
APPEND)IX B 833

7. Induction station problems

Discussion ------- Lt. Col. Esmond R. Long, MC, Chief, Medicine Branch, Office of

the Surgeon General

a. Qualifications of examining personnel

b. Evaluation of efficiency of examination

c. Differences in service commands

d. Relation of C.D.D.'s to induction

e. Special difficult medical problems

AGENDA FOR ROUND TABLE DISCUSSIONS

The first 5 minutes of each special topic listed on these round table discussions will be

devoted to a general statement, after which free discussion by members of the group is

invited.

MONDAY, 25 OCTOBER 19-13

1:80 p.m. to 5:00 p.m., room 826

Brig. Gen. Hugh J. Morgan, Chief Consultant in Medicine, presiding

1:30 p.m.

1. Professional service in Army hospitals

Discussion ------- Col. Walter Bauer, MC, Consultant in Medicine, Eighth Service

Command

a. Adequacy of personnel

b. Histories; physical examinations; use of laboratory and X-ray facilities and their

interpretation: records

c. Therapy, including sulfonamides

d. Dietetics

e. Psychological aspects of the patient's illness

f. Length of hospitalization

3:00 p.m.

2. Methods used in carrying out duties of service command consultants

Discussion ------- Lt. Col. E. V. Allen, MC, Consultant in Medicine, Seventh Service

Command

a. Present difficulties

b. Suggestions for improvement

4:00 p.m.

3. Tropical diseases

Discussion ------- Lt. Col. Francis R. I)ieuaide, MC, Medicine Branch, Office of the

Surgeon General

a. Malaria: Treatment: epidemiology: policies; studies

b. Filariasis: Policies: studies

4:30 p.mn.

4. Clinical investigation in Army Medical Department

l)iscussion------- Lt. Col. Herrman L. Blumgart, MC, Consultant in Medicine,

Second Service Command

a. Opportunities: policies

b. Penicillin: What medical diseases need further investigation in the Army? Present status of its distribution and use in Army hospitals

c. War prisoners: Studies of diseases in this group

5649J70" 61 55
834 ACTIVITIES OF MEI)ICAL, CONSULTANTS

TUESDAY, 26 OCTOBER 1943

9:00 a.m. to 12:00 noon, room 826

Brig. Gen. Hugh J. Morgan, Chief Consultant in Medicine, presiding

9:00 a. ti.

1. Epidemioloqical aspects of certain diseases as they relate to medical practice

Discussion--- IA. Col. Verne It. Mason, MC, Consultant in Medicine, Ninth

Service Command

a. Rheumatic fever

b. Upper respiratory infections

c. Diphtheria

d. Streptococcal infections: scarlet fever

e. Meningococcal infections: sulfonamide prophylaxis

f. Malaria

g. Rickettsial diseases

h. Filariasis

10:00 a.m.

2. Laboratory and X-ray services

Discussion---- -. lt. Col. F. l)ennette Adams, MC, Consultant in Medicine, Fourth

Service Command

a. Equipment

b. Adequacy of personnel

c. Rh serum

11:00 a.m.

3. Venereal diseases

Discussion ------- Lt. Col. T. B. Turner, MC, Venereal Disease Control Branch,

Office of the Surgeon General

11:30 a.m.

4. The use of outpatient departments, receiving iwards, and Army dispensaries

I)iscussion ------- Col. Walter B. Martin, MC, Consultant in Medicine, Fifth Service

Command

CONFERENCE OF NEUROPSYCHIATRIC CONSULTANTS

MONDAY, 25 OCTOBER 1943

Col. Roy I). Halloran, MC, Chief Consultant in Neuropsychiatry, presiding

1:30 p.m.-Plans and policies of the Neuropsychiatry Branch.

Visit of Brigadier Rees: division neuropsychiatrists; office policy regarding

special subjects: personnel; training; reports of inspections. Lt. Col.

Malcolm J. Farrell, MC

2:00 p.m.-linduction problems.

Plans of Selective Service System; report of special committee; special

problems, personnel; role of psychologist. Lt. Col. Douglas A. Thom, MC,

and Maj. Wilfred Bloomberg, MC

2:30 p.m.-Preventive psychiatry.

Screening; mental hygiene units; morale; ideology; malingering; statistics.

1st Lt. John W. Appel, MC

3:15 p.m.-Neurology.

Need for supervision; coordination between other sections; personnel; greater

stress on iml)ortane.; need for neuropsychiatric officers to be more neurologically astute; diagnostic procedures; management. Maj. William H.

Everts, MC
APPENI) 13X B 835

4:00 p.m.-Treatment.

Psychotherapy; shock therapy; occupational therapy; management of cases;

rehabilitation; responsibilities of section officers. Lt. Col. William C.

Menninger, MC

4:30 p.m.-Gencral discussion.

TUESDAY, 26 OCTOBER 1943

9:00 a.m.-Special neuropsychiatric problems in the service command.

What types do well in Army; consultations; advisal)ility of a second Screening; educational methods; nomenclature. Col. Franklin, G. Ebaugh, MC

10:00 a.m.-Meeting with Maj. Gen. F. H. Osborn, Director, Special Service Division.

11:30 a.m.-General discussion.

CONFERENCE OF MILITARY AND CIVILIAN CONSULTANTS IN MEI)ICINE

ASHIFORD GENERAL HOSPITAL, WHITE SULPHUR SPRINGS, WEST VIRGINIA

30 and 31 October 1944

SUNDAY, 29 OCTOBER 1944

7:30 p.m.-The Use of Specialized Personnel on Medical Services of Army HlospitalsBrig. Gen. Hugh J. Morgan, Chief Consultant in Me(dicine

Discussion:

Are personnel allotments of specialized personnel in medicine in Army

hospitals adequate?

Classification of professional personnel (War I)epartment Circular 232 (1944)

and War D)epartment Technical Manual 12--406).

Role of service command consultant in assignment of specialized personnel.

Exchange of information regarding specialized personnel bIetween service

command consultants and the Medical Consultants D)ivision.

What are the specialized personnel needs in the service commands?

Exchange of personnel within the service commands.

How can qualified personnel returning from overseas be most effectively

assigned to service command installations?

Comments in consultants' reports regarding professional classification and

performance of specialized personnel.

MONI)AY, 30 OCTOBER 1944

8:30 a.m.-Greetings__- Maj. Gen. Norman T. Kirk, The Surgeon General

Hospital functions in the Zone of Interior (Dispensaries; station hospitals;

regional hospitals; named general hospitals: convalescent facilities)-

Brig. Gen. RMaymond W. Bliss, Chief of Operations Service, SGO (30 min.)

Discussion

9:15 a.m.- Problems of hospitalization _ Dr. Eli Ginzberg, Sp)ecial Assistant to I)irector,

Hospital Division, SG() (30 rain.)

Transfer of patients between hospitals in the Zone of Interior.

What kind of medical service is needed at hospitals where the work is predominantly surgical?

Anticipated bed needs in hospitals designated for medicine.

I)iagnoses, sorting and distriblution of patients from debarkation hospitalIs.

Specialized general hospitals.

What can the consultamnts do to help?

l)iscussion (60 miin.)

10:45 a.m.- Ilecess
836 ACTIVITIES OF MEDICAL CoNIS'LTANTS

11:00 a.m.-Economy of Hospitalization

Most effective use of dispensaries___-Col. Walter Bauer, MC, Consultant

in Medicine, Eighth Service Command (10 miin.)

The O'Reilly General Plan___Col. E. V. Allen, MC, Consultant in Medicine,

Seventh Service Command (10 min.)

Discussion (20 miin.)

12:00 noon-Lunch

1:00 p.m.-Organization of the Reconditioning and Rehabilitation Program_ -- Col. Angustus Thorndike, MC, Director, Reconditioning Division, SGO (15 miin.)

Flow of patients-Class IV, III, II, 1.

Supplementary report of reconditioning in Weekly Health Report.

Special reconditioning program at rheumatic fever center and tropical disease

center.

Convalescent hospital program.

Relationship of the con)sultants iii medicine to the reconditioning program.

Discussion (30 miii.)

1:45 p.m.-The Venereal Disease Program of the Army.---Lt. Col. Thomas I1. Sternberg,

MC, Director, Venereal Disease Control Division, SGO (15 nin.)

Discussion (30 min.)

2:30 p.m.-Recess

2:45 p.m.-Sulfadiazine Prophylaxis in Upper Respiratory Infections

Experiences in Army Air Forces --- Col. W. P. Holbrook, MC, Chief of

Professional Service, AAF, Office of the Air Surgeon (20 min.)

Medical Department policy--- Lt. Col. Thomas G. Ward, MC, Director,

Epidemiology Division, SGO (10 min.)

Discussion (30 min.)

6:00 p.m.-Dinner

TUESDAY, 31 OCTOBER 1944

8:30 a.m.-Rheumatic Fever

Present policies --- Lt. Col. Roy H. Turner, MC, Chief, Communicable

Disease Treatment Branch, SGO (15 min.)

Results of research in rheumatic fever in the Army Air Forces-_- Col. W. P.

Holbrook, MC, Chief of Professional Service, AAF (15 min.)

Discussion (30 miin.)

9:30 a.m.-Skin I)iseases in the Army

Experience in the European Theater of Operations -- Col. Donald M.

Pillsbury, MC, Consultant in Dermatology, European Theater of Operations (15 min.)

A lichen planus-like syndrome_--_Dr. John H. Stokes, Consultant in Dermatology to The Surgeon General (15 min.)

Consultants in dermatology within service commands ---Lt. Col. Harrison

J. Shull, MC, Chief, General Medicine Branch, SGO (10 min.)

Discussion (30 min.)

10:30 a.m.-Recess

10:45 a.m.-What can be done in the Way of Clinical Investigation in Army Hospitals---

Lt. Col. Herrman I.. Blumgart, MC, Consultant in Medicine, Second Service

Command (15 nin.)

Discussion (15 min.)
APPENDIX B 837

11:15 a.m.-Problems of C.D.D. and Retirement___Col. Arden Freer, MC, Chief, Professional Administrative Service, SGO (30 min.)

(Disability separations from the service; retirement proceedings in general;

retirement proceedings, medical officers; CDD proceedings, general; CDD

proceedings in connection with WD Circular 370; CDD proceedings at

separation centers; redistribution stations)

Discussion (30 min.)

12:15 p.m.-Lunch

1:15 p.m.-Tropical Diseases in the Army-_lit. Col. Francis R. l)ieuaide, MC, Chief,

Tropical Disease Treatment Branch, SGO (20 min.)

The Tropical Disease Center_-_Lt. Col. Joseph M. Ilaynman, Jr., MC,

Chief of Medical Service, Moore General Hospital, Swannanoa, N.C.

(10 min.)

Discussion (30 min.)

2:15 p.m.-Followup Reports of Patients Transferred from one Hospital to another---

Col. Walter Bauer, MC, Consultant in Medicine, Eighth Service Command

(5 min.)

Discussion (15 min.)

2:35 p.m.-A Statement Relative to the History (Medical Department) of World War

1 --- Brig. Gen. Hugh J. Morgan (15 min.)

Discussion (30 min.)

3:20 p.m.-Recess

3:30 p.m.-Other Professional or Administrative Problems (open discussion)

ADJOURN

MEETING OF MILITARY AND CIVILIAN CONSULTANTS IN MEDICINE

ENGLAND GENERAL HOSPITAL, ATLANTIC CITY, NEW JERSEY

3 and 4 August 1945

FRIDAY, 3 AUGUST 1945

Morning Session

9:00 a.m.-Introductory remarks ------------ Maj. Gen. Norman T. Kirk, The Surgeon

General

Welcome ---------------------- Brig. Gen. Charles M. Walson, Surgeon,

Second Service Command

Col. Sidney L. Chappell, M C, Commanding

Officer, England General Hospital

Problems of internal medicine in convalescent hospitals and hospital

centers --------------------- Col. Alexander Marble, MC, Consultant

in Medicine, Sixth Service Command

The Operations Service, Office of the

Surgeon General ---------------- Brig. Gen. Raymond W. Bliss, Chief

The Resources Analysis Division,

Office of the Surgeon General ----- )r. Eli Ginzherg, Director

Luncheon
838 A'rITIVITIES OF CEI)IC.I ('ONSI'LTANTS

Afternoon Session

1:00 p.m.-The Professional Administrative

Service, Office of the Surgeon

General --------------------- Col. Arden Freer, MC, Chief

The correlation of laboratories with

medical services --------------- Brig. Gen. J. S. Simmons, Chief, Preventive Medicine Service, SG()

Chemoprophylaxis ---------------- Brig. Gen. S. Bayne-Jones, Deputy Chief,

Preventive Medicine Service, SGO

The relationship of veterinary medicine to Army medical problems Brig. Gen. R. A. Kelser, Chief Consultant

in Veterinary Medicine

Penicillin (present status of therapy

with remarks on new methods of

administration, ---------------- Col. John Minor, MC, Consultant in

Medicine, Third Service Command

Streptomycin ------------------- Brig. Gen. Hugh J. Morgan, Chief Consultant in Medicine

Etvening Session

General discussion of medical problems of interest to military and civilian

consultants

SATURDAY, 4 AUGUST 1945

Morning Session

8:30 a.m.-Tropical diseases, introductory

comments (malaria, schistosomiasis, filariasis, amebic dysentery, cutaneous diphtheria, etc.)- Lt. Col. Francis R. Dieuiaide, MC, Chief,

Tropical Disease Treatment Branch,

Medical Consultants Division, SGO

General discussion of each topic

Luncheon

Afternoon Session

1:00 p.m.-Lichen planus ------------------- Maj. Clarence S. Livingood, MC, Consultant in Dermatology, Medical Consultants Division, SGO

The hepatitis problem ------------- Maj. Richard B. Capps, MC, Chief of

Medical Service, DeWitt General llospital

Methods for followup of medical

deaths ---- ------------- Col. Walter Bauer, MC, Consultant in

Medicine, Eighth Service Command

Psychosomatic medicine on general

medical wards ------------------ Col. William C. Menninger, MC, Chief

Consultant in Neuropsychiatry

Concluding remarks -------------- Brig. Gen. Hugh J. Morgan
APPENDIX C

Civilian Consultants in Medicine During World War II

Name Civilian position ,Specialty

Amberson, .J. Burns, Professor of Medicine, Colunbia Univer- Tuberculosis.

M.D. sity College of Physicians and Surgeons,

New York, N.Y.

Boyd, Mark F., M.I)___ Staff, International lhealth Division, Tropical diseases.

Rockefeller Foundation, New York, N.Y.

Brown, Ilarold W., M.I). Professor of Parasitology, Columbia Uni- Tropical diseases.

versity College of Physicians and Surgeons, New York, N.Y.

Burch, (eorgeE., M.D___ Associate Professor, Department of Medi- Peripheral vascular

cine, Tulane University School of Med- diseases.

cine, New O )rleans, La.

Cooke, Robert A., M.D Consultant Physician and Director, In- Allergy.

stitute of Allergy, Roosevelt Hlospital,

New York, N.Y.

Frazier, Chester N., M.D_ Professor of I)ermatology and Syphilol- Dermatology.

ogy, University of Texas School of

Medicine, Galveston, Tex.

Iloagland, Charles L., Associate, Rockefeller Institute, The Ilos- Hlepatic diseases.

M.D. pital of the Rockefeller Institute for

Medical Research, New York, N.Y.

Hopkins, J. Gardner, Professor of Dermatology, Columbia Uni- Dermatology.

M.D. versity College of Physicians and Surgeons, New York, N.Y.

.Jones, Chester I., '%i.D- Clinical Professor of Medicine, Harvard Gastroenterology.

Medical School, Boston, Mass.

Keefer, Chester S., M.I) Wade Professor of Medicine, Boston Uni- Chemotherapy.

versity School of Medicine, Boston,

Mass., and Medical Administrative

Officer, Committee on Medical Research, Office of Scientific Research and

Development.

Levy, Rogert L., M.D_ - Professor of Clinical Medicine, Columbia Cardiovascular disUniversity College of Physicians and eases.

Surgeons, New York, N.Y.

MacLeod, Colin M., Professor of Bacteriology, New York Uni- Infectious diseases.

M.D. versity College of Medicine, New York,

N.Y.

Meleney, Ilenry E., M.D_ Hlermann h\. Biggs, Professor of Preven- Tropical diseases.

tive Medicine, New York University

College of Medicine, New York, N.Y.

Palmer, Walter L., M.D_ Professor of Medicine, The School of Gastroenterology.

Medicine, University of Chicago, Chicago, Ill.

Rackemann, Francis M., Lecturer in Medicine, Harvard Medical Allergy.

M.D. School, Boston, Mass.

839
840 ACTIVITIES OF MEI)ICAL CONSULTANTS

Name Civilian position .SI pecially

Shannon,JamesA.,M.D_ Assistant Professor of Medicine, New Tropical diseases.

York University College of Medicine,

New York, N.Y.

Smith, Charles E., M.D_) Professor of Public Health and Preven- Infectious diseases.

tive Medicine, Stanford University

School of Medicine, San Francisco,

Calif.

Stokes, John H., M.D Director, Institute for Control of Syphilis, Dermatology.

and Professor, Emeritus, Cutaneous

Medicine and Syphilology, University

of Pennsylvania School of Medicine

and Hospital, Philadelphia, Pa.

Thomas, Caroline B., Associate in Medicine, Johns Hopkins Infectious diseases.

M.D. University School of Medicine, Baltimore, Md.

Tillett, William S., M.D Professor of Medicine, New York Univer- Reconditioning.

sity College of Medicine, New York,

N.Y.

Waring, James ,J., M.I)- Professor of Medicine, Emeritus, Univer- Tuberculosis.

sity of Colorado School of Medicine,

Denver, Colo.

Watson, ('ceil J., M.1) Professor and Head, Department of Med- Hepatic diseases.

icine, University of Minnesota College

of Medicine and Surgery, Minneapolis,

Minn.

Watson, Robert B.,M.I) Principal Malariologist, Tennessee Valley Tropical diseases.

Authority, Chattanooga, Tenn., and

Assistant Professor of Preventive Medicine, University of Tennessee College

of Medicine, Memphis, Tenn.

White, Paul I)., M.D-_ Lecturer in Medicine, Harvard Medical Cardiovascular disSchool, Boston, Mass. eases.

Wood, W. Barry, Jr., Professor of Medicine, Washington Uni- Infectious diseases.

M.D. versity School of Medicine, St. Louis,

Mo.
APPENDIX D

Program of Conference on Internal Medicine in the Ninth

Service Command, Letterman General Hospital, San

Francisco, Calif., 7 and 8 November 1945

Wednesday, 7 November 1945

MORNING SESSION

Presiding-Col. Irving S. Wright, MC, Consultant in Medicine, Ninth Service Command

0815 Address of WelcomeBrig. Gen. Charles C. Hlillman, Commanding General, Letterman General Hospital

The Significance of Medical Services in the Hospitals of the Ninth Service CommandCol. Luther R. Moore, MC, Surgeon, Ninth Service Command

The Plan and Objective of This ConferenceCol. Irving S. Wright, (MC

0930 Panel l)iscussion on Hepatitisl)r. Cecil J. Watson, Professor of Medicine, University of Minnesota School of

Medicine, and Consultant in Hepatic l)iseases to The Surgeon General, Chairman

Col. F. Dennette Adams, MC, Consultant in Medicine, Fourth Service Command

Capt. Albert M. Snell, MC, USNR, Chief, Medical Service, Oak Knoll Naval Hospital

Lt. Col. Frank B. Queen, MC, Chief, Laboratory Service, Bushnell General Hospital

Maj. Richard B. Capps, MC, Chief, Medical Service, DeWitt General Hospital

Maj. Roger W. Robinson, MC, Chief, Medical Service, Bushnell General Hospital

1200 Luncheon

AFTERNOON SESSION

Presiding-Col. Edgar Durbin, MC, Chief, Medical Service, Madigan General Hospital

1315 Panel Discussion on Diphtheria-Skin, Faucial and Postdiphtheritic Paralyses,

D)iphtheritic MyocarditisMaj. Clarence S. Livingood, MC, Consultant in Dermatology, Office of the Surgeon

General, Chairman

Lt. Col. William C. Spalding, MC, Chief, Medical Branch, Letterman General

Hospital

Maj. James M. Bazemore, MC, Medical Service, Moore General Hospital

Maj. Herbert S. Gaaskill, MC, Neuropsychiatric Consultants Division, Office of

the Surgeon General

Maj. John J. Sampson, MC, Chief, Medical Service, Baxter General Hospital

Maj. ('alvin F. Kay, MC, Chief, Medical Section, ASF Regional Hospital, Fort

Benning, Ga.

1445 Panel Discussion on Rtheumatic FeverMaj. Ephraim P. Engleman, MC, Chief, Medical Service, Torney General Hospital, Chairman

Lt. Col. George H. Houck, MC, Air Force Regional Consultant in Medicine

Lt. Comdr. O. C. Griffith, MC, USNR, Assistant Director of Cardiology, Graduate School of Medicine, University of Pcnns. Ivania

Capt. Jules C. Welch, MC, Rheumatic Fever Section, Birmingham General

Hospital 841
842 ACTIVITIES OF MEI)I('AL CONSULTANTS

1700 Dedication of Letterman Swimming Pool

1715 Aquacade, Featuring Ann Curtis, Swimming Champion of the Year and Winner of

the A.A.U. Medal as Outstanding Athlete for the Year 1945

1830 Dinner, Letterman Club

Thursday, 8 November 1945

MORNING SESSION

Presiding-Lt. Col. Orlando B. Mayer, MC, Chief, Medical Service, Barnes General

Hospital

0815 Panel Discussion on CoccidioidomycosisDr. Charles E. Smith, Professor, Public Health and Preventive Medicine, Stanford

University School of Medicine, Chairman

Maj. Norman Nixon, MC, Chief, Medical Service, AAF Regional and Convalescent Hospital, Santa Ana Army Air Base

Maj. David M. Goldstein, MC, Chief, Communicable Diseases Section, Letterman General Hospital

Maj. Edward J. Denenholz, MC, Chief, Medical Service, Hammond General

Hospital

Capt. Edward G. Whiting, MC, Chief, Medical Service, Lemoore Army Air Field

0930 Panel Discussion on Lichenoid and Allied Skin DiseasesMaj. Clarence S. Livingood, MC, Consultant in I)ermatology, Office of the Surgeon General, Chairman

Maj. Thomas W. Nisbet, MC, Chief, Dermatology Section, Letterman General

Hospital

Maj. John A. Hookey, MC, Chief, Dermatology Section, Torney General Hospital

Maj. James M. Bazemore, MC, Medical Service, Moore General Hospital

1045 Discussion of the Role and a Tour of the Debarkation Hospital-Brig. Gen. Charles

C. Hillman

1200 Luncheon

AFTERNOON SESSION

Presiding-Lt. Col. E. Richmond Ware, MC, Chief, Medical Service, Oakland Regional

Hospital

1315 The Health Survey of Repatriated American Prisoners of War From the Far EastCol. Irving S. Wright, MC, Coordinating Officer of Health Survey

1415 Panel Discussion on Psychotherapy as a Technique in Internal MedicineCol. Lauren H. Smith, MC, Consultant in Neuropsychiatry, Ninth Service Command, Chairman

Maj. Clarence H1. Godard, MC, Chief, Neuropsychiatric Service, Letterman

General Hospital

Maj. Herbert S. Gaskill, MC, Neuropsychiatric Consultants Division, Office of

the Surgeon General

1515 Panel Discussion on Virus and Rickettsial Diseases- Experience in the Ninth Service

Command-Recent AdvancementsCol. Francis E. Council, MC, Chief, NSC Laboratory, Presidio of Monterey,

Calif., Chairman

Capt. Alfred L. Florman, MC, NSC Laboratory, Presidio of Monterey, Calif.

Dr. William McD. Ilammon, Consultant to Secretary of War on Neurotropic

Viruses and Encephalitis

Maj. Stanley J. Carpenter, SnC, NSC Laboratory, Presidio of Monterey, Calif.

Concluding Remarks-(Col. Irving S. Wright, MC
INDEX

Abaiang, 690 AFIIQ. See Allied Force Headquarters.

ABBEY, Col. E. A., 740 Africa, 320, 649

Abdomen, examination of, 715 Age, in poliomyelitis, 546

Abdominal pains, in amebiasis, 715 Agra, 789

Aberdeen Proving Ground, Md., 388 A(;REss, Capt. C. M., 745, 748

Abscess, hepatic. See Amebic hepatitis. Air Force, l2th-163

Abuyog, 545 Air Force Field Service School, 252

Acute catarrhal jaundice, 648, 667-669 Air Force hospitals, 58

Acute respiratory diseases: reconditioning program in, 27

commission on, 398 Air Service Group, 329th-795

in Zone of Interior, 89 Air Surgeon, 27, 55, 74, '2297, 388, 396, 433

statistics on, 415 Air Transport Command, 220, 790

treatment of, 31 AISNER, Maj. M., 440

ADAMS, Col. F.D)., 7, 78-83, 89-94, 111-115, Alamo Force (United States), 474

126-127, 135 Aldershot, 236

Administrative advances, in medical treat- Algeria, 225

ment, 27-32 Algiers, 150

Administrative considerations: ALLEN, Col. E. VAN N., 5-6, 124

activities of medical consultant, 485--492 ALLEN, Lt. Col. K. 1). A., 244, 404, 405, 409,

blood bank, 512--514 410, 432, 458

clinical investigation, 514-515 Allergy, in European theater, 413

convalescent care, 503-506 Allergy program, in Zone of Interior, 90

evacuation, 506-5509 Allied Consultants Club, 259-264

functions of medical consultant, 482-485 Allied Expeditionary Force, 152

hospitals, 492-501 Allied Force H eadquarters, 144

laboratories, 501-50:3 Allied Forces, Pacific, 476

medical service, 492-501 ALLING, Col. E. N., 263

nurses,. 509-510 Alps, 214

organization of Medical l)epartment, 473- AMBLER, Maj. J. V., 490, 548

482 Amebiasis, 707, 710-714

supplies, 514 abdominal pains in, 715

visitors, 510-512 carriers of, 714

Administrative Memorandums: diagnosis of, 541-542, 714

No. 17, Office of the Chief Surgeon, clinical, 715

ET )USA 1945.--376 laboratory, 716-717

No. 22, Office of the Chief Surgeon, directives onETOUSA 1944.-412, 443 Circular No. 9, Office of the Surgeon,

No. 151, Office of the Chief Surgeon, IBT, 2 Apr. 1945--713, 720

ETOUSA 1944.-435 Circular Letter No. 33, Office of the,

Adrenalin, 135 Surgeon General, 2 Feb. 1943-720

Aedes, 691 emetine hydrochloride in, 174

Aedes aegypli, 524, 678, 679, 683, 684, 763 epidemiology of, 539-541

Aedes albopictus, 678, 679, 683, 684 esseintial facts of, 539-542

Aedes pandani, 683 in Central Pacific Area, 648, 688

Aedes scutellaris pseudoscutellaris, 691 in India-Burmna theater, 7 l0- 724

Aedes tenegatuis 671) in South Pacific Area, 620

Aedes vexans, 683, 684 in Southwest Pacific Area, 539-543

Aestivo-autumnal malaria, 172. incidence of, 539-541, 711

See also Malaria. incubation period of, 542

843
844 ACTIVITIES OF MEDICAL CONSULTANTS

Amebiasis-Con tiitted Armies:

patients with - First V.S. Army, 299., 304, 305, 306, 309,

followup observations of, 722-724 328, 332, 333, 337, :352, 353, 363, 390,

hospitalization of, 175 394, 395, 417, 426, 430, 432, 435, 437,

preventive measures in, 711 452

problem of, 710-713 Third U.S. Army, 299, 304, 305, 306, 332,

survey of, 541-543 339, 353, 373, 390, 394, 395, 432, 4:35,

symptoms of, 714 441, 445, 446, 452

therapy, 720-722 Fifth U.S. Army, 150, 155, 158, 159, 160,

effectiveness of, 721 176, 181, 354

results of, 720 Sixth U.S. Army, 474, 481, 486, 524, 525,

Amebic colitis, 716 526, 536, 550, 562, 799, 800, 801-807,

Amebic dysentery. ,•t, Amebiasis. 808, 814, 817, 819-822, 825, 826

Amebic hepatitis: Seventh U.S. Army, 150, 158, 339, 353,

criteria for cure of, 721 390, :395, 4:32, 800

diagnosis of, 717-718 Eighth U.S. Army, 474, 495, 799, 814

symptoms of, 717 Ninth U.S. Army, 353, 354, 390, 395, 432,

Amebic infection. Sec Amebiasis. 799, 800, 814

American Board of Internal Medicine, 255 Tenth U.S. Army, 633, 6:35, 662-666, 799,

257 814

American Board of Neurology and Psychi- Fifteenth U.S. Army, 799, 801, 814

atry, :167 389 ARMSTRONG, Col. If. G., 251, 252

American Board of Ophthalmology, 159 Army Air Forces, 55-58, 75n, 76, 79, 84, 86,

American College of Physicians, 16n, 46, 105 176, 251, 252, 299, :390, 410, 43:3, 434,

American College of Surgeons, 46 443-444, 481, 491, 635, 680, 695, 701, 795

American l)ental Association, Council on Army and Navy 6enerai liospital, 35

I)ental Therapeutics of, 25 Army Board for Clinical Research, 63

American Expeditionary Forces, 231-232, Army Epidemiological Board,

332, 366 Commission on Neurotropic Virus Disease

Americani Medical Association, 46 of, 545

Council on Pharmacy and Chemistry of, Commission on Tropical Diseases of, 554

25 Sub-Commission on Dysentery of, 724

Americanm Medical Society, ETOUSA, 257 Army Ground Forces, 58

American National Red Cross, 59, 404 Army Medical Bulldtin, 41, 114

Aminophylline, 741 Army Medical Field Service School, 252

Amobarbital sodium, 165, 741 Army Medical Library, 46, 49-50, 106

Amphetamine, 741 Army Medical Museum, 46, 275

Anacardiaceae, 774 Army Medical School, 84, 545

Ancqdosloma, 496 Army Regulations No. 40-1025, 12 Dec.

Ancylostomiasis, in South Pacific Area, 620, 1944-541

623 Arnhem, 436

See also Hookworm infestation. Arsenical intoxication, treatment of, 313

AxNCEvIN, Col. 1). M., 275 Arsenicals, 737

Anguar, 6:34 effects of, in treatment of malaria, 738

Anorexia, in amebiasis, 715 Arsenotherapy for syphilis, 291-293

Antityphoid immunization, 793 advantages of, 292

directive on, Circular Letter No. 138, Apennines, 6:, 6Office of the Chief Surgeon, ETOUSA

Apennines, 214 1943-293

Aphonia, in neuropsychiatric casualties, 163 disadvantages of, 292

Appendicitis, 716 dosage schedules for, 293

ARIMA, NIaj. .J. K., 281n, 318n, 396n in field armies, :305

ARMBURST, L.t. Col. C. A., 491 results of, 293, 295
INDEX 845

Arsphenamine dermatitis, 313 Atypical pneumonia-Continued

Arterial hypertension, patients with: in Zone of Interior, 89

disposition of, 418 research on, 400-401

statistics, 274 See also Primary atypical pneumonia.

Arteriovenous fistulas, study on, 115 Auckland, 571, 601

Arthritis, 227 Australia, 473, 475, 476, 481, 518, 543, 560,

disposition of patients with, 274 801

hospitals for management of. 35 Australian New Guinea Administrative

in South Pacific Area, 618 Units, 499

Arthritis centers, hospitals designated as. 35 Austria, 452

Ascaris, 540 Autohemagglutinins, in pneumonia, research

Ascoli, 174 on, 400-401

Ascorbic acid, 209 Autopsy protocols, in Zone of Interior,

ASH, Col. J. E., 275 101-102

Ashburn General Hospital, 35 AvER, Col. W. D., 256

ASHE, Lt. Col. B. I., 256

Ashford General Hospital, 40, 115 Bacillary dysentery, 524, 724-725

ASPER, Maj. S. P., Jr., 408 differential diagnosis in, 724

Aspiration, for hepatic abscess, 721 in Central Pacific Area, 687

Assam, 715, 717, 726 mortality rate for, 31

"Assam fever," 764 treatment of, 31

See also Fever of undetermined origin. sulfadiazine in, 175

Assignment, of personnel, 16-21, 157-158 sulfaguanidine in, 174

Asthma, bronchial. See Bronchial asthma. See also Dysentery.

Atabrine, 197, 429, 430, 481, 560, 733, 737. Bacteriologic examination, in treatment of

738-739 thoracic injuries, 650

as cause of atypical lichen planus, 549 BADcGER, Col. T. L., 235, 237, 238, 256, 257,

effect of, on liver function, 739 260, 263, 397, 403-412, 430-432, 443-461,

in treatment of malaria, 518, 607,612-613, 468-472

615 BAKER, Col. B. M., 7, 543, 575-623

dosage schedules, 173, 519 BAKER, Lt. Col. M. P., 7, 480, 491

results of, 605 BAL, 313

South Pacific Area policy on, 603 Balmoral, 468

studies on, 519-523, 608-611, 615-617, BANG, Maj. F. B., 503, 514, 519, 522, 549,

618 552, 554, 812

pharmacology of, 173 Bari, 218, 220

reaction to, 740 BARKER, Col. M. H., 160, 176. 178, 226

skin eruptions attributed to, 779 BARKSDALE, Lt. W. L., 498, 499

study of, 227, 802-807 BARNARD, Col. W. H., 364

toxicity of, 699 Barnstable, 327

Athlete's foot, treatment of, 31 BARTEMEIER, l)r. L. H., 391,393, 396

Atypical lichen planus, 32, 549, 740 Battle of the Bulge, 335

Atabrine as cause of, 549 BAYER, Col. W., 5, 7, 74, 8.3-86, 96-99, 101-

diagnosis of, 776 102, 104-110, 118-119, 128, 140

etiologic agent of, 778, 779 BAUMAN, Sgt. P. W., 554

in India-Burma theater, 776-779 BAYLIS, Col. M. W., 606

study of, 549 BEARDSLEY, Lt. Col. J. M., 773

Atypical pneumonia, 227, 700 BEA-TIE, Col. J., 275

cold-agglutinin test in diagnosis of, BECK, Maj. I. A., 739

400-401 Bed capacity, of hospitals in India-Burma

directive on, Circular Letter No. 2, theater, 695

Office of the Chief Surgeon, ETOUSA Bed rest, in management of1934-400 infectious hepatitis, 32

in European theater, 398-402, 468 scrub typhus, 753
846 ACTIVITIES OF 1F'I)('AL C'O)NSI'LTANTS

Bed space, utilization of, 150-156 Blood transfusion(s), 755

BEImITLER, Maj. Gen. I. S., 590 in cerebral malaria, 741

Belfast, 468 BLUMNART, Col. tH. L., 7. 695-797

Belgium, 260, 270, 333 Board for Medical Care of Repatriated

Belgium Army Medical Service, 258 American Prisoners of War, 51

Bellsdyke, :387 Board for Medical Program in Liberated

Benigtn tertian malaria, 172 Countries, 49

See also Malaria. Board for Review of Books and Periodicals,

Benzedrine, 741 46, 49-50

Benzocaine, 312 Board for the Coordination of Malarial

Benzyl bIenzoate, 285, 312 Studies, 50-51

BERCOVITZ, lt. Col. Z. T., 715, 722 Board for the Investigation and Control of

Bermuda Base Command, 7 Influenza and Other Epidemic Diseases in

BERNE, Lt. Col. C. J., 773 the Army, 114

Bernhard Baron Research Laboratories, Board for the Study of the (linical TreatRoyal College of Surgeons, 275 mient of Mararia, 38, 50

BERRY, Lt. Col. M. G., 552 BouGcs, Col. T. It., 231

Beru, 690 BOLAND, Brig. E. It., 152, 221, 263

Besan4on, 447, 471 BOLEMAN, Capt. A. P., Jr., 275

Biak, 525, 536 Bolzano, 203

BIGGANI, Maj. Gen. Sir ALEXANDER IL., 245, Bombay, 706, 726

260 "Bombay fever," 764.

Billets, for consultants, 492 See also Fever of undetermined origin.

BILLINGs, Lt. Col. F. T., 16, 480 BOND, Maj. I). D., 321n

Birmingham General Hospital, 38, 136 Bora-Bora, 570, 641), 643

Bisnop, I)r. F. C., 522 BORDEN, Brig. Gen. W. A., :391

Bismark Archipelago, 592 BORDLEY, Col. J. Il1, 5311, 543

Bismuth, 607 BORLAND, Maj. J. L., 536

Bismuth-penicillin-Mapharsen treatment of Bougainville, 570, 581, 583, 588-592, 593,

syphilis, 297 599, 618, 620

Bitche, 444 Boutonneuse fever, 227

Bizerte, 217 BoWDITCH, Maj. S., 263

Blackwater fever, 519, 742 BOYD, Col. J. S. K., 260

BLAISDELL, Lt. Col. E. It., 256 BRACKEN, Lt. Col. M. M., 552

BLAKE, Dr. F. G., 486, 526 BRADLEY, Gen. 0. N., 165

BLANK, Capt. H1., 758, 761 BRADLEY, Dr. W. H., 257, 442

Blast syndrome, studies on, 377-380 Braintree, 275

BLESSig, Brig. Gen. F. A., 169, 172 BREENE, Maj. Gen. R. G., 590

Blindness, hysterical, in neuropsychiaitric BRENN, Col. E., 250, 406

casualties, 163 BriAbane, 486, 487, 492, 510, 536, 801

Blood: Bristol, 383

studies on quantitative analysis of Ata- Britain, 433

brine in, 608 British, professional relationships with,245-

supply of, in Central Pacific Area, 661 246

Blood bank, in Southwest Pacific Area, 512- British Army, 788, 789, 792

514, 641 consultant in dermatology to, 281

Blood count, in dengue, 680 consultant in medicine to, 245

Blood picture, in poliomyelitis, 547 consultants in neuropsychiatry to, 319

Blood pressure, in patients in shock, 653-654 cooperation of, 420

Blood replacement, in management of shock, physical standards in, 277-278

649, 650, 652, 654, 655 tuberculosis in, 403

as cause of pulmonary edema, 657, 662 See also Royal Army Medical Corps.

Blood test, for syphilis, 288 British Army Groups, 150
INDEX 847

British Army Medical Congress, 745 CARTER, Maj. F. C., 767

British convalescent depots, 214 CARTER, Lt. Col. G. G., 618

British facilities, 285, 289, 320-321, 366 Casablanca, 225

British hospitals, use of, in European theater, Case fatality rates. See Mortality rates.

261 Case histories:

British Isles, 390 Japanese B encephalitis, 674-675

British military Hospital, I)elhi ('anton- schistosomiasis, 555-556

ment, 792 Casualties. See Patients.

British 95th General Hospital, 162 Catarrhal jaundice, acute, 648, 667-669

Bromsulphalein, 739 CAULFIELD, Capt. T. E., 263

Bronchial asthma, 274, 413, 785 CAV;LL, Col. It. W., 344

Bronchiectasis, 274 Cebu, 541, 808

Bronchitis, 274 Central nervous system:

BROSTER, L. R., 258 involvement of, in scrub typhus, 752

BROWN, Col. E. E., 267 study of effect of Atabrine on, 610-611

BROWN, Lt. Col. M. II., 281, 287 Central Pacific Area, 625-693

BROWN, Lt. Col. M. S., 275 amebiasis in, 648, 688

BROWN, Maj. T. MelP., 551 coccidioidomycosis in, 678

Bruden Neurological Institute, 383 consultant in medicine in, 629, 633, 635,

Brussels, 262 641-693

BURNS, Col. E. M., 256 consultant system in, 628-693

Burns General Hospital, 33 dengve in, 648

BUCHOLT, Maj. D. J., 256 diarrheal diseases in, 686-688

Bulletin of the U.S. Army Medical D)epart- diphtheria in, 669

ment, 41-43, 48, 528, 553, 585, 824 dysentery in, 648, 686-688

BULMER, Brig. E., RAMC, 260, 262 filariasis in, 643, 688-692

BUMSTEAD, Lt. Col. J. If., 620 infectious hepatitis in, 648

BURGOON, Lt. D. F., 739 leprosy in, 647-648

BURLINGAME, Dr. C. C., 384 plague in, 647-648, 667

Burma, 695 schistosomiasis in, 647, 670-671

Bushnell General Hospital, 50 supplies in, 622, 630

BYWATERS, Dr. E. G. L., 257 Surgeon of, 628, 629, 631, 633

typhus in, 672-673

Cairns, 522 venereal diseases in, 671-672

Calcutta, 706, 707, 763 Central Pacific Base Command, 633, 635,

Camps. See military installations. 639, 640

Canadian Army: Cerebral malaria, 519, 606, 700, 729, 733-737

consultant in medicine to, 245 741-742

consultant in neuropsychiatry to, 319 clinical picture of, 736

experience of, with arsenotherapy for etiologic agent of, 736

syphilis, 293 incidence of, 733

physical standards in, 277-278 See also Malaria.

tuberculosis in, 403 Chabua, 742

See also Royal Canadian Army Medical CHALLMAN, Col. S. A., 478

Corps. Charan Kanoa, 680, 681

Canton Island, 638, 639 Chalanhan, 680, 681

CAPPS, Maj. R. B., 178 Cheltenham, 232, 241,246, 318

Carbarsone, 175, 720, 721 Chemical warfare medicine, consultant in,

Cardiology, bonsultant in, 236, 397, 418 236

Cardiovascular findings, in scrub typhus, 751 Chemotherapy, 700

Cardiovascular physiology, study on, 115 in treatment of bacillary dysentery, 724

Carmarthen, 270 Chest examinations, 26

Carriers, of amebiasis, 714 Chest wounds, associated with shock, manCARROLL, G(en. P. J., 4'1-, 476, 478 agement of, 654, 656-657
848 ACTI vrmI'l oF01 MEIC: (AL. CO~NSULTANTS

Chief constultant in medlicine: Circular lettter- Conid ied

ini I'L1)tirope theater, 6, 7-1l, 2:32-280, :318 No. 24, O ffice of the Chief Surgeoii,

in Surgeon General's O ffice, 21-70, 102, ETOUSA, 16 Feb. 194-1-416

240-241 No. 24, Office of the (Chief Surgeon,

Chief consultant in surgery: NATOUSA, 15 Apr. 19)44-175

in European theater, 74, 233, 2,52, 404 No. 27, Office of the Suirgeon General,IT.S.

in Surgeon General's O ffice, 11-12 Arniv, 22 I.m. I1943-46

Chie f Surgeon: No. .32, O ffice of the Surgeon, N ATOI'SA,

European theater, 6, 74, 2:32, 266,30)5, 418, :1 Sept. 19)43-173

426 No. 33, Office of the Surgeon Geneiral, U.S.

Souith Pacific Area, 576, 578, 585, 588, 59)0 Army, 19)42-737, 7:38

China, 6915, 742 No. 33, Office of the Suirgeon General, U.S.

('hina-lBurnia-India theater, See India- Army, 2 Feb. 19143-720

Burmia theater. No. 314, Office of the Suirgeon, NATOUTSA,

Chinglow, 742 14 Sept. 1943-173, 175

Chinijofon, 720, 721 No. :36, Office of the (Chief Surgeon,

(Cholera, 6195, 61t)1), 708 ETOUSA, 19) Apr. 19145--456

in India-liurma theater, 7914-79)5 No. :37, Office of the Surgeon, N ATOUSA,

Christ mas island, 6391 2 Oct. 19)43-179)

('IuRcnim.i. Col. E'. D ., 22:3 No. .37, Office of the Surgeon, NATOUSA,

Ciney, 333, :337 8 July 19)44-17~8

Circular- No. 318, Office of the Chief Surgeon,

No. 8,. Office of the Surgeon, USAFII3T, ETOUSA, 8 Apr. 11145-444

2 Apr. 1945-706 No. 4 1, Office of t he Suirgeon, N ATOUSA,

No. 9, Office of the Surgeon, USAFI BT, 291) Jly 19)44-174, 175, 1 82, 184

2 Apr, 1945-71:3, 720 No. 55, Office of fthe (Chief Surgeon,

No. It, Office of t he Surgeon, USAFIBT, ETOUSA, 23 Oct. 19142-265

231 Dec. 19)44-756 No. 56, Office of the Suirgeoni General, U.S.

No. 21, Office of the Suirgeon, USAFIBT, Army~, 9) June 19141-736

21) Jtilv 11)45-769) No. 57, Office of the Chief Surgeon,

No. 117, .Office of the Surgeon, tTSAFFE, E'TOU7SA, 27 Juiite 1914& -451)

:31 1Detc. 19143-528 No. 60, Office of the Chief Surgeon,

No. 164, NAT( I

T SA, 29) Aug. 1943-211 L'SFET, 2 Auig. 19)45-46()

See also War D)epartment circulars. No). 61, Office' of the (Chief Surgeon,

('irciflar letter- UTSFET, 8 Auig. 19)45-46()

No. 2, Office of fthe Chief Surgeon, No. 69), Office of the C'hitef Surgeon,

ETOUTSA, 19).3 and 11144-:351, 400 USFET, 28 Sempt. 19145-461

No. 2, Office of the Surgeon, NATOUSA, No. 7:3, Office of the (Chief Suirgeon,

18 Mar. 1943-216 ETOUSA, 20 'May 19144-418

No. 4, Office of the S'urgeon, NATOUSA, No. 74, Office of the Suirgeoni General, U.S.

22 Mar. 19)4:3-165 Army, 25 .Juily 19)42-287, 288, 2192

No. 6, Office of fthe Surgeon, NATOUSA, No. 77, Office of the Chief Surgeon,

10 Apr. 19)4:3-170 ETOUSA, 8 May 19143-285

No. 10, Office of the Suirgeon, NATOITSA, No. 86, Office of the C~hief Surgeon,

15 Feb. 1944-173 ETOUSA, 22 June 19)44-299)

No. 19, Office of the Surgeon, NATOUSA, No. 9:3, Office of the Chief Surgeon,

28 Mar. 1944-178 ETOUSA, 24 May 19)4:3-288

No. 21, Office of the Surgeon, NATOUSA, No. 100, Office of the Chief Suirgeon,

3 Apr. 1944-186 FTOUSA, 25 Juily 11)44-431, 44:3

No. 21, Office of the Surgeon, MTOUSA, No. 106, Office of the Chief Surgeon,

20 JTune 11)45-179 ETOUSA, 25 June 1945-288

No. 22, Office of the Chief Surgeon, No. 107, Office of the (Chief Suirgeon,

ETOUSA, 4 Feb. 19)43-289 ETOUSA, 25 Aug. 19)44-29)6, 300
INDEX 849

Circular letter-Continued Clinical investigation,

No. 117, Office of the Chief Surgeon, in India-Burma theater, 704-705

ETOUSA, 12 Aug. 1943-416 in Southwest Pacific Area, 514-515

No. 135, Office of the Surgeon General, Clinical malaria, 172.

U.S. Army, 21 Oct. 1942-737, 738 See also Malaria.

No. 135, Office of the Surgeon General, Clinical manifestations, of cutaneous diphU.S. Army, 21 Oct. 1943-170 theria, 758-759

No. 138, Office of the Chief Surgeon, Clinical picture, ofETOUSA, 10 Sept. 1943-293 cerebral malaria, 736

No. 142, Office of the Chief Surgeon, infectious hepatitis, 537-538

ETOUSA, 17 Sept. 1943-416 poliomyelitis, 546-547

No. 148, Office of the Chief Surgeon, Clinical research, 60-63, 110-116

ETOUSA, 2 Oct. 1943-289 in hepatitis, 62

No. 153, Office of the Surgeon General, in penicillin, 63

U.S. Army, 19 Aug. 1943-737, 738, 739 in streptomycin, 63

No. 165, Office of the Surgeon General, in trenchfoot, 62, 63

U.S. Army, 15 Sept. 1943-43 in tropical diseases, 62

No. 168, Office of the Surgeon General, Clinical services, in Army hospitals, 31-32

U.S. Army, 21 Sept. 1943-117, 118 chest examinations, 26

Civilian consultants: drugs, 25

in medicine, 4, 66-67, 103 management of diseases, 23-25

in neuropsychiatry, 391 organization of medical service, 21-23

Civilian Personnel Division, OTSG, 47 Clinical studies, in infectious hepatitis,

CLAOETT, Lt. Col. A. H., Jr., 256 536-539

CLAIBORNE, Col. J. W., Jr., 305 Clinicopathologic conferences, 103-104, 106

CLARK, Col. C. J., 256 Clothing, impregnation of, in prevention of

CLARKE, Cal. C. D)., 256 scrub typhus, 528-531

COBIRN, Brig. Gen. H. C., 566

Classification, of personnel, 16-21 Coccidioidomycosis, 32

Climate, 695 in Central Pacific Area, 678

factor of, in- COHEN, Maj. B., 358, 364

diagnosis of disease, 705-708 COHEN, Lt. Col. S., 256, 263

relation to skin diseases, 771 CoHN, Lt. Col. A. E., 2:32

Clinical advances, in medical treatment, CoLRY, Col. E. G., 634

27-32 Cold-agglutinin test, in diagnosis of pneuClinical aspects: monia, 400-401

of malaria, 733 Cold injury:

of scrub typhus, 747-749 disposition of patients with, 440-441

Clinical considerations, in- in European theater, 436-441, 470

amebiasis, 539-543 treatmenm ofdengue, 524 responsibility for, 437-438

dermatological conditions, 547-549 studies on, 439-441

differential diagnosis of acute fevers, CoLE, F. L., 566

534--536 COLEMORE, Lt. Col. H. P., 416, 417

diphtheria, 543-544 Colitis, 686

dysentery, 523-524 Commander in Chief:

filariasis, 550-551 Allied Expeditionary Force, 152

general observations, 515-517 Allied Forces, SWPA, 474

infectious hepatitis, 536-539 Commission on Acute Respiratory Diseases,

malaria, 517-523 114, 398

poliomyelitis, 544-547 Committee on Medical Reasearch, Office of

psychoneuroses, 559-564 Scientific Research and Development, 227

schistosorniasis, 551- 559 Committee on Medicine, National Research

scrub typhus, 524-533 Council, 16n

564970v61 -06
850) AC'TI VITI ES t 1" FM1EDIC'AL. t'CONS1,TrANTS

Commnission o(1 Nt'irotrotie Virus 1)iseases, (ConsuIllanlt in clinical psvchohgo , 323

Army Elpidemiological Board, 5.15 ('onsuilant(s) in derm-atology:

(COnlIliSsiOnl on Tropical D)iseastes, Army Britis'h, 281

Elpidt'VIiolhgical Board, Sulwconmi.ssion oil evaluiatioii of consultant systenm by, 315

SellistosoIn ijasis of 55.4 318

(Commfitee oil Troplical Me'dit'cine, I Igivnte, ini European theater, 235, 236 237. 2791,

and Satnit:ttion, .176 281 318

(Conll\llol':lt lt Funld, -16 iln Sootihest Pacific Area, 5"S

(Com imnllli('ablt, Diseaset Treatmnnult 1Br:tnch, ill Siirgeon (Chural's Office, 15 16

()FS(',, 15 role of, ill--

(onllpi'gnl', 272 ttllaInIgv'illlil of diseases, 2m;6 300

Conferences: lwi-rsontl mn: lageientl, 3019 311

inhtr:dllid, 258 1 rofessiowal ICt iv it ies, 31-1 :115

of chiefs of medical serv ices, 103, 2-11 - 2-15 training p)rogramls, 284, 310 31

of medical consultants, -40 to Sixth U.S. Army, S25

on (dermatology, 284 Consult'alit (s) in infect ions liseass:

on neuuropsychiatry, 385 ill E'tiropean thtaht'r, 237, 3147

o01 training, 103 104, 105 suinlary ill rettrosplect by, .161 -167

oil veiert'al diseases, 287 288 Consultant (s) ill uIlldieil,:

C'onsidehratlions, ill diagnosis of disea'se: a('tivitites of, -IS. .4142. 696 705

diagnostic reasoning, 706 707 at headquarters. 697 701

effects of climate, 705-706 in tilt' fieldI, 701 705

Constantine, 225 advisor 'a ca:p('it v of, 1 -1

Consultant activities, 15-1-157 .11)litilltent of, I

dmhinistration of professional 1lt'rsont,1, assignments of, 7

145 Brit ih, 2-15

-t I:t'(d(luatrters, 6(97-701 (C'aadian, 215

coordint:lion with consultanl ill ne'uo- civilial, -1, 66 67, 103

psyclhiatry, 698-699 clinical problemIls tencounhtred Iy, 88 98,

coordination with 1pr•,v-•,ntive imnediti'v (W- 812

offict'r, 699 conifert'nc'es of, -10. 259 264

review of elinital r'cords and post ntlor- coordination with other coi!suiltants, 1241

tern findings, 701 127, 825 826

in care of prisoners of war, 1-46 difliciilt ies enct'oltered )y, .18-1 .15

ill tilt' fivld, 1-15 duties of, 3, 17, 227 230,318, -179), 700 701

etheation, 702 703 evaluation of consultant system III-, 1035

promotion of clinical r'si':(r('h, 704 705 141

reports 70)5 for laboratories, 99- I1)1

training, 71)2 703 funictions of, 2-16 2 48, .182-185

visits to hosplitals, 703-70.1 liaison :and1 stalf. 117 149

miedical rv'st'ar('h, 146 professional, 1.11 1.17

plersonnI managmen(,tt, 157 1NO hospital visits by, 580

assignment and rea:tssignme'nt, 157 158 ill Centnral P'acitic Areai, (621, 6133, 6135,

classific'at ion and promotin i(, 1610 641 - (64•3

rvd't'l4oy nl*t', 159 160 in l'rtro)ean theat er, 6, 232 280, 281 318

rep'la('t'llac'elts, 158 159 assigtlnlt'ilts of, 238

p)rofe'ssional edict :lion, 145 redeplloymene:t of, 278 2810

('onlsilltantl (s) for haloratories, ill Soith inl fitei "trlldites, 5 9, 799 827

Pac'ific Area, 582 assignment of 799

Consult ant (s) ill cardiology, 397 dlt it's of, 818 826

in Europe'an tiheater, 236. -118 in Inlia-lBurna theater, 6915 797

('onsultant(s) in chchmic:uI warfart mwdicin', ill Mt'literran'an tlwater, I-13 230

236 ill oversv:a tlw'athrs, 5 9)
INI)EX 851

Consultant(s) in medicine-Contimued Consultant(s) in neuropsychiatry, 562, 698

ill service conmmanids, 5-1), 40, 58, 71-141 699

assignment of, 799 British, 319

duties of, 5, 74-82 Canadian, 319

in South Pacific Area, 476, 575-623 civilian, 391

in Surgeon General's Office, 1-70 duties of, 322, 341, 397

in Zone of Interior, 1-70 field visits by, 372-:373

liaison activities of, 578-579 in European theater, 235, 279, 318-396

liaison alnd staff functions of: summary in retrospect by, 394-396

hospitalization and evacuation, 147 in "Mediterranean theater, 170, 392-393

interp)ersonal relations with head(quar- in Southwest Pacific Area, 478

ters staff, 148 1)rofessionaf activities of, 384-386

medical laboratories, 147 role of, in training, 366-372

medical supply, 147 to Fourth Service Command, 94

staff work, 148 to Sixth U.S. Army, 825

visits in the field, 148-149 Consultant(s) in radiology, 404

personnel management, 701) Consultant(s) in surgery, 233, 252

relationship of, to nonhospital medical Consultant(s) in syphilology, 281-318

operations, 127- 134 Consultant(s) in tul)erculosis:

role of, ini- in European theater, 235, 237, 397,

autopsy protocols, 101-102 403-412, 430-432, 443-461

clinical research, 62-63, 110-116, 807- summary in retrospect by, 469-472

809 in Surgeon General's Office, 10, 408 409,

dissemination of information, 583-585, 44:3, 458, 471

824 Consultant system, 1

evacuation policies, 271-274 beginning of, 2-9

exchange of ideas, 822 chief consultant in medicine, 2-4

exchange of p)rofessional information, service command, theater, and army

39-46 consultants, 5-9

laboratory activities, 26, 98- 101, 811- directive on, War Department Circular

812 No. 101, 4 Apr. 1946-68-61)

management of diseases, 12, 23-25 growth of, 478-482

medical supply, 123-124 in Central Pacific Area, 628-693

p)ersonnel management, 16 21, 82-88, in Eighth U.S. Army, 481

2-18 252, 577-578 in European theater, 74, 231-280, 318-472

preventive medicine, activities, 580 evaluation of, 315-318, 461-467, 468

professionail meetings, 257 264 472

r'conditioning p)rogriims, H16-119 summary in retrospect on, 394-396

rehabilitation programs, 27 summary of, 280

researeh, 274-277, 586 in field armies, 5-9

statistical data evahat ion, 579 summary of, 826-827

supervision of laboratories, 580-583 in India-Burma theater, 797

supply and use of drugs, 264-266 in Office of the Surgeon General, 2-4

supply services, 578 in service commands, 5-9

training, 102-109, 583 evaluation of, 135-141

training p)rograins, 45-46, 252 257, 366- in Sixth U.S. Army, 481

372, 824-825 in Southwest Pacific Area, 473-568

to Sixth U.S. Army, 481, 825 in theaters of operations, 5-9

to Eighth U.S. Army, -181 postwar plans for, 68-69

to Tenth U.S. Army, 654, 662-666 Contact der'natitis, 773-774I

visits to field units by, 58:3 ('onvalescence, 32

See also Chief consiultants in medicine; programs for, 26-27

Rlegional consultants in mdi(ine; Seniior ('Covalescent care:

consulllltails in Inl(lieine. ill smrl) typhus, 756
8512 ACTIVITIES OF MEIDICAL CO)NSILTANTS

Convalescent care-Continued DARNELL, Col. J. C., 244

in Southwest Pacific Area, 51)3-506 DART, Col. R. 0., 480, 550, 566

Convalescent hospitals. See Hospitals, con- DAC.IITON, Lt. Col. A. V., 26:3

valescent. DAVIEs, Maj. J. 11. T., 284

Cook Islands, 571, 640 DANIS, Lt. Col. .J. K., 24:3

CooLEY, Col. E. E., 744 DDT, 301, 312, 491

Coral Sea, 486 use of, in mos(liuito control, 680 682,

Coramine, 380 685-686

CORBY, Col. J. F., :344 Deafness, in neuropsychiatric easualties,

Corps: 163

V-369, 406 Deaths. See Mortality; Mortality rates.

XIX-354 Deaths due toXXI V-634, 662 cutaneous diphtheria, 761

Correspondence, for exchange of profes- infectious hepatitis, 537, 538

sional information, 40 malaria, 729, 730

Cortina, 203 in South Pacific Area, 606

Corynebacteriurm diphtheriae, 181, 436, 751), poliomvelitis, 545

761 typhoid fever, 793

COTTRELL, Lt. Col. J. E., 707, 785 Debarkation hospitals, 134

Council on Dental Therapeutics, American DECOURSEY, Brig. Gen. E., 635

Dental Association, 25 "Delhi Belly," 724

Council on Pharmacy and Chemistry, Dengue, 700, 706, 707, 762-765

American Medical Association, 25 control of, 680

COURVILLE, Lt. Col. C. J., 310, 311 diagnosis of, 5:34

COVELL, 'Maj. Gen. Sir GORDON, 725 diagnostic difficulties in, 594

Cox, Capt. C., 760 epidemicity of, 707

CPA. See Central Pacific Area. in Central Pacific Area, 648, 678-686

CPBC. See Central Pacific Base Command. in Southwest Pacific Area, 524

CRAIG, Capt. W. G., 244 symptoms of, 534-535

('RAWFORD, Col. P. M., 258 DENIT, Brig. Gen. G. B., 478, 481, 495,

CREW, Lt. Col. R. S., 7:36 524

CRONE, Col. N. L., 417, 430 DENNY, Col. G. P., 116, 135

Culex, 691 I)EREN, Maj. M. D., 263

Culex annulirostris, 683 Dermatitis, 284

Culex.fatigans, 768 arsphenamine, 313

Culex quinquefasciatus, 678, 683, 684, 691 contact, 773-774

CURLEY, Col. E. M., 242 ])hobi-mark, 772

CusHmNG, Col. E. C., 418 seborrheic, 284

Cutaneous diphtheria, 32, 669, 707 See also Skin diseases.

bacteriologic studies of, 760--761 Dermatologic conditions:

clinical manifestations of, 758 -759 associated with cold injury, 441

comment on, 761 in Mediterranean theater, 184 -185

complications of, 759-760 in Southwest Pacific Area, 547 -541)

in India-Burm.a theater, 756 761 management of:

in South Pacific Area, 620 hospitals for, 39

treatment of, 760 in E'uropean theater, 285 287, 301 -302.

Cutaneous leishmaniasis, :32 306-308

Cutler, Brig. Gen. E. C., 74, 233, 252, 258, recommendations on, 294

260, 278, 388, 404, 4:31), 440, 469 patients withCuTTs, Lt. Col. F. B., 736 disposition of, 282

Czechoslovakia, 452 evacuation of, :308-309

hospitalization of, 308 :309

DAMMIN, Col. G. ,J., 766 statistics on, 283 -284

I)ANIELS, Col. W. B., 39, 111, .181 Dermatologists, 284, 301) -311
IS DIEX 853

Dermatology: DIEUAIDE, Col. F. R., 15, 16, 49, 50, 59,

conference on, 284 63, 510

consultant in, in- Differential diagnosis, in diarrheal and

European theater, 235, 279, 281-318 dysenteric diseases, 724

Sixth U.S. Army, 825 Dijon, 339

Southwest Pacific Area, 490, 548 DILLON, Maj. J. A., 737

Surgeon General's Office, 15-16 Dinjan, 726

in Zone of Interior, 93 Diodoquin (diiodohydroxyquinoline), 514,

problems in, 282, 285-287 720, 721

research in, 311-313 Diphtheria:

training in, 284, 301, 310-311 directives onDermatophytosis, study on, 114 Administrative Memorandum No. 151,

DEXTER, Lt. Col. R., 232 Office of the Chief Surgeon, ETOUSA,

Dhobie-mark dermatitis, 772 1944-435

Diagnosis, of- Circular Letter No. 37, Office of the

amebiasis, 541-542, 714-717 Surgeon, NATOUSA, 1943-179

amebic hepatitis, 717-718 Circular Letter No. 51, Office of the

atypical lichen planus, 776 Surgeon, NATOUSA, 1944-181

dengue, 534 Circular Letter No. 69, Office of the

diarrheal disease, 535 Chief Surgeon, USFET,1944--461

disease, considerations in, 705-707 Technical Memorandum No. 17, Office

dysentery, 174-175 of the Chief Surgeon, USAFFE,

effects of heat, 535 1944-543-544

enteric fevers, 535 in Central Pacific Area, 669

hookworm infestation, 766, 767 in European theater, 435-436, 461

infectious hepatitis, 176, 538 in Mediterranean theater, 179-181

malaria, 534 in South Pacific Area, 619-620

poliomyelitis, 545-546 management of, 24, 435

respiratory diseases, 535 treatment of, 266

typhoid fever, 792 See also Cutaneous diphtheria.

typhus fever, 535 Directive(s), onDiagnostic sign(s)- amebiasis, 175, 713, 720

of cutaneous diphtheria, 758 consultant system, 68-69

of scrub typhus, 748 convalescent care of patients, 531-533

Diarrhea, 725 differential diagnosis of acute fevers, 534

outbreaks of, 90 diphtheria, 179, 181, 543-544

Diarrheal and dysenteric diseases: disposition of patients, 186

conclusions on, 725 dysentery, 174

diagnosis of, 535 field rations, 211

directive on: filariasis, 769

Technical Memorandum No. 7, Office first aid for soldiers, 48

of the Chief Surgeon, USASOS, hospital diet, 48

1944-534 infectious hepatitis, 178-179, 536

epidemiologic factors in, 708-710 maintaining adequate urinary output, 706

in Central Pacific Area, 686-688 malariu, 170, 173, 174, 736-738

noneffectiveness due to, 707 neuropsychiatric casualties, 165-168

types of- respiratory diseases, 535

amebiasis, 710-724 scrub typhus, 531-533, 756

bacillary dysentery, 724-725 trenchfoot, 182

Dieppe, 165 tuberculosis, 184

Diet, 656 Dirofilaria immitis, 691

directive on, War Department Technical Disciplinary centt .s, neuropsychiatric servManual 8-500, March 1945-48, 123 ices at, 359-360

in infectious hepatitis, 32, 179, 538 evaluation of, 395
854 ACTIVITIES OF MEDICAL CONSULTANTS

Diseases- Drugs-Continued

of medical interest, in Mediterranean supply of, 282

theater, 161-185 in European theater, 264

of military importance, in India-Burnma in Southwest Pacific Area, 514

theater, 707-797 use ofpolicies formulated for inanagenient of, in European theater, 265-266

23-25 in treatment of malaria, studies of,

Dispensaries, in Zone of Interior, 129-132 738-739

Disposition of patients, with- DUDLEY, Surgeon Vice Admiral Sir SHELallergic disturbances, 90 DON, 263

amebiasis, 724 Dulag, 545, 546

arterial hypertension, 418 DUNCAN, Col. G. G., 7, 123, 481, 487, 801-

borderline neuropsychiatric conditions, 807

355-366, 560 DURST, Col. G. G., 355, 358, 364

bronchial asthma, 785 Dysentery, 31, 227, 487

cerebral malaria, 742 diagnosis of, 174-175

cold injury, 440-441 directive on, Circular Letter No. 91,

cutaneous diphtheria, 761 Office of the Surgeon, NATOUSA,

dermatologic conditions, 282 6 Apr. 1943-174

filariasis, 550, 551, 643-645, 768-769 in Central Pacific Area, 648, 686-688

infectious hepatitis, 176 in Mediterranean theater, 174-174, 225-

malaria, 430 226

neuropsychiatric conditions, 97, 329, 352, in Southwest Pacific Area, 523-524

380 treatment of, 174-175

peptic ulcers, 90-92 See also Diarrheal and dysenterie diseases.

schistosomiasis, 558

scrub typhus, 531-533 EBERPHART, Capt. C. M., 244

skin diseases, 302 EBERT, Lt. Col. R., 468

tuberculosis, 403, 412 Ecthymatous ulceration, 31

veneral diseases, 306 Eczema, 284

See also Evacuation. Editorial duties, of consultant in medicine,

I)IVELEY, Col. R. L., 244, 389 227-230

Division of Medical Sciences, National Re- Education, 145

search Council, 143 hospital programs, 216-217

Division of War Research, Columbia Uni- in Mediterranean theater, 215-224

versity, 114 meetings, 217-221

DoAN, Col. 11. W., 315, 360 of medical officers, 702-703

Dobodura, 486, 528 postarmistice training plans, 222-224

DOUGLAs, Lt. Col. J., 267 rotation of medical officers, 221

DowNs, Maj. WV. G., 676 societies, 217-221

Drainage, for he i a , 71 Effort syndrome, 756 Drainage, for hepatic abscess, 721 Egypt, 174

I)rimycarpus, 774 EHRLICH, Capt. A., 715

Drinker respirator, 175 Eighth Air Force, 251, 252, 284, 320, 390,

Drinker-Collins respirator, 789 410, 434, 443-444

D)rugs, 25 surgeon to, 297

antisyphilitic, 282 Eighth Air Force Provisional Field Service

dermatologic, 312-313 School, 252

British use of, 285 Eighth Service Command:

problems with, 282 autopsy protocols in, 101-102

distribution of, 25 consultant in medicine to, 74-77, 9.6-97,

for neuropsychiatric use, 354, 380-381, 383 98-99, 101-102, 104-110, 118-119, 128,

selection of, 25 140-141
INDEX 855

Eighth Service Command-Continued Epinephrine, 174

consultant system in, 76 EPPINGER, Col. E. C., 7, 16, 480, 481, 484,

evaluation of, 140-141 488, 491, 543

personnel management in, 83-86 Equipment, electrocardiographic, 418

reconditioning program in, 118-119 Ergotamine tartrate, studies on, 380-381

surgeon of, 4, 5 Eschar, of scrub typhus, 748-749

training program in, 104-109 Espiritu Santo, 571, 587, 588, 600, 634, 669

Eighth U.S. Army, 485, 495, 799, 814 Essential Technical Medical Data report, 40

consultant in medicine to, 481 ]tampes, 252, 358

consultant system in, 481 Etiologic agents, in cerebral malaria, 736

EISENHOWER, Gen. D. D., 152 Etiologic factor, in contact dermatitis, 774

El Guettar, 165 ETOUSA (European Theater of )perations,

Electrocardiographic equipment, 418 U.S. Army). See European theater.

Electroencephalograms, in diagnosis of neu- Europe, 304, 392, 394, 404, 457, 649

ropsychiatric conditions, 377 European theater, 6, 799

Electroencephalographic machines, supply allergy in, 413

of, 383 Allied Consultants Club in, 259-264

Electric-shock machines, supply of, 383 American Medical Society in, 257

Electroshock therapy, 377 Chief Surgeon, 150, 232, 266, 305, 418, 426

ELKIN, Col. D. C., 115 clinical research in, 274-277

ELLENBERG, Lt. Col. M., 711, 715, 723 cold injury in, 436-441, 470

Ellice Islands, 678, 690 conferences in, 241-245

ELLIS, Lt. Col. L. B., 279, 439 on dermatology, 284

ELSOM, Lt. Col. K. A., 717, 720, 721, 723, 724 on venereal diseases, 287-288

EMERSON, Lt. Col. C. P., Jr., 263, 468 consultant(s) in, inEMERSON, Col. G. V., 39 cardiology, 236, 397, 418

Emetine hydrochloride, 174, 514, 648, 720, clinical psychology, 323

721 dermatology, 281-318

Emirau Island, 570 infectious diseases, 397, 461-467

Encephalitis, Japanese B, in Central Pacific medicine, 232-280, 318

Area, 673-677 neuropsychiatry, 318-396

Endamoeba coli, 712 radiology, 404

Endamoeba histolytica, 496, 516, 540, 541, surgery, 233, 252, 404

620, 686, 710, 712, 715, 724 syphilology, 281-318

England, 232, 257, 270, 275, 281, 282, 285, tuberculosis, 397, 443-461, 468-472

286, 313, 318, 321, 352, 359, 362, 365, consultant system in, 74, 231-280, 318-

366, 369, 372, 383, 387, 388, 395, 398, 472

411, 414, 416, 419, 426, 432, 434, 468, 469 evaluation of, 315-318

Eniwetok, 639 evolution of, 232-240

Enteric fevers: in World War 1, 231-232

diagnosis of, 535 summary of, 280

directive on, Technical Memorandum dermatologic conditions inNo. 7, Office of the Chief Surgeon, evacuation for, 308-309

USASOS, 1944-534 hospitalization for, 308-309

Enteritis, 686, 687 management of, 301-302, 306-308

Eosinophilia, in relation to ancylostomiasis statistics on, 283-284

and strongyloidosis, 623 dermatologists in, 309-311

Ephedrine, 741 dermatology inEpidemiological studies, in infectious hepa- problems in, 282, 285-287

titis, 536-539 research in, 311-313

Epidemiology, of- training in, 284, 310-311

amebiasis, 539-541 diphtheria in, 435-436, 461

diarrheal and dysenteric diseases, 708-710 disposition of patients in, 274, 430

infectious hepatitis, 537 drugs in, 264-266
856 ACTIVITIES OF MEDICAL CONSULTANTS

European theater-Continued FAHINCN, Lt. Col. H. D., 369, 370, 380, 395

evacuation policy in, 271-274, 419-422, Facilities:

423-428, 457 British, 285, 289, 320-321, 366, 403, 420

homologous serum jaundice in, 441-443 Canadian, 403

hospitals in, 283, 323-340 disciplinary centers, 359-360

influenza in, 414-415 dispensaries, 129-132

interallied relationships in, 245-246 evacuation, 812

laboratory problems in, 289 exhaustion centers, 352-353

malaria in, 416-418, 429-430 induction station, 128

neuropsychiatric facilities in, 341-355 laboratory, 26, 98-101, 289, 300, 306,

if] nonmedical agencies, 355-366 501-503, 580-58:3, 811-812

neuropsychiatrists in, 320, 322-323, 358, library, 46, 50, 106-107, 584-585, 824

"359, 360, 363-365 neuropsychiatric, 561

rwersonnel in- outpatient clinics, 132

management of, 248-252, 373-377 ports of embarkation, 132

physical standards in, 277-278 reception centers, 128-129

redeployment of, 278-280 recovery centers, 360-361

pneumonia in, 398-402 replacement depots, 355-359

directive on, Circular Letter No. 2, replacement training centers, 129

Office of the Chief Surgeon, ETOUSA, research, 110-116

7 Jan. 1943,-400 roentgenographic, 285-286, 404-412, 443

professional meetings in, 257-264 separation centers, 132

research in, 400-401, 417, 418-419 See also Hospitals; Personnel; Supplies.

training in, 252-257, 366-372, 395 FAHLSTROM, Col. S. C. W., 256, 26.3

tuberculosis in, 430-432, 443-457 FAIRLEY, Brig. N. H., 522, 523, 476

surveys of, 402-412, 457-461 Fanning Island, 639

typhus commission in, 418 Far East Air Forces, 475

venereal diseases in, 282-283, 287-293, Fatality rate(s), for scrub typhus, 525, 526

295-301,303-306 FAUST, Dr. E. C., 540, 554

Evacuation: FERGUSON, Capt. M. S., 552

of casualties: Fever:

from forward areas, 812 acute, differential diagnosis of, 534-536

in Central Pacific Area, 661, 663, 664 in scrub typhus, 749

in European theater, 423-428, 430-432, Fever of undetermined origin:

457 diagnostic problem of, 762

in South Pacific Area, 587-588 in India-Burma theater, 762-765

in Southwest Pacific Area, 506-509 statistics, 762

of patients- Fever therapy, 24

with dermatologic conditions, 308-309 Field hospitals:

with neuropsychiatric conditions, 329- in India-Burma theater, 695

332 See also Hospitals, field.

with tuberculosis, 430-432 Field Medical Bulletin, 698, 700, 703, 736,

plans for, 419-422 737, 739, 772, 773, 775, 782

policy of, 271-274 Field Medical Card (Form 52c), 507

problems of, 191 Field Medical Record Jacket (Form 52d),

to Zone of Interior, 756 507

Evacuation hospitals: Field rations, directive on, Circular No. 164,

in India-Burma theater, 695 NATOUSA, 29 Aug. 1943-211

psychiatrists assigned to, 165 FIELDS, Lt. W. S., 276

See also Hospitals, evacuation. Fifteenth Air Force, 218, 220

EVANS, Capt. E. R., 745, 748 Fifteenth U.S. Army, 799, 801, 814

EVERTS, Lt. Col. W. H., 377, 390, 635 neuropsychiatrist to, 344

Exeter, 321, 324 Fifth Air Force, 475, 481, 485

Exhaustion centers, 352-353 V Corps, 369, 406
INDEX 85 7

Fifth Service Command: XIV Corps, 587

clinical research in, 115 Fourth Service Command:

consultant in medicine to, 86-87, 115, clinical problems in, 89-94

139-140 clinical research in, 111-115

evaluation of consultant system in, consultant in medicine to, 78-83, 89-94,

139-140 99-101, 111-115, 126-127, 135

personnel management in, 86-87 consultant in neuropsychiatry in, 94

Fifth U.S. Army, 150, 155, 158, 159, 160, coordination among consultants in, 126-

176, 181,354 127

surgeon to, 70 evaluation of consultant system in, 135

Fifth U.S. Army medical society, 218 laboratories in, 99-101

Fiji Islands, 571, 573, 586, 587, 588, 600, surgeon of, 3, 90, 127

607, 615, 620, 634, 643 France, 240, 252, 263, 266, 272, 302, 358, 362,

Filariasis, 32, 699 432, 447, 471, 800, 801

disposition of patients with, 643-645 FRANKAU, Sir CLAUDE, 263

effect of, on morale, 707 Fraxine, 738

in Central Pacific Area, 643, 688-692 FREER, Col. A., 10, 15

in India-Burma theater, 768-769 FREMONT-SMITH, Dr. F., 703

in prisoners of war, 691 French Army, 152

in Southwest Pacific Area, 550-551 FRENCH, Col. S. W., 6, 90

manifestations of, 550 French Indochina, 695

FINE, T/3 R., 739 French Morocco, 225

FINGERMAN, Lt. D. L., 275 Frenchay Park, 257

FINNEY, Brig. Gen. J. M. T., 231, 232 FRONK, Col. C. E., 628, 629

Finschhafen, 486, 503, 525, 543, 807 Frostbite:

First aid, directive on, War Department disposition of patients with, 441

Field Manual 21-11, April 1943-48 responsibility for treatment of, 438

First Service Command: Fuadin, 514, 558, 796

consultant in medicine to, 116-118, 135 in treatment of schistosomiasis, 647, 671

evaluation of consultant system in, 135 FUO. See Fever of undetermined origin.

reconditioning program in, 116-118 FULLER, Maj. Gen. H. H., 525

First U.S. Army, 299, 304, 309, 328, 332, Functions, of consultant in medicine, 144-

333, 337, 352, 353, 363, 390, 394, 395, 149, 246-284, 482-485

426-427, 430, 432, 435, 437, 452 Fungus infections, 284

consultant in medicine to, 417 treatment of, 31

neuropsychiatrist to, 337, 344 Furunculosis, 31

surgeon to, 305, 362

venereal disease management in, 304, 305, G-1 (personnel), 158

306 G-4 (logistics (supply)), 209

FITZ, Col. F. W., 256, 263 GAGE, Capt. D. P., 553

FITZ-HUGH, Col. T., Jr., 116, 124, 136, 732, GALLEMAERTS, Col. V., 258

735, 736 GANNON, Capt. H. E., 244

Fitzsimons General Hospital, 33 Garapan, 681

FLEMING, Col. W. D)., 236, 241, 242, 244, 284 Gastritis, 715

FLEMING, Prof. Sir ALEXANDER, 435 GATES, Col. K. H., 633

FLICK, Col. J. B., 635 Gatton, Australia, 487

FLOOD, Maj. J. M., 779 GAULD, Lt. Col. R. L., 178

FLOREY, Prof. H. W., 265, 266 Gaya, India, 706

Fontainebleau, 272 General hospitals:

FORRESTER, Lt. Col. J. S., 724, 745, 749. in India-Burma theater, 695

752 in Zone of Interior, 90

Forts. See Military installations, plans for, 5

FORTUNE, Lt. Col. C. H., 256, 263 See also Hospitals, general.

Foster General Hospital, 38 Geneva Convention, 202, 203, 208
8•5 ACTIVITIES O(F MEDIiCAL (CO)NSXULTANTS

(eriran prisoners of war, diphtheria in, 435 IIAGINs, Brig. Gen. W. A., 481, 4918, 526, 536,

(Germiany, 354, 394, 432, 452, 471, 485, 800, 550

80)1 IIAIRSTON, Lt. N. G., 552

Gilbert Islands, 626, 632, 678, 688, 690 HIALILORAN, Col. t. D)., 368 369, 373, 381,

GINSBERG, Maj. It. S., 441 386

(;iivt, 272 iiANsON, Lt. Col. F. It., 165, 170, 320, 321,

(lasglow, 150 344, 352, 359, 392 393

(LASSHERG;, 1t. ('ol. 1. J., 541 HIARGREAVES, Lt. ''ol. G. It., 387

GLE.N, lt. ('ol. F., 503, 512 IIARMON, It. Ge(n. M., 590

Glyceriie, 773 H armon (Gieneral i lospital, 39, 50, 62

GOLD, (ol. D)., 276 IIARPE'R, Col. I'. A., 580, 613

GoLn•IN, ('ol. T., 440 I|ART, Brig. Gen. W. L., 4

GoLz, Lt. Col. II. If., 178 H1ARVEY, Maj. A. Nic., 503, 514, 522, 523,

Gonorrhea, 185- 186, 227 549

management of- - IIAsTI us, Lt. Col. D. W., 321

conference on, 287 288 Hlastings Air Base, Calcutta, 768

directive on, 24 IIATTi'ER, Colonel, 275

Circular Letter No. 107, Office of the ilawaii, 545, 630, 635, 639, 647, 667

Chief Surgeon, iTr)USA, 1944 II awaiian De)partient, 628 635

296 IHawaiian Islands, 627 635, 639, 643, 646,

penicillin in, 296,305 6.47, 6-18, 667, 671, 672 673, 678

renissibility for, 295 IHAWLEY, Maj. Gen. P. It., 6, 74, 232, 234,

sulfonamides in 296, 305 239, 245, 250, 251, 259, 2615, 267, 270, 274.

penicillin-resistant, 300 275, 293, 305, :112, 324, 327, 328, 344, 352,

Good(enough Island, 486, 524, 525, 550 359), 361, 362 363, 3661, 368, 369, 3701, 391,

GOOIDM.A N, J. 1., 775 395, 396, 399, 40:3, 4014, 405, 4116, 417, 418,

;OOTNICK, (Capt. A., 783, 784 432, 440, 459, 469

(G()atY, Maj. (Gen. A. L, "390 IIAwLFY:, l~t. \W. If., 257

GORDON, Lt. Vol. If. II., 39 ilay fever, in E'uropean theater, 413

GORDON, ('ol. J. E'., 238, 242, 244, 246, 257, IHAYMAN, Col. .1. M., Jr., 38, 478, 480

263, 382, 399, 4W0, 414, 417, 433, 468 IHead wounls, associahtd with shock, mia in-

(ORD)oN-TAYLOR, Surgeon Rlear Admiral G., agvinntt of, 654

263 I [4anMza Shim'a, 673

(Gothic Line, 175 I leart diseases, man.1ilagement of, reconlmeiGOW , (d(ations on, 1" consiltant in cardiology,

GRwNT, Col. Ge. II., 26N, 27:3 418

(;RA NT, Mj. (;n. 1). N., 27, 3;88 ,rSee also Rheumatic heart disease.

(;RAVES, Maj. C. L., 257 lheat, effects of, 534, 535

(Great Britain, 243, 253, -101 H leatt exhatust ion, 705

(;rEELEY, MIaj. D)., 263 lheatstroke, 705

(Grmý,, Li. ('o1. M., 250, 266 |IMIN, ('o1. (G. E., 2:V6, 238, 256, 257, 260, 278,

G(REEN, Maj. I. A., 617 397, 418, 429)

G reetiland, 135 Ilematuria, 706

GRIFFITli, Col. W. If., 263, 275 1lhnmoglobinuria, in patients with malaria,

GRINDLAY, Lt. Col. .1. If., 773 606

GRiwN KR, (ol. R. It., 163 Ilhnorrhag,, associated with shock, iiIanGround Forms, Army, 58 ageitent of, 655

HVAem8iorrhaigic plienomenIa, in scrid) typlhus,

GRow, Maj. Gen. M. C., 251, 252, 388 753

Guadadlcan'a, 571, 573, 575, 581, 587, 588, Ih1mnothorax, removal of, 656

591), 593, 596, 598, 59)9) 600, 61)1, 605, 61)7 lIkENilERsoN, I)r. I). K., 387

612, 6l13, 615, 617, (19,l 620, 634 hlepatitis, 226

Guam, 6134, 1:13), 641, 649, 676 clinical research on, 274-275

Guillain-liarr6 syndronie, 546 diagnostic difficulties in, 594
INDEX 859

Hepatitis-Continued llospitalization-Continued

disposition of patients with, 274 1)roi)lemus of, 191

See also Homologous serum hepatitis; statistics, 600-602

Infectious hepatitis H0ospitals:

High \\ycomblx, England, 252 adequacy of care in, 109-110

HILL, Captain, RAMC, 235 Air Force, 27, 58, 75n, 76, 79, 84, 86

HILL, Col. R. B., 338, 388 British, 267, 320-321

IIILLMAN, Brig. Gen. C. C., 2, 13, 15, 483, convalescence in, 118-119

486 directive on, War Department MemoIIINDE, Brig. R. M., 213, 214 randum W40-6-43, 11 Feb. 1943-

Hiroshima, 642, 808 27

Iis, W., Jr., 692 debarkation, 134

Historical Unit, OTSG, 27 deficiencies on medical services of, 80-83

Hitler Line, 175, 181 for natives, 499-501

Ilonn;ES, Capt. 11. Il., 753 in Central Pacific Area, 635-641

lloCAN, Lt. Col. HI., 282 in European theater, 266-270, 320-321

llollandia, 543, 559 in Southwest Pacific Area, 492-501

Hlomahika Shimna, 673 in Zone of Interior, 32-39, 76, 79-83,

Homologous serum hepatitis, 468 102-110, 119-126

in Central Pacific Area, 668 laboratories in, 98-101

in European theater, 441-443, 468 responsibility for, 26

Hlonolulu, 628, 632, 638, 642, 667, 671, 678 libraries in, 106-107

1oo0), Lt. Gen. Sir ALEXANDER, 246 management of diseases in, 23-25

H lookworm disease, 725 neuropsychiatric, 323-329

lookworm infestation, 706, 725 organization of clinical services in, 21-23

diagnosis, 766 directive on, War D)epartment Technidiagnostic difficulties in, 594 cal Manual 8-260, 16 .July 1941-21

hospitalization for, 766 personnel in, 814-818

in India-Burma theater, 765-768 reconditioning in, 116-1 19

incidence of, 765 directive on, War Department Memosymptoms of, 766, 767 randum W40-6-43, 11 Feb. 1943-27

lHookworin larvae, 516 research in, 110-116

h|OPKINS, Dr. J. G., 114 statistics on, 5

ihoPKiNs, Lt. Col. Ii. U., 732 tour of, inH|ORAN, Maj. T. N., 179 Leyte, 488-490

Hlow%, Capt. L., 263 Manila, 4W0-492

IOSPER-s, Lt. Col. C. A., 305 New Guinea, 486, 488

Hospital centers: visits to, 79-80, 819-822

818th-337, 338 Hospitals, convalescent:

821st-634 2d-214, 490

H|ospital Division, OTSG, 47 4th-305, 306, 328, 430

Hospitalization- 5th-642

for amrehiasis, 175 Hospitals, evacuation:

for cutaneous diphtheria, 761 1st-473

for hookworm infestation, 766 7th-573, 607

for prickly heat, 772 8th-218

in European theater, :308-309 10th-473

in South Pacific Area, 600-602

of dermatologic patients, 308-309

of neuropsyehiatric patients, :324 l4th-726, 735, 7:36, 753

period of: 21st-618

during arsenotherapy for syphilis, 293 25th-59

for malaria, 172 36th-495, 496, 498, 499, 554

statistics on, 27 45th-452
860 ACTIVITIES OF MEI)ICAL CO NSI'LTANTS

Hospitals, evacuation-Continued Hlospitals, general-Continued

48th-726, 733, 737, 739, 740, 753, 777, numbered-Continued

785 7th-438, 441

52d-481, 515, 573, 550 9th-524

56th-209 12th-i176

58th-495 14th-487

73d-726, 727, 731, 733, 737, 740, 741, 15th-437

745, 748, 753, 773, 782, 784 17th-183

77th-337, 364 18th-543, 573, 590, 607, 608, 764, 771,

120th-452 778

Hospitals, field: 19th-363, 364, 365, 387

l8th-794 20th-16, 715, 716, 721, 723, 724, 726,

31st-635, 648 727, 730, 731, 733, 735, 736, 737, 738,

36th-635, 648 740, 741, 745, 748. 751, 752, 756, 759,

38t li-635, 641 761, 772, 77:3, 775, 776, 778, 779, 785

52(1-590 24th-183

57th-446, 450 26th- 183, 218, 220

Cith-635, 648 28th-338

74th-648 30th-257, 293, 369, 407

75th-648 32d-4 14

76t h-648 33d-224

77th-452 39th-590, 601, 620, 642

86th-676 42(1-474, 476, 503

94th-642 44th-490, 496, 498, 516

SI ospitals, general: 45th-185, 214

named: 46th-183, 263, 447, 450, 451, 470

Army and Navy, 35 48th-423

Ashburn, 35 50th-445, 446, 451, 451

Ashford, 40, 115, 314 52d-258

Birmingham, 38, 104 54th-480, 491, 493

Bruns, 33 56th--329, 338

Bushnell, 50 64th-223

Fitzsimons, 33 69th-715, 722, 726, 758, 761, 779

Foster, 38 96th-:329, 361, 391

Harmon, 39. 50, 62 100th-438

Kennedy, 50 105th-474, 480, 487, 50:3, 536

Lawson, 368 108th-259, 262, 414

Lovell, 117 118th-474, 480, 487, 490, 496, 498, 503,

Mason, :388 516, 5:36, 539, 540, 542, 551, 552, 559

Moore, 33, 38, 62, 90 126th-489, 552

North Sector, 6:35, 638, 639 127th-258

Percy Jones, 50 130th-333-339, 358, 387, 390, 392

Schick, 117 133d-490, 496, -198, 516, 540, 541, 542

Thomas M. England, 40 142d-573, 590, 607, 707, 722, 768, 779,

Torney, :38, 104 785

Tripler, 632, 6:15, 638, 639, 640, 647, 689 147th-632, 635, 6:38, 640, 641

Wakeman, 115, 116 148th--639, 642, 682, 685

Walter Reed, 63 154th-4:34

numbered: 158th-423

2(1-258, 265, 266, 293, 297, 416 163d-444

4th-473, 478 181st-785, 794

5th-250, 257, 270, 275, 283, 293, 321, 188th-441

:363, 383, 406, 407, 414, 468 191st-372

6th-183, 214 192d-308
II)DEX 861

Hospital, general-Continued Hospital, station-Continued

numbered-Continued numbered-Continued

204th-635, 641 176th-682, 685

217th-308 180th-446

218th-639, 640, 641 182d-178

219th-639, 641 227th-488

232d-641 230th-639, 640

234th-742, 765, 777, 782, 784 266th-635

298th-257, 270, 274, 293, 338, 413, 430 268th-488

300th-220, 224, 227 280th-270

306th-452 284th-635

Hospitals, regional, Fort Bragg, 63 289th-635, 641

Hospitals, station: 290th-635

named: 307th-388

Fort Bragg, 481 312th-328, 329, 332, 333, 344, 358, 361

Schofield Barracks, 635, 638, 639 365, 369, 371, 389, 390

numbered: 316th-442

lst- 6 38 337th-635

3d-399, 417 347th-389

8th-640, 641 369th-642, 682

10th-267, 270, 283, 407 373d-641

20th-575 374th-642

22d-635, 638, 639, 640, 641 HOVLAND, Dr. C., 381

24th-711 Howe, Col. P. E., 212

26th-639 HOwELL, Capt. J. M., 304, 305

33d-358 HOWITT, Brig. F. D., 246

35th-446 HUGHES, Maj. Gen. E., 208

36th-324-328, 332, 333, 359, 367, 369, HULL, Col. H. C., 722

374 HUNT, Capt. J. S., 16, 55

38th-270, 423 HUNTER, Maj. G. W. III, 554

48th-641 HUNTINGTON, Maj. B. L., 614

49th-312, 410 Hyperhidrosis, generalized, 32

51st-339, 340, 390 Hypertension, arterial, disposition of patients

69th-225 with:

71st- 5 73, 607 in European theater, 418

73d-225 statistics on, 274

76th-517 Hypohidrosis syndrome, 775-776

90th-503

99th-765, 784 Iceland, 135, 410

100th-742, 765, 782, 784, 792 Immersion foot, responsibility for treatment

110th-321, 324, 440 of, 438

111 th-793 Immunization, antityphoid, 793

116th-524, 541 Immunization program, for smallpox, 794

117th-552 Impetigo, 31

121st-275 Inai Fahu, 682

124th-488, 498 Incidence, of125th-488 amebiasis, 539-541

129th-635 cerebral malaria, 733-735

130th-415 fever of undetermined origin, 762

139th-503 hookworm infestation, 765

151st-225 infectious hepatitis, 787

159th-736 malaria, 727-730

165th-635 poliomyelitis, 545

168th-410 primary atypical pneumonia, 782
862 ACTIVITIES OF MEDICAL CONSULTANTS

Incidence, of-Continued Infectioias hepatitis-Continued

pulmonary tuberculosis, 785 diagnostic difficulties in, 594

scrub typhus, 746 diet in, 179

skin diseases, 771 directives on:

smallpox, 794 Circular Letter No. 19, Office of the

Incubation period, of- Surgeon, NATOUSA, 28 Mar. 1944-

amebiasis, 542 178

infectious hepatitis, 537 Circular Letter No. 21, Office of the

scrub typhus, 74 Surgeon, MTOUSA, 20 June 1945-

India-Burma theater, 695-797 179

climate of, in diagnosis of disease, 705-707 Circular Letter No. 37, Office of the

clinical investigation in, 704-705 Surgeon, NATOUSA, 8 July 1944-

consultant in medicine in, 695-797 179

activities of, 696-705 Tcchnical Memorandum No. 16, Office

consultant system in, evaluation of, 797 of the Chief Surgeon, USAFFE 1 Oct.

diseases of military importance in, 707-797 0944-536

bacillary and other forms of dysentery, War Department Technical Bulletin 206,

724-725 November 1945-24

cholera, 794-795 epidemicity of, 707

cutaneous diphtheria, 756-761 epidemiology of, 537

diarrheal and dysenteric diseases, 708- historical note on, 536

725 in Central Pacific Area, 648, 667-669

fever of undetermined origin, 762-765 in European theater, 443

filariasis, 768-769 in India-Burma theater, 785-788

homologous serum jaundice, 785-788 in Mediterranean theater, 175-179

hookworm infestation, 765-768 in South Pacific Area, 668

infectious hepatitis, 785-788 in Southwest Pacific Area, 536-539

lead poisoning, 769-771 incidence of, 787

leishmaniasis, 796-797 incubation period of, 537

malaria, 725-742 management of, 31-32

melioidosis, 795 studies on, 226

poliomyelitis, 780-790 treatment of, 538-539

respiratory diseases, 780-785 Influenza, 707

schistosomiasis, 795-796 in European theater, 414-415

scrub typhus, 742-753 INGALLS, Sgt. J. W., 554

skin diseases, 771-780 Institute of Living, 384, 393

smallpox, 793-794 Insulin therapy, 377

typhoid and paratyphoid fevers, 791- Inter-Allied Conferences on War Medicine,

793 258, 259, 414

hospitals in: Interallied Medical Congress, 219

bed capacity of, 695

personnel assigned to, 695 intErnists in European 69-70theater, 248, 250

policy for smallpox vaccination, 794 in forward areas, 817-818

Induction stations, 128 qualifications of, 85

photoroentgen units in, 26 aifciosf,8 role of, in management of shock, 649, 811

Infectious diseases, consultant in, 397 utilization of, 428, 580

in European theater, 236-2:37, 46 1-467

Infectious 

infEctousan 

hepatitis, thepatit , 

700, 236 

70762 , 4 7 Intestinal parasitism, in South Pacific Area, 63

clinical picture of, 537-538 620-623

clinical research in, 62 Ioribaiwa, 487

control of, 539 Ireland, 321, 468

death due to, 537, 538 Irvinetown, 266

diagnosis of, 538 Italy, 150, 339, 351, 354, 394, 649, 800

tests in, 179 Iwo Jima, 617, 634, 640, 641, 643
INIEX S63

JA.IMs, Brig. G. W. B.. 246 KINo, Lt. Col. A., 300

Japln, -175, 63-4, 6412, 677. 808, 819 KING, ('ol. 1). S., 160

JapaZnese Army. 552 IK.', Brig. Gen. E"., 628. 629. 633

Jap)ite.se B encepjihalitis: KIRK, Maj. Gen. N. T.. 388, 512

case histories, 674-675 KIRKLAND, Maj. If. B., 256

in ('entral Pacific Area, 673-677 KzIKs~:, Col. (). C., 257

Japanese prisoners of war, 66;;- 667 KLATSKIN, L~t. Col. G., 718, 721

filariasis in, 691 KLI.,•GMAN, Lt. ('ol. N. 0., 390

Jaundice, 176 KNEEI.AND, ('oi. Y., Jr., 236, 238. 240. 215.

acute lcatarrha', 648. 667-669 248, 257, 260, 263, 279, 397, :.•1. 100, 414,

as factor in diagnostict difficulties. 594 415, 417, 418, 419, 420, .121, 422. 429. 4:32,

homologous serum: 438, 440, 441-44:1. 461 .467, 168

in luropean thealter. 441-443 loc'HR, Nt. Col. R. A.. 263, 4:15

in India-Burnia tlheuter, 785-788 Korea, 545

in i~fectious hepatitis, 537, 5:18 KRUE;ER, Lt. (Gen. W., 525

JvLLI5ON, Lt. ('ol. W. L., 743 Kuakini, 6:19

JENxsN,. ('ol. W. S., 633 KHrIE, D)r. L. S., :191

JE ifNsox, Maj. A. S.. Jr., 552 Kunming. ('hina, 742

Johnst, n Island, 639 Nunului, 6:18

JiONHINSTONE, ('aptainl, 275 Kwajalein, 6:14, 639

JOLLIFFE, ('apt. L.. S., 179

JoNEs, Maj. W. S., 742 TLaboratories:

Jorhat. 711 clinical, in Army hospitals, 26

Josiah Macy, Jr., Foundation, 384, 39:3,703 consultants for, 582

i n forwatrd areas, 811-812

Kahl test. for svphilis, 288, 30:3 in South Pacific Area. 580-583

Kala-azar, 699, 700. 707 in Southwest Pacific Area. 501-503

effect of. on morale, 707 in Zone of Interior. 98 101

Kanlnela, 6:19 ptroblems of, 289. 3100, 306

Kaneohe, 639 responsibility for, 216, 825

Karachi, 706. 726, 762, 785 1,ahoratory consultant, need for, 99, 101

hauai. 630, 667 1.aborattory Division. O TS ;, 98

KAIUF'•AN, Lt. ('ol. M. It., 368, 633 1.ahoratory findings, in scrub typhus, 749

Kavieng, 592 Lahoratorv, medical:

KAY, ('apt. C. F., 7:11, 7:38 2d- 225

K ELER, ('ol. M. G.. 250, -106 90h--704. 716. 767

KFmrr,i:R, (Co1. W. 1., 2311 14t h -- 66(5

KELLEY, lt. (Col. 1). M., 323. 369, :375, :176 15t h--225. 226

Km:i.Ev, Dr. W. E., 775 181h-667. 672

KENDALL. ('01. C. 1B., 257-258 190h-5-15

Kl.\;.mY', I1t. Col. It. A., .139-440 27th-496. 498

Kennedy General Hiospital, 50 Lahoratory procedures. 700. 707

KF,\-NER, Maj. (;en. A. A., 150, :362. 390 problems in, 289, :100. 306

Kerosene, use of. in mosquito control, 680- zinc sulfate flotation. 767

682 lahoratorv services, in Mediterranean thearesults of, 682-685 ter. 191

Kholscheid, 354 1Labrador, 1:15

KnnB.:, ('apt. F. W., 764 LARsoN, L.t. Col. E.. A.. 617

Kidderminister. 258

KILLiNGSWROitH, L.t. ('0o. NV. P., 31-1 LAwRENcE:, Maj. E. A., 740

Kimio i Col. J. 2:12, .'., 2:1:, 242. 244. L\wsow', 1.t ('ol. It. A., 737

245, 259, 278, 287, 309, 333, 355, 361, 370. Lawson General Ilospital, 368

396, 404, 42:1, 4:32 L1ead poisoning. in India-Burnma theater,

KnXimEutAN, T/3 L. J., 739 769 771
864 .ATIVITIES OF MEI)ICAL C( )NSI'LTANTS

Ledo Road, 726, 774 MAcKENNA, Brig. R. M. B., 246, 262, 281,

See also Stilwell Road. 284

Leeds, 387 MACLEAN, Capt. P. D., 620

Leghorn, 217 MADDOCK, Col. W. G., 270

Legion of Merit, 481 "Madras fever," 764.

Leishmaniasis, 227, 796-797 See also Fever of undetermined origin.

LEMKAU, Lt. ('ol. P. V., 323, 339, 370, 375 MAGEE, Maj. Gen. J. C., 2, 3

Leprosy, in Central Pacific Area, 647-648 Magnesium sulfate, 773

Leptospira icterohaemorrhagiae, 538 Makin, 634, 678, 679, 689, 690

LESLIE, Lt. Col. G. L., 256 Maknassy, 165

LEWIS, Capt. I. A., 608, 738 Malaria, 48, 224, 227, 487, 695, 707, 725

Leyte, 475, 640, 668, 670, 671, 688 clinical aspects of, 733

hospitals in, comment on, 495-498 diagnosis of, 534, 606

invasion of, 536, 551 diagnostic difficulties in, 593-595

LIDz, Lt. Col. T., 610, 612 directives on:

LIEBoW, Lt. Col. A. A., 620, 623 Circular Letter No. 24, Office of the

Li6ge, 263, 270, 336, 337, 338 Chief Surgeon, ETOUSA, 1944-416

LISANSKY, Capt. E. T., 611-612 Circular Letter No. 55, Office of the

LISTON, Col. D. E., 242, 335 Chief Surgeon, ETOUSA, 1942-265

Liver, effect of drugs on, 739 Circular Letter No. 73, Office of the

Liver abscess. See Amebic hepatitis. Chief Surgeon, ETOUSA, 1944-418

Liver function, 227 Circular Letter No. 117, Office of the

effect of Atabrine on, 739 Chief Surgeon, ETOUSA, 1943-416

Liverpool, 324, 360 Circular Letter No. 142, Office of the

LIVINGOOD, Lt. Col. C. S., 16, 39, 758, 761, Chief Surgeon, ETOUSA, 1943-416

773, 774, 775, 778, 779 dosage schedule for Atabrine in, 173

Lobar pneumonia, 401 drugs used in treatment of:

Loin pain, 706 reactions of, 740

LoISEAUX, Maj. M., 263 studies of, 738-739

London, 232, 233, 236, 246, 264, 385, 386, gent( ral considerations of, 517

387, 470 hospitalization periods for, 172

Londonderry, 266 in European theater, 416-418, 429-430

LONG, Col. A. P., 300 in India-Burma theater, 725-742

LONG, Col. E. R., 10, 13, 15, 26, 263, 408-409, in Mediterranean theater, 170-174

410, 443, 451, 458, 471 in South Pacific Area, 603-618

LONG, Col. P. H., 7, 149, 155, 160, 163, 169, in Southwest Pacific Area, 517-523

172, 176, 183, 185, 191, 193, 212, 215, 236 incidence, 727-730

LONGCOPE, Col. W. T., 231 in Chinese soldiers, 730

Lovell General Hospital, 117 in U.S. soldiers, 727-729

Low Countries, 266, 302 infectious agents of, 730-732

Lowlands, 432 management of:

LUDWIG, Maj. A. 0., 260, 344, 391 directives on, 265, 416, 418

Luzon, 475, 490, 541, 640 hospitals for, 50

Lymph nodes, enlargement of, in dengue, 679 in First U.S. Army, 430

Lymphadenitis, generalized, of scrub typhus, studies on, 50-51, 519-523

749 mortality rates for, 31

Lymphadenopathy, 749 noneffectiveness due to, 707

LYON, Comdr. G. M., 236 patients with:

LYTLE, Lt. Col. C. S., 263 demalarialization attempt in, 612-615

disposition of, 430

MAcARTHUR, Gen. D., 474, 476, 486 immunity studies on, 618

MAcFEE, Lt. Col. W. F., 257 relapse in, 607, 609-610, 613

MACHELLA, Maj. T. E., 738, 739, 741, 745, preventive measures, 517

779 relapse rates in, 732-733
INDEX 865

Malaria-Continued MCKEE, Lt. 'ýol. J. B., 260, 263, 442

relapses of, 173-174 MCLEAN, Maj. F. C., 231

research on, 417 MCMICHAEL, Dr. J., 257

statistics, 598, 606, 613, 726-727 MCMULLEN, Dr. D. B., 554

study on, in Sixth U.S. Army, 801-809 MCNINCH, Col. J. H., 242, 243, 244, 443

treatment of, 606 Medical Bulletin of the Mediterranean TheaAtabrine in, 699 ter of Operations, 227

plan for, 736-738 Medical Bulletin of the North African Theater

Malaria Institute of India, 725 of Operations, 227

Malaria survey unit(s): Medical Consultants Division, OTSG, 1-70

5th-552 evolution of, 9-16

18th-744 organization, 9-13

MALLORY, Lt. Col. T. B., 179, 225 personnel, 13-16

Malvern, 329 interoffice relationships of, 46-59)

MANIFOLD, Maj. Gen. J. A., 387 intraoffice relationships of, 46-59)

Manila, 473, 491 personnel in, 13-16

Manila Jockey Club, 491 problems of, 11

MANN, Lt. Col. A. F., 256 role of, inMannheim, 471 designation of specialized centers, 33

MANSFIELD, Capt. J. S., 444 exchange of professional information,

Manual of Therapy, European Theater of 39-46

Operations, 351 laboratory activities, 26

Mapharsen (oxophenarsine hydrochloride), management of diseases, 12, 23-25

282, 291, 607, 738 personnel management, 16-21

Mapharsen-penicillin-bismuth, in syphilis, plans for postwar Army, 67-69

297 rehabilitation programs, 26-27

Mapharside. See Mapharsen. research, 62-63

Marakei, 690 visits to field by staff of, 63-65

MARBLE, Col. A., 7, 39, 87-88, 125-126, 139 Medical Department, U. S. Army, mission

Mariana Islands, 626, 632, 634, 648, 669, of, 4, 58

672, 678, 679 Medical Department Supply Catalog, 25

Marine Corps, 545 Medical Field Service School, in European

Mariiz Division, 2d-682 theater, 252

Marquesas Islands, 571 Medical intelligence, in Mediterranean theaMarshall Islands, 632, 679 ter, 230

MARTIN, Maj. Gen. J. 1., 70 Medical laboratory:

MARTIN, Col. W. B., 7, 654, 662-666 9th-716, 760, 767

MASON, Col. J. B., 241, 243, 253 14th-665

MASON, Col. V. R., 5, 7, 635, 641-693 18th-667, 672

Mason 'Neneral Hospital, 388 Medical research, 146

Massachusetts General Hospital, 103, 107 Medical Research Advisory Board, in MedMaui, 630, 638, 639, 667 iterranean theater, 226

MAXCY, Dr. K. F., 486, 526 Medical service:

MAY, Maj. C. D., 278, 468 in Army hospitals, sections of, 21

MCCANN, Capt. W. S. (USN), 255 in Southwest Pacific Area, comments on,

MCCARRY, Capt. F., 618 492-501

MCCARTHY, Lt. Col. G. D)., 244 Medical supply, 147

MCCOLLuM, Dr. J. K., 257 in Mediterranean theater, 161

MCCUSKEY, Lt. Col. C. F., 635 Medical treatment, advances in, 27-32

McEWEN, Col. 0. C., ?2:8, 260, 279, 461 Mediterranean theater, 143-230, 283, 294,

McGRIOoR, Brig. D. B., 246 296, 324, 328, 361, 367, 416, 418, 429

McGUINNEss, Lt. Col. A. C., 461 consultant in medicine in:

MCGUIRE, Col. J., 86-87, 115, 139 arrival of, 149-150

McKEAN, Col. R. M., 256, 446 assignment of, 150

564970v- 61- - 57
866 ACTIVITIES OF MED)ICAL CONSULTANTS

.Mediterranean theater-Continued Micronesia, 643

consultant in medicine in--Continued Middle East Service Command, 7

editorial duties of, 227-230 Middle Pacific Area. See Central Pacific

consultant in neuropsychiatry in, 392-393 Area.

diseases of medical interest in 161-185 'MIDDLETON, Col. W. S., 6, 74, 232-280, 318

dermatological conditions, 184-185 327, 333, 344, 367, 370, 373, 394, 396,

diphtheria, 179-181 398-400, 403, 405, 406, 408, 409, 410, 411,

dysentery, 174-175 414, 416, 417, 419-428, 430, 432, 433, 435,

infectious hepatitis, 175-179 438, 440, 461, 469

malaria, 170-174 MILES, Maj. V. I., 744

neuropsychiatric casualties, 161-170 Military importance of diseases, in Indiapoliomyelitis, 175 Burma theater, 707-797

sandfly fever, 183 Military installations:

tren)chfoot, 181-183 Camp Atterbury, 116

tuberculosis, 183-184 Camp Claibourne, 398

hospitals in: Camp Custer, 176

convalescent, 214 Camp Edwards, 117

evacuation, 209, 218 Camp Landis, 745

general, 176, 183, 185, 214, 218, 220, Camp Sibert, 89

224, 227 Camp Upton, 388

station, 178 Fort Benning, 114

infectious hepatitis in, epidemic of, 175- Fort Bragg, 111, 115

176, 179 Fort Devens, 117

laboratory services in, 191 Fort Jackson, 100

medical intelligence in, 230 Fort McPherson, 100

medical meetings held in, 217-221 Fort Shafter, 628, 630

nutrition in, 208-214 Military occupational specialty ratings, 144,

organization, 150-154 257, 491, 577, 641, 692-693

penicillin in, 185 Milne Bay, 486, 488, 503, 517

prisoners of war in, 193-208 Mindanao, 541

professional education in, 215-224 Mindoro, 541, 640

reconditioning program in, 214-215 MINOR, Col. J. R., 124, 127, 137

research in, 224-227 MINTER, Maj. D. R., 552

Mediterranean (formerly North African) Mite typhus. See Scrub typhus.

Theater of Operations, U.S. Army. See Mobilization Regulations 1-9, 15 Mar.

Mediterranean theater. 1942-403

Meetin|gs, for exchange of professional infor- MONTGOMERY, Col. L. C., 245, 276, 287

mation, 40 MooRE, Dr. J. E., 291, 293, 491

Melbourne, 473, 487 Moore General Hospital, 33, 38, 62, 90

Melioidosis, 795 Morale, 707

Meningitis, 31 Morale Service, Army Service Forces,

Meningococcic infections: 381-382, 384

in Zone of Interior, 11 Moreton Hampstead, 324

mortality rates for, 31, 89 MORGAN, Brig. Gen. H. J., 2-70, 102, 136,

treatment of, 31 240-241, 313, 390, 416, 441, 442, 482, 485,

MENNINCER, Dr. K., 391 565, 585, 618

MENNINGER, Brig. Gen. W. C., 94, 353, Morphine, in treatment of shock, 653

365-366, 374, 382, 384, 387-389, :392, 396, Mortality rates, for562 arsenotherapy for syphilis, 293, 295

Merrill's Marauders, 744, 748, 773 bacillary dysentery, :31

•Merthiolate, 300 cerebral malaria, 735

Methyl phthalate, 528-531 homologous serum jaundice, 442

Metz, 444 malaria, 31

NICIIAEL, Capt M., Jr., 582-583 meningococcic infection, 31, 89
INDEX 867

Mortality rates, for-Continued Netherlands, 354

pneumonia, 31 Neuritis, peripheral, following cutaneous

poliomyelitis, 545, 788 diphtheria, 669

scrub typhus, 743-744 Neurologic diseases, responsiblity for mantyphoid fever, 793 agement of, 23

MORTON, Lt. Col. P. C., 259 Neurological manifestations, of scrub typhus,

MOS (Military Occupational Specialty), 752

144, 257, 491, 577, 641, 692-693 Neuropsychiatric conditions:

MOSLEY, Lt. Col. K. T., 744, 794 directive on, Circular Letter No. 2, Office

Mosquito control: of the Chief Surgeon, ETOUSA, 1944-

DDT in, 680-682, 685-686 351

in prevention of dengue, 680-686 in Mediterranean theater, 161-170

MosT, Maj. HI., 38 management of, 94-98

Motion sickness, research on, 276-277 patients with:

Mourmelon, 254 disposition of, 97, 161-170, 329, 332,

MTOUSA (Mediterranean Theater of Op- 352, 355-366, 380, 560

erations, U.S. Army). See Mediterranean evacuation of, 329-332

theater. hospitalization of, 324

MUCKENFUSS, Col. R. S., 237, 238, 242, 243, statistics on, 333

244, 257, 260, 289, 399, 414, 416, 442 studies on, 377-382

MUELLER, Dr. H. J., 461 treatment of, 351

MULVEY, Lt. Col. B. E. 618 Neuropsychiatric facilities:

Munda, 586, 587 evaluation of, 394-396

MURCHISON, Col. J. L., 258 exhaustion centers, 352-353

Murine typhus, 672-673 MURRA, t ayph N.uL, 72567 for training, 366-372, 395

MURgRAY, Park, 266, 270 in European theater, 320-340, 341-355

in nonmedical agencies, 355-366, 395

MYER, Maj. J. M., 549 in Southwest Pacific Area, 561 Myitkyina, 744, 760 supplies for, 382-384

Naga sore. See Tropical ulcer. Neuropsychiatric services:

Nagasaki, 808 in armies, 341-355

NAPIER, Dr. L. E., 765 in Army hospitals, 21

Naples, 185, 217, 221 Neuropsychiatrists:

Narcotherapy, 377 assignment of, 341-344

National Academy of Sciences, 60 division, 321-322, 394

National Formulary, 25 field-army, 341-344

National Institute of Health, 554 in European theater, 320-323, 341-344,

National Research Council, 4, 50, 60, 61, 66, 363-365, 366-372, 373-377

173, 227 organization of, 385-386

Committee on Medicine, 16n, 291 training of, 366-372

subcommittee on venereal diseases, 11, utilization of, 358, 359, 360, 363-365

292, 297 Neuropsychiatry:

Division of Medical Sciences of, 143 conference on, 385

NATOUSA (North African Theater of Op- consultant in, 561

erations, U.S. Army). See Mediter- civilian, 391

ranean theater, in European theater, 235, 279, 318-396

Nausea, in amebiasis, 715 in Mediterranean theater, 392-393

Naval Base Hospital, 18th-641 to Sixth U.S. Army, 825

Naval Medical Research Unit No. 2-676 research in, 377-382

Near East, 418 training in, 366-372, 395

Nembutal, 354 Neuropsychiatry Consultants Division,

Neoarsphenamine, 282, 737 OTSG, 21, 23, 386-388
868 ACTIVITIES OF MEDICAL CONSULTANTS

Neurosyphilis: Nurses-Continued

directive on: in Southwest Pacific Area, 509-510

War Department Technical Bulletin in Zone of Interior, 124-126

48, 1944-300 training of, 252

hospitals for, 35 tuberculosis in, 407-408, 431, 458

management of, 300 Nursing care, in scrub typhus, 753

New Caledonia, 571, 573, 586, 587, 600, 640, Nutrition, in Mediterranean theater, 208-

643 214

New England Journal of Medicine, 107 Nutritional management, of recovered perNew Georgia, 573, 581, 586-588, 590, 596, sonnel, 456, 471

601

New Guinea, 473, 474, 476, 480, 481, 491, Oahu, 627, 630, 635, 639, 640, 646, 649, 666,

559, 560, 561, 619, 640, 801 667, 671, 678, 679, 688, 691

convalescent care in, 503-506 Ocular changes, associated with scrub

hospitals in, 493-495 typhus, 752

New Guinea Force (Australian), 474 Office memorandum No. 23, ETOUSA, 21

New Hebrides, 571, 587, 605, 640, 643, 669 Oct. 1944-384

New Ireland, 592 Office of Scientific Research and DevelopNew York Postgraduate Medical School, 103 ment, 50, 114, 391

New Zealand, 570, 571, 587, 600-602, 616, Committee on Medical Research of, 227

618, 620 Office of the Chief Surgeon, ETOUSA, 150

NEWELL, Lt. Col. H. W., 610 Office of the Surgeon General, 1-70

Newfoundland, 135 Office of the Surgeon, USAFIBT, 697, 698,

NEWMAN, Dean C., 263 699, 706, 710

NEWTON, Lt. Col. G. D., 252 Okinawa, 625, 635, 640, 642, 643, 646, 648-

NICHOL, Lt. Col. A. D., 256 667, 668, 673-677, 688

NICHOLS, Capt. E., 612 Oliguria, 706

Nicotinic acid, 209, 742 Oncomelania quadrasi, 552

Nikethamide. See Coramine. Operations Service, OTSG, 47-48, 573

XIX Corps, 354 OPPEL, Lt. Col. T. W., 619

Ninth Air Force, 390 Oran, 162, 217, 219, 225

Ninth Service Command: Organization:

conference in, 103 In SWPA:

consultant in medicine to, 102-104 command, 474-475

training program in, 102-104 medical department, 473-482

Ninth U.S. Army, 353, 354, 390, 395, 432, of Mediterranean theater, 150-154

799, 800, 814 ORTH, Lt. Col. G. L., 523

neuropsychiatrist to, 344 OSBORN, Maj. Gen. F. H., 381

Nitroglycerin, 742 OSMOND, Brigadier T. E., 246, 262

Noneffective rate(s), for diarrheal diseases, OTSG. See Office of the Surgeon General.

709 OTrENHEIMER, Lt. Col. E. J., 635

Nonouti, 690 OUGHTERSON, Col. A. W., 633

Normandy, 332, 394, 432 Outpatient clinics, in Zone of Interior, 132

North Africa, 283, 303, 339, 344-351, 367 Owen Stanley Range, 486

369, 392, 394, 396 Owi, 524, 525, 536

North African Theater of Operations, U.S. Oxford, 266

Army. See Mediterranean theater. Oxophenarsine hydrochloride, 738

North Sector General Hiospital, 635, 638, 639 See also Mapharsen.

Northern Ireland, 245, 250, 254, 320, 322, Oxygen, 653, 657, 741

359, 419, 468 Oxyquinoline derivatives, in treatment of

Northfield, 366 amebiasis, 720

Nukunau, 690

Nurses: Pacific, 383, 800, 812

in European theater, 252, 407-408, 431 Pacific Ocean Area, 625, 633, 634
INDEX 869

PADGET, Col. P., 257, 287, 289, 291, 303 Penicillin-resistant gonorrhea, management

Pain, relief of, in management of shock, 653 of, 300

Palau, 541 Pentobarbital sodium. See Nembutal.

Palau Islands, 634 Pentothal Sodium, 380

Palm Beach Convalescent Camp, 214 PEPPER, Col. D. S., 724, 732, 743, 744

PALMER, Brig. J. H., 262 Peptic ulcers:

PALMER, Maj. J. P., 444 patients with, 90-92, 274

Palo, 541 research on, 274

Pamaquine naphthoate, 519 Percy Jones General Hospital, 50

Paratyphoid fever, 791-793 Peripheral neuritis, following cutaneous

Parenteral fluids, in management of shock, diphtheria, 669

654-656 Peritoneoscope, 179

as cause of pulmonary edema, 657, 662 PERKINS, Lt. Col. G., 264

See also Blood replacement. PERLMAN, Lt. Col. F., 256

Paris, 240, 259, 262, 339, 437 PERRY, Capt. 1). J., 759

PARNALL, Lt. Col. C., Jr., 256 PERRY, Col. W. L., 243, 244

PARSONS, Col. E. H., 324, 328, 332, 335, 344, Persian Gulf Service Command, 7

351, 367, 391, 395 Personnel:

PARSONS, Col. W. B., 478, 486, 503 assignment of, 1G-21, 86

Patients: classification of, 16-21

convalescent care of, 503-506, 531-533 clinical psychologists, 374-377

disposition of, 186-191, 558, 560-561, 724 dermatologists, 284, 309-311

evacuation of, 191, 270-274, 506-509, 812 internists, 69-70, 248-250, 428, 580, 649,

followup observations of, 722-724 811, 817-818

hospitalization of, 191 neuropsychiatrists, 320-323, 341-344, 358,

PAUTL, Dr. J. R., 545 359, 360, 363-365, 367-377, 394

Pearl Harbor, 627 problems of, 11

Pediculosis, 301 procurement of, 46-47, 67

PEET, Lt. Col. H. 0., 390 shortages of, 817

PELZMAN, Lt. Col. I. A., 491 technicians, 581

Penicillin, 24, 31, 179, 227 training, 45-46, 824-825

absorption of, research on, 313 Personnel management, 157-160

directives on: assignment, 32, 82-84, 157-158, 484

Administrative Memorandum No. 151, certification, 255-257

Office of the Chief Surgeon, ETOUSA, classification, 160

1944.-435 in European theater, 248-252, 373-377

Circular Letter No. 86, Office of the in field armies, 812-818

Chief Surgeon, ETOUSA, 1944.- in service commands, 16-21, 82-88,

299 102-109

Circular Letter No. 107, Office of the in South Pacific Area, 577-578

Chief Surgeon, ETOUSA, 1944.- in Southwest Pacific Area, 484

296 military occupational specialty ratings

in management of diptheria, 266, 435-436 in, 692-693

in treatment of- promotion, 160

gonorrhea, 296, 305 reassignment, 157-158

malaria, 607 redeployment, 159-160, 278

meningococcic infections, 31 replacements, 158-159

syphilis, 295, 296-300, 305 training in, 84, 102-109

plan for use of, 265-266 utilization in, 27

study on, 114, 418-419 Personnel Section, Office of the Surgeon,

Penicillin-bismuth-Mapharsen treatment of USAFIBT, 698

syphilis, 297 Personnel Service, OTSG, 16-17, 46-47

Penicillin ointment, 313 PETERS, Prof. R. A., 313
810 ACTIVITIES OF MEI)I(CAL CONSILTANTS

Philippine Islands, 473, 670 Poliomyelitis-Contin ued

Civil Affairs Unit, 496 effect of, on morale, 707, 788

Philippines, 473, 475, 491, 502, 551, 626, 819 in India-Burma theater, 788-790

PHILLIPS, Capt. N. J., 771 in Mediterranean theater, 175

PhIebolom us, 537 in Southwest Pacific Area, 544-547

Phlebolomus papatasii, 763 incidence of, 545

Physical findings: mortality rate for, 545

in hookworm infestation, 766 source of infection of, 546

in scrub typhus, 749 symptoms of, 545, 546

Physical standards, 277-278 POLLACK, Lt. Col. If., 263

Physical Standards Division, OTSG, 48 POND, ('apt. 11. S., 745, 747, 748, 752

PIr.LsRSURY, Col. 1). M., 235, 238, 240, POPPEN, Capt. J. It., 287

242, 243, 244, 260, 263, 279, 280, 281-318, Port Moresby, 486, 487, 499, 500

435, 441 PORTER, Col. W. C., 368

PINCOFFS, Col. M. C., 7, 476, 478, 490, Ports of embarkation, 132

501,502 Postwar, U.S. Army, plans for, 67-69

PISANI, Col. B. J., 253, 278 Preventive Medicine Service, Office of the

Plague, 695, 708 Surgeon:

in Central Pacific Area, 647-648, 667 in India-Burma theater, 698, 699, 710

Plasma: in the Mediterranean theater, 191

as cause of jaundice, 442 Preventive Medicine Service, OTSG, 12, 26,

use of-- 225

in malnourished patients, 456 Laboratory Division, 98

in management of shock, 649, 652, Prickly hlatt, 772

653, 654, 655 PRIEST, Brig. R. C., 262

Plasmochin, 172, 606, 607, 612-613 Primary atypical pneumonia, 227

Plas.mochin-Atabrine, 609-610 clinical characteristics of, 784

Plasmochin naphthoate, 50, 519 epidemiology of, 783

Plasmodiurn falciparurm, 602, 605, 612, 730, in European theater, 468

731, 736 in India-Burma theater, 782

Plasmodiutm malariae, 730 incidence of, 782

Plasmodinm vivax, 50, 517, 602, 603, 605, sequelae of, 784

607, 608, 609, 611, 612, 613, 615, 617, Prisoners of war, 146, 470, 471

618, 730, 731, 736 board for survey of, 51

Plasmoquin, toxicity of, 738, 740 diphtheria in, 435

Pneumonia, 31, 89, 398-402 filariasis in, 691

See also Primary atypical pneumonia. in Mediterranean theater, 193-208

Pneumoperitoneun, in localization of hepatic management of, 51

abscess, 722 statistics, 666

Pneumothorax, correction of, 656 tuberculosis in, 444-457

Pneutmothorax treatment, of tuberculosis, Professional education of medical officers.

430 See Education.

Po Valley, 214 Professional information, media for exchange

Podophyllum, 31 of, :39-46

Poliomyelit is: Professional Services Division, SWPA, 476-

age in, 546 478

blood picture in, 547 Professional Services, OTSG, 5, 10, 143, 483

clinical picture of, 546-547 Prognosis, in schistosomiasis, 647

deaths due to, 545 Propionic acid, :11

diagnosis of, 545-546 Psoriasis, 284

differential diagnosis of, 546 Psychiatric service, capabilities of, 561-562

directive on, Circular Letter No. 42, Psychiatry. See Neuropsychiatry.

Office of the Surgeon, NATOUSA, Psychologic factors, in diagnostic difficulties,

i 943.1-175 595-597
INDEX 871

Psychologists, clinical, 323, 374-377 Regional consultants in medicine, 238-240

Psychoneuroses, 487, 559-564 in Eighth Service Command, 76

Public Health Commissioner of India, 791, in European theater, 238-240

793 Regional hospitals, in Zone of Interior, 90.

Publications, for exchange of professional See also Hospitals, regional.

information, 41-45 Rehabilitation of patients, 531-533

Pulmonary edema, after shock, 655, 657 Reinforcement depots. See Replacement

pathologic evidence of 657-661 depots.

Pulmonary tuberculosis, 785, 284 Rennes, 263

Pyogenic infections, 284 Replacement, of medical officers, 158-159

Replacement depots, neuropsychiatric servQuartermaster work battalions, assignment ices at, 355-359

of combat-exhaustion patients to, 361-:366, evaluation of, 395

395 Replacement training centers, 129

Queensland,560 Reports, for exchange of professional inforQuinacrine hydrochloride. See Atabrine. mation, 40

Quinine, 737 Research:

directive on use of, Circular Letter No. 55, problems of, 224-227

Office of the Chief Surgeon, ETOUSA, See also Clinical research.

1942-265 Reservoir, of poliomyelitis infection, 546

in treatment of malaria, 519, 607, 612-613 Respirators, 789

South Pacific Area policy on, 603, 607 Respiratory diseases, 89, 398, 415

studies on, 617 diagnosis of, 535

toxicity of, 740 directive on, Technical Memorandum No.

Quinine-Atabrine, 609-610 7, Office of the Chief Surgeon, USASOS.

Quinine-Atabrine-Plasmochin, 170 1944-534

in India-Burma theater, 780-785

Radiology, consultant in, 404 in Zone of Interior, 89

Randalestown, 236 incidence of, 780

RANKIN, Brig. Gen. F. W.. 11, 17, 47 treatment of, 31, 433-435

RANSMEIER, Maj. J. C., 227 Respiratory infections, acute, 31, 433-535.

Rash: 780-782

in dengue, 679 Respiratory system, involvement of, in

in scrub typhus, 750 scrub typhus, 751

RATHE, Maj. I1. W., 256 Rheims, 254

Raticosa, 218 Rheumatic fever, 227

RAYMOND, Maj. R. W., 619 Rheumatic fever centers, hospitals desigReception centers, 128-129 nated as, 38

Reconditioning: Rheumatic heart disease, 274

in Mediterranean theater, 214-215 Riboflavin, 209

of patients with scrub typhus, 756 RIcE, Brig. Gen. G., 475

Reconditioning Center, Sixth U.S. Army, RIcHARDs, Prof. A. N., 266

487 RIDDocH, Brig. G., 246, 260, 262

Reconditioning programs, 26-27, 116-119 ROBERTSON, Lt. Col. R. C., 629, 633

Recovered Allied military personnel, 264, ROBINSON, Col. J. N., 272

452-457, 470, 471 Rockefeller Foundation, 46. 107, 393

Recovery centers, 360-361, 395 Rockhampton, 487, 801

Roentgenographic examinations:

Red Cross, 59, 404 facilities for, 26

REDDICK, Capt. W. G., USNR, 614 See also X-ray examinations.

Redeployment, 159-160 RoGERs, Capt. A. M., 716, 720, 721, 723, 766

REES, Brig. J. R., 246, 319, 387, 394 ROMANO, Dr. J., 391

REESER, Maj. R., 263 ROOK, Air Commodore A., 246. 398
S72 ACTIVITIES OF MEDICAL CONSULTANTS

ROSENAK, Maj. B. D., 256 Schistomiasis-Continued

ROUSSELOT, Col. L. M., 262 direetives on:

ROWLANDS, Surgeon Rear Adm. R. A., 246, Technical Memorandum No. 5, Office

263 of the Chief Surgeon, USAFFE,

Royal Air Force, 403 31 Mar. 1945-556

Royal Army Medical Corps: Technical Memorandum No. 15, Office

cooperation of, 232, 235-236, 245-246, of the Chief Surgeon, ISAFFE,

281,319 21 Oct. 1944-553, 557

school of, 235 disposition of patients with, 558

Royal Australian Army Medical Corps, 476 early observations of, 554

Royal Canadian Army Medical Corps, co- in Central Pacific Area, 647, 670-671

operation of, 232, 245, 281, 319 in India-Burma theater, 795-796

Royal College of Surgeons, 275 in Southwest Pacific Area, 551-559

Royal Society of Medicine, 258, 259 preventive measures in, 558-559

ROYCE, Maj. 0. B., 618 prognosis, 647

RUCKER, Lt. Col. J. C., 244 publications on, 552-556

RUSK, Col. H. A., 27, 116 research, 552-556

Russell Islands, 581, 640 symptoms, 647, 670, 671

RYLE, Prof. J. A., 246 treatment of, 557-558

Ryukyu Islands, 625, 643 SCHMICK, Col. P., 390

SCHMIDT, Lt. Col. C. L., 825

Saipan, 625, 632, 634, 639, 640, 642, 648, Schofield Barracks, 630, 640

669, 672, 679, 680, 688 School(s):

Salerno beachhead, 183 Air Force, 252, 284

Salisbury, 257, 468 British, 235

SALISBURY, Col. L. A., 390, 396 evaluation of, 395

SALMON, Col. T. W., 231 Medical Field Service, ETOUSA, 252, 284,

Salmonella newport, 688 366, 372

Samoa, 605, 612-615, 643 of neuropsychiatry, 366-372

Sandfly fever, 227, 706, 707, 762-765 School of Tropical Medicine, 416, 737

epidemicity of, 707 epidmiciy of 707Schouten Islands, 619

in Mediterranean theater, 183

Sandhills, 258 SCHULLINGER, Lt. Col. R. N., 265, 266

Santo Tomas, 491 Scotland, 410

Sarreguemines, 444, 445 Scrub typhus, 486, 487, 707

SAYEN, Capt. J. J., 745, 746, 747, 748, 752 clinical aspects of, 747-749

Scabies: directives on:

directive on, Circular Letter No. 77, Office Technical Memorandum No. 9, Office

of the Chief Surgeon, ETOUSA 1943- of the Chief Surgeon, USAFFE, 1944

285 -528

drugs for, 285, 312 Technical Memorandum No. 10, Office

in European theater, 284 of the Chief Surgeon, USAFFE,

in World War I, 302 1944.-531-532

management of, 285 disposition of patients with, 531-533

SCHAFFER, Lt. Col. A. J., 608, 609 in India-Burma theater, 742-753

SCHEIE, Maj. It. G., 752 in Southwest Pacific Area, 524-533

Schick General Hospital, 117 incidence of, 746

Schistosoma, 540 incubation period of, 747

Schislosora cecariae, 552, 554 laboratory findings, 749

Schistosoma haematobium, 795 manifestations of, 750-753

Schislosoma japonicurn, 551, 647, 671 mortality for, 746-747

Schistomiasis, 32, 699 prevention of, measures in, 528-531

case histories, 555-556 signs of, 747-749

clinical consideration of, 556-557 special investigations of, 526
1NI)EX 873i

Scrub typhus-Continued SINTON, Brig. J. A., 246

treatment of, 753-756 SIPEs, Maj. I. 11., 361

vector of, 743 Sixth Service Command:

SEA;RAVE, Lt. Col. G. S., 7:37 consultant in medicine to, 87-88, 102-104,

Seborrheic dermatitis, 284 139

II Corps, 162, 165, 170, 209, evaluation of consultant system in, 139

Secretary of War, 4, 390, 398 nurses in, 125-126

SEELEY, Col. S., 254 personnel management in, 87-88

SEIDEN.ELD, Lt. Col. M. A., 375 Surgeon of, 87

Semecarpus, 774 training program in, 102-104

Senior consultant, in- Sixth U.S. Army, .474, 485, 486, 495, 496,

cardiology, 236, 397, 418 524, 525, 526, 550, 562, 799, 800, 801-

chemical warfare medicine, 236 807, 814, 817

dermatology, 235, 279, 281-318 consultant in dermatology to, 825

infectious diseases, 236-237, 397, 461-467 consultant in medicine to, 481, 801-807.

neuropsychiatry, 235, 279, 318-396 808, 817, 819-822, 826

radiology, 404 consultant in neuropsychiatry to, 825

syphilology, 281-318 consultant system in, 481

tuberculosis, 235, 237, 397, 403-412, Medical Bulletin, 824

430-432, 443-461, 468-472 reconditioning center of, 487

Separation centers, 132 Surgeon of, 481, 536

Septicemia, 31 SKAT, mosquito repellent, 778

Serologic tests: Skin diseases, 31

directives on: associated with the Tropics, 32

Circular Letter No. 22, Office of the climate in relation to, 771

Chief Surgeon, ETOUSA, 1943.-289 in European theater, 283-284, 301-302

Circular Letter No. 148, Office of the in India-Burma theater, 771-780

Chief Surgeon, ETOUSA, 1943.-289 in Southwest Pacific Area, 547-549

in diagnosis of syphilis, 289 incidence of, 771

Seventh Service Command: management of, 294, 301-302

consultant in medicine in, 124 patients with:

nurses in, 124 disposition of, 302

Seventh U.S. Army, 150, 158, 339, 353, 390, evacuation of, 308-309

395, 4:32, 800 hospitalization of, 308-309

neuropsychiatrists to, 344 statistics, 283-284

SHANNON, D)r. J. A., 519 Skin infections, superficial, management of.

SHELDON, Col. J. NM., 274, 413 313

Shepton Mallet, 359 SKOBBA, Col. I. S., 344

Shigella, 225, 667 SMADEL, Lt. Col. J. E., 414, 415, 418

Shigella, dysenteriae, 524 Smallpox, 695, 699, 708

Shigella fiflexrneri, 488 immunization program, 794

Shigellc paradysenteriae, 687, 688 in India-Burma theater, 793-794

Shingbwiyang, 742, 743, 774 incidence of, 794

Shock: SMEDAL, Lt. Col. N1. I., 406, 408, 410, 469

management of, 648-657, 664 SMILEY, Lt. Col. .1. T., 744

in field hospitals. 650-652 SMITh, Lt. Col. C., 263

treatment of, role of internists in, 811 SMITH, Col. H. F., 746

Shortgrove Park, 270 SMITH, Capt. K., 253

Shrivenham, 252, 284, 366, 372 SN 6911 bisulfate, 739

Shugborough Park, 328 SNYDER, Col. 1). C., 632

SHULL, Col. 11. .J., 2, 7, 15, 16, 49, 817 Society Islands, 570, 571, 640, 643-645

Sicily, 152, 183, 416 Sodium Amytal, 165, 383, 741

S•iMoNs, Brig. Gen. J. S., 510, 512 Sodium chloride, 657

SINGEWALD, Lt. Col. M. L., 612 Solomon Islands, 570, 571, 582, 586, 605, 620
8 74 ACTIVITIES OF MEDICAL CONSULTANTS

South Pacific Area, 569-623, 633, 643 Southwest Pacific Area-Continued

ainebiasis in, 620 p)sychoneuroses in-Continued

ancvlostomiasis in, 620, 623 management of, 560-562

arthritis in, 618-619 schistosomiasis in, 551-559

Chief Surgeon to, 576, 578, 585, 588, 590 scrub typhus in, 524-533

consultant for laboratories in, 582 skin diseases in, 547-549

consultant in medicine in, 575-623 Surgeon of, 475

disease casualties in, evaucation of, 587- visitors to, 510-512

588 SOUTuWORTIl, Lt. Col. 1l., 263

hospitalization in, 600-602 Soviet prisoners of war, recovered, tubercuinfectious hepatitis in, 668 losis in, 444-452, 470

intestinal parasitism in, 620-623 SPA. See South Pacific Area.

malaria in, 603-618 Special Orders No. 3, AFIIQ, 3 Jan. 1943-

personnel management in, 577-578 150

statistics, 598, 600-602, 613 Specialization, in Army hospitals, 32-39

supply services in, 578 SPECK, Maj. C. D., Jr., 580

training in, 581, 583 Spinal tap, in patients with cerebral malaria,

Sout hhampton Water, 267 741

Southwest Pacific Area, 799 Spinal wounds, associated with shock,

amebiasis in, 539-543 management of, 654

blood bank in, 512-514 SPITTLER, Col. A. W., 629

clinical considerations of diseases in, SPRUIT, Col. C. B., 233, 242, 327, 352, 360,

515-564 432, 434

clinical investigation in, 514-515 SRODES, Lt. Col. W. G., 337, 344, 352, 353

command organization in, 474--475 STANDLEE, Maj. Gen. E. G., 227

comments on medical service in, 492-501 STANLEY, Col. 0. H., 236, 405

consultant system in, 473-568 Station hospitals:

administrative considerations of, 473-- in India-Burma theater, 695

515 in Zone of Interior, 90

conclusions and recommendations, 564- outpatient clinics in, 132

568 plans for, 5

growth of, 478-482 See also Hlospitals, station.

consultants in, in- Statistics, ondermatology, 490, 548 acute respiratory infection, 415

medicine, 476-479, 482-492 allergic patients, 413

neuropsychiatry, 478 arsenotherapy for syphilis, 293, 295

surgery, 478 bacillary dysentry, 31

dengue in, 524 casualties from (Okinawa campaign, 666

diphtheria in, 543 544 causes of evacuation, 598

dysentry in, 523-524 deaths, 27, 31

evacuation in, 50G 509 dengue, 678, 679, 680, 685

filariasis in, 550-551 dermatologic conditions, 283 -284

hospitals in, comments on, 492-501 diagnosis and diposition, 599 -600

infectious hepatitis in, 536-539 diarrheal diseases, 687

laboratories in, 501 503 diphtheria, 669

malaria in, 517-523 disease casualties, 598

nurses, 509--510 disposition of patients, 274, 361, 363, 365

officer personnel in, 484 fever of undetermined origin, 762

organization of Medical Department in, filariasis, 689, 690, 691

473--482 homologus serum jaundice, 442

Professional Services D)ivision, 476 hospital beds, 5

polionyelitis in, 544 547 hospitalization, 27, 600-602

psychoneuroses in, 559 564 infectious hepatitis, 443

causative factors of, 559 560 influenza, 415
INDEX 875

Statistics, on-Continued Surgeon-Continued

Japanese B encephalitis, 672, 675 Fourth Service Command, 3, 90, 127

malaria, 31, 598, 606, 613, 726-727 Hawaiian Department, 628, 629, 631

meningococcic infections, 31, 89 Middle Pacific Area, 635

neuropsychiatric casualties, 333 Pacific Ocean Area, 633

penicillin therapy of gonorrhea, 296 Sixth Service Command, 87

pneumonia, 31 Sixth U.S. Army, 481, 536, 544

prisoners of war, 666-667 Southwest Pacific Area, 475

pulmonary edema after shock, 657, 662 Tenth U.S. Army, 665

scrub typhus, 746-747 Third U.S. Army, 304, 305

tuberculosis, 263-264, 402, 406, 408, 410, USAFIBT, 697, 699, 700, 701

411 Surgeon General, The, 1, 2, 4, 5, 6, 12, 13, 15,

typhus, 672-673 17, 24, 25, 27, 32, 38, 40, 46, 50, 58, 60, 61,

veneral diseases, 31, 671 66, 71, 74, 82, 115, 146, 234, 235, 275, 280,

STAI-FFER, Dr. S., 381 282, 297, 312, 313, 318, 354, 362, 380, 384,

STAYER, Maj. Gen. M. C., 263 388, 391, 396, 398, 436, 476, 510, 512, 617

STEAD, Dr. E. A., 115 Surgeon General of the Navy, 46, 50

STEARNS, Maj. W. H., 13, 15. 16 Surgeon General of the U.S. Public Health

STEELE, Maj. C., 275 Service, 50

STEPHENSON, Maj. S. L., Jr., 305 Surgeon General's Office. See Office of the

STERNBERO, Col. T. H., 297, 301 Surgeon General.

STEUER, Lt. Col L. G., 263 Surgical Consultants Division, OTSG, 17, 25,

Stibophen (Fuadin), 796 35, 41

STILWELL, Lt. Gen. J. W., 695 SWANK, Maj. R. L., 364

Stiiwell Road, 695, 706 SWARTZ, Lt. Col. H. E., 606

See also Ledo Road. SWITZER, Capt. M. D., 244

STOKES, Dr. J. H., 291,292, 297 Switzerland, 383

STONEBURNER, Capt. L. T., 214, 215 SWPA. See Southwest Pacific Area.

Strassburg, 471 Sydney, 487

STRECKER, Dr. E. A., 388, 389, 396 Symptoms, ofStreptomycin, 31 aniebiasis, 715

Strongyloidiasis, 623, 725 amebic hepatitis, 717

Subcommission on Dysentery, Army Epi- dengue, 534-535

demiological Board, 724 hookworm infestation, 766

Subeommission on Schistosmiasis, of Com- poliomyelitis, 545-546

mission on Tropical Diseases, 554 schistosomiasis, 647, 670, 671, 796

Sulfadiazine, 31, 175, 433-435, 524, 611, 612 Syndrome:

706, 724 effort, 756

Sulfaguanidine, 31, 174, 523, 524, 687, 724 Guillain-Barr6, 546

Sulfamerazine, 611-612 hypohidrosis, 775-776

Sulfanilamide, 300 Syphilis, 227

Sulfonamide emulsion ointments, 285 directives on:

Suilfonamides, 24, 31, 296, 305, 6 11-612, 706 Circular Letter No. 22, Office of the

Supply(ies), 123, 124, 264, 282, 382-384, 514, Chief Surgeon, ETOUSA, 1943-289

578, 630-632 Circular Letter No. 74, Office of t he SurSupply Service, OTSG, 48 geon General, U.S. Army 1942-288,

Suppressive treatment of malaria. See Ata- 292

brine. Circular Letter No. 86, Office of the

Surgeon: Chief Surgeon, ETOUSA, 1944-299

Eighth Air Force, 297 Circular Letter No. 107, Office of the

Eighth Service Command, 4, 76 Chief Surgeon, ETOUAS, 1944-300

Fifth U.S. Army, 70 Circular Letter No. 148, Office of the

First U.S. Army, 305, 362, 426 Chief Surgeon, ETOUSA, 1943-289

Fleet Amphibious Force, 7th-513 in Central Pacific Area, 672
876 ACTIVITIES OF MEDICAL CONSULTANTS

Syphilis-Continued Third U.S. Army, 299, 304, 332, 339, 353,

in European theater, 282-283, 287-293 373, 390, 395, 432, 435, 444, 445, 446,

management of, 287-289, 291-293, 295, 452

296-301, 305 neuropsychiatrist to, 344

See also Neurosyphilis. surgeon to, 304, 305

Syphilology, consultant in, 281-318 venereal disease management in, 304, 205

306

Tahetauea, 690 Thirteenth Air Force, 485

Tacloban, 514, 544, 545, 554 THOMAS, Col. 11. M., ,Jr., 5, 7, 93-94, 99-101,

Tahiti, 640 III. 476, 478, 479, 483, 485, 486, 491, 495,

Taira, 675 496, 498

TALKIN;TON, Lt. Col. P. C., 344 THOMAS, Lt. Col. J. M., 367, 395

Tanapa, 681 Thomas M. England General IHlospital, -40

Tarawa, 678, 690 THOnMePsoN, Col. L. .J., 235, 2:38, 240, 242,

Tartar emetic, 558 243, 244, 260, 279, 280, 318-396

Technical Bulletins. See War Department Thoracotomy, indication for, 656

Technical Bulletin (TB MEl)). TI)m, Maj. Gen. Sir IIENRY, 258, 263

Technical Information Division, OTSG, 48 TILLMAN, Col. A. J., 489, 552

Technical Memiorandums: Tinian, 634, 639, 642, 688

No. 5, Office of the Chief Surgeon, Tonga Islands, 573

USAFFE, 1945-556 Ton-ands, 570

No. 7, Office of the Chief Surgeon, Tongarva, 570

USASOS, 1944--534 Tongatahu Island, 550, 573

No. 9, Office of the Chief Surgeon, Torney General Hospital, 38, 104

USAFFE, 1944-528 Totaquine, in treatment of malaria, studies

No. 10, Office of the Chief Surgeon, on, 617

USAFFE, 1944-5531 Tow-Nsv\D, Lt. Col. J. H., 214, 215

No. 15, Office of the Chief Surgeon, Townsville, 486

USAFFE, 1944-55:3, 557 TRACY, Maj. E. J., 257

No. 16, Office of the Chief Surgeon, TRAIL, WVing Comdr. R. R., 403

USAFFE, 1944-536 Training, 581, 583, 702-703

No. 17, Office of the Chief Surgeon, evaluation of, 395

USAFFE', 1944 -54:3-544 in dermatology, 252-257, 284, 310-:311

TEITELBAUM, Colonel, 275

Temperatures curves, in dengue, 679 in forward areas, 824-825

Tenth Air Force, 792 in neuropsychiatry, 366-372

Tenth U.S. Army, 633, 6:35, 799, 814 in service commands, 102-109

consultant in medicine to, 651, 662-666 lack of, :101

of medical officers, 45-46

surgeon of, 665 of technicians, 581

Teok, 726 ne o,8

Thailand, 695 need for, 84

THAYER, Brig. Gen. W. S., 231, 232 Transfusions, in management of shock, 654,

Thiamine, 209 655, 657

Thimerosal, 300 Transit hospitals, 329-332

Thiolmntal sodium, 181 Transmission, of infectious hepatitis, 537

III Amphibious Corps, 62:3, 662 Treatment, ofThird Service Comnmand: ameniasis, 720-722

consultants in medicine in, 116, 124, 127, bacillary dysentery, 724

136-139 cutaneous diphtheria, 760

evaluation of consultant system in, dysentery, 174-175

1:36-139 infectious hepatitis, 176

nonhospital facilities in, 127 neuropsychiatric casualties, 163, 165, 168

nursing care in, 124 schistosomiasis, 557-558
INDEX 877

Trenchfoot, 227 Tuberculosis-Continued

directive on, Circular Letter No. 41, evacuation of, 430-432, 443

Office of the Surgeon, NATOUSA, hospitals for, 33

29 July 1944-182 management of, 444

disposition of patients with, 441 statistics, 274, 402

in European theater, 470 survey, 402-412, 457-461

in Mediterranean theater, 181-183 Tuberculosis Branch, OTSG, 13

occurrence of, 181 Tuberculosis center, designation of hospital

responsibility for treatment of, 438 as, 33

studies on, 227 Tulane University of Louisiana, 554

Tripler General Hospital, 632, 635, 638, 639. TUMULTY, Capt. P. A., 612

640, 647, 689 Tunisia, 162, 163, 165, 168, 183, 209, 800

Tropical disease centers, designation of TUREEN, Maj. L. L., 165

hospitals as, 38 TURNER, Lt. Col. J. C., 400, 401, 434

Tropical Disease Treatment Branch, OTSG, TURNER, Col. R. H., 7, 15, 16, 64, 479

13 TURNER, Col. T. B., 12

Tropical diseases: XXIV Corps, 634, 662

clinical research in, 62 Typhoid fever, 791-793

hospitals for management of, 38-39 Typhus commission, in European theater,

Tropical ulcer, 772-773 418

TRUPP, Capt. M., 742 Typhus fever:

TRUSSEL, Maj. It. E., 545 diagnosis of, 535

Tsutsugamushi fever. See Scrub typhus. directive on, Technical Memorandum No.

Tuberculosis: 7, Office of the Chief Surgeon, USASOS,

consultant in, 10, 235, 237, 397, 403-412 1944-534

430-432, 443-461, 471 Typhus, murine, 672-673

directives on:

Administrative Memorandum No. 22, Ulcer(s):

Office of the Chief Surgeon, ETOUSA, cutaneous diphtheria, 761

1944-412, 443 peptic, 718

Circular Letter No. 38, Office of the tropical, 772-773

Chief Surgeon, ETOUSA, 1945-444 Undecylenic acid, 31

Circular Letter No. 41, Office of the United Kingdom, 162, 238, 240, 245, 247,

Surgeon, NATOUSA, 1944-184 251, 267, 280, 281, 285, 295, 306, 308,

Circular Letter No. 57, Office of the 310, 311, 329, 333, 351, 358, 362, 387,

Chief Surgeon, ETOUSA, 1945-459 390, 398-402, 403, 410, 416, 418, 419,

Circular Letter No. 60, Office of the 430, 432, 433, 442, 457

Chief Surgeon, ETOUSA, 1945-460 United States. See Zone of Interior.

Circular Letter No. 61, Office of the United States of America Typhus CommisChief Surgeon, ETOUSA, 1945-460 sion, 476, 486, 526, 531

Circular Letter No. 100, Office of the United States Pharmacopoeia, 25

Chief Surgeon, ETOUSA, 1944-431, University of Maryland Medical School, 476

443 University of Oklahoma, 554

hospitalization plan for, 183 Upper respiratory diseases. See Respiratory

in British Army, 403 diseases.

in Canadian Army, 403 Upper respiratory infections. See Respirain European theater, 402-412, 430-432, tory diseases.

443-461 Urinary bladder, streptomycin in infections

in Mediterranean theater, 183-184 of, 31

in recovered prisoners of war, 263-264, Urticaria, 780

442-457, 470 USAFCBI (U.S. Army Forces in Chinain World War I, 402 Burma-India), 695

patients with: USAFCT (U.S. Army Forces, China theater),

disposition of, 412, 443 695
8 78 ACTIVITIES OF MEDFIICAL CONSULTANTS

USAFFE. See U.S. Army Forces in the Vener:il Disease Subcommitt ee, National

Far East. Research Council, 11, 292, 297

USAFIA. See U.S. Armyv Forces in Ails- Venereal diseases, 24

tralia. conference onl, 278-288

USAF113T (U.S. Army F'orces, India-Burmia control of, 294

theater). See India-Burma theater, directive onl, 25, 282

USAFICPA. See Central Pacific Area. Circular Lectter No. 74, Office of the

UTSAFISPA. See South Pacific Area. Surgeon General, U.S. ArmY, 1942-

USAFMNIDPAC. See U.S. Army Forces in 287

the Middle Pacific. in Central Pacific Area, 67t-672

USA FPOA. See Pacific Ocean Area. ini European theater, 295-:301

USAFWESPAC. See U.S. Army Forces in field armies, 304-306

in the Western Pacific. in Zone of Interior, 93-94

L'.S.A.Il.S. Macfan, 47:3 management of, 25, 282, 287

USAPAC. See U.S. Army Forces, Pacific. recommenidationis onl, 294, 303

U.S. Armyv, postwar, plans for, 67 responsibility for, 11-12, 25, 672

U.S. Army, Services of Supply, 475 patients with:

U.S. Army Forces in A-4~ralia, 47:3 dispos.ition of, :106

U.S. Army Forces in t. .- Central Pacific. evacuation of, 308-309

Ser Central Pacific Area. hospitalization of, 308-309

U.S. Army Forces in the Far Elast, 474, 475, problem, 304

476 treat ment of, 31

U.S. Army Forces in the Middle Pacific, See also Gonorrhea; Syphilis.

475, 634 Versailles, 240

U.S. Army Forces in the Paeific Ocean Area. Vibrio choterae, 794

See Pacific Ocean Area. VICKOREZN, Lt. Col. A., 244

U.S. Arnay Forces in the Southi Atlantic, 7 Vioformi (iodochilorohyvdroxyquiinolince), 720

U.S. '. illy Forces in the South Pacific Area. Visits, to service and oversea comman"Illds, 63-

See ISouth Pacific Area. 65

U.S. Army Forces in the Western Pacific. Vitamin A, 209)

476, 634 Vitamnin deficiencies, 208

USASOS. See U.S. Army, Services of Viti Levut, 57:3

Supply. V-J Day, 457, 492

U.S. Marine Corps, 545 Volturnmo River, 181

IT.S. Navy, 474 Vomiting, in amehiasis, 715

11.S. Public h~ealthi Service, 476, 554, 74.3 VON RUNSTEDT, 4:37

U.S.S. West Point, 474

Wailpie, 6:39

Vaccinia, 79 WAKEMAN, Lt. Col. D. C., 256

Valkenhurg, :354 Waikemman G;enerail Hospital, 115, 116

Valognes, 240 Wls 7

VAN AU-KEN, Col. IT. A., 703, 716 WalesR, 270 e, A C :3,23 VANDERGRIFT, Lt. Col. NA. B., 536 WALKER, Colonel T, UAMN, 25,136

VTANI)ERVEER, Maj. I B. 550 LECatA.TU ,51

VAN NLOSTR.4Nr, Col. K. It., 319, 394 Walter R~eedl GeneI(ral Hospital, 6:3

Vascular centers, designation of hosp~italls ais, War Department Circulars:

:35 No. 101, 1946-68

Vascular diseases, hospitals for management No. 208, 1943-211

of, 35 No. 2312, 1944-160

Vector(s), of- No. 392, 1944-374

filariasis, 768 War D~epartment Field Manual No. 21-11,

infect ious hepatitis, 537 April 1943-48

scrub typhus11, 74:3 War Department Memorandum W-40-6-43,

V-E Day, 159), 278, 457 11 Fell. 1943-27
INDEX 879

War Department Technical Bulletin (TB WRIGHT, Lt. Col. H. B., 388

MED)-- WRIGHT, Col. I. S., 7, 55, 102-104

31, April 1944-528 WRIGHT, Dr. W. I1., 554

48, May 1944-300 Wroughton, 4:34

119, November 1944-724 Wuchereria bancrofti, 550, 646, 667, 690

138, February 1945-794 Wuchereria malayi, 667

168, June 1945-7

206, November 1945-24 X-ray examinations:

210, D)ecember 1945--46 directive on, for tuberculosis.

War Department Technical Manuals: Mobilization Regulations 1-9, 15 Mar.

No. 8-260, July 1941-21 1942-403

No. 8-500, March 1945-7, 48, 12:3 in British Army, 403

No. 12-406, Officer Classification, Corn- in Canadian Army, 403

missioned and Warrant, October 1943- in European theater, 404-412, 443-444,

144 457-461

Ward rounds, 699, 700, 703 mobile units for, 405-406

WARE, Col. E. R., 735, 737 X-ray therapy, for dermatologic condiWaringfield, 266 tions, 285

WATKINS, Lt. Col. J. 11., 276

WATSON, Lt. Col. B. A., 256 Yellow fever, 176, 708

WATSON, Dr. It. B., 522 Yellow fever vaccine, as cause of hepatitis,

WAuD, Lt. Col. S. P., 7:36 468, 667-668

WEBB, Lt. Col. U. B., 232 York, 387

WEBER, Lt. Col. F. C., Jr., 619 YOUNG, Col. C. T., 629, 633

WEBSTER, Col. B. P., 481, 482 YOUNG, Dr. K., 381

Weight loss, in hookworm infestation, 766

WEIL, Lt. Col. N., Jr., 260, 263 ZANCA, Capt. P., 444

WEILBAECIER, Lt. Col. J. 0., Jr., 223 ZEHMi, Col. A., 452

Weil's disease, 538 ZELLHOEFER, Col. It. W. K., 270

WELSH, Col. A. B., 635 ZOLLINGER, Col. R. M., 257

WELT, Maj. L. G., 260 Zone of Interior, 47, 62, 87, 145, 174, 240,

WERRELL, Dr. W. A., 257 245, 248, 274, 278, 279, 282, :306, 308

Western Pacific Base Command, 634, 635 313, 324, 328, 329, 333, 339, 355, 358,

WHAYNE, Col. Tom F., 305, 355, 390 374, 375, 383, 390, 391, 400, 420, 430,

WHITBY, Brig. Sir LIONEL, 246, 262 431, 442, 481, 569, 584, 587, 597, 607,

WHITE, Col. W. D., 244 612, 615, 632, 638, 706, 707, 724, 807,

WHITEHORN, Dr. J. C., 391 818, 819

WILCOX, Maj. II. B., 256 adequacy of medical care in 109-110

WILLIAMS, Dr. D. A., 413 autopsy protocols in, 101-102

WILLIAMS, Capt. J. C., 276 clinical problems in, 88-98

WILLIAMS, Col. R. P., 695 clinical research in, 110-116

WILLIS, Brig. Gen. J. M., 633, 635 conference in, 40

WILSON, Col. F. W., 38 consultants in medicine in, 1-70

Wiltshire, 468 dispensaries in, 129-132

Winchester, 270 disposition of patients to, 186-191, 756

WING, Maj. W. M., 491 from South Pacific Area, 598

WISE, Lt. Col. C. R., 256, 297 statistics, 274

WOLKIN, J., 775 with bronchial asthma, 413

Women's Army Corps, 411 with filariasis, 643-645

WOOD, Col. F. C., 733, 7:36, 745, 747, 748, with neuropsychiatric conditions, 329,

751,752 352

Woodlark Island, 515, 550 with peptic ulcers, 90-92

WPBC. See Western Pacific Base Corn- with skin diseases, 302

mand. with tuberculosis, 40(9, 412
880 ACTIVITIES OF MEDICAL CONSULTANTS

Zone of Interior-Continued Zone of Interior-Continued

hospitals in, 20, 21, 76, 79-83, 90, 102-110, personnel management in, 82--88

116-126, 134 ports of embarkation in, 132

outpatient clinics in, 132 reception centers in, 128-129

specialization in, 32-39 reconditioning programs in, 116-119

induction stations in, 128 redeployment to, 159

laboratories in, 98-101 replacement training centers in, 129

medical supplies in, 123-124 separation centers in, 132

nurses in, 124-126 training in, 102-109
History of the Medical Department, U.S. Army in World War II

DISTRIBUTION LIST

INTERNAL MEDICINE, VOLUME I

OSD (1) Tech Stf, DA (1) USA Hosp

OSA (1) Bds (1) 25-100 Beds (1)

USofA (1) USCONARC (2) 101-500 Beds (2)

ASA (FM) (1) ARADCOM (1) 501-750 Beds (4)

ASA (LOG) (1) OS Maj Comd (2) 751-up Beds (5)

ASA (MP&RF) (1) SHAPE (2) Med Cen (1) except

USASA (1) OS Base Comd (1) WRAMC (5)

DASA (1) Log Comd (1) BAMC (5)

DCSPER (1) MDW (2) WRAIR (5)

ACSI (1) Armies (2) AFIP (5)

DCSOPS (1) Corps (1) USAPERSCEN (1)

DCSLOG (1) USA Corps (1) Army Terminals (1)

ACSRC (1) Div (2) PG (1)

CCA (1) USATC (1) Med Lab (1)

CARROTC (1) Bde (1) AFES (1)

Cof F (1) Regt/Gp/Bg (1) Arsenals (1)

CINFO (1) Med Bn (1) Med Fld Maint Shops (1)

CNGB (1) Med Co (1) DB (1)

CLL (1) Med Det (1) Disp (1)

CRD (1) USMA (5) MAAG (1)

I)RI) (1) Svc Colleges (2) Mil Msn

CMII (2) Br Svc Sch (1) JBUSMC (1)

TAG (1) Med Specialist Sch (2) Units organized under folTIG (1) Med Sec, Gen Dep (1) lowing TOE's:

TJAG (1) Med Dep (1) 8-510 (1)

TPMG (1) GH (5) 8-551 (5)

CofCH (1) Named AH (4) 8-590 (1)

NG: Div (1); Bde (1); USA llosp (25-100 Beds) (1); USA Hosp (101-500 Beds) (1); USA

HIosp (501-750 Beds) (1); USA Ilosp (751 Beds--over) (1).

USAR: Lag Comd (1); Div (1); Bde (1); USA Hosp (25-100 Beds) (1); USA Hosp (101-500

Beds) (1); USA Hosp (501-750 Beds) (1); USA Hlosp (751 Beds---over) (1); TOE 8-510,

8-551, 8-590 (1).

Request copies remaining on hand after initial distribution be returned to Historical Unit,

Forest Glen Section, Walter Reed Army Medical Center, Washington 12, D.C.

U. S. GOVERNMENT PRINTING OrIFCi: 191