CHAPTER XX
Dermatology
Donald M. Pillsbury, M.D., and
Clarence S. Livingood, M.D.
Part I. Administrative Considerations
GENERAL CONSIDERATIONS
Diseases affecting the skin, though not of great importancefrom the standpoint of the deaths they cause, are of major importance to an armyoperating in the field, because of the high morbidity and ineffectiveness thatthey can produce.1 Hospital admission rates for these conditions givean incomplete and inaccurate picture of their potentialities for producingineffectiveness for the reason that a very large proportion of them are treatedin dispensaries and at sick call on a duty status.
When the "Manual of Dermatology,"2which was prepared under the auspices of the NRC(National Research Council), was published in 1942 (p. 548), the latest figuresavailable for skin diseases in the U.S. Army were for 1940, which means thatthey were for peacetime and that they did not reflect the rapid increase to beexpected-and that occurred-under conditions of military expansion andactual warfare. In 1940, nonetheless, diseases affecting the skin accounted for9.8 percent of all entries on the sick list and for 10.41 percent of allman-days lost. Venereal diseases (exclusive of gonorrhea), that is, syphilis,chancroid, lymphogranuloma venereum, and similar diseases, accounted for anadditional 3 percent of all hospital admissions. In the U.S. Navy, over thepreceding 10 years, diseases of the skin produced 9.79 percent of all admissionsto the sick list, and 8.65 percent of all man-days lost; venereal diseases(exclusive of gonorrhea) accounted for about 8 percent of all hospitaladmissions.
It was evident, well before the United States entered WorldWar II, that dermatologic diseases would constitute a major cause of partialdisability and lost man-days. In the Zone of Interior, where their impact wasfirst felt, their incidence varied with the location of the troops and theseason of the year. It was much higher, understandably, in the southern part
1Appreciation is expressed to Dr. Robert Stolar for hiswork in assembling the source material upon which much of this chapter is based.
2Pillsbury, Donald M., Sulzberger, Marion B., and Livingood,Clarence S.: Manual of Dermatology. Military Medical Manuals. Issued under theauspices of the Committee on Medicine of the Division of Medical Sciences of theNational Research Council. Philadelphia: W. B. Saunders Co., 1942.
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of the country, particularly during hot, humid summer months,because of insect bites that became excoriated or infected, superficial pyogenicand fungal infections, severe miliaria, and dermatitis from plants and othercontacts. It was far higher in some oversea theaters, such as the Pacific OceanAreas, than in more temperate climates, such as the European theater.Everywhere, however, medical officers were confronted with active and latentdermatologic diseases, with all the circumstances favorable to recurrence,reinfection, and relapse, as well as to fresh infections in new hosts. Thesewere superficial conditions, it is true, but they required an undue amount ofattention when they were treated on an outpatient or sick call basis, and theyaccounted for undue bed occupancy in hospitals.
Many wartime hospital reports carry the statement thatdermatologic disabilities could have been cut in half with improved methods oftreatment and if the patients had been brought into contact, in the initialphases of their illness, with properly qualified dermatologists. It was alsofrequently noted, in hospital and other health reports, that, if battalionsurgeons and other medical officers assigned to dispensaries had had adequatetraining in dermatology, there would have been significant decreases in theso-called overtreatment syndrome. These comments assume special significance ifit is borne in mind that, in some tropical oversea areas, dermatologic diseasesaccounted for as much as 75 percent of all visits to dispensaries.
Obviously, these are diseases of serious militarypotentialities. Yet in spite of that fact, the statement may be made withconsiderable confidence that before the outbreak of World War II, and indeeduntil it was almost half over, diseases of the skin received less attention,both administratively and therapeutically, than any other major source ofdisability. Both civilian and military medicine contributed heavily to thissituation for a number of reasons, some of which will be discussed in greaterdetail later in this chapter.
1. As late as 1942, diseases of the skin were still beingcared for in Army hospitals on the urology service, an archaic arrangement thathad been discontinued in civilian practice a quarter of a century earlier. Thispolicy was not officially discontinued in the Army until 1943, except upon theinitiative of commanding officers of a number of individual station and generalhospitals. These officers organized dermatologic services and handled allpatients with diseases affecting the skin on wards that ordinarily included bothdermatology and syphilology. This plan was firmly established in all hospitalsby the end of the war, though the changeover was accompanied by numerousadministrative difficulties.
2. Before World War II, the United States had seldom hadlarge bodies of troops in tropical areas for long periods of time. There wastherefore little realization of the tremendous increases in the incidence ofcommon skin diseases that would occur under conditions of prolonged heat andhumidity. The attention given to unusual medical diseases peculiar to the
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Tropics, fully justified though it was, far overshadowed theattention given to the remarkable exacerbation to be expected in frequentlyencountered but less exotic dermatologic conditions. The British, with theirlong and worldwide colonial and military experience, fully appreciated thesituation. The United States, with its smaller and more limited experience, didnot.
3. Little attention was paid to dermatology by the NationalResearch Council.3 In the prewar period, and well into the war, asingle civilian physician was charged with all dermatologic problems in theDivision of Medical Sciences. There was no subcommittee for dermatology, asthere was for numerous other specialties, and no specific research was directedtoward either the prevention or the management of diseases of the skin undermilitary conditions. In fact, there was no national research program in depthset up to investigate physiologic and pathologic factors in dermatologicdisability.
3Lest the impression be createdthat little assistance was provided by the National Research Council indermatological matters to the Army during World War II, it is desired topoint out the very specific and valuable assistance given in the matter ofcontrol of fungal infections of the feet ("athlete's foot"). Thiswas a chronic and perennial problem amongst troops forced to live close togetherin a barracks environment.
Prewar instructions for the prevention of athlete's footrequired the use of chlorine solutions prepared daily (usually made from calciumhypochlorite) for footbaths in shower rooms, and the daily exchange andsun-drying of duckboards placed on the floor of such rooms. Moreover,responsibility for the supervision of such measures was made a commandresponsibility and therefore placed directly on the shoulders of the unitcommander. Labor details were assigned to this task and many man-hours wereexpended daily throughout the Army in their execution.
Despite these vigorous measures over the years there appearedto be no appreciable impact upon the incidence of athlete's foot and thequestion of their continuing value was raised. To resolve this matter, thequestion was placed before the Division of Medical Sciences, National ResearchCouncil, during 1944. Opinion was divided amongst the dermatologists, but themost anyone would say on behalf of existing prophylactic measures was that theycould do no harm. With this consensus, it was finally agreed that the Army couldsafely discontinue such measures, and action was initiated to that end by theSanitation and Hygiene Division of The Surgeon General's Office.
At a talk given at the Service Command Medical Inspectors'Conference in Baltimore, Maryland, on 14 February 1945, Lt. Col. (later Col.)Arnold L. Ahnfeldt, MC, Director of the Sanitation and Hygiene Division,Preventive Medicine Service of The Surgeon General's Office, stated thatwidespread doubt concerning the value of present footbaths had now beenconfirmed by the National Research Council. As Colonel Robert J. Carpenter, theExecutive Officer for The Surgeon General, reported in an indorsement to theCommanding General, Army Service Forces, on 29 March 1945, the comments ofColonel Ahnfeldt at the Medical Inspector's Conference were being translatedinto action. As a result, War Department Circular No. 146 of 17 May 1945 wasprepared and published. Paragraph I, Athlete's Foot, directed that "Theuse of foot baths containing chemical solutions for the prevention ofdermatophytosis of the feet is hereby discontinued."
This directive resulted in a substantial saving of calciumhypochiorite which was in critically short supply and was needed for otherhighly important purposes, such as water purification. Moreover, there was nofurther need to spend time on the daily preparation of chlorine solutions forfootbaths.
A short while later, the publication of War DepartmentCircular 262, dated 30 August 1945, made the use of "duckboards" inshower rooms optional, pointing out they"are of value only in the prevention of accidents" and therebyindicated their lack of value in the prophylaxis of athlete's foot. Thiscircular led to the almost immediate discontinuation of the use of duckboards inshowers and on aprons of swimming pools Army-wide.
Thus, the two War Department Circulars cited did away withlong-standing practices within the Army mistakenly designed to prevent athlete'sfoot. Attesting to the wisdom of the recommendations of the Division of MedicalSciences, National Research Council, in this matter is the fact that there wasno subsequent increase in the incidence of athlete's foot amongst troops withdiscontinuation of these prophylactic measures, and no increase since that timeattributable to the change in policy. Instead, unit commanders were able tobreathe a sigh of relief, and many man-hours expended in labor details Army-widewere diverted to other uses.-A. L. A.
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4. The training of specialists in dermatology was, in manycivilian centers, superficial and narrow. Trained dermatologists were in shortsupply throughout the war, and the shortages were increased by the lack of anysystem in the Army for assigning those with special training to areas or unitswith high admission rates for skin diseases (p. 571).
5. The consultant system, which operated so successfully inmany other branches of medicine, was slow to operate in respect to dermatology,a situation that helped to explain the poor assignment of dermatologists justmentioned.
6. Numerous large general hospitals, including someaffiliated hospitals, were sent overseas without a single medical officer on thestaff who had even a cursory knowledge of diseases of the skin. The tables oforganization for these units originally had no provision for a dermatologist,and the Personnel Division, OTSG (Office of The Surgeon General), apparently sawno need for providing one.
7. Tables of equipment were extremely inadequate, and oftenentirely deficient, in provision of agents necessary for topical medication.
8. Finally, as was true of other specialists, dermatologistsfailed to realize the potent sensitizing capacity of many new therapeuticagents, whether injected, ingested, or used topically. When the war began,the potentialities for harm of the sulfonamides were slowly being realized, butthe story of penicillin, Atabrine (quinacrine hydrochloride), and many othercompounds remained to be told.
EVOLUTION OF DERMATOLOGIC MANAGEMENT
By the fall of 1941, when it was evident that the UnitedStates would be drawn into the war and that dermatologic disability would be aconsiderable problem in the Army, many commanding officers, particularly ofhospitals in training areas, began to request the assignment of medical officerswith some experience in dermatology. Their requests were often based on theinitial requests of chiefs of medical services, who found themselves unable todeal effectively with the numbers of patients with skin diseases who, under theexisting arrangements, were occupying medical beds for long periods of time.
Improvement of the situation was accomplished, for the mostpart, by the individual efforts of individual medical officers and civiliansrather than by any single centralized effort. Until late in the war, chiefsurgeons, medical consultants, and individual hospital commanders met theproblem in various ways, and, as might have been expected, with varying degreesof success.
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Action in National Research Council
The first general efforts to remedy the situation were madein the National Research Council, with the appointment of Dr. Donald M.Pillsbury, Professor of Dermatology, University of Pennsylvania School ofMedicine, as Consultant in Dermatology to the Committee on Medicine, Division ofMedical Sciences. His specific responsibility was to make recommendationsconcerning this specialty for the Armed Forces by way of this committee. It wasa small beginning, but highly important; it was the first time any governmentalor quasi-governmental organization had ever concerned itself specifically withdiseases affecting the skin.
The previous lack of interest in this specialty was not hardto explain. The NRC Committee on Medicine, although composed of physicians ofthe highest ability and repute, was only mildly concerned with dermatology. Mostof the members of the Committee on Medicine came from medical schools on theeastern seaboard, where skin diseases were regarded as minor problems and where,with occasional exceptions, dermatology had never achieved any specialrecognition. The appointment of a consultant on dermatology to the Committee onMedicine was an advance, but in retrospect, the additional appointment of asubcommittee on dermatology would have been a wiser move.
A development that was ultimately related to Dr. Pillsbury'sactivities was, as already mentioned, the initiative of the commanding officersof certain station and general hospitals in setting up sections of dermatologyand syphilology headed by qualified dermatologists who were called to activeduty from civilian practice. Col. Asa M. Lehman, MC, for instance, sponsored andactively encouraged the organization of such a section at the Indiantown GapStation Hospital, Pa., which served a large training camp that had been set upearly in 1941. Colonel Lehman, a veteran medical officer with a large overseaexperience, was an extremely astute physician, who had a considerable knowledgeof disability from dermatologic disorders, particularly in the Philippines. Hewas greatly disturbed by the lack of any organization within the Medical Corps,as well as the lack of personnel and supplies, to deal with this group ofdiseases. He solved the problem by setting up a dermatology and syphilologysection, with Capt. (later Maj.) Clarence S. Livingood, MC, as chief of thesection.
At Colonel Lehman's invitation, Dr. Pillsbury visited thishospital on numerous occasions and held long conferences with him and CaptainLivingood. The latter soon accumulated an impressive body of statistics thatshowed very clearly that skin diseases were extremely frequent and that earlymismanagement of even simple conditions could lead, at times, to prolongeddisability and, on occasion, to separation from service. In a number ofinstances, key combat personnel, for this reason, had been unable to accompanytheir units overseas.
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Preparation of Manual on Dermatology
The substance of these discussions was communicated to Brig.Gen. Charles C. Hillman, Chief, Professional Service Division, OTSG, who wasthen representing the War Department on the National Research Council. GeneralHillman brought the matter to the attention of Maj. Gen. James C. Magee, TheSurgeon General, with the recommendation that special policies be developed todeal with dermatologic disability. He also recommended that a short technicaldirective be issued for the information and guidance of medical officers who hadto deal with the more common dermatologic syndromes.
As the result of these recommendations, The Surgeon Generalinvited Colonel Lehman, Captain Livingood, and Dr. Pillsbury to a conferencewith him and General Hillman early in 1942, to discuss the preparation of amanual on dermatology, which General Hillman proposed be carried out under theauspices of the National Research Council. The Surgeon General approved theplan, and the National Research Council concurred in the arrangement.
Dr. Pillsbury and Major Livingood had only just begun theirwork on the proposed manual when Capt. Charles S. Stephenson, MC, USN, who wasrepresenting the Navy on the National Research Council, became interested in theproject and asked that it be pursued as a joint Army-Navy effort. Lt. Cdr.(later Capt.) Marion B. Sulzberger, MC, USNR, was therefore added to theauthors. With the warm encouragement of General Hillman and Colonel Lehman, thework proceeded rapidly in spite of the transfer of Major Livingood, in May 1942,to the 20th General Hospital, Camp Claiborne, La.
Though the format was different, this manual became one ofthe series developed under the auspices of the Division of Medical Sciences,NRC, and designed to furnish the Medical Departments of the U.S. Army and Navywith compact presentations of essential information in the field of militarymedicine. While it is unfortunate that it was not ready when mobilization beganin 1940 and 1941, in one sense the delay was an advantage: The whole text waswritten in the light of current, practical experience in military dermatology,with the most pressing needs of the general medical officer in mind. The subjectmatter was strictly limited. It concerned only the common skin diseasesaffecting males of military age. Methods of treatment were restricted to thoseexpected to be available in the usual Army and Navy installations. The manualhad a wide distribution, though it did not become available in many unitsoverseas for a year or more after its publication. The total printing of 40,500copies made it, in this respect, much the largest of all the NRC manualspublished.
It is difficult to assess the real impact of any technicalbulletin or manual upon medical practices in the Armed Forces. It is believed,however,
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that this small, compact volume exerted a great deal ofinfluence. For one thing, since it had the personal attention and backing of TheSurgeon General in the Army Medical Department and the Navy Bureau of Medicineand Surgery, as well as of ranking officers in both services, attention wasfocused on the medical problems with which it dealt. There seems no doubt that,as the result of its publication, increasing efforts were made to achieve betterprofessional care of dermatologic diseases. There were also improvements in thesupply tables of drugs essential for the treatment of these diseases.
Recommendations for Development of Dermatology Service
Meantime, dermatology was receiving further attention in theOffice of The Surgeon General. Shortly after Col. Arden Freer, MC, becameDirector of the Medical Practice Division, OTSG, in October 1942, he requestedLieutenant Colonel (later Colonel) Pillsbury, who had entered the Medical Corpsand had been assigned to Walter Reed General Hospital, Washington, D.C., tosubmit recommendations for the organization and equipment of Army station andgeneral hospitals, for the improved care of dermatologic patients.
Colonel Pillsbury regarded "the request for the opinionfrom a military medical neophyte" as presenting "a calculatedrisk," but, with the collaboration of Major Livingood, undertook theassignment. Their recommendations were based on the material included in the"Manual of Dermatology" and on data collected from various sources forthe Committee on Medicine, NRC, during the previous year. In one way or another,the organization and facilities recommended were achieved in almost all stationand general hospitals by the end of the war.
The substance of Colonel Pillsbury's reply to ColonelFreer, on 25 October 1942, was as follows:4
Incidence.-During 1940, skindiseases were responsible for about 8 percent of admissions to Army hospitals,but the proportion can be expected to vary widely under different conditions.Troops in warm climates will show sharp increases in fungal and pyogenicinfections. Troops on maneuvers will show increases from extensive contact withplants. Parasitic skin diseases will increase in some theaters of operations.
Facilities.-On the basis of these estimates andprojections, about 5 percent of all hospital beds should be kept regularlyavailable for dermatologic patients, and provision should be made for theexpansion that may be necessary.
Since most dermatologic patients are ambulatory and aretreated on an outpatient basis, facilities for their examination and treatment,as well as for the maintenance of adequate records, must be correspondinglylarger than for other dispensary sections. Figures from the Indiantown GapStation Hospital show outpatient visits to the dermatology clinic to be two orthree times more numerous than inpatient admissions. These figures are likely tobe duplicated in other hospitals in isolated areas. In general hospitals servinglarge numbers of posts, outpatient dermatology visits will be at least 10 timesas
4Letter, Lt. Col.Donald M. Pillsbury, MC, to Col. Arden Freer, Services of Supply, Office of TheSurgeon General, War Department, Washington, D.C., 25 Oct. 1942.
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numerous as hospital dermatology admissions, and thedisparity may be even greater. Statistics from Walter Reed General Hospital forAugust and September 1942 support these estimates.
Regular progress notes are particularly essential ondermatologic patients, and provision for storage of records must be adequate.
Complete examination of dermatologic patients is essential,and often it must be made with them stripped. Privacy and good lighting aretherefore necessary in outpatient clinics. Examination of outpatients with skindiseases in open wards has a bad effect on both the outpatients and theoccupants of the wards. Private examining rooms or cubicles must be provided.
Unit organization.-Whilepolicies of hospitalorganization vary from installation to installation, there is now rather generalagreement that syphilis should be treated on dermatologic wards. Certainly, itis hard to justify its treatment on a surgical service. At the present time[October 1942], there is no specific provision for a dermatology section in thetable of organization of a general hospital (TM 8-260, 13b), but there is suchprovision in the table of organization of a station hospital (TM 8-260, 275c).In some station hospitals, such as the hospital at Indiantown Gap, skindiseases, syphilis, and all other venereal diseases except gonorrhea are treatedon a single section, a plan that requires about double the bed space necessaryfor dermatology alone. The advisability of combining the management of thesediseases has long been under discussion in the Army, and combined management isthe established policy of the Navy. The plan also has the complete approval ofDr. Joseph Earle Moore and Dr. John H. Stokes, both members of the Subcommitteeon Venereal Diseases, NRC. An argument in favor of the arrangement is the factthat all physicians trained in good dermatology clinics in recent years havealso had adequate training in the diagnosis and treatment of syphilis.
Wards for dermatology and syphilis require the samefacilities as are provided on any general medical wards. In recent years,dermatologists have been more and more inclined to study the systemic backgroundof skin diseases as well as their surface aspects.
Personnel.-Whenever practical, a medical officerexperienced in dermatology should be assigned to station and general hospitals,since there is no other branch of internal medicine in which generalpractitioners have as much difficulty in diagnosis and management. It is hopedthat directives and other instructional efforts will enable medical officersuntrained in dermatology to treat the more common skin diseases effectively, butthese materials will not be helpful in the management of uncommon and chronicdiseases. It would lessen disability from dermatologic causes, includingovertreatment, if board-certified dermatologists were available for consultationon patients with such diseases.
The ward officer on a dermatology-syphilology section shouldpreferably have had some special training in these fields. The assistant wardofficer does not require it. Nurses and enlisted personnel who have had sometraining in dermatology greatly improve the efficiency of a dermatologicservice. A noncommissioned officer, who is a keyman on such a ward, can betrained by a ward officer within a month, by reading assignments anddemonstrations, to clean lesions, make topical applications, obtain scrapings,prepare solutions for injection, and assist at such minor surgical procedures asbiopsy and electrodesiccation. Nurses, enlisted men, and officer personnelshould not be rotated to other services; frequent changes of dermatologicpersonnel invariably mean less effective treatment. In military practice, aswell as civilian, the difference between cure and chronicity can often beattributed to nursing care and attention to small details of treatment.
It is always desirable for the ward officer on thedermatology section to maintain good rapport with the laboratory. In themanagement of syphilis, regular comparisons of clinical and serologic findingsredound to the good of the patient. Close cooperation on darkfield examinationsis particularly useful.
Equipment and supplies.-Provision should be made forthe performance on the dermatology section of minor surgical procedures such asbiopsy; electrocoagulation of
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warts, small papillomas, and epitheliomas; drainage of acnecysts; and similar procedures. The performance of biopsies by surgicalconsultants is often unsatisfactory because of the amount of paperwork involvedas well as because the site is not always properly selected for thedermatologist's purposes. The treatment of small warts by X-ray is anuncertain and expensive method. Small electrocoagulation units, without cuttingcurrent, which cost no more than $30 or $40, are entirely adequate for theirremoval and, in fact, are less hazardous and more efficient than some of thelarger obsolete units now in use. If space must be conserved, these units can behung on the wall.
At the present time, the greatest obstacle to treatment ofdermatologic conditions is the lack of certain common therapeutic agents. Thesebasic preparations are essential and should be kept on all dermatologic wardsready for immediate use. The supply list is presently undergoing considerablerevision, but the need for these agents is immediate and urgent.
Minimal organization.-Colonel Pillsbury closed hiscommunication to Colonel Freer with recommendations for atentative minimal organizational dermatology setup, with practicalconsiderations in mind, for a thousand-bed station or general hospital. He madeit clear that some additions would be necessary for a hospital like Walter ReedGeneral Hospital, in which difficult cases were treated and to which newlyinducted medical officers were sent for training.
Colonel Pillsbury's specifications were as follows:
1. Wards of 35 or 40 beds would be required for both thedermatology and syphilology sections, with, at a minimum, 1 or 2 examining roomsand 1 or 2 treatment rooms. Additional facilities would be required if aconsiderable number of outpatients were treated. Also required would be officesfor the ward officer and the ward nurse; three cubicles for infectious patientson the dermatology section and six to eight (possibly less) for infectiouspatients on the syphilology section; and the usual closet and storeroomfacilities required on any medical ward.
2. Standard items for ward and office equipment shouldinclude a sufficient number of filing cases; outpatient and other records shouldnot be kept in desk drawers.
3. Equipment for the dermatology section should include a setof simple instruments (2 forceps, straight and curved scissors, scalpels, 2 ringcurettes, a stilet, a biopsy punch, 2 syringes for skin tests and for localanalgesia, and a microscope which, if there were difficulty in procuring it,could be dispensed with). The need for an electrodesiccation unit has alreadybeen mentioned. An ultraviolet unit should be provided unless treatment wasreadily available in the physical therapy department. The X-ray section of thehospital should provide the facilities for superficial X-ray therapy. Ifstandard equipment was not available, the diagnostic units used in fieldhospitals could be calibrated and used for skin therapy.5
Special equipment for the syphilology section should includeadequate numbers of syringes, needles, and mixing glasses; material for Frei andDucrey tests; and anti-syphilitic drugs. The needles presently in use forintramuscular injection are usually too heavy and too short. A darkfieldmicroscope is not considered necessary; ward officers can use the one in thelaboratory.
5This plan was widely used in oversea hospitals as well as inhospitals in the Zone of Interior during the war.
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CONSULTANTS IN DERMATOLOGY
Zone of Interior
Early in the war, consultants in medicine, surgery, andneuropsychiatry were appointed in the Office of The Surgeon General. Later,consultants were appointed in various subspecialties, including orthopedicsurgery, ophthalmology, otolaryngology, radiology, and physical medicine. Stilllater, consultants in medicine, surgery, and neuropsychiatry, as well as in somesubspecialties, were assigned to all nine service commands, and, in time, to theheadquarters of all oversea theaters, as well as to all armies and many basesections.
Office of The Surgeon General.-Consultantservice in venereal diseases was provided in the Preventive Medicine Division,OTSG, early in the war, but a consultant in dermatology was not appointed inthat office until April 1945, shortly before the end of the war in Europe andonly 4 months before the end of the war against Japan. The position was filledby Major Livingood, who served from that time to January 1946.
A review of the various changes of policy by which the careof dermatologic patients was improved, chiefly by betterutilization of medical officers with special training in this field, makes itclear that a large share of the credit for the improvement evident during thelast year of the war should go to Brig. Gen. Hugh J. Morgan, Consultant inMedicine, Office of The Surgeon General. GeneralMorgan requested the appointment of a consultant in dermatology, 18 monthsbefore the request was honored. The policies he introduced in internal medicine greatly influenced the correctutilization of all medical officers and encouraged their accurate classificationon the basis of their training and experience. Through the use of consultantsin internal medicine in the servicecommands and the ultimate addition of Major Livingood to his Medical ConsultantsDivision, OTSG, General Morgan was able to direct increasing attention todermatologic disability in the Zone of Interior. His efforts to assignconsultants in this specialty to all major commands, both in the United States and overseas, were largely thwarted bythe fact that there was no provision for them in tables of organization.
The following letter from General Morgan to all servicecommand surgeons early in 1943 illustrates his broad point of view:
In my visits to army hospitals, overseas and in this country,I have been impressed by the fact that dermatological diseases are somewhatneglected. The reason for this is obvious-we haven't enough gooddermatologists to go around (and a poor dermatologist is often worse than none)and the dermatologists assigned often must work in the medical service alonewithout the benefit of any exchange of ideas with fellow practitioners. I amperfectly certain that much good could be accomplished by good dermatologicalconsultations. I believe that a great deal can be done in army hospitals toraise the level of dermatologic practice by providing occasional visits from anexpert in the field. I realize
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that our medical consultants are interested and that, in ageneral way, they keep their eyes on the dermatological problems; nevertheless,I suspect they adopt the same attitude that I do about the matter. Personally,in visiting army hospitals, I am very loath to put my opinionup against the opinion of the dermatologist on the ward. Moreover, I find itdifficult to even evaluate his professionalperformance. Actually, my knowledge of, and experience with, dermatologicproblems are limited and in the army, I make little or no contribution tohospital practice in this field. I expect a large majority of the medicalconsultants share my feeling in this regard. This letter is being written to theend of asking you to consider the suggestion that you select one of the bestdermatologists in your service command and have him visit the hospitalsthroughout the service command to the end of stimulating better dermatologicalpractice and bringing you information regarding the performance of personnel.You could do this of course, by having a dermatologist work out of your officefrom time to time on a temporary duty status. I am certain that many of ourstation hospitals would profit by such visits and I think that it is highlyprobable that regional, station, and general hospitals would also, and I amequally certain that the hospitals would welcome such a consultant. The systemhas been used successfully in the European and Southwest Pacific theaters as asupplement to the work of the permanently assigned medical consultants.
Service commands.-It wasdifficult, as just noted, to appoint consultants indermatology in service commands because there was no provision for them intables of organization. Some officers trained in dermatology were able toperform dermatologic duties on an informal basis, but the only consultantformally appointed was Maj. Herbert L. Traenkle, MC, who was assigned to theFifth Service Command as venereal disease control officer and who was authorizedto serve as consultant in dermatology in this command on 5 January 1945. Theclear understanding, however, was that his dermatology assignment was strictly"in addition to other duties." He was the only consultant indermatology who functioned as such in the Zone of Interior during the war. Hemade an extremely important contribution, and the standards of dermatologic carein the hospitals of the Fifth Service Command were raised as the result of hisefforts.
The background of this odd situation should be emphasized:Venereal disease control had had a high priority in Armymedicine for many years before the war, and control officers were thereforeassigned at once to headquarters of all service commands as well as to overseatheaters and many base sections. The training and interests of these officersvaried. Most of them were trained primarily in epidemiology and venereal diseaseprevention. Others were primarily dermatosyphilologists. It is unfortunate thatthe dermatologic abilities of this latter group of officers were not alsoutilized for dermatologic purposes. They were not so utilized. The officers wereassigned to preventive medicine, and while their work in venereal diseasecontrol was extremely important and rewarding, a considerable part of itconcerned matters far removed from medicine.
Oversea Commands
Consultants in dermatology were eventually appointed inETOUSA (European Theater of Operations, U.S. Army) and in SWPA (Southwest
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Pacific Area), but none was ever formally appointed in MTOUSA(Mediterranean Theater of Operations, U.S. Army) or in the CBI(China-Burma-India)theater.
European theater.-The consultant system in the Europeantheater was unusually well developed early in the war. Itincluded medicine, surgery, orthopedic surgery, plastic surgery, neurosurgery,otolaryngology, ophthalmology, and radiology.6 In the summer of 1942, Brig. Gen.(later Maj. Gen.) Paul R. Hawley, Chief Surgeon,Headquarters, ETOUSA, requested the Office of The SurgeonGeneral to make a consultant in dermatology available to him. In December ofthat year, Colonel Pillsbury joined General Hawley's consultant staff andfunctioned on it until the end of the war, with ultimate responsibility fordermatology and for diagnostic and therapeutic venereology.
The European theater differed from other commands in twoimportant respects:
1. It was the only major Army command with a formal,full-fledged consultant system that received consistent and vigorous supportfrom the theater surgeon. The system was distinctly on trial when it wasinstituted, and it suffered in its early days from organizational and othergrowing pains. With General Hawley's unwavering support, however, it was ableto function efficiently in the European theater, and by V-E Day, there was nodoubt of its value.
2. The European theater was the largest of all theaters, andby 1945, it had a considerably greater number of medical installations andmedical officers than the Zone of Interior itself.7
The appointment of a consultant in dermatology in theEuropean theater provided the same advantages that were inherent in the totalconsultant system, as well as certain advantages peculiar to the specialty:
1. Personal visits by the consultant to hospitals and armiespermitted him to keep abreast of current problems and to anticipate others longbefore he might have been alerted to them by reports through official channels.
2. Observation of therapeutic methods at the bedside and inoutpatient dispensaries permitted prompt correction of poor techniques anddeficiencies.
3. Contacts with large numbers of medical officers on apersonal as well as professional basis had many advantages.
4. Personal observations permitted intelligentrecommendations for transfer of specially qualified personnel toinstallations in which there was special need for their services.
6(1) Medical Department, United States Army. Radiology inWorld War II. Washington: U.S. Government Printing Office, 1966. (2) MedicalDepartment, United States Army. Internal Medicine in World War II. Volume I.Activities of Medical Consultants. Washington: U.S. Government Printing Office,1961.(3) Medical Department, United States Army. Surgery in WorldWar II. Activities of Surgical Consultants. Volume I. Washington: U.S.Government Printing Office, 1962. (4) Medical Department, United States Army.Surgery in World War II. Activities of Surgical Consultants. Volume II.Washington: U.S. Government Printing Office, 1964.
7Medical Department, United States Army. Personnel in WorldWar II. Washington: U.S. Government Printing Office, 1963.
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5. Dissemination of information concerning improved methodsof treatment, changes in methods which had not proved satisfactory, and otheritems was greatly facilitated.
6. Because of the short lines of communication betweeninstallations in the United Kingdom Base as well as on the Continent, at leastuntil well into 1945, it was possible for all consultants to visit medicalinstallations frequently, sometimes as many as four or five in a single day.These visits permitted a considerable amount of on-the-job training indermatology for medical officers with no previous experience in skin diseases.This informal training was supplemented by seminars and by discussions at theMedical Field Service School at Cheltenham, England, and at the Eighth Air ForceProvisional Medical Field Service School at PINETREE (High Wycombe, HeadquartersVIII U.S. Bomber Command). In all discussions and classes, great emphasis wasput upon the common diseases of the skin that could be treated in the field orin dispensaries if they were recognized early but that, if neglected ormaltreated, could produce prolonged disabilityand sometimes require hospitalization.
Separate sections of dermatology were set up within theframework of the medical service in all hospitals in which the patient loadjustified such subdivision. With the introduction of intensive arsenical therapyfor early syphilis and the later useof penicillin (p. 581), the diagnosis and treatment of all venereal diseasebecame the responsibility of thesection on dermatology. In installations of 500 bedsor more, as a result, the patient load was sufficient to occupy the full-timeattention of one medical officer and sometimes of two.
When it became evident that penicillin therapy for earlysyphilis would become available shortly after D-day, detailed plans were drawnup by the Consultant in Dermatology with the surgeons of the various armies forcentralization of all patients with acute venereal disease; they were usuallycared for in convalescent centers, in charge of specially qualified personnel.By this plan, all but a few patients in this large group were kept out ofstation and general hospital areas and were returned to duty as soon as theirtreatment was concluded. A great waste of manpower was thus prevented.
As of 1 January 1945, the number of dermatologists classifiedby MOS (military occupational specialty) ratings in the European theater was 47,while the number of fixed medical installations was 146. With the representationwhich dermatology had in the Office of the Chief Surgeon, ETOUSA, it waspossible for Colonel Pillsbury to assign the limited number of well-qualifieddermatologists in the theater, either formally or on an ad hoc basis, to theinstallations in which they were most needed. Difficulties arose later, ofcourse, when the number of hospitals increased, casualties were heavy, and linesof communication lengthened. Then, with the support of the Chief Surgeon, thebase surgeons, and the commanding officers of strategically located generalhospitals, all dermatologic patients who presented difficult and resistantconditions were grouped in certain hospitals with competent dermatologists onthe staffs. In addition, dermatologic officers with wide experience made regularrounds at adjacent hospitals without qualified dermatologists on their staffs.Among those who functioned in this informal
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consulting capacity were: Capt. Frank E. Cormia, MC, 49thStation Hospital; Capt. (later Maj.) C. J. Courville, MC,298th General Hospital; Maj. Emerson Gillespie, MC, 67th(later 5th) General Hospital; Maj. Herbert H. Holman, MC,40th General Hospital; Maj. Adolph Loveman, MC, 49th StationHospital; Capt. (later Maj.) Thomas W. Murrell, Jr., MC, 28th General Hospital(Major Murrell was later attached to dispensaries in London and inParis); Maj. (later Lt. Col.) Maurice H. Noun, MC, 30th General Hospital;and Capt. (later Maj.) Samuel R. Perrin, MC, 58th General Hospital.
The service was not always easy to provide, but it wasprovided, and it seems fair to say that, by the plans just outlined, everypatient with a skin disease of significant severity received prompt and adequateconsultation service. The validity of this statement is borne out by the factthat, in spite of the large troop strength in the theater,not more than 30 or 40 patients per monthwere boarded to the Zone of Interior for skin disease. Themaximum, 40, was reached only once, in June 1945.
Southwest Pacific Area.-In September 1943, General Morgan,noting the increasing number of dermatologic conditions inthe Southwest Pacific Area, made a consultant indermatology available to it on his own initiative, withouta request from the area. When the consultant (Maj. (later Lt. Col.) JohnV. Ambler, MC) arrived, he found himself unable to function because of theindifference, bordering on hostility, of the area surgeon. When this incumbentwas replaced, early in 1944, by Brig. Gen. (later Maj. Gen.) GuyB. Denit (Chief Surgeon, U.S. Army Services of Supply, SWPA), a general officerwith a real understanding of the value of the consultant system,Major Ambler was able to function efficiently for the first time.
It is only fair to interpolate at this point that while someadministrative officers took the attitude toward consultants just described,others welcomed them cordially. It is also only fair to note that thedifficulties attendant on operation of the consultant system were often nothelped by the habit of some consultants, fresh from civilian practice, of makingrecommendations without sending them through proper channels and by their lackof appreciation of the problems of commanding officers. In other words,attitudes on both sides sometimes furnished serious roadblocks to theachievement of better methods of prevention and treatment of diseases andinjuries and also militated against the most profitable assignment of speciallyqualified personnel.
Once he was able to function unhampered, Major Amblerrecognized the existence of certain problems:
1. Were some of the more unusual skin disorders encounteredcaused by infection by fungi?
2. Were the numerous cases being diagnosed as trichophytosisor epidermophytosis really fungal infections? There was little clinical, and no laboratory,support for these diagnoses.
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At the direction of General Denit, an investigation to settlethis point was undertaken by Dr. J. Gardner Hopkins, a mycologist of wideexperience, Professor of Dermatology, Columbia University College of Physiciansand Surgeons, Civilian Consultant in Dermatology to The Surgeon General, andinvestigator (dermatophytosis) for the Committee on Medical Research, OSRD(Office of Scientific Research and Development). Dr. Hopkins was not eligiblefor military service because of age and other reasons, but he devoted most ofhis time during the war in a civilian capacity to the Office of ScientificResearch and Development. His numerous field studies were an outstandingcontribution to the work of the Medical Corps.
Dr. Hopkins reached the SouthwestPacific Area on 2 September 1944, and after his survey made his report toGeneral Denit on 13 March 1945.8 By the time Dr. Hopkins reached the area,diseases of the skin had become an extremely serious problem. In some hospitals,20 percent of the medical admissions were forthis cause, and many hospitals hadfrom 100 to 300 patients on the dermatology wards. The rate of evacuation to theZone of Interior for skin diseases had reached 17 percent of all medicalcases and was exceeded only by the rate for neuropsychiatry.
Under Major Ambler's guidance, Dr. Hopkins visitedstation and base hospitals in Brisbane, Australia; Oro Bay, Dobodura, Lae,Nadzab, Finschhafen, and Hollandia, in NewGuinea; and Leyte and San Fabian in the Philippines. He also visiteddispensaries at Lae (New Guinea) and Leyte, and battalion aid stations on theRosario Front, in the Philippines. He was thus able to obtain a comprehensiveview of dermatologic problems at different points in the line of evacuation,from the frontline to general hospitals in therear. His observations are reported, under appropriate headings, elsewhere inthis chapter.
China-Burma-India theater.-Asalready mentioned, there was no dermatology consultant in the China-Burma-Indiatheater during the war, but Col. Herrman L. Blumgart, MC, served as Consultantin Medicine during the latter months of fighting.
Three general hospitals assigned to India had dermatologysections. The 20th General Hospital, which arrived in March 1943, was located inAssam, near the border of Burma. The 69th General Hospital, also assigned toAssam, arrived in June 1944, during the height of the intensive campaign beingconducted by Merrill's Marauders at Myitkyina. The 142d General Hospitalarrived in Calcutta in September 1944.
Each of these hospitals had from three to five wards setaside for dermatology and syphilology, and the two hospitals located in Assamalso had wards for treatment of these conditions in Chinese soldiers. Theexperience of all three hospitals was essentially the same.
8Letter, J. G. Hopkins, M.D., Technical Observer,Office of Field Service, Office of Scientific Research and Development, to Brig.Gen. Guy B. Denit, Theater Surgeon, Headquarters, USAFFE, 13 Mar. 1945, subject: Report of Observations on Fungus Infections and Other Dermatoses in the SWPA.
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PERSONNEL AND ASSIGNMENT
Before the beginning of mobilization in September 1940, therewas not a single qualified (certified) dermatologist inthe Regular Army Medical Corps, nor was there a section ofdermatology in any Army hospital. With the mobilization of the members of theMedical Corps Reserve, in 1941, a few officers with special dermatologicaltraining came on duty, and some of them were assigned to hospitals in the Zoneof Interior.
When maneuvers began, in the summer of 1941, it becameabundantly clear that dermatologic admissions to station hospitals would besignificant. The maneuvers in Louisiana were especially instructive in thisregard (p. 572), for a continuing flow of soldiers wererendered ineffective by complications of insect bites,especially chiggers; primary or secondary bacterial infections; contactdermatitis caused by plants; miliaria; and the sensitizingeffects of topical medicaments, particularly the sulfonamides. Thecommanding officers of the station hospitals that received these patients soonfound it necessary to set up special dermatologic sections, even though in manyinstances they had no qualified dermatologists to put in charge of them.
Even though tables of organization did not provide for them,some affiliated general hospital units were ableto recruit dermatologists by various methods. Other hospitals did not recruitthem, and such university-sponsored units as the 2d General Hospital (ColumbiaUniversity), the 18th General Hospital (Johns Hopkins University), and the 30thGeneral Hospital (University of California) went overseas without dermatologistson their staffs.
Original Misassignments
Dermatologists called to active duty in 1941 were sometimesassigned to dermatologic duties but very frequently were not. Those who were notassigned as dermatologists communicated their dissatisfaction rather vigorouslyto civilians in high academic and organizational positions, and inquiriesarising from these complaints were sent to appropriate authorities.
The first communication on the matter was a letter from Dr. (later Captain, Medical Corps) William B. Guy, Chairman,Section on Dermatology and Syphilology, American Medical Association, to TheSurgeon General and to Maj. (later Brig. Gen.) Sam F. Seeley, MC, Chief, Officeof Procurement and Assignment Service, War Manpower Commission, Office forEmergency Management. In this letter, dated 17 April 1942, Dr. Guy requested from Major Seeley specific informationregarding (1) the need for dermatologists in the Armed Forces; (2) the officialpolicy regarding the utilization of specialists in their own branches ofmedicine; (3) the routine by which dermatologists should proceed when theyapplied for commissions
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in the Armed Forces, so that they would be utilized in theirspecial field; and (4) the possibility of transfer of dermatologists presentlyassigned to nondermatologic duties in the Armed Forces.
Col. (later Maj. Gen.) George F. Lull, MC, replied for TheSurgeon General, on 19 April 1942, in substance, as follows:
1. Because of the difficulty of assigning all specialists topositions in which they will do work they are accustomed to do in civilian life,many medical officers will have to adjust themselves in the Army and learn newoccupations.
2. Dermatologists will be needed in the Armed Forces, but howmany is not known. They can be utilized in the larger hospitals, but usuallythere will not be sufficient work to utilize them exclusively in theirspecialty.
3. An attempt will be made to assign dermatologists whovolunteer for service to hospitals in which they will be used in the treatmentof skin diseases and syphilis, but no promises can be made in this regard.Moreover, in many hospitals, skin diseases are treated in one department andsyphilis in another.
4. If the names of those now in service who are not now doingdermatology and syphilology are provided, it may be possible to transfer most ofthem.
5. Dermatologists applying for commissions should state theirpreference for assignment, and every attempt will be made to grant theirrequests.
Major Seeley's reply to Dr. Guy was even less encouraging.In substance, he wrote:
1. The number of dermatologists needed by the Armed Forceswould be so limited that he would be disinclined to encourage dermatologists tothink their duties would be strictly in this field.
2. Those recognized in the specialty and now in service mustcontinue to serve in their present capacities until such time as The SurgeonGeneral had the advantage of an oversupply of medical officers. There would beno justification in asking him to make assignments until the rest of the professionhad come forth for service and rearrangements were feasible.
3. Dermatologists applying for commissions shouldemphasize their training and ask for assignment to their specialty on the formfor statement of preferences.
4. Many physicians who anticipated that military servicewould make specialists out of general practitioner's must be satisfied withbeing made better practitioner's if they were not engaged as specialists."We must win this war," Major Seeley concluded, "and then enjoyour highly developed specialization in peacetime."
The replies to Dr. Guy's letter from Colonel Lull and MajorSeeley are indicative of the misunderstandings and dissatisfaction thatprevailed at this time. Newly inducted medical officers, without previousmilitary experience, failed to understand the tremendous difficulties inherentin the assignment of personnel to the professional activities that would bestutilize their previous training and talents. On the military side, it is clearlyevident from these letters-entirely unrealistic in the light of laterexperience-that there was no anticipation of the volume and complexity of thedermatologic problems likely to be encountered in a global war. The lack ofunderstanding before and early in the war led to a gross underestimate of theneed for medical officers with special training in dermatology. For these andother reasons, adequate staffing for dermatologic diseases was never achieved.As the war progressed, it became clear that the Army alone
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could have used every qualified dermatologist in civilianpractice if they had become available.
After the formal declaration of war on 8 December 1941, anincreasing number of dermatologists came on active duty and, almost withoutexception, requested dermatologic assignments. They did not always get them, onereason being, as mentioned several times already, that the table of organizationof a general hospital did not provide for a dermatologist, though the table oforganization of a station hospital did. The chief reason for the originalmisassignment of dermatologists, however, was that the Personnel Division, OTSG,had had no previous experience with the need for dermatologists in any type ofhospital. Moreover, there was then no dermatologic consultant in the Office ofThe Surgeon General, no classification existed for medicalspecialists, and the need for medical officers was urgent without regard tospecialty. Dermatologists were in theparticularly unenviable position of having a specialty that had no officialrecognition.
Transfers
Some dermatologists, when they entered service, joined theAGF (Army Ground Forces), in which they did not function except at sick call.Some joined the AAF (Army Air Forces) which, during the first years of the war,did not operate enough hospitals to utilize the special experience of thedermatologists available to it. Since, however, neither ofthese groups came under the jurisdiction of The SurgeonGeneral, it was impossible to change the assignments ofthe dermatologists in them. The ASF (Army Service Forces), in May 1945, had theresponsibility for staffing some 108 general, regional, and station hospitals inthe Zone of Interior, each with a bed capacity of 800 ormore, and had available for them only 42 qualifieddermatologists. At the same time, the Army Air Forces had 12 regional hospitals,each with the same bed capacity, and had some 28 qualified dermatologistsavailable for them. Evident as was the disparity, it was impossible to effect asingle transfer from the Air Forces in spite of the vigorous efforts ofGeneral Morgan and the Personnel Division. The only concession offered by theAir Forces personnel was the suggestion that ASF patients with dermatologicconditions be sent to their hospitals, an obviously impossible plan.9
There was similar difficulty in transferring dermatologistsfrom one service command to another; the concurrence of all headquartersconcerned had to be secured, and that was no simple matter. This lack offlexibility made it almost impossible to adjust changing situations in thedermatologic sections in the various hospitals.
9This situation is an excellent illustration of the forcedineffectiveness of The Surgeon Generaloccasioned by his subordination in the command structure to the CommandingGeneral, Army Service Forces, early in World War II.-A. L.A.
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Dermatologic situations were not static. Early in the war,during the training period, the greatest concentration of patients with skinconditions was in station hospitals. Later in the war, when patients with skindiseases were being evacuated from overseas, the concentration was heaviest ingeneral hospitals. It was one of the principal functions of the Consultant inDermatology, OTSG, once he had been appointed, to recommend assignments ofpersonnel on a preferred basis. Though it was never achieved, the assignment ofqualified dermatologists which he recommended in order of preference was to-
1. General hospitals designated as dermatology centers (p.575).
2. General hospitals designated as neurosyphilis centers.
3. General hospitals designated as medical centers.
4. Regional hospitals.
5. Station hospitals.
6. General hospitals.
If this list had been prepared in 1941 rather than in 1945,high preference would have been given to the station hospitals that providedcare for troops in training and on maneuvers, such as the station hospitals inLouisiana and the hospital at Indiantown Gap. A major factor in the change ofpreference was the large, active campaigns conducted overseas. To anyone whoviewed the situation broadly, the changing hospital functions and the changes inthe types of patients cared for in general and station hospitals were mostimpressive and instructive.
Another factor that complicated personnel assignments in dermatology was the necessity of utilizing a certainproportion of available dermatologists for themanagement of venereal diseases. Dermatologists furnished the principalprofessional reservoir of officer's with training in syphilis and in othernongonorrheal diseases. Almost all neurosyphilis centers in general hospitalswere staffed by dermatosyphilologists. It was possible to train general medicalofficers quite adequately in the management of early syphilis and other acutevenereal diseases within a few months, and the plan was generally followed inthe European theater, but trained dermatologists had to be kept available toprovide the training.
Certification
At the close of the war, the Army Service Forces had 137medical officers with recognized competence in dermatology. Of these, 107 werecertified by the American Board of Dermatology and Syphilology, and the other 30had demonstrated their competence and had had sufficient formal training towarrant their certification when and if they chose to apply to take theexaminations for it.
Another group of 151 medical officers had had only a smallamount of formal training but enough previous experience in civilian practice to
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justify an MOS rating of C. Many in this group had increasedtheir proficiency and experience in the Army. These officers were usuallycapable of serving as chiefs of dermatologic services in small hospitals or in hospitals whose primary mission was the care of battlecasualties.
Still another group of officers, of considerable size, hadhad no training in dermatology other than what they had obtained in the Army buthad developed an interest in it during their service.
A precise appraisal in the Medical Consultants Division, OTSG,after the war in Europe had ended indicated that at least 275 qualifieddermatologists were then needed to carry the dermatologic load in the variousinstallations of the Army Service Forces in the Zone of Interior and overseas.
Despite all the problems of personnel assignment justoutlined, it is gratifying to note that on V-E Day, 102 ofthe 107 medical officers certified in dermatology were in posts offering theopportunity to do professional work in dermatology,syphilology, or both. Furthermore, almost all the officers who were notcertified but who had had sufficient formal training and experience to qualifyas dermatologists also had relevant assignments. Thisfavorable situation was finally brought about by the efforts of many medicalofficers in various headquarters with broad interest in providing adequatemedical service for all patients. They had been impressed by the increasingevidence throughout the war that dermatologic disease was responsible for muchdisability and that lost manpower could be greatly curtailed if these patientswith skin conditions were treated byqualified specialists early in their illness.
FACILITIES, EQUIPMENT, AND SUPPLIES
When the United States entered the war, in view of the statusof dermatology in the Army, it wasnot surprising that no special provision had been made inmost hospitals for dermatology or syphilologywards. When the need for these facilities arose, they hadto be improvised, for both clinic and ward patients, fromwhatever space was available.
Early in the war, a great deal of equipment needed on thesewards and clinics was on the critical list because of shortages and priorities,and treatment of patients was sometimes adversely affected. Even such items astubs, basins, hotplates, bandages, dressings, instruments, and ordinary drugscould not be procured at all or were in continuously short supply. Vitamin B andzinc oxide, both badly needed, could be procured only in small amounts.
The medical supply officer at each station received from themedical depot certain items regularly used in dermatologic practice, such asingredients for lotions, baths, ointments, and pastes (particularly zinc oxide); that is, starch, benzoic acid, salicylic acid, phenol, boric acid, potassiumper-
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manganate, sodium chloride, coal tar, ammoniated mercury,sulfur, alcohol, lanolin, and petrolatum. Local medical officers, depending upontheir special needs and their own experience in dermatology, used these itemsas best they could, making up for shortages with substitutes among availablepharmaceutical stocks. The usual situation developed: Each dermatologist desiredthe items he had been accustomed to use in private practice. The supply policywas somewhat flexible, and in late 1942, Col. Charles F. Shook, MC, thenAssistant Chief, Finance and Supply Service, OTSG, recommended thatdermatologists in the Zone of Interior be permitted to use local funds forpharmaceuticals they particularly desired, especially when only small quantitieswere needed. One reason for this recommendation was to avoid further changes inthe master supply catalog, which by this time had been completed.
During the last year of the war, only a few dermatologiccategories were in short supply, such as benzyl benzoate for scabies, tragacanthas an emulsifying agent, sulfurated potassium for lotio alba, and olive oil forlotions. In the summer of 1945, the Consultant in Dermatology, OTSG, recommendedthe addition of accepted dermatologic items to the standard supply tables. Whenthe war ended in August of that year, most shortages had been overcome.
ARMY AIR FORCES
Administrative Considerations
In spite of the number of dermatologists on duty in the Army AirForces (p.560), no special professional attention was paid to dermatologic diseases inthis service until August 1944. Then, in accordance with recommendations made tothe Air Surgeon several weeks earlier, a dermatology branch was created in theProfessional Division of his office, and Lt. Col. Jud R. Scholtz, MC, wasappointed to direct it.10
In the recommendations made to the Air Surgeon in June 1944, itwas pointed out that dermatologic diseases were an important cause of morbidityin military personnel. Separate statistics were not available for the Army Air Forces, but it was noted that collective figuresforthe Army in the continental United States revealed that time lost from duty fromthis cause each year approximated 3 million man-days, with an average loss of 11days per patient. It was estimated that about 20 percent of all diseases in theArmy required dermatologic management, and it was emphasized that hospitaladmissions did not give a true picture of the situation, since half or more of all cutaneous conditions did not requirehospitalization.
10The material for this section on the Army Air Forceswas supplied by Dr. Jud R. Scholtz who, as Lieutenant Colonel, served as Chiefof the Dermatology Branch, Office of the Air Surgeon, when the dermatologyprogram was set up in that office.
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It was therefore considered desirable to institute adermatology program in the Army Air Forces; to establish dermatologic servicesin the regional hospitals of the service; to develop a consultation system indermatology for station hospitals; to utilize to the maximum specialistpersonnel in the Army Air Forces; to set up a consultative and preventiveprogram for civilian employees of the ATSC (Air Technical Service Command); andto develop a teaching program in dermatology for residents and general servicemedical officers.
Personnel.-When these recommendations were made in June1944, there were in the Army Air Forces in the United States 31 medical officersclassified as dermatologists; of these, 17 were board certified, and many of theothers were well qualified, by training and experience, to be consideredspecialists. When the Dermatology Branch was created in the Office of the AirSurgeon in August 1944, 22 medical officers, 16 of whom were certified by theAmerican Board of Dermatology and Syphilology, were available for assignment.Some of them were already working on dermatologic services in AAF hospitals. ByMarch 1945, dermatologists had been assigned to 26 regional hospitals, and anadditional 6 medical officers had been certified by the board.
Establishment of program.-The recommendations made in June1944 were generally put into effect when the Dermatology Branch was establishedin the Office of the Air Surgeon in August 1944 in the following steps:
1. Regional AAF hospitals were staffed with qualifieddermatologic personnel in relation to the availability of such personnel, thegeographic location and bed capacity of the hospitals, and the prevalence ofskin diseases in each area.
2. An official letter was issued announcing the creation of adermatologic consultant service and listing the stations at which dermatologistswould be available for consultation. Recommendations were also made concerningthe area hospitals to be served by regional consultants; the routine treatmentof common skin diseases; and the disposition of special categories of patientswith skin conditions.
3. Consultant functions included initial visits to areahospitals to determine the scope and nature of the dermatologic problem;investigation of patients currently under treatment, to determine whether theyshould be transferred to the dermatologic service; the establishment of a basicroutine of treatment; and the identification of qualified dermatologists who hadnot yet been classified as such.
4. After the initial visit to each hospital just described,provision was made for consultation service to area hospitals by telephone or bypersonal visits as indicated. It was part of the consultant function torecommend the transfer of patients from area to regional hospitals.
5. The dermatologic needs of the Air Technical ServiceCommand in relation to its civilian employees were investigated and implemented.
6. Information was disseminated concerning treatmentpractices in both dermatology and venereal diseases.
7. An attempt was made to accumulate and analyze data onmorbidity due to dermatologic diseases, the sick call load, and time lost fromduty by hospitalization. An attempt was also made to institute clinical studiesin skin diseases of particular significance in AAF personnel by virtue of typeof duty or geographic location.
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8. After the program was in full operation, return visitswere made to AAF medical installations to evaluate the quality of dermatologicservice in them.
Regional hospitals.-Each dermatologist assigned to aregional hospital developed a separate dermatologicservice in it. A ward was set aside for the hospitalization of patients withsevere, disabling dermatoses and for the definitive treatment of patientsreferred from satellite hospitals at which specialized medical care was notavailable. Clinics for outpatients who could be treated on an ambulatory basiswere conducted several times a week, the number of clinics depending upon thecaseload.
In his capacity as regional consultant, the dermatologist ateach regional hospital visited each satellite stationhospital once a month, to handle special problems and to evaluate the quality ofdermatologic service provided.
Duty-assignment training.-In October 1944, aduty-assignment training program was set up in each major AAF command, intendedto indoctrinate medical officers without training or experience in dermatologyin the management and treatment of the common skin diseases encountered inmilitary service. Each trainee was assigned for a 3-month period to aboard-certified dermatologist who had been associated with a teachinginstitution in civilian life. The trainee assisted in the management of ward andclinic patients and, when it was practical, visited adjacent civilian teachinginstitutions.
The medical officers trained in this manner were assigned tostation hospitals and proved of great assistance to the consultants indermatology. It should be emphasized that the training program was set up onlybecause of the shortages of qualified dermatologists in the Army Air Forces andthe need for larger numbers of medical officers who could treat common skindiseases in installations to which no dermatologists were assigned. There was noidea that the training provided would qualify the trainees as dermatologists; infact, it was specifically directed that officers thus trained would not beclassified as dermatologists.
Manual.-The survey of dermatologic practices and patientsin AAF hospitals and clinics undertaken when the new program was put into effectin August 1944 revealed that perhaps half of all admissions to the dermatologywards were the result of improper early treatment and overtreatment. It was also found that about 90 percent of all skin disordersencountered in the Army Air Forces were included in a small number of diagnoses.Similarly, large numbers of patients seen in outpatient clinics also presentedconditions overtreated and aggravated by improper and irritating sensitizingtherapy.
To remedy this situation, a manual was prepared particularlyfor AAF medical officers who had had no special training in dermatology. This manual, "Management of CommonCutaneous Diseases" (AAF Manual 25-1), which was the composite effort ofseveral dermatologic officers, was dis-
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tributed to all AAF installations in the continental UnitedStates for use in dispensaries and station hospitals. The manual was not adirective and did not restrict the exercise of clinical judgment by individualmedical officers.
The initial distribution of this manual was 1 copy each tostations with strengths of 500 and under; 2 copies each to those with strengthsbetween 500 and 1,000; 3 copies each to those with strengths between 1,000 and5,000; 5 copies each to those with strengths between 5,000 and 10,000; and 9copies each to those with strengths over 10,000.
Requests were subsequently received from several AAF commandsfor individual copies of this manual for allmedical officers within the commands. Some 2,000 copies were distributed as theresult of these requests, including 800 copies to the Army Air Forces in theMediterranean theater. The manual was also reproduced in toto and used as acircular letter by the Tenth AirForce in the China-Burma-India theater.
Categories of Disease
In the recommendations made to the Air Surgeon inJune 1944 on the establishment of a dermatologic program in the Army Air Forces,it was pointed out that skin diseases in the age group in this service fell intothree categories:
1. Approximately 90 percent of all cutaneous morbidity wereaccounted for by a group of conditions which were not in themselves disablingand most of which, if properly treated initially, did not requirehospitalization. In this group were pyodermatoses, superficial fungalinfections, parasitic diseases, disturbances caused by excessive perspiration,and contact dermatitis, including plant dermatitis.
2. Major dermatoses, which caused serious disabilityand required prolonged hospitalization, included erythema multiforme, drugreactions, generalized eczema, exfoliative dermatitis, dermatoses caused byphotosensitization, chronic granulomas, and lupus erythematosus.
3. Emergency situations were so uncommon in dermatologicpractice that they required no consideration in the routine of dermatologic careand could be handled, usually bytelephone consultation, when they arose.
Occupational dermatoses.-The Air Technical Service Commandhad among its other duties the responsibility for maintenance and repair ofaircraft. For this purpose, it operated a number of large depots in the UnitedStates, where several hundred thousand civilians were employed, 35 percent ofwhom, it was estimated, were exposed tooccupational hazards and chemical agents that could cause dermatitis. The annualreport of this command for 1943 revealed that the time lost from work foroccupational reasons was almostentirely the result of occupational dermatitis. This was clearly an importantcondition, not only because of the time lost from work
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but also because the treatment of occupational disease incivilian employees was an Air Forces responsibility. The depots at which itoccurred were served by medical officers trained in industrial medicine, butwith few exceptions, they were not trained in dermatology and experienceddermatologists were not available for consultation.
Another problem of considerable magnitude because of thelarge number of employees involved in these AAF projects was the cutaneouscomplications of sulfonamide prophylaxis, which was widely used for protectionagainst bacterial disease. Reactions to this technique were fairly frequent, andcutaneous reactions were the most common of all. Qualified medical personnel hadto be available to classify and treat these dermatoses and to advise, on anindividual basis, concerning the propriety of continuing the medication.
As the result of these observations, a consultation servicewas set up by which AAF dermatologists in the general area of ATSC depots maderegular visits to them, to assist in the diagnosis, classification, andmanagement of skin diseases in civilian employees engaged in the care and repairof aircraft. This arrangement resulted almost immediately in more accurateclassification of occupational dermatitis and in shorter periods of disability.It also laid the groundwork for the collection of valuable informationconcerning the cutaneous occupational hazards encountered in the maintenance andrepair of aircraft.
In January 1945, a conference on occupational dermatoses washeld in the Office of the Air Surgeon, the participants including Lt. Col.George Sladczyk, MC, Chief of the Industrial Medicine Branch, Headquarters, ATSC;Maj. (later Lt. Col.) Frank J. Lacksen, MC, Chief, Dermatology Section, MitchelField AAF Regional Station Hospital; Maj. (later Lt. Col.) Shepard Quinby, MC,dermatologic officer, Headquarters, Personnel Distribution Command; and ColonelScholtz.
The agenda for this conference covered the following items:
1. The dermatologic consultation service in the Office of theAir Surgeon.
2. The scope of the problem of occupational dermatoses asindicated in reports available to Headquarters, Air Technical Service Command.
3. The desirability of preparing a manual on the preventionand management of occupational dermatoses for use by medical officers andcontract physicians engaged in the industrial hygiene program.
4. The need for standardization of hand cleansers.
5. The need for increasing the number of medicamentsavailable for treatment.
6. The need for further investigation of causes ofdermatitis in ATSC depots and the development of engineering techniques fortheir elimination.
The conferees reached the following decisions:
1. The consultation service provided in the dermatologicprogram was by far the most important and most essential phase of the program.Headquarters, ATSC, agreed to institute a survey to evaluate its adequacy as itwas presently operated.
2. Headquarters, ATSC, also agreed to make an additionaleffort to determine the
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extent and nature of the problem of industrial dermatoses bycompilation of reports to be securedfrom consultant dermatologists.
3. Any one of several hand cleansers was consideredacceptable, and none of them could be regarded per se as the cause ofdermatitis. Recommendations for standardization of these agents was notconsidered advisable.
Pressures engendered by the final campaigns of the warexplained why these plans were not carried through to definitive conclusions.
DISTRIBUTION AND ADMINISTRATIVE MANAGEMENT OF
SKIN DISEASES IN ZONE OF INTERIOR
Induction Centers
As might have been expected, diseases of the skin encounteredin inductees occurred in about the same proportions and were of about the samecharacter as in civilian practice. Some men who wished to avoid military serviceoveremphasized their dermatoses. Others who wished to serve tried tounderemphasize them and gave incomplete or misleading histories of past skintroubles.
There were few established policies for the acceptance orrejection of men with these diseases. Many physicians on examining boards, atleast early in the war, tended to recommend for induction candidates with avariety of skin diseases, on the ground that a trial of military life wasjustifiable. As time passed, it became evident that a decidedly less liberalpolicy would have been wiser and would have eliminated a heavy burden on Armydispensary and hospital facilities. Experience showed that soldiers withextensive psoriasis, significant atopic dermatitis and related allergicdiseases, extensive seborrheic dermatitis, severe acne involving the face andupper trunk, and chronic eczematous eruptions of the hands and feet were seldomable to do full duty. These men constituted problems in the Zone of Interior andconstituted more difficult problems when they were sent overseas, especially totropical areas. The burden on outpatient dispensaries and the long periods ofhospitalization that many of them required far outweighed the military effortcontributed by the small numbers able to do general or limited duty.
The literature before the United States entered World War IIcontained numerous studies of the incidence and age distribution of diseases ofthe skin but none of them dealt with diseases in the age group (18 to 45 years)encountered at induction stations. Lt. (later Maj.) Eugene S. Bereston, MC, andLt. (later Capt.) Edward M. Ceccolini, MC, remedied the deficiency in 1943 by astudy of the incidence of dermatoses in 20,000 men who passed through the U.S.Army Recruiting and Induction Station at Tacoma, Wash., in both the enlistmentand selective service systems.11
11Bereston, E. S., and Ceccolini, E. M.: Incidence ofDermatoses in 20,000 Army Induction Examinations. With Note on Syphilis WithNegative Serologic Reactions. Arch. Dermat. & Syph. 47: 844-848, June1943.
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All the men were examined stripped, with at least ordinarycare, but not by physicians with any special dermatologic training. One ofthe points made in the report of the investigation, in fact, is that aconsultation dermatologic service that could have been called upon as neededwould have been extremely helpful.
In these 20,000 candidates for induction into the Army,733 (3.67 percent of the total number) were found to have diseases of the skin,12 but of these, only 44 (6.00 percent of those with skin diseases and0.22 percent of the total number of candidates) were rejectedfor diseases of the skin as compared with 4,650 (23.25 percent) of the totalnumber rejected for all causes. Some candidates with skin diseases were, ofcourse, rejected for other causes.
The 733 men with skin diseases presented 77 differentclinical entities, the most common of which (except for dermatophytosis ofthe feet and small pigmented and nonpigmented nevi) are shown in table 101.Generalized psoriasis was the chief cause for rejection in the group of skindiseases, with disseminated neurodermatitis second and neurofibromatosisthird. Other causes of rejection, in addition to those tabulated and discussedin footnote 11, were parapsoriasis (2 of 5 cases); epithelioma of the lip (4 of4 cases); latent syphilis (3 of 3 cases); squamouscell epithelioma of the eyelid (1 case); epithelioma of the penis (l case);generalized combined vascular and pigmented nevus (1 case); sarcoma (1 case); andepidermolysis bullosa (1 case).
Dispensaries
Most soldiers with dermatologic complaints were first seenat sick call. They were usually treated in company or training camp dispensariesthat were staffed by one or more medical officers without any training indermatology and with only limited facilities for treatment.
There was considerable variation in policy regarding theduration of dispensary treatment. In some camps, the patients were treateddaily, often for several weeks,until they were cured (at least relatively) or were incapacitated fromovertreatment. In others, patientswith even simple and uncomplicated dermatoses, such as mild dermatophytosis,were promptly referred to the outpatient departments of station or regionalhospitals. Their management depended to some degree on whether medicalofficers qualified in dermatology were on the staffs of the station or regionalhospitals to which they would be sent. As in civilian practice, some medicalofficers without special training in it were interested in dermatology and somewere not.
12Included in this number are nine cases of central nervoussystem syphilis, one of which was an instance of dementia paralytica. Thesecases deserve special comment. All occurred in selectees who, before comingto this station, had had negative complement fixation or precipitation reactiontests reported by their local draft boards. It is not unusual, in centralnervous system syphilis, to encounter positive clinical findings with negativeserologic reactions.
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Diseases in order of frequency | Number of cases | Number of rejections |
Acne vulgaris | 248 | 0 |
Psoriasis | 55 | 11 |
Pyoderma | 35 | 0 |
Tinea | 27 | 0 |
Varicose eczema | 20 | 0 |
Neurodermatitis disseminata | 20 | 3 |
Lipoma | 18 | 0 |
Sebaceous cyst | 18 | 0 |
Seborrheic dermatitis | 17 | 1 |
Naevus flammeus | 17 | 1 |
Neurodermatitis, localized | 15 | 0 |
Neurofibromatosis | 14 | 2 |
Rosacea | 14 | 0 |
Contact dermatitis | 12 | 0 |
Giant pigmented nevus | 12 | 0 |
Scabies | 11 | 0 |
Pilonidal sinus | 11 | 3 |
Vitiligo | 10 | 0 |
Ichthyosis | 9 | 0 |
Source: Bereston, E. S., and Ceccolini, E. M.: Incidence ofDermatoses in 20,000 Army Induction Examinations, With Note on Syphilis WithNegative Serologic Reactions. Arch. Dermat. & Syph. 47: 844-848, June 1943.
It soon became evident, however, that most medical officershad no familiarity with even the most common forms of dermatitis. Overtreatmentof minor dermatologic diseases at the dispensary level, particularlyovertreatment of scabies, inflammatory eruptions of the feet, insect bites, andcontact dermatitis, was therefore distressingly frequent and frequently producedmajor disabilities. The situation was not helped by the self-treatment practicedby the soldiers themselves. It should also be noted that if there was noqualified dermatologist at the station hospital to which the patient wasreferred, his referral to it did not insure him care superior to that he wasreceiving at the camp dispensary.
An analysis of the referral slipsaccompanying the patients sent to one station hospital,considered typical, showed that most dispensary medical officers were inclinedto diagnose all eruptions of the hands and feet as fungal. Others madeconscientious efforts to single out patients who could be treated in the campdispensary on an ambulatory basis and referred others selectively to thedermatologic clinic of adjacent station hospitals. Frequently, an informalliaison was established between the dermatologist at thehospital, if there was one on the staff, and medical officers in the field, tothe benefit of all concerned.
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Station Hospitals
Although during the training period station hospitals werethe most important units from the standpoint of dermatologic care, almost noprovisions for it were originally made in them. Dermatologic care was entirelyinadequate when it was most needed. As already mentioned, about 20 percent ofall dermatologists who came into service expressed a preference for the Army AirForces, and the majority of the remainder were assigned to general hospitals inthe Zone of Interior or to units going overseas. Only a smallnumber were left for duty in station hospitals, in most ofwhich a medical officer became a dermatologist simply byorder of the commanding officer.
From November 1940 to the middle of 1943, station hospitalssupporting the various training camps in the Zone of Interior were much moreimportant in meeting the problem of dermatologic disability than were generalhospitals. Yet in late 1942, not a single qualified dermatologist was on thestaffs of the hospitals caring for the large numbers of troops in training inLouisiana, and this situation was not unusual.
An occasional patient with severe, intractable, or obscurecutaneous disease was sent from the camp dispensary to a general hospital or,later in the war, to a regional hospital, but most patients with skin diseaseswere sent to station hospitals from dispensaries. The number referred to generalhospitals from station hospitals was in inverse ratio to the skill andexperience of the medical officers handling dermatologic conditions in thestation hospitals. By this time, personnel in the Office of The Surgeon General,as well as surgeons of the service commands, fully recognized the importance ofdermatologic care at station hospitals and tried to staff them accordingly, buttheir efforts, as already indicated, were seldom effective (p. 560).
One of the major responsibilities of station hospitals wasthe physical reclassification of inductees. Their staffs had the authority torecommend a man's change of status from full combat duty to limited service,as well as to recommend his discharge from service. After his induction, asoldier with a dermatosis first came to the attention of the medical officer inhis unit either through his own professed inability to perform his duties orthrough detection of this inability by his superiors. When, usually after sometreatment at the company dispensary, he was referred to a station hospital, hewas either observed and treated tentatively on an ambulatory basis or washospitalized at once for investigation. If it was determined, after carefulexamination, that his dermatologic condition warranted a change of status, hewas recommended to the hospital disposition board, by the officers who hadexamined him, for reclassification for limited duty or for discharge from theArmy. The procedure described was eventually streamlined, at least in comparisonto the earlier routine, but it was always long, costly, and cumbersome, and asalready pointed out, much time and
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effort would have been saved if men with certain skinconditions had been rejected when they appeared at the induction station.
There were several reasons why it was difficult to determinewhether a man with skin disease was able to perform full duty or limited duty orshould be discharged from service. One was that if he wished to escape fullcombat duty or to be separated from service, he could achieve his desire simplyby aggravating his objective findings by vigorous scratching or by theapplication of irritating local agents.
It became clear early in the training period that medicalpractice in the treatment of soldiers with skin diseases on a duty status wasquite different in an army in active training and a peacetime army. A soldierwith partly disabling dermatitis in a combat unit had to be fit for full duty orclassified as not fit for duty at all. Early hospitalization was necessary forsoldiers with dermatoses that were disabling, contagious, or so extensive as tomake dispensary and self-treatment impractical. Once the situation wasrecognized, admissions for dermatologic disease constituted an increasingproportion (from 6 to 12 percent) of all admissions to station hospitals,depending upon the time of year and the part of the country in which thehospitals were located. Annual reports13 from variousstation hospitals bear out these remarks. Many of them were located in areas inwhich climatic conditions were ideal for the development of a high incidence ofdisabling dermatoses.
Camp Polk, La.-Maneuvers were conductedin Louisiana during August and September 1941 for a total of 53 days. Duringthis period, 4,391 patients were admitted to the stationhospital at Camp Polk, which had a bed capacity of 600 and an expansion capacityof 804 beds. Gastroenteritis came first in the 10 leading causes of admission,but cutaneous diseases of various types came next, including dermatitis ofvarious origins, dermatophytoses, pyogenic infections, insect bites withcomplications, eczematous dermatitides, scabies, pediculosis, and contactdermatitis of various types, including that caused by poison ivy. Thedermatologic clinic set up to handle these patients registered 1,030 new patients in 1942 and 1,040 in 1943, when there were31,553 hospital admissions. In the 1943 report, it was noted that delays of 4 to8 weeks occurred before [dermatologic] patients could be transferred to generalhospitals.
Camp Livingston, La.-At Camp Livingston, La., in 1942, 788patients were hospitalized on the dermatologic section that had been set up inthe station hospital, and 1,629 were hospitalized in 1943.The 858 hospitalized in 1944 constituted9 percent of the total admissions. In 1943, 6,137 dermatologic patients wereseen in consultation, and in 1944, there were 9,547 visits to the outpatientclinic. Many uncommon dermatoses were observed, including systemic lupuserythematosus, leprosy, hidradenitis suppurative,
13When it is evident from the textthat an annual report is the source for thematerial presented, no footnote reference is furnished for such source.
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Fox-Fordyce disease, creeping eruption, epidermolysis bullosa,scleroderma, and prurigo nodularis. This was a burden far too heavy to becarried by a medical officer without special qualifications in dermatology.
Camp Shelby, Miss.-The station hospital at Camp Shelby,Miss., treated patients with skin diseases on a separateward in the medical section in 1941 but did not establish a dermatology sectionuntil 1942. During the latter year, 453 patients were seen in the outpatientdermatology clinic. In 1943, 1,126 wereseen in this clinic, about 19.7 percentof the total number of outpatients (5,699), and a figuresecond only to the neuropsychiatric visits.
Fort Bragg, N.C.-The station hospitalat Fort Bragg, N.C., had 3,438 beds, which could be expanded to 4,469, and hadother facilities for the care of about 75,000 troops in training. Diseases ofthe skin were first cared for entirely in the camp dispensary, but in 1942,three wards were established for the care of patients with these conditions, anda special clinic organization was also established. In 1943, a total of 1,721 patients were admitted to the dermatologic wards, 4,801were seen in consultation, and 5,370 were treated in the outpatient clinic. Thishospital had facilities for superficial X-ray therapy, and 851 treatments weregiven in 1942. A qualifieddermatologist was assigned to the staff early in the training period, butmost of his time had to be devoted to the diagnosis andtreatment of syphilis and other venereal diseases.
Regional Hospitals
After regional hospitals were organized in the Zone ofInterior, in the middle of 1944, an effort was made to assign qualifieddermatologists to them, with priorities second only to certain named generalhospitals and units going overseas. Excellent dermatologic services wereeventually established in most of them.
The experience of the regional hospital at Camp Lee, Va., maybe cited as typical. During 1945,when the average camp census was about 25,000 men, 2,884dermatologic patients were seen, an average of about 9 new patients per day. Thedistribution of diseases appears in table 102. The unusually high incidence ofscabies is explained by the fact that many of the patients had returned fromEurope, where this condition was extremely frequent (p. 631). Before 1945, theincidence of scabies in station and regional hospitals was not more than 1 or 2percent.
Staging Areas
Dermatologic conditions instation hospitals in staging areas presented rather special problems. Theexperience at Camp Kilmer, N.J., was typical:
Between its opening in June 1942 and 1 September 1945, thishospital admitted 52,788 patients, 38,209 to themedical service, and 2,968, about
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575
6 percent of the total admissions, to the dermatology wards.In addition, 7,183 patients were observed in the dermatology outpatientclinic.
Every soldier who arrived at this camp was immediatelyexamined by a medical officer and was reexamined 48 hours before he wasscheduled for departure. The second inspection sometimes disclosed dermatosesthat had originally been mild but that had recently become aggravated to such adegree that the soldier had to request treatment just as his unit was preparingto go overseas. At this point, the medical officer had to make an important andoften difficult decision: It was his responsibility to send men forward withtheir units, but it was also his responsibility to hold back men who could notperform full duty. This was a decision that required wide experience and soundjudgment and that involved more than strictly medical considerations. Theindividual's importance to his unit also had to be taken into account; it wasmuch more difficult, for instance, to replace a trained technical sergeant thana private. It is worth noting that the majority of men in this group did notattempt to remain behind; most of them, even when their dermatoses wererelatively severe, pleaded to be allowed to proceed with their units.
General Hospitals
The function of named general hospitals in the Zone ofInterior was to provide definitive care for all types of patients. For thisreason, patients with difficult diagnostic and therapeutic dermatologic problemswere referred to them. Later in the war, when patients began to be evacuatedfrom oversea theaters and were sent directly to general hospitals, Zone ofInterior patients with special problems were sent to regional hospitals, leavingthe bed space in general hospitals for patients from overseas.
In 1941, when Reserve officers who werequalified dermatologists began to come into service, general hospitals weregiven a high priority in their assignment, and the majority of these hospitalshad excellent dermatology and syphilology sections during most of the war. Inmany instances, the dermatologist first assigned to a particular hospitalremained in it until the end of the war; commanding officers were understandablyreluctant to release qualified specialists for whom there were no suitablereplacements.
In 1945, Moore General Hospital,Swannanoa, N.C., and Harmon General Hospital, Longview, Tex., were designated astropical disease centers. Both had large, well-staffed dermatology sections, andit was planned that these general hospitals, as well as six others, should bedesignated as dermatology centers and that the best qualified dermatologistsavailable should be assigned to them. The war ended before these plans could beimplemented.
The dermatologic experiences of several general hospitals inthe Zone of Interior are worth relating in some detail.
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LaGarde General Hospital.-The first dermatology section onthe medical service of a general hospital in the Zone ofInterior was set up in the summer of 1941 at LaGarde General Hospital, NewOrleans, La., with Capt. (later Maj.) Robert Stolar, MC, as chief of thesection. Captain Stolar remained in this assignment throughout the war. As inother hospitals, dermatology had originally been part of the urology service,but the chiefs of the medical and surgical services decided, wisely andpromptly, that this was a totally illogical arrangement, and as just noted, aseparate dermatology section was established without delay.
LaGarde General Hospital was located in a city that was aseaport as well as an important rail center. Many trainingareas were in Louisiana and other adjacent States, and during the training periodand later, this hospital received large numbers ofpatients who required specializeddermatologic care. During the same period, it also received patients from theCaribbean Command and the Panama Canal Zone, and it therefore had a largerdermatologicsection during the last half of 1941 and all of 1942 than other generalhospitals. The annual report for 1942 records 10,800 visits to the dermatologyoutpatient clinic, and the 1943 report shows an average of 1,075 visits permonthto this clinic.
By 1944, the routine of diagnosis and treatment was well established at this hospital, and the reportfor this year emphasizesseveral points:
1. All dermatologic conditions, as well as all primary andsecondary syphilis, were treated onthe dermatology and syphilology section. Darkfield apparatuswas obtained for use on these wards, and examinations were made on them ratherthan in the laboratory. Patients with tertiary syphilis were admitted to othersections, depending upon the particular system involved.
2. Early in the year, a number of patients with neurosyphiliswere treated with fever (malaria) therapy. This modality was discontinued withthe establishment of neurosyphilis centers. The therapy of syphilis underwent anotable change with the introduction of penicillin.
3. The variety of skin diseases encountered was challengingand instructive. Biopsy was frequently necessary for diagnosis, and manypathologic examinations were made.
4. The number of fungal infections conformed to the generalimpression that cutaneous conditions of this origin were less frequent than hadgenerally been supposed.
5. The incidence of psychosomatic manifestations in the formof skin disease was impressive.
6. Cold quartz ultraviolet light therapy, as well as otherforms of therapy, produced good results, and most patientswere returned to duty.
Brooke General Hospital.-At Brooke General Hospital, FortSam Houston, Tex., the dermatology section of the medical service in 1943consisted of an 84-bed ward and an outpatientclinic, in which soldiers and their
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civilian dependents were seen daily. As many dermatoses aspossible were treated on an outpatient basis. The admission rate to the hospitalvaried with the season of the year but averaged 110 per month. During the springand summer, when field units were maneuvering in the vicinity, the admissionrate was high. Most admissions were for fungal infections, pyodermas, andcontact dermatoses, chiefly caused by poison ivy (Rhus toxicodendron).
In addition to standard equipment, the dermatology sectionhad three large tubs available, in a separate room, for medicated baths. Theequipment of the clinical laboratory, on the floor below, was used for fungal cultures and other diagnosticprocedures. The radiology and physical therapy sections cooperated closely withthe dermatology section. All X-ray therapy was administered by the radiologydepartment, but the indications for it and the dosage were the province of thedermatologist.
Walter Reed General Hospital.-In 1943,patients with skin conditions were hospitalized at Walter Reed General Hospital,on the communicable disease section, under the supervision of Maj. (later Lt.Col.) Zeno N. Korth, MC, who also conductedthe dermatology clinic. This clinic operated 4 mornings aweek and had 3,341 new patients during the year. X-raytherapy was administered by the radiology department. In 1943, 2,550 patientsreceived 5,025 treatments.
Foster General Hospital.-When Foster General Hospital,Jackson, Miss., began to receive patients in September 1943, a dermatologysection was part of its original table of organization. The workload was alwaysheavy. In 1944, 1,508 patients werehospitalized on this section, and 1,125 others were seenin consultation from surrounding posts and station hospitals. Microscopicstudies and cultures for fungi were carried out, and biopsies and other standarddiagnostic procedures were performed as indicated. The most frequentdermatologic conditions encountered were trichophytosisand acne vulgaris. The disease of greatest interest in 1944 was so-called NewGuinea dermatitis, a then obscure and puzzling type of dermatitis apparentlyendemic in this part of the Pacific Ocean Areas and later diagnosed as atypicallichen planus (p. 638).
The chief of the dermatology section gave numerousdemonstrations in the hospital and also provided instruction in dermatologicdiseases here and elsewhere.
Harmon General Hospital.-Harmon General Hospital did notbecome operational until December 1942, and dermatology is not mentioned in itsannual report for that year. In 1943, the report states that there were 400admissions, with 366 dispositions, to its 66-bed dermatology section. Visits tothe dermatology outpatient clinic averaged 100 per month. By 1944, thedermatology section had expanded to 8 wards, and there were 1,142 admissionswith 908 dispositions. The highest daily census was 315. The 2 medicalofficers assigned to the section also saw 822 patients in consultation
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on other services and supervised the X-ray treatments (422)of 182 patients. Many patients with resistant chronic dermatoses showed greatimprovement after superficial X-ray therapy.
In March 1945, Harmon General Hospital was designated atropical disease center, with dermatology a subdivision. The report covering theperiod from 1 January to 1 Novemberof that year showed 1,053 admissions to the dermatology section, with an averagedaily census in September of more than 500 patients. By this time, many patientswere being received who did not need intensive dermatologic care; their originalcondition had improved with the elimination of the etiologic factors andpredisposing causes of the diseases after the end of the war in the Pacific andtheir evacuation to the Zone of Interior. Their disposition, usually by furlough to convalescent hospitals, wasrapidly accomplished.
Among the wide range of dermatoses seen at Harmon GeneralHospital were bacterial infections; cutaneous ulcers, some with Corynebacteriumdiphtheriae as the etiologic factor (p. 607); and the variety of dermatitis latertraced to the use of Atabrine (p. 646).
The variety of dermatoses observed at this hospital and theconcentration of patients there provided, theoretically, opportunities for closeand prolonged study and created a field for many investigations. There wereseveral reasons why the opportunities were not utilized. One was thesmall number of dermatologists on the section, whoseprofessional duties kept them fully occupied. Another was the constantly highcensus, which generated an urgency for the rapid turnover of patients, toprovide bed space for others. Still another was the pressure created by the endof the war, which required rapid demobilization of patients with the imminentclosing of the hospital. It is unfortunate that a planned, well-controlledseries of studies was not possible; such an investigation could have opened upavenues of further research that would have resulted in important advances inmilitary dermatology.
Lovell General Hospital.-Little dermatology was done atLovell General Hospital, Fort Devens, Mass., during 1941. During 1942, thesection had 123 admissions for both skin diseases and syphilis. The skinconditions more frequently encountered were eczematoid dermatitis,dermatophytosis, disseminated neurodermatitis, and seborrheic eczema. In mostinstances, these conditions were difficult to handle because they were chronicand had been treated-and often overtreated-for many months in dispensariesand station hospitals.
In 1944, Lovell General Hospital became a 4,000-bed hospital, with an allotment of500 beds for the dermatology section. It was one of the hospitals that wasdesignated, the following year, as a dermatology center but did not becomeoperational because of the end of the war.
During 1945, of the 22,923 admissions to the hospitals, 2,068were to the dermatology section, and from 10 to 15 new patients were seen dailyin
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the outpatient clinic. This was another section that wasconstantly under pressure because of the heavy influx of patients. It wasimperative to handle these incoming patients as promptly as possible, to clearthe beds for other patients. The annual report for 1945 mentions with regretthat, chiefly because of these pressures and because of understaffing, thewealth of dermatologic materials available could not be handled asscientifically as it should have been.
Fitzsimons General Hospital.-Between June 1943 and latein 1945, most of the patients on the dermatology service at Fitzsimons GeneralHospital, Denver, Colo., were evacuated directly to it from various overseahospitals because of incapacitating disease. Between 1 July 1944 and 1 July1945, there were 969 admissions to the dermatologic section and 5,652consultations. The peak dermatologic load occurred in January and February 1945,when the ward census reached 154 and the average monthly admissions were 120.
The survey of the various diseases observed in this hospitalmade at the end of the war by Lt. Col. Arthur R. Woodburne, MC, Chief of theDermatology Section, is discussed under appropriate sections elsewhere. Many ofthe patients flown directly to the hospital from overseas, especially from theSouthwest Pacific Area and the China-Burma-India theater, could be held longenough for careful observation and definitive treatment. An interesting featureof this survey concerned the skin diseases common in civilian dermatologicpractice but altered by military conditions.
DISTRIBUTION AND ADMINISTRATIVE MANAGEMENT OF
SKIN DISEASES IN OVERSEA COMMANDS
Mediterranean Theater of Operations
With the notable exception of plant dermatitis, the majordermatologic problems in the North African (later Mediterranean) theaterparalleled those encountered in troops under similar conditions of deployment inthe Zone of Interior. In order of prevalence, they included bacterialinfections; fungal infections; dermatitis of unknown etiology, includingpsoriasis, lichen planus, erythema multiforme, and the eczemas; dermatitis ofknown etiology, including dermatitis venenata, dermatitis medicamentosa, andinfectious eczematoid dermatitis; and parasitic infections. The majority ofthese were bacterial infections, in which penicillin proved a valuable agent, fungalinfections, and parasitic infections. A considerable number of cases ofcutaneous diphtheria were observed in North Africa. Details of special diseasesare commented on under appropriate headings.
Not very many trained troops were lost to duty in theMediterranean theater because of skin diseases. A survey of 3,030 patientshospitalized for
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these conditions in 4 general hospitals showed that 95.75percent were returned to full duty after treatment.
European Theater of Operations
In the European theater, the proportion of admissions tohospitals for dermatologic conditions was at first similar to what it would bein civilian hospitals in peacetime except for the higher incidence of scabies(p. 631). When the care of battle casualties became of major importance, thenumber of dermatologic conditions increased in all categories because of theincreased troop strength in the theater. Because of the pressing need formanpower, the pressure to return patients with medical diseases to duty was evengreater than it had been before D-day.
The incidence of disability from skin diseases wassignificant in the European theater but not excessive as it was in the PacificOcean Areas and the China-Burma-India theater. Certain personally collectedstatistics will make this clear:
In the 21st Evacuation Hospital, from 26 December 1942 to 5 March1943, 10percent of all medical admissions were to the dermatology section and 30 percentof all dermatologic admissions were for scabies.
In the 5th General Hospital, during the latter part of 1942,6.8 percent of 7,049 admissions were for the primary diagnosis of skin disease.
In all hospitals of the European theater, during November andDecember 1943, 7.2 percent (1,035) of 14,408 admissions were for skindisease.
Interviews with medical officers in the European theaterrevealed that the incidence of skin disease at sick call in both service andcombat units ranged from 15 to 40 percent. Medical officers in the Mediterraneantheater reported about the same proportions.
Syphilis.-Venereal diseases (fig. 64) are dealt withextensively in other volumes of this historical series,14 but certainaspects of therapy in the European theater should also be mentioned here:
1. All patients with ulcerative venereal disease wereadmitted to the dermatosyphilology sections of hospitals, to insure moreaccurate diagnosis and adequate treatment. The responsibility for their carerested with the Professional Services Division, Office of the Chief Surgeon, butclose liaison was maintained with the Preventive Medicine Division.
2. Individual treatment records were issued, which werecarried on his person by the individual soldier. They served as guides tomedical officers when, as often happened, syphilis registers were nottransferred from unit to unit.
14(1) Medical Department, United States Army. InternalMedicine in World War II. Volume I. Activities of Medical Consultants. Washington: U.S.Government Printing Office, 1961, pp. 281-318. (2) Medical Department, United StatesArmy. Internal Medicine inWorld War II. Volume II. Infectious Diseases. Washington: U.S. GovernmentPrinting Office,1963, pp. 409-435.
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3. All syphilis registers of presumably cured patients weresubmitted to examination at the Medical Records Division, Office of the ChiefSurgeon, by the Consultant in Dermatology and Syphilology before they weretransferred from the theater to the Office of The Surgeon General. Deficiencies,which consisted of inadequate treatment or insufficient evidence of cure, couldthus be detected and corrected at once.
4. Massive arsenotherapy was introduced into the theaterearly in 1943. Between April 1943 and July 1944, approximately 4,000patients were treated by this technique; the absence of fatalities proved thevalue of careful supervision.15 The technique was criticized later in somequarters
15See footnote 14 (1), p. 580.
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because of presumed infectious relapses, but the experiencewas fairly comparable to the experience after penicillin therapy was introduced;biologic cure was frequently achieved, but reinfection on subsequent exposurewas common.
5. Penicillin therapy for early syphilis was officiallyintroduced into the theater on 26 June 1944, 20 days after D-day. In January1944, it had been recommended that penicillin be used for the treatment ofsyphilis in operational Air Forces crews in the theater, but permission wasrefused by the Air Surgeon in Washington.
6. One of the most impressive figures to come out of the Armymedical experience in World War II is the man-days lost because of venerealdisease as compared with the figures for the American Expeditionary Forces inWorld War I.16 For 1918, in World War I, the figure was 6,804,818 days, almost19,000 men per day per year. For 1944, the comparable figure in the Europeantheater was 221,184 days, a rate of 606 men per day per year. Over half of theWorld War II figures covered the period before the introduction of penicillin.
Southwest Pacific Area
Incidence.-Dr. Hopkins, in his report to General Denitafter his survey of installations in the Southwest Pacific Area,17 statedthat time had not permitted extensive microscopic or cultural studies. It hadalso not been possible to obtain statistical data concerning the incidence ofdiseases observed in his survey because the number of troops from which thehospitalized patients were drawn could seldom be determined. His conclusionswere therefore based on extensive discussions with medical officers who hadstudied these diseases; on clinical examination of numerous patients; and onmycologic examination of a few representative samples.
It was Dr. Hopkins' impression that the majority ofpatients who were hospitalized in the Southwest Pacific Area for severe skinconditions fell into two groups. The first, and larger, group of hospitalizedpatients had what was termed "symmetrical eczematoid dermatitis." Thesecond group of hospitalized patients had what was termed "atypical lichenplanus." Other men in the Southwest Pacific Area, who constituted an evenlarger group than those hospitalized, presented characteristic blue pigmentationof the nail beds. They had no symptoms, and they reported for treatment only when they became disturbed by the cosmetic appearanceof their nails.
Although these three groups of skin conditions bore someresemblance to well-known dermatoses, none of them seemed precisely identifiablewith
16Medical Department of the United States Army in the WorldWar. Communicable and Other Diseases. Washington: U.S. Government Printing Office, 1928, pp. 263-310.
17Unless otherwise indicated, the discussion of dermatologicdiseases, presented for the Southwest Pacific Area throughout this chapter, isbased on Dr. Hopkins' report to General Denit, submitted on 13 March 1945. Seefootnote 8, p. 557.
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any disease which Dr. Hopkins, an experienced dermatologistand mycologist, had previously observed. It was his conclusion that theyrepresented either three new clinical entities or three phases of a single newentity.
An analysis of all patients admitted to the dermatology wardsof the 27th General Hospital, Hollandia, New Guinea, from 1 August 1944 to 7 July 1945 by Maj. (later Lt. Col.) Charles L. Schmitt, MC,Chief of the Dermatology Section, showed that 1,820 had been observed duringthis period. Of this number, 1,182, more than two-thirds, were returned to duty,and 636 were boarded to the Zone of Interior. There were two deaths, one fromexfoliative dermatitis. The cause of the other death was not stated.
Investigation of these 1,820 cases showed that a considerablenumber previously diagnosed as dermatophytosis and dermatitis venenata were inreality early eczematoid dermatoses and were due, at least in part, to a drugintolerance. The investigation also showed that drug intolerance represented theprincipal cause for boarding patients to the Zone of Interior.
In this single hospital, for the 11-month period studied,38,430 mandays were lost from duty because of skin diseases.
Recommendations.-At the conclusion ofhis survey of skin conditions in the Southwest Pacific Area, in his letter toGeneral Denit, dated 13 March 1945, Dr. Hopkins made a number of suggestions,many of which were generally applicable, as follows:
1. Mycologic problems in the Southwest Pacific Area would notbe solved until one or two mycologists competent in research were sent to thearea. They must be provided with technical assistance, the necessary apparatusand media, and dustproof rooms for inoculation and preservation of cultures.
2. For accurate diagnosis of fungal infections (figs. 65,66, 67, and 68), each medical laboratory sent to the Tropics should have on itsstaff an officer sufficiently trained to identify common pathogenic forms offungi. Each hospital should have a technician competent to detect fungi bydirect slide examination.
At the time Dr. Hopkins made his report, there seemed to beonly a single officer in the whole Southwest Pacific Area with any training orexperience in the identification of fungi. In only a single clinic, the 13thMedical Service Detachment, did Dr. Hopkins see practical use made of slideexaminations for diagnosis; here, with the excellent cooperation of the 27thMedical Laboratory, examinations were made promptly and accurately. The samefavorable situation might perhaps prevail in some of the installations that hehad not visited, but in those that he had investigated, he did not encounter asingle dermatologist who believed that he could obtain reliable examinations forfungi. Laboratory officers who were, reluctantly, making cultures for fungistated that they were at a loss to identify any positive cultures that theymight observe.
584
FIGURE 65.-Erythrasma or fungalinfection of thighs.
FIGURE 66.-Acute tinea cruris.
In Dr. Hopkins' opinion, the situation could be correctedat once if a few laboratory officers were trained in mycology before they weresent to the Southwest Pacific Area and if short laboratory courses weresubstituted for the one or two lectures that now seemed to constitute the onlymycologic training given to technicians.
The use of mycologic methods for diagnosis was more importantthan research in this field. Slide examinations would usually be sufficient, butcultures were necessary for the detection ofMonilia and some of the more
585
FIGURE 67.-Typical acutedermatophytosis caused by Trichophytonmentagrophytes.
586
uncommon parasites. The routine use of such techniques wouldimprove the accuracy of diagnosis and eventually result in therapeuticimprovement.
3. As a therapeutic test, 1,000 tubes each of undecylenicacid and sodium propionate ointment should be issued to each of several infantrydivisions, so that division surgeons could report on their effectiveness underfield conditions. Liquid preparations of fatty acids might be similarly tested.
4. Sandals should be issued to infantrymen, for use aspermitted by command after consultation with the medical officers concerned (p.602). It was also recommended that troops be allowed to work during the daywithout shirts at such times and in such areas as were considered safe. Externalinfection might sometimes be a causative factor in dermatophytoses of the groinand other parts of the body, but the prevalence of these eruptions in theSouthwest Pacific Area, just as in the southern United States during the summer,could more reasonably be attributed to the wearing of impervious clothing thatprevented the evaporation of sweat. Giving permission for troops to go nakedduring the sunny hours of the day would probably almost abolish extensiveringworm of the trunk without endangering the antimalarial program and wouldhave an equally good effect on miliaria and the impetigoes. If this plan wasconsidered undesirable, then it was recommended that the fabric used in Armyshirts be changed. Closely woven, uncomfortable herringbone twill might benecessary under combat conditions, but in rear areas, a more loosely wovenfabric, such as was used in the Australian Army, would be preferable.
5. To prevent ecthyma, which was prevalent among troops incombat areas, medical officers and company commanders should be instructed inthe use of Freon-12 aerosol insecticide or DDT for the control of flies. Bothwere practical agents for forward use.
6. To prevent so-called tropical immersion foot (p.600), mineral oil should be issued before landings on wet terrain, and thetroops should be instructed to grease their feet before they went ashore and asoften thereafter as possible. Careful check should be made of the condition ofthe feet and legs of the men thus treated as compared with a control group ofsimilar size without treatment.
7. To prevent disability from acne, medical officers whoexamined troops before embarkation from the Zone of Interior should be informed of the bad prognosis for the cystictype of acne in the Tropics (p. 617) and should be advised against sending menwith this disease to the Southwest Pacific Area.
8. One or more permanent hospitals should be designated forthe treatment of warts by X-ray. A standard technique should be developed fortheir management in dispensaries. Formalin therapy18 wasconsidered well worth a trial.
18Thomson, S.: The Treatmentof Plantar Warts by Formalin. Brit. J. Dermat. 55: 267-269, November1943.
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9. Every effort should be made to clarify the etiology of eczematoiddermatitis, which was the most serious dermatologic problem in the SouthwestPacific Area and the most frequent dermatologic cause for evacuation ofpersonnel from this area to the Zone of Interior. It would be well if some ofthe men evacuated would volunteer to continue suppressive doses of Atabrineafter their return to the United States.
10. The issue of multiple vitamin tablets should be increased, in the hopethat their use might lower the incidence of dermatoses.
11. The following research studies were recommended:
a. Determination of the presence of fungi in the lesions of lichen planus or in symmetrical eczematoid dermatitis, especiallyin the lesions of the nail so frequently seen in New Guinea(p. 643).
b. The frequency of fungal infection as a cause of intertrigo of the toes anddermatitis of the feet.
c. Identification of the species of fungi found in dermatomycoses ondifferent parts of the body.
d. The relation of Monilia albicans to miliaria.
e. The relation of fungal infection to so-called tropical immersion foot.
f. The possibility of sensitization to bacteria or fungi in lichen planusand eczematoid dermatitis with allergies.
China-Burma-India Theater
Venereal diseases.-The venereal disease rate in India among U.S. troopswas one of the highest encountered in any theater or area in World War II. Maj. Harry M. Robinson, Jr., MC,19reported thatone laundry battalion station in Calcutta had a rate of 1,500 per 1,000 peryear. Although syphilis and gonorrhea were the major problems, chancroid andlymphogranuloma venereum were common. It was not unusual for a man to report fortreatment with two, three, or even four separate venereal diseases at the sametime, following several exposures over a short period.
Dermatologists of the 20th, 69th, and 142d General Hospitals played animportant part in the management of these patients. During 1944 and early 1945,one of three wards in each of these hospitals was continuously filled with menwith early syphilis, chancroid, lymphogranuloma venereum, or combinations ofthese diseases. Penicillin became available in the theater for the treatment ofsyphilis in September 1944, but supplies were limited.
Dermatologic diseases.-The major dermatologic problems in Burma and Indiawere quite similar to those encountered in the Southwest Pacific Area.Many skin diseases with a high incidence in the United States were also commonin the China-Burma-India theater. During the hot, humid monsoon season inparticular, primary bacterial infections were widely
19Robinson, H. M., Jr.: Personal communication
588
prevalent, especially ecthyma and bullous impetigo. Secondarybacterial infections of eczematous eruptions, contact dermatitis, and tineapedis were common, and their course was protracted. During the summer months,the incidence of miliaria rose to 75 percent in some units, and the conditionwas often incapacitating. Scabies was an important cause of disability inChinese troops but was uncommon inU.S. Army personnel.
A unique form of contact dermatitis observed in theChina-Burma-Indiatheater was dhobie mark dermatitis (p. 626). Othercutaneous diseases of interest and importance in U.S.personnel included cutaneous diphtheria (p. 613) and the lichenoid andeczematoid dermatitis syndrome caused by Atabrine (p. 638). Among the unusualcutaneous diseases and systemic diseases with cutaneous manifestations seen inChinese troops were leprosy, kala-azar, tuberculosis, syphilis of the bones andother deeper structures, and true tropical phagedenic ulcer associated withmalnutrition. Superficial fungal infections were identical with those that occurin the United States, but they were more frequent, more extensive, and moredifficult to control.
In summary, the effects of the hot, humid climate in Indiaand Burma, plus the skin trauma incidental to active military campaigns andengineering activities in a jungle type of environment, led to a high incidenceof incapacitating cutaneous bacterial infections, miliaria rubra, infectedindolent insect bites, contact dermatitis, superficial fungal infections,eczematoid dermatitis, and cystic acne. In addition, the total disability causedby cutaneous diphtheria, dhobie mark dermatitis, and the lichenoid andeczematoid dermatitis syndrome was significant. Comment is made on certain ofthese conditions under appropriate headings.
Part II. Clinical Considerations
FUNGAL INFECTIONS
General Considerations
Zone of Interior.-The popularimpression that fungal infection was a serious condition in U.S. troops in WorldWar II was universally disproved whenever adequate methods of diagnosis andevaluation were employed. At Fitzsimons General Hospital,20over aperiod of months, all patients hospitalized on the dermatology service werestudied by direct examination of all lesions, fungal cultures, and thetrichophytin test. The generally negative results of this careful study showedthat superficial fungal infections were not a cause of significant disabilityamong troops evacuated to the Zone of Interior because of skin diseases. Similarstudies at other hospitals were to the same effect.
20Woodburne, Lt. Col. Arthur R., MC: Dermatology atFitzsimons General Hospital, n.d.
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At Fitzsimons General Hospital, the incidence ofonychomycosis of the nails was somewhat greater than in civilian practice. Itwas treated by removal of all infected material by nail clippers, files,curettes, and dental burs, after which the fingertips were soaked in soapsuds orin a 20-percent sodium hydroxide solution. Whitfield's ointment, fullstrength, was rubbed vigorously into the nails at night, and the affected partswere painted with a 3-percent iodine solution in the morning.
Mediterranean theater.-In the Mediterranean theater,mycotic infections accounted for about a fifth of all skin diseases, as thefollowing personally collected figures show:21
1. These infections accounted for 16.7 percent of theadmissions and dispositions for skin conditions and for the patients remainingin MTO hospitals in the week ending on 22 September 1944.
2. They accounted for 19.3 percent of all skin diseases inthe Fifth U.S. Army for the same week.
3. They accounted for 21.9 percent of all skin diseases inthe 34th, 85th, and 88th Infantry Divisions for the 3-week periodending on 22 September 1944.
4. They were less frequent in rear echelon troops. Accordingto one survey, they accounted for only 13.3 percent of all the skin conditionstreated in the outpatient dispensary of a large general hospital.
These figures, however, need some explanation before they areaccepted absolutely. The Army figures were collected in September, when fungalinfection was frequent. The outpatient dispensary figures just cited werecollected over a period of several months. Furthermore, a higher incidence offungal infections would be expected in combat troops because of long marches andtheir frequent inability to bathe, remove their shoes, change their socks, anduse foot powder. Nonetheless, the fact that fungal infections accounted for 13.3percent of all skin conditions in an outpatient dispensary in a base section,where living conditions were at least fair and where reasonable personal hygienewas possible, indicated that they were rather prevalent. When field and combatconditions are taken into account, it is small wonder that these conditions wererecorded so frequently and meant the loss of so many man-days. One reason forthe amount of disability they produced lies in the fact that most mycoticinfections involved the feet or the genitocrural region.
Two conditions secondary to primary fungal infection in theMediterranean theater require special comment:
1. In many instances of cellulitis (figs. 69, 70, 71, and72), the portal of entry of the invading organism was a fissure or rupturedvesicle in which dermatophytosis was the original lesion. The primary diseasewas not in
21All data for the Mediterranean theater were provided byDr. R. N. Buchanan, Jr. (formerly Lieutenant Colonel, MC), Dr. R. E. Imhoff(formerly Major, MC), Dr. C. Barrett Kennedy (formerly Major, MC), and Dr.Richard C. Manson (formerly Major, MC).
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FIGURE 69.-Proved leishmaniasis of toe, withnumerous Vincent's spirochetes.
FIGURE 70.-Cutaneous leishmaniasis.
itself disabling, with the secondary condition was potentially serious,likely to be disabling, and very often entirely preventable.
2. Dermatophytids developed in a great many instances of fungal infection.Many patients were sensitized to the products of infection because
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FIGURE 71.-Diphtheria of skin of foot.
the fungal infection had been allowed to persist; to gothrough phases of more or less activity; to become acute, with fissuring andoozing; then to improve but never to heal completely. Often, patients of thistype, when they were received in the Zone of Interior, had not only primarymycotic infections but also eczematous vesicular dermatitis, usually on thepalmar and plantar surfaces, which was quite resistant to treatment. It wasrepeatedly stressed to medical officers that early, appropriate treatment ofprimary fungal and other infections would result in their control and wouldprevent complications. Many of these conditions, unfortunately, resulted fromsensitization by the use of strong fungicidal preparations, particularlyointments issued for use on a duty status.
When soldiers with fungal infections presented themselves onsick call, it was often because of secondary infection, to which primary thera-
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FIGURE 72.-Scrub typhus witheschar.
peutic attention had to be directed. Measures mostfrequently used included compresses and soaks of boric acid solution, dilutepotassium permanganate solution, aluminum acetate solution, or a saturatedsolution of magnesium sulfate. After secondary infection had been controlled,therapeutic measures included Lassar's paste; Whitfield's ointment, halfstrength; keratolytics; a 3-percent sulfur and salicylic acid ointment; 4percent salicylic acid; 2 percent thymol in tincture of benzoin compound; and a5-percent crude tar ointment. Some patients with chronic fungal infections werebenefited by superficial X-ray therapy. When treatment was concluded, thepatient was given a can of GI (Government-issue) foot powder and urged to useit.
Most men with fungal infection seen in the Mediterraneantheater were returned to duty, but occasional patients with chronic diseases anddermatophytid reactions were resistant to all types of therapy. They wereusually evacuated to the Zone of Interior, but only after they had beenhospitalized for long periods of time and spent many days away from their units.
Southwest Pacific Area.-Fungal infections in the SouthwestPacific Area have been discussed in detail elsewhere (p. 582) and will bediscussed further under appropriate headings.
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Inflammatory Conditions of the Feet
Zone of Interior.-The extremely unsatisfactoryterminology of athlete's foot was used by many medical officers to cover awide variety of disturbances of the feet (figs. 73, 74, 75, and 76). Thenomenclature was not scientific. It had no etiologic significance, and it waseven more unreliable as a basis of treatment.
At Fitzsimons General Hospital, after classification andappropriate studies, patients referred with this diagnosis were divided into thefollowing categories and proportions:22
1. The hyperhidrosis (dyshidrosis) syndrome, 51 percent.
2. Pyoderma secondary to trauma, maceration, or the hyperhidrosis(dyshidrosis) syndrome, 14 percent.
3. Dermatophytosis, 20 percent.
4. Dermatitis venenata produced by medication (which hadusually been prescribed for the treatment of the presumed fungal infections), 11percent.
5. Other dermatitis venenata, 2 percent.
6. Resistant pustular eruptions (the so-called bacterid ofAndrews), 1 percent.
7. Pustular psoriasis, 0.5 percent.
8. Acrodermatitis continua of Hallopeau, 0.5 percent.
Hyperhidrosis (fig. 77) was the most frequently observedentity at this hospital. It was psychogenic in origin, and it was seen not onlyon the dermatology wards but also in consultation on neuropsychiatric wards andon other services. It was readily explained by removal of men from their normalenvironment, disciplinary restrictions, their often hazardous living conditions,and similar precipitating causes. The correctness of these theories of etiologywas proved by the fact that a quiet, restful environment, without othertreatment, was frequently sufficient for a cure.
Hyperhidrosis in the Zone of Interior and elsewhere was anannoying and uncomfortable condition, but one that was seldom disabling per se. What made it important was that it was widely prevalentand that the lesions that developed in it constituted portals of entry for secondarybacterial invasion, with resulting and disabling pyoderma, cellulitis,lymphangitis, and lymphadenitis. Another consideration was that the diagnosis offungal infection as the cause of the hyperhidrosis was often made incorrectly,and the strong and irritating fungicidal agents used unnecessarily oftenresulted in severe and disabling dermatitis.
Local therapeutic measures included 20 percent benzoic acidin Lassar's paste; 1:500 solution of formalin used as a soak for a briefperiod once daily; compresses of Burow's solution; and foot powder. Theinclusion
22See footnote 20, p. 588.
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FIGURE 73.-Allergic dermatitis.
FIGURE 74.-Allergic dermatitis.
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FIGURE 75.-Severe fissuringbilateral keratosis of heels. The patient was completely disabled.
FIGURE 76.-Epidermolysisbullosa.
in the supply tables of one or more soluble aluminum salts, such as aluminumchloride or aluminum sulfate, would have provided additional agents for thetreatment of ambulatory patients and would have been useful in preventingrecurrences.
It was the opinion at Fitzsimons General Hospital that elimination of theso-called fungicidal prophylactic footbath and the substitution of indi-
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FIGURE 77.--Hyperhidrosis ofhands.
vidual prophylaxis, including thorough drying of the feet andthe liberal use of foot powder, would have materially decreased the incidence offungal infections of the feet.
Mediterranean theater.-Hyperhidrosis of thefeet was extremely common in the Mediterranean theater where, as elsewhere, itwas associated with emotional stress and strain. It was also secondary tovascular changes, particularly those associated with trenchfoot.23Itwas frequently antecedent to that condition. It was difficult to handle andextremely resistant to treatment. Indeed, it often required reclassification ofthe soldier.
Among the multiple treatments used were painting the areawith straight formalin once daily for 3 days; 1-percent formalin soaks;potassium permanganate soaks; and foot powders, such as tannic acid powder orthe regular-issue foot powder. Lumbar sympathetic ganglionectomy wasoccasionally necessary to convert disabling hyperhidrotic feet to dry andserviceable members.
European theater.-In the Europeantheater, inflammation of the feet, whether from fungal infection (figs. 78, 79,80, and 81), mechanical irritation, sensitivity to footgear, or hyperhidrosis,particularly after mild trenchfoot,24 represented an important aspectof dermatology, because soldiers with any degree of inflammation of the feetwere frequently unable to do full duty either in the rear or in the field.
An epidemic of what was diagnosed as fungal infectionoccurred in July 1943 and well illustrated the factors that can contribute tosuch a condition. Word of the incidence of the infection reached the ears of theCommanding General, SOS, who had had difficulties with a presumed fungal in-
23Medical Department, United StatesArmy. Cold Injury, Ground Type. Washington: U.S. Government PrintingOffice, 1958.
24See footnote 23.
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FIGURE 78.-Typical dry tinea pediscaused by Trichophytonrubrun.
FIGURE 79.-Typical dry tineapedis caused by Trichophytonrubrun.
fection himself and who was correspondingly preoccupied with the problem. TheSenior Consultant in Dermatology was directed to investigate the situation andcorrect it immediately. The circumstances were as follows:
A large detachment of men at Depot G-25 were doing heavy work in themachine shops or elsewhere that often involved long periods of standing
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FIGURE 80.-Secondarily infected interdigital fungal infection.
FIGURE 81.-Symmetrical lividity ofsoles.
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on cold, damp concrete floors. When the depot was visited byMrs. Eleanor Roosevelt in 1942, she apparently heard a number of complaints ofcold feet from the men with whom she talked, and with her usual sympatheticunderstanding, she arranged for heavy British-issue socks to be supplied tothem. These socks were much heavier than any regular U.S.-issue socks, and theyproved very satisfactory during the winter of 1942-43. Over the sameperiod, there was a steady increase in the issue of GI shoes with rubber soles.
In late May and early June 1943, the weather in Englandturned unseasonably warm, and with the change came a precipitous rise in theincidence of inflammatory conditions of the feet at this particular depot.Medical officers reported that between 50 and 75 percentof the soldiers serving there were examined at the post dispensary and showedsome changes, ranging from mild scaling between the toes to more severeinvolvement, with blisters and fissures. It was estimated,without benefit of microscopic examinations and cultures,that about two-thirds of these men were suffering fromtrue ringworm infections, a percentage that, at a distanceof years, now seems somewhat excessive.
In any event, the epidemic was promptlybrought under control by the institution of foot inspections, issue of lighterfootgear, particularly socks, and emphasis upon the importance of foothygiene, including regular washing and careful drying of the feet and theapplication of foot powder.
This minor episode was instructive. It emphasized therelation between proper footgear and climatic and industrial conditions, as wellas the great importance of individual foot hygiene, withspecial relation to thorough drying of the feet,particularly the intertriginous areas, and the regular use of foot powder topromote dryness and prevent friction.
A survey of showers, sterilization ofduckboards, and similar matters showed that they played nopart in the increased incidence of infection at this depotor elsewhere. The provision of chemically treated footbaths servedno useful purpose. In fact, there was some evidence that, ifthe solution in them was not changed regularly, they might serve as a means oftransmitting infection rather than of preventing it. During 1942-43, whenshipping space to the European theater was desperately short, tubs for thesefootbaths were received on a regular schedule. The Consultant in Dermatology,ETOUSA, could not understand why they were ever introduced into Armydermatologic practice.
Southwest Pacific Area.-In base and station hospitals inthe Southwest Pacific Area, well removed from the front, interdigital infectionof the feet accounted for only a small number of cases,fewer, indeed, than might be found in a group of healthy soldiers on activeduty. All these patients had been hospitalized for varying periods, and theirinfections had cleared, with or without treatment. In many cases in which thediagnosis of epidermophytosis had been recorded, Dr. Hopkins found no fungi on
600
examination. He could not, it is true, exclude thepossibility that the eruptions observed were primary fungal infectionssecondarily infected with pyogenic bacteria, but he found very few cases inwhich there seemed a sound basis for this assumption.
In base dispensaries, fungal infections of the feet were farmore frequent than in hospitals, but the incidence was apparently no higher thanin military dispensaries in the Zone of Interior. In regimental aid stations,however, and in clearing companies directly to the rear, fungal infections ofinterdigital areas and of the soles of the feet among troops in combat were farmore numerous and were often severe.
After the Leyte landings, men stood, marched, and even sleptfor long periods in flooded rice paddies. There was a significant amount ofdisability from the resulting dermatoses. Patients were sent back to rearhospitals with the diagnosis of immersion foot (tropicalcold injury),25 though no evidenceof peripheral vascular damage was ever obtained. Dr. Hopkins, whoobtained his information about the condition from Maj. James R. Webster,MC, at the 54th General Hospital, considered the term unfortunate. No fungi wereidentified in the lesions during the acute phase, which suggested that they wereessentially bacterial, but in many instances, fungi were found after acutesymptoms had subsided, which suggested that bacterialinfection was secondary to fungal infection. Whatever the chronology,the essential etiologic factor was maceration of the stratum corneumby prolonged immersion.
Etiology.-Available evidence in both the Zone of Interiorand the Southwest Pacific Area indicated that attacks ofdermatophytosis were almost never caused by externalinfection or by reinfection from shoes or clothing. Probably few men contractedthe infection in the Southwest Pacific Area. More likely, most of them broughtit with them, in latent form, and itsimply flared up under climatic conditions. Acute outbreaks were usually causedby sudden lowering of the natural resistance of the skin, which permitted fungialready present on the surface to multiply. The essential factor was lowering ofresistance by maceration of the skin by sweat or water. It wasa common observation, as already mentioned, that whenpatients were confined to bed for some reason, their dermatophytoses healedwithout treatment.
Apparently some individual immunity existed todermatophytosis of the feet because, in any platoon or company, a certain numberof men, constituting not more than 10 percent of the total number, would neverdevelop the condition though they mingled freely with infected men and for themost part used no special prophylactic measures. The basis of their immunity wasunknown, and Dr. Hopkins considered that a study of it mightbe rewarding.
25See footnote 23, p.596.
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Therapy.-The treatment of dermatophytosis in men on activeduty was frequently ineffective. The tendency was to useirritating fungicides, such as salicylic acid in alcohol,full-strength Whitfield's ointment, and Frazer's solution. These agents werefrequently curative, but they sometimes produced severe irritation and led tothe development of the acute dermatitis seen later in many hospitals.
In a study conducted at Fort Benning, Ga.,26 itwas found that water-soluble ointments prepared fromundecylenic acid or sodium propionate could be used in dermatophytoses withoutthe risk of irritation inherent in the agents just listed.When these ointments were tested at base and station hospitals, the results werefairly satisfactory but not striking. When, however, theywere issued to groups of infantry in combat, results were highlyfavorable. Capt. William B. Guy, MC, for instance, who served as battalionsurgeon with the 136th Infantry, reported, after he had used them for severalweeks, that these ointments had given more prompt relief than any preparationshe had previously used and that they caused no irritation. He thought solutionssomewhat more satisfactory than ointments but was unwilling, because of thebrief period of observation, to commit himself definitely on this point.
In some instances, an ointment containing 5percent undecylenic acid and 10 percent peroxide was usedfor testing purposes, but as a rule, fatty acidpreparations of the following composition were employed:
Sodium propionate ointment: Sodium propionate, 16.4 percent;propionic acid, 3.6 percent; n, propyl alcohol, 10.0 percent; zinc stearate, 5.0percent; and Carbowax base, 65.0 percent.
Undecylenic ointment: Undecylenic acid, 5.0 gm.;triethanolamine, 3.0 gm.; methocel 15 CP, 2.0 gm.; propyleneglycol, 22.0 cc.; zinc stearate, 13.0 gm.; and Carbowax 1500, 55.0grams.
Undecylenic solution: Undecylenic acid, 5.0 gm.;triethanolamine, 3.0 gm.; ethyl alcohol, 30.0 cc.; and propylene glycol, 62.0cubic centimeters.
Prophylaxis.-Dermatophytosis of the feet, as alreadyindicated, was seldom disabling in itself in rear areas.Practically all the patients hospitalized with it either had secondaryinfections or had been so overtreated that their lesions had become eczematized.The number of such cases was, unfortunately, quite large. Under combatconditions, in which men had little opportunity to care for their feet and couldnot remove their shoes for days at a time, a significant amount of completedisability apparently occurred, though Dr. Hopkins did not consider hisinvestigation of troops in combat sufficient to warrant generalizations.
Tests of prophylactic measures were also not conclusive:
1. Nothing at all was achieved by measures aimed atpreventing con-
26Grauer, Franklin H., Helms, Samuel T., andIngalls, Theodore H.: Skin Infections. In Medical Department, United States Army. Preventive Medicine in World War II. Volume V.Communicable Diseases. Washington: U.S. Government Printing Office, 1960, pp. 83-125.
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tagion, such as the use of hypochlorite footbaths ordisinfection of shoes, socks, and shower room floors.27
2. At Fort Benning, systematic attempts were made to preventrecurrences of dermatophytosis by prolonged treatment after manifestations hadsubsided. They failed utterly, as might have been expected. Experiences withattempted surgical disinfection of the hands have always shown that it isimpossible to rid the skin of Staphylococcus; the application ofantiseptics simply reduces the number of organisms present. It was found equallyimpossible to rid the skin of fungi; once the infection had occurred, it wasunlikely that the application of any fungicide would destroy all the sporespresent.
3. Even under combat conditions, if the terrain was dry and the dermatophytosis was latent or very slight, theuse of a mild fungicide, such as regular-issue foot powder, seemed reasonablyeffective in preventing severe outbreaks. It was also more comfortable andconvenient to use routinely than were ointments. Whatever the explanation, theuse of this powder seemed to prevent fungi from multiplying to the point atwhich they would become troublesome.
Civilian experience had showed that painting the toes onceweekly with Frazer's solution was even more effective than the use offungicidal powder in preventing recurrent attacks of dermatophytosis, but thismeasure was aimed at the suppression of latent infection, not at cure. Reportsfrom dispensaries and hospitals indicated that it was effective in chroniccases. It was often irritating in active infections and therefore was notsuitable for the emergency relief of acute conditions, though it was included injungle kits for this purpose.
4. All the evidence indicated that the most effectiveprophylaxis in dermatophytosis of the feet was strict skin hygiene, which meantkeeping the skin as dry as possible, provision of ways for evaporation of sweat,and direct exposure to sunlight for its tonic and sterilizing effects.
A convincing controlled study along these lines was conductedby Maj. (later Lt. Col.) Laurence Irving, Chief,Physiology Section, Headquarters, Eglin Field, Fla.28Sandals were issued to approximately 1,000 men, who were permitted to wearthem on the post as much as they wished; most of them practically gave upwearing shoes. A similar number of men wore shoes asusual. Within a month, the proportion of severe dermatophytoses inmen wearing sandals fell from 30 to 3 percent, while in the control group, thedisease remained as troublesome as usual.
A similar study was conducted in New Guinea, while the 43d Infantry Division was in a rest area. Some 300 men with unclassified skin diseases, many of whom undoubtedly had dermatophytosis of the feet, were kept on the beach for 4 hours daily, without clothing or shoes. They bathed, exer-
27See footnote 26, p. 601.
28See footnote 26, p. 601.
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cised, or just lay in the sun as they wished. Within a month,the majority of infections had cleared without any other treatment.
Any measures adopted in the Southwest Pacific Area forprophylaxis of skin conditions had to avoid serious interference with theantimalarial program or with the protection against hookworm and otherparasites. These considerations made the wearing of sandals impractical in manyareas, though it was entirely practical in New Guinea for men on ground duty onairstrips and in headquarters. In the Philippines, the plan was consideredpractical during the dry season except for troops in combat or training forcombat. In most areas, it seemed safe to expose the feet during the middle ofthe day; they would never be more exposed to mosquito bites than the face, neck,and hands were exposed at all times. The use of thick-soled sandals, with somesort of guard in the toe to prevent scuffing up of dirt, would afford reasonableprotection against hookworm. The plan seemed worth a trial to Dr. Hopkins. Hebelieved that the issuance of sandals to the majority of troops, with permissionto wear them in areas and during hours defined by the surgeon in charge, wouldbe the most effective measure that could be adopted for the prevention ofdermatophytosis of the feet. When the ground was extremely muddy, this plan, ofcourse, was impractical from any point of view.
5. Comparative tests of undecylenic acid ointment, sodiumpropionate ointment, and regular-issue foot powder during the landings atLingayen in the Philippines were too fragmentary to permit conclusions, but Dr.Hopkins believed that a full field test with them was warranted. In all suchtests, it had to be remembered that any study that involved self-treatment wassubject to error, beginning with doubt as to whether the agents issued were usedat all.
Other Dematophytoses
Dermatophytosis of the hands.-Dermatophytic infection ofthe skin of the hands was extremely infrequent. Dr. Hopkins saw only 1 provedinstance in his survey of SWPA installations, and in a study that he haddirected at Fort Benning, of 1,472 cases in which dermatophytes were isolated,the hands were involved only twice.
Eczematous eruptions frequently seen on the hands in theSouthwest Pacific Area and frequently diagnosed as dermatophytids were not soregarded by Dr. Hopkins because they were far more exudative and far moreinflammatory than true dermatophytids and also because they occurred in manysoldiers with no visible mycoticlesions of the feet. He did not exclude the possibility of a mycotic origin, buthe considered it highly improbable.
Even in the Southwest Pacific Area, dermatophytosis of thehands was not of military significance.
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Dermatophytosis of the groin-Dermatophytosis of the groin(tinea cruris) had a high incidence in the Southwest Pacific Area, especiallyamong troops in combat or in active training. While it was seldom the cause ofcomplete disability or an indication for hospitalization, it was a frequentsource of great discomfort, and it handicapped many men in the performance oftheir duties.
No extensive trials of therapy were made in the SouthwestPacific Area, but in the cases of tinea cruris treated under Dr. Hopkins'direction at Fort Benning, undecylenic acid and sodium propionate proved assatisfactory for the treatment of lesions in this location as it had proved forsimilar lesions on the feet.
Dermatophytosis of the trunk andextremities.-Widespread involvement of the skin of the trunk, arms, and legs(tinea corporis) was frequently encountered in the Southwest Pacific Area andwas sometimes severe enough to require hospitalization. In almost everydermatologic ward that Dr. Hopkins visited, he found 3 or 4 patients withgeneralized ringworm in each 100 to 200 patients. The condition was no more severe, however, and the incidence was probably nohigher, than at Fort Benning during August and September. The condition was ofmilitary significance in the Southwest Pacific Area chiefly because it wasperennial.
The growth of fungi on the skin of the trunk and limbs seemedto depend upon the presence of unevaporated sweat, which was related, in turn,to the wearing of clothing in hot, humid weather. The effect of clothing on thedistribution of these infections was strikingly illustrated in a group of some700 prisoners of war, among whom there were almost 100 cases of extensive tineacorporis. Most of the prisoners had confluent lesions extending from the ankleto the knee, a distribution seldom observed in U.S. troops. Questioning revealedthat these men had worn spiral cloth puttees, which most certainly increasedsweating and prevented evaporation of sweat on the lower legs. In U.S. soldiers,the eruption was often concentrated in a band about the belt and over thebuttocks, where there were several layers of clothing.
Dr. Hopkins had little success in identifying the species offungi responsible for tinea corporis in the Southwest Pacific Area. His visitsto hospitals were brief, and cultures had to be made and studied in laboratorieshoused in temporary buildings or tents, without assistants trained in mycology.Reliable mycologic work was impossible under such conditions. In a total groupof 13 positive cultures, 2 of which were isolated by Lt. Walter L. Barksdale,SnC, 10 were Trichophyton gypseum, 2 Trichophyton purpureum, and1 Epidermophyton floccosum (inguinale). Thesefindings were in sharp contrast to those obtained in a study at Fort Benning:In 62 cultures of tinea corporis, 68 percent were T.purpureum and 32 percent E. floccosum; T. gypseum was not represented. In 198positive
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cultures in dermatophytosis of the groin, 36 percent were T. purpureum, 62 percent E. floccosum, and only 2percent T. gypseum.
These differences, of course, are not statisticallysignificant. It was also noted in the Southwest Pacific Area, however, that, indermatophytosis of the body, a pattern was frequentlyobserved of small, well-defined annular lesions. Lessoften, there were large areas of involvement, with serpiginousborders, corresponding to the type frequently observed in Georgia. It wasthought that these differences might be corrected with the species of causativefungus present. The observations in the Southwest PacificArea, though few, confirmed the opinions expressed by Lieutenant Barksdaleand a Navy colleague that dermatophytoses seen in the Pacific were caused by thesame fungi that caused similar lesions in temperate climates.
The best therapy of tinea corporis was the application ofgentian violet, wet boric acid solutions, or undecylenic acid or sodiumpropionate ointment until the acute inflammation had subsided. Then Frazer'ssolution was applied, or tincture of iodine, or a solution of 3 percentsalicylic acid in Mercresin (mercocresols).
Dermatophytosis of the beard-Dr.Hopkins saw only one instance of tinea barbae in a U.S.hospital in the Southwest Pacific Area. The culture was positive for T.purpureum. He observed two additional cases in an Australianhospital.
Tinea versicolor-Tinea versicolor was frequently observed atFitzsimons General Hospital in troops received fromtropical oversea theaters.29 The eruption usually disappearedpromptly after the application of an ointment consisting of 3 percent salicylicacid and from 6 to 8 percent ammoniated mercury in a standard emulsion base.Treatment was continued for several weeks, until all evidence of infection haddisappeared.
Tinea versicolor was also extremely prevalent in theSouthwest Pacific Area. It presented no military problem,since it seldom caused symptoms, and most men complained only of thediscoloration of the skin. If the body had been exposed to sun, the usualcoloration was reversed; the involved areas appeared white against the tannedareas of normal skin. Some native physicians, for obvious reasons, called thecondition tinea alba. Some explained it by the growth of saprophytic molds onthe skin, with consequent protection of it fromultraviolet rays.
Tinea versicolor in the Tropics was undoubtedly the samedisease that was observed in temperate climates, but in the Tropics, it was morefrequent as an acute eruption of small, round macules.
Scrapings from representative cases showed a fungusindistinguishable from the Malassezia furfur foundin temperate climates. Dr. Hopkins observeda typical case of achromia parasitica in a Philippine child, whose
29See footnote 20, p. 588.
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lesions resembled tinea versicolor, though they were lessscaly. Malassezia could not be demonstrated.
Applications of saturated solution of sodium thiosulfate,followed by a 3-percent aqueous solution of tartaric acid, were often effective.Lesions refractory to this method were painted with 3 percent iodine in spiritsof camphor. The disease was more resistant to treatment in the Southwest PacificArea than it was in temperate climates.
Tinea imbricata.- Tinea imbricata was extremely common innatives of New Guinea but does not seem to have beenreported in either United States or Australian troops. The disease was readilyidentified by the beautiful, scroll-like patterns that often covered the trunkand extremities. If it was of longstanding, this pattern changed to sheets of large rhomboidal scales, firmlyadherent at the center but free at the border.
On slide examination, an astonishing amount of delicatebranching mycelium was found in these scales. Cultivation of the causativeorganism, Endodermophyton tropicale, was difficult because it is slowgrowing and flora of the Papuan epidermis proved extremely luxuriant. The fewcultures resembling this parasite that were isolated were sent to the UnitedStates for identification.
Australian physicians reported that tinea imbricata haddisappeared in natives employed to spray pools with Diesel oil, an observationthat was confirmed by several U.S. medical officers. Dr. Hopkins suggestedfurther investigation of the possible fungicidal properties of Diesel oil.
Otomycosis
Otomycosis (otitis externa) was a frequent diagnosis inpatients received from tropical oversea theaters, but hospitals such asFitzsimons General Hospital reported that the diagnosis could seldom if ever beconfirmed by culture of pathogenic fungi.30 The opinion ofdermatologists in the Zone of Interior was that none of these patients hadfungal infections of the external auditory canal but that, instead, they couldbe divided into two groups, a larger group composed of those with seborrheicdermatitis and another composed of those with eczematous dermatitis caused bymaceration of the skin, collections of cutaneous debris, and secondary pyogenicinfections.
Otitis externa was reported to be prevalent in the PacificOcean Areas31 but was seldomobserved on dermatologic wards. Dr. Hopkins had the opportunity to study a smallnumber of patients with this condition at the 37th General Hospital, where Capt.A. Reas Anneberg, MC, had separated them into two groups. In the first group,the clinical diagnosis of otomycosis was made because a fluffy mycelium wasvisible on the surface of the aural
30See footnote 20, p. 588.
31Medical Department, United States Army. Surgery In WorldWar II. Ophthalmology and Otolaryngology. Washington: U.S.Government Printing Office, 1957, pp. 417-426.
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canal. Aspergillus (species not identified) wasdemonstrated on slide examination, and the response to undecylenic ointment wasgood and was even better when peroxide of hydrogen was added to it. The secondgroup of cases was characterized by fissures, exudation, and crusting, and fungiwere not found on slide examination. These patients, whose disease was assumedto be of bacterial origin, responded well to penicillin ointment.
Dr. Hopkins' opinion, which was concurredin by many otolaryngologists in the area,32 was that mostof the reported cases diagnosed as otomycosis were not fungal infections, thougha sizable number were. He believed that fatty acidsoffered a more satisfactory treatment for them than any method previously usedand recommended a systematic trial of these agents.
BACTERIAL DISEASES
General Considerations
Bacterial infections of the skin (figs. 82, 83, and 84) werepresent in all theaters, and the experience of theMediterranean theater may be described as typical. In this theater, theprincipal etiologic agent in the largest number of such cases was Staphylococcusor Streptococcus. Bacterial infections were consistently responsiblefor the highest morbidity rates in statistics collected from representativehospitals, and in a spot check of three divisions for the 3-week period endingon 22 September 1944, they were found responsible for 69.6 percent of lostman-days. A considerable number were also caused by Corynebacteriumdiphtheriae (p. 614).
The high incidence of bacterial infections is easy to explain-irregularbathing habits; the difficulties of access to, or lack of access to, facilitiesfor personal hygiene; irritation of the skin by rough clothing; exposure to oilsand greases; minor traumatic abrasions incidental to combat; insects bites,which were frequent; patronizing civilian barber shops; and mingling with thenative population.
Bacterial infections in the Mediterranean theater fell intotwo chief groups:
1. Cellulitis, which had its highest incidence in fieldtroops because of lack of facilities for personal hygiene; antecedenttrichophytosis, whether treated or untreated; and antecedent insect bites andtrauma, including trauma from ill-fitting shoes.
2. Furunculosis, which was extremely frequent, again becauseof lack of facilities for personal hygiene; the high incidence of scabiesreported from all dispensaries and other installations; and repeated chronicreinfections from equipment and clothing.
32See footnote 31, p. 606.
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FIGURE 82.-Epidermophytosis with eczematoid dermatitis.
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FIGURE 84.-Recurrenterysipeloid infection of lower leg.
Diagnosis of bacterial infections was made by clinicalobservation, supplemented by laboratory studies (smearsand cultures), which were carried outwhenever practical before therapy of any kind was instituted. A survey of50 bacterial infections at one general hospital revealed that 6 distinct groupsof diseases were present, including sycosis vulgaris, impetigo contagiosa,impetiginous dermatitis, secondarily infected trichophytosis pedis, generalizedfurunculosis, in addition to a small group of miscellaneous conditions. In 48of the 50 cases, the predominant organism cultured was Staphylococcusaureus haemolyticus. Streptococcus haemolyticus, which was the sole organism cultured in 2 cases, was alsopresent in 11 of these 48 cases.
Penicillin, which became available in the spring of 1944,proved remarkably effective in the treatment ofcarbuncles and miscellaneous staph-
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ylococcic and streptococcic infections of the skin andsubcutaneous tissues. The usual effective dose was 1 million units given in25,000-unit doses every 3 hours intramuscularly for 5 days or until obviousregression of the lesions. In the 50 cases just described culturally, cure wasachieved in 43, and only 4 were entirely unimproved. In 90 cases treated bypenicillin in another general hospital, the period of hospitalization wasshortened on an average of 12 days per case as compared with 124 cases in whichpenicillin was not employed. Hot compresses, local antiseptics, and topicalsulfonamide therapy were used in conjunction with penicillin therapy, and whennecessary, accumulations of pus were incised and drained.
Ecthyma
Zone of Interior.-Ecthyma was one of themost frequent causes of disability in men evacuated fromoverseas to Fitzsimons General Hospital.33 The lesions were chiefly on thelegs, ankles, and feet, though they also appeared on other portions of the body.Questioning revealed that important antecedent causes wereinsect bites, small scratches, abrasions, and cuts, particularly cuts caused bycoral in the Southwest Pacific Area. Apparently any small abrasion, whenconstantly macerated by perspiration and infected with surface organisms, could produce ecthymatousulcers.C. diphtheriae was cultured from the lesions of some patients evacuatedfrom the Mediterranean theater, the China-Burma-India theater, and the PacificOcean Areas.
Most ecthymas cleared up promptly in the cool, dry climate ofDenver. Local treatment consisted of cleansing with soap and water, simple boricacid dressings, and the application of 3-percent ammoniated mercury ointment. Specificmedications were unnecessary in most cases, but penicillin parenterally,sulfadiazine orally, or both agents in combination were useful in lesionssurrounded by a considerable inflammatory response. Ulcerated areas that wereclean but were slow in healing were sometimes managed by the application of Unna'sgelatin boot.
Southwest Pacific Area.-Dr. Hopkins, who discussedecthyma and tropical ulcer under the same heading, noted that ecthyma wasusually a mixed infection caused by hemolytic streptococci and hemolyticstaphylococci. Unlike impetigo, which was confined to the stratum corneum,ecthyma invaded the deeper epidermis and, at times, the cutis. It usually tookthe form of discrete lesions covered with a thick crust and somewhat underminedat the border. The location of the lesions on the lower legs and the dorsum ofthe feet suggested that venous stasis might be a possible factor, though similarlesions were frequently observed on the dorsum of the hands, on the arms, and,occasionally, on the trunk.
33See footnote 20, p. 588.
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Deeper ecthymatous lesions often became persistent ulcers.All lesions diagnosed as tropical ulcer that Dr. Hopkins observed in U.S. troopshe regarded as deep ecthyma and unrelated to the destructive ulcers seen in thenative population.
Ecthyma usually resulted from infection of an insignificantscratch or insect bite. It was extraordinarily prevalent among U.S. troops onthe Rosario Front in the Philippines; Dr. Hopkins was informed by battalionofficers that, exclusive of battle wounds, 70 to 80 percent of the men whoattended sick call complained of these lesions. At the time of his survey, flieswere an uncontrollable plague and were probably the chief factor in spreadingthe infection, for they promptly attacked any exposed bleeding or exudingsurface. Two situations explained the presence of flies in such numbers-therehad been no time to construct latrines, and enemy dead and dead animals wereoften inadequately buried because of shellfire.
Bed rest was apparently the most important component oftreatment. Healing was usually satisfactory if the part were kept elevated andcovered with boric acid dressings. Ambulant patients treated with mercurialantiseptics and sulfonamides improved only moderately. The application of iodineand other irritating solutions caused dermatitis.
Penicillin, however, produced spectacularly good results.Hospitalized patients were treated with penicillin solutions applied as wetdressings. This technique was less practical for ambulant patients, but equallygood results were obtained by another method: Crusts were removed as thoroughly(and as atraumatically) as possible, by cutting them off or by wiping them offafter they had been moistened with water or peroxide of hydrogen. Penicillinincorporated in a water-miscible base was then applied in a thick layer, whichwas covered by a gauze dressing. The patient was instructed to keep the dressingmoist with water from his canteen. The effect of a wet dressing was thusobtained with the expenditure of only a small amount of penicillin, which wasusually in short supply. As soon as exudation was ended, ointment was applieduntil healing was complete. Exposure to sunlight was helpful during the laterstages of healing if covering was not necessary for protection from flies.Whenever practical, the dressing was changed at least once daily, and more oftenif practical. Every medical officer interviewed by Dr. Hopkins regarded thistechnique with great favor.
Good results were also reported from the use of penicillin inlanolin or in combinations of lanolin and petrolatum. In general, however,ointments with these bases were not well tolerated in the climate of theSouthwest Pacific Area. Droplets of penicillin emulsified in a continuous phaseof oil seemed to reach the skin less effectively than in an emulsion in whichthe continuous phase was aqueous.
The prophylaxis of ecthyma was based on cleaning any visiblescratch or traumatic lesion with soap and water. An antiseptic was sometimesadded. The use of iodine was not recommended, as it destroyed tissue and
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created foci of lowered resistance. Tincture of Merthiolate(thimerosal), Mercresin, and tincture of Zephiran (bensalkonium chloride) werepreferable. In the special circumstances that prevailed on the Rosario Front,control of flies was extremely important. Fairly effective protection againstthem could be obtained, as well as protection against mosquitoes, if the foxholewas covered with a shelter half or a bit of thatch and if a Freon-12 aerosol"bomb" was used. It was found at aid stations that if a bandage wassprayed with Freon-12 aerosol insecticide (the so-called "mosquitobomb") before it was removed and the wound or inflamed area was sprayed assoon as it was exposed, flies could usually be kept from contact with thelesion. DDT was not available until later, but it was thought that it would beeven more effective. Under battle conditions, men were prone to neglect anythingthey considered unessential to their safety, but if they were properlyinstructed and were provided with the mosquito bomb, it was found that they werelikely to use it.
Impetigo
Ordinary impetigo of the face was frequently encountered inthe Southwest Pacific Area under battleconditions. Numerous lesions of the toes and feet that were essentiallyimpetiginous were also encountered. These lesions occurred on the face in theform of large, discrete pustules, which ruptured quickly, in contrast to lesionson the feet, which tended to remain intact and to penetrate the underlying softtissues. A survey of dermatoses in the 43d Infantry Division by Capt. Charles S.D'Avanzo, MC, showed that theytended to occur most frequently in men who sweated excessively. It was generallyobserved that inadequately treated impetigo tended to persist longer in theTropics than in temperate climates.
Another eruption, variously called tropical impetigo, pyosisMansoni, or bullous impetigo, was widely prevalent. The characteristic lesionwas a flaccid bulla, from 5 to 8 millimeters in diameter, filled with thick,purulent fluid, often without surrounding erythema. These lesions occurred in groups, especially just below the axillary fold and inand below the groin. They appeared only on the parts of the body covered byclothing. Cultures were reported to show Staphylococcus aureus, andclinically the lesions resembled the type of staphylococcic impetigo observed introublesome epidemics in the newborn. It was Dr. Hopkins' opinion thatso-called tropical impetigo resulted from excessive sweating and was closelyrelated to skin conditions of miliarian etiology. He did not consider contagionimportant. He observed a number of extremely interesting generalized eruptionson the trunk that appeared to be circinate impetigo. They simulateddermatophytosis of the trunk so closely that differential diagnosis wasdifficult. No fungi could be found after repeated search.
Treatment directed toward aeration of the skin and preventionof sweating was apparently much more important in the management of these
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cases than the application of antiseptics. When circumstancespermitted, patients were allowed to remove their shirts and take short sunbaths.Bathing the skin with a mild antiseptic or antipruritic lotion was useful, aswas the use of talc or foot powder. In obstinate cases, rupture of the bullaeand painting of their bases with 10 percent silver nitrate usually effected acure.
Pyogenic Intertrigo of the Feet and Groin
Many of the intertrigos of the feet in the Southwest PacificArea that were inflamed and troublesome were apparently pyogenic in origin,though the general assumption was that the infection was secondary to anoriginal fungal infection. Dr. Hopkins thought there was little reason for thisassumption, since fungi could seldom be demonstrated.
Reliable differentiation of these lesions fromdermatophytosis was impossible without laboratory study, which was frequentlynot practical (p. 604). Certain clinical criteria, however, were useful: Thelesions were more likely to be pyogenic than mycotic if (1) the patient sufferedfrom hyperhidrosis; (2) the inflammation was more pronounced on the dorsal thanon the plantar aspect of the feet; (3) there was about equal involvement of allthe toes; (4) the skin was red and edematous and there was weeping from pinpointvesicles; (5) the patient complained of pain rather than itching; and (6)pustules were present on the dorsum or the sole.
Without facilities for laboratory diagnosis, the best planwas to treat these very common dermatoses of the feet with penicillin ointmentor wet dressings and to resort to fungicides only if there was no improvement oronly slight improvement. Instances were observed in which a change of therapyfrom penicillin to fungicides resulted in prompt cures of hitherto refractorylesions. Since the causes of intertrigo of the feet were probably the same asthose of dermatophytosis, the same methods of prophylaxis were employed.
Intertrigos of the groin of pyogenic and seborrheic originrather than mycotic origin were rather frequently encountered.
Diphtheria34
Zone of Interior-In the detailedstudy of skin conditions made at Foster General Hospital, it was found that inindolent cutaneous ulcers organisms of the diphtheria group, which in mostinstances were biologically avirulent, could often be recovered. In August 1945,a special investigation of cutaneous diphtheria and tropical ulcers included asurvey of all incoming patients with medical and dermatologic conditions. Thesepatients were studied bacteriologically and by the Schick test, and specialattention was
34McGuinness, Aims C.:Diphtheria. In Medical Dcpartment, United States Army. PreventiveMedicine in World War II. Volume IV. CommunicableDiseases. Washington: U.S. Government Printing Office, 1958, pp. 167-189.
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paid to those received from tropical theaters. All hospitalpersonnel were also Schick tested.
Of 70 patients admitted to isolation wards because of theproved or suspected presence of diphtheria bacilli, 56 had ulcerative lesions.Two patients with faucial diphtheria were identified in this group, and 12suspected or proved faucial carriers were found.
Therapy of the ulcerative lesions consisted of dressings ofphysiologic salt solution; local or parenteral penicillintherapy; or combined local and parenteral penicillin therapy. Local applicationof penicillin was generally the preferable treatment.
Mediterranean theater-In a survey of bacterial lesions in6 hospitals in the Mediterranean theater, 32 cases were found in whichthe diagnosis of cutaneous diphtheria had been made. Although this was a ratherlarge number of cases in itself, it was thought that the condition was even morefrequent than the figures suggested and that additional instances would be foundif there were a more diligent effort to culture the organisms, especially whenfaucial diphtheria was present in the local area. Of the 32 patients,2 died, both of myocarditis, and 2 others survived serious complications(myocarditis with cardiac failure, peripheral neuritis).
Nothing in the clinical appearance of a diphtheritic ulcerdistinguished it from other ulcers. Diagnosis was possible only by culture, butcertain suggestive observations were made:
1. The lesions were painful when they were exposed to air.
2. The lymphatics draining the ulcers showed noninflammatoryhypertrophy in the form of thickened vocal cords.
3. The regional lymph nodes were enlarged.
4. All forms of therapy failed except penicillin.
Most instances of diphtheria in the Mediterranean theateroccurred before penicillin became generally available. Itwas important to remember that this agent so altered thebacterial flora of cutaneous ulcers that cultures positive for C. diphtheriaecould not be obtained. In other words, a man might have cutaneous diphtheriaand might be improving under penicillin therapy but at the same time beharboring toxins from which polyneuritis, myocarditis, and other seriouscomplications might develop.
Once the diagnosis of diphtheria was established, 100,000units of diphtheria antitoxin were given. If the patient demonstrated any of theclinical features typical of absorption of diphtheria toxins, and if he had acutaneous lesion possibly caused by C. diphtheriae, the antitoxin wasgiven without waiting for the results of cultures.
European theater-Diphtheria cutis occurred in the Europeantheater but was uncommon as compared with its incidence in thePacific Ocean Areas and the China-Burma-India theater. The small number ofcases, however, engendered lack of suspicion, and there were sometimes dangerousdelays in diagnosis. In one of the first cases observed in the theater, for
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instance, myocarditis appeared before it was realized that anulcer on the genitalia was diphtheritic and not an unusual type of venerealdisease.
Southwest Pacific Area.-In his survey of dermatologicdisease in the Southwest Pacific Area, Dr. Hopkinsobserved that at several bases virulent diphtheria bacilli had been recoveredfrom chronic ulcers resembling those usually described as ecthyma (p. 610). Hebelieved that several other exceptionally deep and necrotic ulcers that heobserved might also be of the same origin. There was little doubt that theparalyses reported in these cases were diphtheritic. Major Webster, at the 13thGeneral Hospital, was able to recover diphtheria bacilli from eczematouslesions of the eyebrow, paronychia of the toe, suppurating keratosis of theheel, and otitis externa. Brigadier Robert M. B. MacKenna, RAMC, ConsultingDermatologist to the British Army, made a study of diphtheria of the skin inIraq in 1944.35 He reported acutebullous diphtheria on the basis of previous erythema; diphtheritic cellulitisthat often went on to ulceration; and a chronic type of cutaneous diphtheriathat simulated infectious eczematoid dermatitis.
Diphtheria bacilli were seldom isolated from cutaneouslesions in the Southwest Pacific Area, except in patients known to have beenexposed to pharyngeal diphtheria. Mixed streptococcic-staphylococcic infectionscould produce ulcers clinically indistinguishable from most of those from whichthe Klebs-L?ffler bacillus was recovered. It was Dr. Hopkins' opinion that thebacilli found in most cutaneous lesions in the Southwest Pacific Area weresecondary invaders and that, if there was sufficient exposure, they could infectany severely damaged area of skin. He doubted that they could invade normalskin. Their presence sometimes seemed to have no effect on the clinical picture,but they sometimes increased the severity and chronicity of the lesions, and ina few instances, they seemed responsible for regional or distant paralyses.
Most diphtheritic infections of the skin responded well todressings wet with penicillin solution. Some healed only after antitoxin wasgiven. Brigadier MacKenna recommended the use of antitoxin in all cases, but Dr.Hopkins did not consider the information then available (1944-45) sufficientlyconclusive to warrant the recommendation of definitive policies. Heemphasized the risk of contagion, considering skin lesionsat least as dangerous as pharyngeal diphtheria as a sourceof infection, and perhaps more dangerous.
China-Burma-India theater.-The whole group of tropicaldermatoses was of little significance in China-Burma-India as regards totaldisability except for cutaneous diphtheria, which canproperly be classified as a tropical disease since it is very much more commonin hot, humid climates than in temperate climates. In this theater in the summerof 1944, during and after the Myitkyina campaign, its incidence reachedepidemic proportions. Capt. (later Maj.) Harvey Blank, MC, Chief of Dermatologyand
35MacKenna, R. M. B.: Notes on Military Dermatology. Brit. J. Dermat. 56: 1-11, January 1944.
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Syphilology at the 69th General Hospital, reported 70 cases,and Major Livingood and his associates observed 140 at the 20th GeneralHospital.36 In most instances, the disease was contracted initiallyin Burma, but later cases were contracted in Assam, and some occurred inhospital personnel who were attending infected patients.
Cutaneous diphtheria occurs in epidemic form under thefollowing circumstances:
1. A significant percentage of exposed individuals must besusceptible to the infection.
2. There must be a source of diphtheritic infection. Amongmilitary personnel, the source was either the native population or a highcarrier rate in their group.
3. Factors must exist which make for multiple superficialtraumata to the skin. Poor personal hygiene and close personal contact mustprevail.
All these circumstances were present in the Mitykyina combatarea during the campaign which began in the latter part of May 1944 and endedthe first week of August 1944. The high incidence of leech and other insectbites and the constant maceration of the skin, combined with lack of bathing andlaundry facilities, predisposed to superficial abrasions and cutaneous infections of all types. The epidemic of cutaneous diphtheria that ensuedreached its height during combatactivities and the hot, humid monsoon (rainy) season, and decreased after thecessation of fighting, the advent of cooler weather, and improved facilities forpersonal hygiene.
According to Captain Blank, neurologic complications occurredin about 40 percent of all cases of cutaneous diphtheria, and cardiaccomplications occurred in about 5 percent. Other studies bore out these figures.37There were two deaths, both caused by myocarditis.
Almost all patients with cutaneous diphtheria required atleast 4 months of hospitalization before their return to duty. The slow healingof the lesions was characteristic. On the average, skin ulcers persisted forabout 3 months. In 6 of the 140 patients observed at the 20th General Hospital,the lesions were still unhealed at the end of 6 months.
It should be emphasized that almost all the patients whocontracted diphtheria in the China-Burma-India theater had secondarydiphtheritic infection of skin lesions, such as insect bites. None of them hadfaucial diphtheria, and diphtheritic infection of surgical wounds was extremelyuncommon.
36Livingood, C. S., Perry, D. J., and Forrester, J. S.:Cutaneous Diphtheria: A Report of 140 Cases. J. Invest. Dermat. 7: 341-364,December 1946.
37(1) Gaskill, H. S., and Korb, M.: Occurrence ofMultiple Neuritis in Cases of Cutaneous Diphtheria. Arch. Neurol. &Psychiat. 55: 559-572, June 1946. (2) Kay, C. F., and Livingood, C. S.:Myocardial Complications of CutaneousDiphtheria. Am. Heart J. 31: 744-756, June 1946.
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Acne
Zone of Interior.-The survey of skin conditions (fig. 85)at Fitzsimons General Hospital38 showedoily skins and seborrheic dermatitis to be less frequent there than in similarcivilian groups, probably because of the vigorous outdoor activity that was apart of military life in the United States. Acne vulgaris (often called tropicalacne) was, however, definitely activated by military service in the Tropics,particularly in older men, many of whom were returned from overseas to thishospital.
A typical history revealed that the patient had had sometrouble with blackheads and acneiform lesions when he was 15 to 18 years of age,but none since, including his period of training in the Zone of Interior.Trouble began, however, some 6 months after his arrival in the Southwest PacificArea or some other tropical area. The first manifestation was the development oflarge, tender, inflammatory cystic lesions on the shoulder and back, which madeit impossible to carry a pack. After he was treated for a considerable time bythe battalion surgeon, sometimes in a forward hospital and occasionally in ageneral hospital, the patient was evacuated to the Zone of Interior.
Such patients, on their arrival, presented the usualcombination of comedones, papulopustular lesions, and numerous deep,inflammatory, tender cystic lesions from which oily, purulent material could beexpressed. Many lesions, particularly on the dorsal surface of the neck,shoulders, hips, and thighs, hadbecome confluent. Extension over the buttocks and over the dorsal and lateralsurfaces of the thighs was not uncommon in these patients, though such anextension is seldom observed in acne vulgaris seen in civilian practice.
Most acne vulgaris observed at Fitzsimons General Hospitaloriginated in tropical theaters, in combat troops who had been deprived ofproper bathing facilities and who had been in an environment characterized byextreme heat and poor hygienic conditions for long periods of time. This diseasewas not observed in supply or garrison troops evacuated from tropical theatersor in men evacuated from the European theater. In that theater, it was acondition of no consequence.
Southwest Pacific Area.-In his survey of skin conditions inthe Southwest Pacific Area in 1944-45, Dr. Hopkins was impressed with thecomplications that could arise from the type of acnecharacterized by double comedones and cysts, even in men who had had littletrouble with acne in civilian life. The original lesions became very large,exquisitely tender, and suppurative. If packs werecarried, the infected cysts often ruptured, and rupturewas followed by painful ulceration.
Treatment was not satisfactory. The care required to evacuate and dress multiple individual lesions was more than could be afforded in a mili-
38See footnote 20, p. 588.
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tary hospital. Some men were returned to duty afterdrainage of the suppurative lesions and treatment with sunbaths, hotpacks, anddrying lotions, but relapses were prompt. In Dr. Hopkins' opinion, the SWPApolicy of hospitalization of men with relatively mild acne was unwise. Hebelieved that they should be kept on duty as long as possible and that, if thelesions became severe enough to require hospitalization, immediate return to theZone of Interior was preferable,because of the risk of relapse after any treatment.
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China-Burma-India theater.-The experiences in Burma andIndia with acne was much the same as in the SouthwestPacific Area. There was a notable tendency for the condition, particularly thecystic type (acne conglobata), to increase in severity after affectedindividuals had been overseas for a short time. The development of large,painful cystic lesions on the shoulders, back, neck, and face resulted invarying degrees of disability. It was necessary to hospitalize many of thesepatients for prolonged periods. Exacerbations were common after theyhad been returned to duty, and it soon became obvious that the best course tofollow was the evacuation of men with severe cystic acne to the Zone ofInterior.
Miliaria
The condition loosely known as prickly heat (fig. 86) was oneof the three dermatologic diseases most frequently encountered in the Tropics,and all Army and Navy dermatologic statistics placed it near the top of thelist.39 It was also something of a problem in the Zone of Interior.
Zone of Interior.-The clinicalpicture of miliaria in the Zone of Interior was usually typical. Theeruption, which was originally confined to the flexural and intertriginous areas of the body, was a brightly erythematous, follicular,vesicopapular dermatitis. It tended to flare up during the heat of the day and subside atnight. Pruritus was usually intense, and many patients also complained ofsevere burning. As time passed without treatment, the eruptions became moreand more extensive and, after varying periods, failed to involute during thenight. Its character also changed; it became more inflammatory and morefixed, and individual lesions appeared as single hypertrophic sweat glands. Whenperspiration was excessive, the papules were capped with small, hard vesicles.
Miliaria was one of the conditions associated withdysfunction of the sweat apparatus that were not incapacitating in themselvesbut that had a propensity for damaging the protective barriers of the skinand thus increasing the tendency to both mycotic and pyogenic infection.Impetigo contagiosa and bullous impetigo were frequent complications.
Southwest Pacific Area.-Miliaria was widely prevalentand extremely troublesome in the Southwest Pacific Area. British observers,according to Dr. Hopkins, considered it to be a Monilia infection,and it was generally believed to be caused by sodium depletion. He consideredboth theories worth further investigation.
The usual routine of management was exposure to air and sunand application of drying and cooling lotions. No form of therapy was reallysatisfactory.
According to Dr. Hopkins, a condition generally known asheat rash was even more common in the Southwest Pacific Area than true vesicular
39The others were Atabrine dermatitis and bacterialinfections.
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miliaria. It took the form of blotchy, red, wheal-likeeruptions that appeared suddenly on the trunk after exposure to heat. Thecondition was not described in texts, and he thought that both etiology andtherapy should be investigated.
DERMATITIS VENENATA
Zone of Interior.-Contact dermatitis(figs. 87, 88, 89, and 90) was a rather frequent form of disability in soldiersobserved in outpatient clinics and on dermatologic sections in Zone of Interiorhospitals. As a rule, a single agent was responsible for only small numbers ofcases and was therefore of no particular military importance, though this wasnot always true. The so-called rubber dermatitis seenearly in the war is an illustration. The etiologic agent was the rubber used ingas masks, and the dermatitis characteristically appearedon the forehead, the chin, and the lateral aspects of the cheeks. Theresponsible agents were probably the antioxidants and accelerators used in themanufacture of the rubber. Men who were sensitive to them were provided with gasmasks of different manufacture, such as the older blackrubber type or the cloth-impregnated type.
Rhus toxicodendron (poison ivy) was the most frequent cause of plant dermatitis (figs. 87 and88), but dermatitis caused by ragweed and marsh elder was also relativelyfrequent.
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FIGURE 87.-Reaction to poison ivy.
FIGURE 88.-Reaction to poison ivy.
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FIGURE 89.-Reaction to Merthiolate(thimerosal) appliedbefore spinal puncture.
FIGURE 90.-Reaction to elastic in shorts.
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The experience at Fitzsimons General Hospital40and other hospitals in the United States indicatedthat sensitization and primary irritant reactions caused by topical medicationwere more significant and more frequent causes of disability than other types ofcontact dermatitis. Dermatologists in the Zone of Interior, observing the casesof contact dermatitis due to the unwise use of Whitfield's ointment in thetreatment of acute and subacute dermatitis, took the position that correcttraining of battalion surgeons and other medical officers doing dispensarypractice would have resulted in a considerable decrease in the incidence of theso-called over-treatment syndrome. Their reasoning seems particularly sound whenone recalls that in some oversea theaters, dermatologic diseases accounted foras much as 75 percent of dispensary practice.
Sulfonamides were also responsible for a high incidence ofdermatitis medicamentosa in Zone of Interior hospitals. As time passed, theoriginal routines were modified in the light of experience, but many medicalofficers failed to learn the lesson and continued to use sulfonamide ointmentsin the treatment of pyogenic infections as well as for other cutaneous diseases.Some of the most serious drug reactions encountered were the generalized id typeof sulfonamide dermatitis first reported by Major Livingood and ColonelPillsbury.41 Several patients in this group were seriously ill for as long as4 to 6 weeks. Other sulfonamide reactions were reported by Peterkin,42Weiner,43and Cohen and his associates.44
Mediterranean theater.-In the Mediterranean theater, truedermatitis medicamentosa (fig. 91) was infrequent, which is remarkable,considering the widespread administration of drugs capable of producing rashes,particularly the sulfonamides and barbiturates. Reactions to the sulfonamidesmost often followed their topical use on moist, eczematized lesions. Subsequentexposure to sunlight precipitated the appearance of eruptions on exposed parts,and oral medication after local sensitization sometimes precipitated exfoliativedermatitis.
Dermatitis venenata, especially of the face, ears, andeyelids, was frequently reported in men preparing penicillin solutions forinjection. Once the danger was realized, enlightened techniques usuallypermitted individuals who had been sensitized to penicillin to work safely withit.
Contact dermatitis ordinarily responded promptly to avoidanceof the offending contact and the use of soothing and drying topical agents.Local therapy with sulfonamides was discouraged because sensitization to itafter
40See footnote 20, p. 588.
41Livingood, C. S., and Pillsbury, D.M.: Sulfathiazole in Eczematoid Pyoderma; Sensitization Reaction in Successive Local and Oral Therapy; Report of 12 Cases.J.A.M.A. 121: 406-408, 6 Feb. 1943.
42Peterkin, G. A. G.: Skin Eruptions Due to the LocalApplication of Sulphonamides. Brit. J. Dermat. 57: 1-9, January-February 1945.
43(1) Weiner, A. L.: Cutaneous Hypersensitivity to Topical Application of Sulfathiazole. J.A.M.A. 121: 411-413, 6 Feb. 1943. (2) Weiner, A. L.: CutaneousEruptions Following Topical and Oral Sulfathiazole (Correspondence) J.A.M.A. 123:436, 16 Oct. 1943.
44Cohen, M. H., Thomas, H. B., and Kalisch, A. C.:Hypersensitivity Produced by the Topical Application of Sulfathiazole. J.A.M.A.121: 408-410, 6 Feb. 1943.
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its topical use prevented its later administration ininfections in which such therapy might be lifesaving.
Plant dermatitis was conspicuously absent in the Mediterraneantheater, because of the absence of common plant offenders. Contact withgasolines and oils, however, was often the cause of a refractory dermatitis andfolliculitis, which sometimes required change in duty assignments. Deter-
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gents used for dishwashing sometimes produced a severedermatitis, which was responsible for a large loss of man-days among Italiancivilians working in Army kitchens.
European theater-Contactdermatitis was extensively prevalent in the European theater, but sincepoison ivy is not indigenous to the British Isles or continental Europe,there were no cases of that origin.
The topical application of sulfonamide ointments wasresponsible for many cases of contact dermatitis, sometimes with associatedphotosensitivity. After penicillin became available, dermatitis caused by itbecame increasingly frequent, and as in the Mediterranean theater, it occurredin hospital teams engaged solely in the preparation and administration ofpenicillin solutions.
In retrospect, many dermatologists who had served in theEuropean theater expressed the opinion that, in spite of their immediatevalue, it might have been better if topical sulfonamide and penicillinpreparations had not become available, for individuals who became sensitizedto them from their local use frequently had systemic reactions when eitheragent was used, either orally or parenterally,for more serious conditions.
Southwest Pacific Area.-Therewere some reports of acute but short-lived eruptions from contact withunidentified plant or animal life encountered in sea bathing in New Guinea,but as a rule, dermatitis from contact with plants was a problem of minorimportance in that area.
Dermatitis venenata in New Guinea was also reported ascaused by the sap of palms used in building bridges and other structures.It began on exposed areas but often became generalized. The eruption wassometimes severe but did not last very long. Dr. Hopkins did not observe anyinstances of this type of dermatitis himself, but obtained his information aboutit from Maj. Delmar R. Gillespie, MC, at the 233d Station Hospital, who hadstudied it carefully.
China-Burma-India theater-A numberof special forms of contact dermatitis were observed in military personnelstationed in China-Burma-India:
1. Tree sap dermatitis was caused by contact with thefoliage and sap of certain indigenous trees encountered by the Corps ofEngineers when they were clearing the forest in the early stages ofconstruction of the Ledo (Burma) Road in Assam and Burma. Contact causedconsiderable disability in susceptible personnel, who amounted to some 15 to 20percent of those exposed and represented the manpower loss of several hundredbadly needed workers. The sap of these trees (family Anacardiaceae) wasoriginally milky-white, but on contact with air it turned black or dark red.
2. In some areas of India and Burma, a lacquer preparedfrom another tree of the Anacardiaceae family and used to paint toiletseats gave rise to dermatitis of the anogenital area in susceptible individuals.
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3. The most interesting type of contact dermatitisencountered in China-Burma-India was the result of sensitivity to the substanceused by native washermen (dhobies) for marking clothes tobe laundered.45 Soon after the 20th General Hospital arrived in thetheater and its personnel sent their clothes to belaundered by dhobies, a small epidemic of patchy dermatitismade its appearance. The eruption always involved, singly or in severalareas, the nape of the neck, the upper back, the waistline (anterior, posterior,or unilateral), the lateral aspects of the ankles, the dorsal surface and sides of the feet, and the lower third of the legs. Itsoon became apparent that these circumscribed patches ofdermatitis exactly corresponded with the parts of the body in contact with thelaundry mark used by the dhobies. They marked shirts on the collar, whichaccounted for the localization of the dermatitis on the dorsal surface of theneck. Shorts were marked on the waistband, socks atvarious places, and nurses' brassieres at the point at which the strap wasattached to the cup (fig. 92).
Dhobie mark dermatitis was characterized by intense pruritus,vesiculation, oozing, and, in some instances, a more orless chronic eczematoid
45Livingood, C. S., Rogers, A. M., and FitzHugh, T.: DhobieMark Dermatitis. J.A.M.A. 123: 23-26, 4 Sept. 1943.
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reaction. The intensity of the process depended upon thesensitivity of the individual. The incidence of the condition was some 15 to 20percent of those exposed.
Investigation of the condition at the 20th General Hospitalin Assam in collaboration with the Forest Research Institute in Derha Dun,India, and the Indian Botanical Institute in Calcutta resulted in theidentification of the offending trees as members of the Anacardiaceae family.This family includes poison ivy, poison oak, sumac, the cashew nut tree, theBhilawanut tree, and the Japanese lacquer tree. Persons sensitive to poison ivywill almost always be sensitive to the nut of the Bella gutti tree, the sap ofwhich the dhobies were using for laundry marks, as well asto other plants and trees of this family.
When the native washermen were questioned, it was found thatthe marking fluid they were using was obtained from the nut of the Ral or Bella gutti(Bhilawanut) tree, which grows all over India. A straight pin was pushed throughthe hard capsule of the nut, and enough brown or black fluid adhered to it for themarking of garments with small crosses, dots, or lines invarying identifying combinations. The marks were fairlypermanent and withstood repeated washings.
The term "dhobie itch" had been in use indermatology for some time. Sutton and Sutton,46 inthe 1935 edition of their textbook on diseases of the skin, defined it, withwasherman's itch as a synonym, as tropical epidermatophytosis, correspondingto eczema marginatum observed in other climates. They pointed out that symptomswere greatly exacerbated by warmth and perspiration and that violent scratchingand secondary pyogenic infections often rendered the parts raw and inflamed, sothat impetigo, infectious eczematoid dermatitis, and even furunculosis mightresult.
In India and other countries, the terms "dhobieitch" and "tinea cruris" seem to have beenused more or less interchangeably for many years. The explanationwas that the nomenclature was associated with the premise that clothingwas infected by the dhobies when it was washed. The concept was entirelyerroneous. It was never demonstrated that cutaneous fungal infections weretransmitted via clothing washed by dhobies. On the contrary, the World War IIexperience showed that dhobie-mark dermatitis was exactly what the term implies,a contact dermatitis caused by an allergen, the marking fluid, which is notunlike the allergen that causes Rhus dermatitis.
PSORIASIS
Mediterranean theater.-Psoriasis was not a problem in theMediterranean theater because of its frequency. The difficulties connected withit,
46Sutton, Richard L., and Sutton, Richard L., Jr.:Diseases of the Skin, 9th ed. St. Louis: C. V. Mosby Co., 1935.
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like those connected with seborrheic dermatitis (figs.93 and 94), arose from the chronicity of these diseases, their resistance totreatment, and their tendency to recurrence. The causes of both were unknown,but it was recognized that good personal hygiene, if it did not prevent thementirely, at least maintained the underlying dermatitis at a subclinical level.Exposure to direct sunshine was of prophylactic as well as therapeutic value.Cold, wet weather had a particularly adverse influence on psoriasis, andpatients seeking treatment for it increased sharply in numbers as winter cameon.
In addition to sunlight, certain other measures were atleast temporarily successful, including local applications of tar, resorcin(resorcinol), and chrysarobin (Goa powder). With theuse of these agents, it was possible to discharge the majority of patients toduty, but relapses were frequent and repeated hospitalization was necessary.When the condition developed or became apparent overseas, relapses could bereduced by assigning the men to duty in base sections or other areas wheregood personal hygiene was possible and specialized medical care was available.This was not a desirable expedient, however, and it was the conclusion ofdermatologists in the Mediterranean theater that it was highly questionable whether men withsignificant psoriasis and seborrheic dermatitis should ever be sentoverseas. There was no doubt at all that only in the most unusual circumstancesshould they be assigned to combat units.
There was also an important psychic factor in psoriasis.Men with this disease, who understood their problems and adjusted to them,could be given what medicine had to offer and returned to their units,occasionally even to combat units. Often they became sterling soldiers. Others,however, when the going became hard, were willing to use their disease as ameans of getting into the hospital or being sent home. It is fair toassume that perhaps 20 percent of all patients with seborrheic dermatitis andpsoriasis became liabilities rather than assets to the troops in theMediterranean theater and had to be evacuated to the Zone of Interior.
Observations at Fitzsimons General Hospital47 bore out theseconclusions. The histories showed that good soldiers had ignored theirdisease and continued on duty until they were incapacitated, while others whowere indifferent to their responsibilities continued to report at sick calluntil they were hospitalized and returned to the United States.
Southwest Pacific Area.-Dr. Hopkins' 1944-45survey of dermatologic conditions in the Southwest Pacific Area revealed only afew instances of severe psoriasis.
PARASITIC INFECTIONS
Parasitic infestations (scabies and pediculosis) wereamong the major sources of disability in the American and British ExpeditionaryForces in
47See footnote 20, p. 588.
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FIGURE 93.-Extensive acutepsoriasis of trunk.
FIGURE 94.-Acute seborrheicdermatitis of suprapubic and crural region.
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World War I. The principal reasons were not the primaryinfestation but the sequelae of secondary bacterial infection and chronicdermatitis from excoriation and overtreatment.
In World War II, scabies was very common in some theaters,but pediculosis was a most infrequent reason for seeking medical attention.
Mediterranean theater.-Parasitic infestations of the skinaccounted for 4 to 18.5 percent of the admissions to dermatologic services insix hospitals in the Mediterranean theater surveyed in 1943, with the greatmajority of cases scabies. These percentages cover only primary diagnoses andrequire some explanation: It was repeatedly noted in this theater that patientswho presented themselves for treatment for furunculosis, pyoderma, cellulitis,impetigo, and similar conditions were referred with those diagnoses, while thecoexisting parasitic infestation, which frequently was the underlying cause ofthese infections, was either reported as a secondary diagnosisor was not reported at all. It is therefore fair toconclude that the actual prevalence of parasitic diseases in this theater washigher than collected statistics indicate. This consideration is of specialimportance in the evaluation of figures collected from forward hospitals, whereopportunities for examination with the patient stripped, in a good light, andfor detailed history taking were frequently lacking.
Pediculosis, sample checks showed, was not frequent in theMediterranean theater. Over a 3-week period in1944, no cases were reported from the 34th, 85th, and 88th Infantry Divisions;none were reported from 10 hospitals surveyed in the spring of 1944, and nonefrom the Fifth U.S. Army for the week of 15-22 September 1944. For the entireyear, only 2 cases were reported from the 64th General Hospital and only 11,from the 8th Evacuation Hospital.
Soldiers with pediculosis pubis frequently treated thecondition themselves with aerosol bomb sprays or blue ointment, and anoccasional patient presented himself with dermatitis caused by suchself-treatment. There was no doubt that aerosol sprays would kill the irritatingparasite and that repeated applications of blue ointment to infested areas wouldkill both adults and eggs, but less irritating methods were more desirable.Pubic lice were readily eliminated by the application of calomel ointment on 2 successivedays. For head lice, the hair was cut short and the head was shampooedfor 3 successive nights with a mixture of 1 part keroseneto 3 parts of hot, soapy water. Both patient and clothingwere sprayed with Army louse powder, which was extremely efficient.
The most frequent parasitic infection in the Mediterraneantheater was scabies, caused by the itch mite Acarus scabiei hominis. Thecondition was acquired, as in civilian life, by contactwith the person, personal clothing, or, less often, bedding of an infectedindividual. In this theater, the great reservoir for the spread of infection wasthe native population, in whom the incidence was very high and by whom it wasregarded with amazing in-
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difference. The incidence in U.S. troops reflected the extentof their co-mingling with the natives.
Uncomplicated scabies could be treated effectively withsulfur ointment or benzylbenzoate by the unit surgeon. Both produced good results, but sulfur waspreferable in cases complicated by scratching, secondary infection, ordermatitis. Clothing and bedding were disinfested by laundering, dry heat, livesteam, louse powder, or the use of a methyl bromide bag. The reward of earlydiagnosis and treatment was a lower incidence of contact cases, less discomfortfor the patient, shorter duration of treatment, and fewer days lost fromduty.
Men with complications of scabies were usually hospitalized,for soap and water baths, moist compresses as indicated, and treatment for 3 or4 days, preferably with the active assistance of a medical aidman, by theapplication of sulfur ointment from chin to toes. The application wasfollowed by a warm soap and water bath and the use of an antipruritic lotion.
If a second course of treatment was necessary, modifiedsulfur ointment was used, containing 2 to 5 percent of balsam of Peru. Ifdermatitis was only slight, benzyl benzoate ointment could be used instead ofsulfur ointment. Benzyl benzoate, however, was extremely irritating and had tobe used with caution if there were many breaks in the skin and in fair-haired,blue-eyed blonds.
The average stay for patients with scabies in station andgeneral hospitals in the Mediterranean theater was 14 days, because of thehigh proportion admitted with either secondary infection or complications ofearlier treatment. Return to duty was practically total.
Experience showed, however, that it was not sufficient tosupply these patients with antiscabitic ointment and oral instructions. It wasnecessary to give them printed sheets, setting forth the routine in simple,detailed fashion and stressing also the absolute necessity for 100-percentcompliance with it. The difficulties of managing scabies could be considerable,and complications could be alarmingly frequent, but both were overcome bycomplete adherence to the routine of treatment prescribed.
European theater.-In 1942, scabieswas rife in the British civilian population, in which it constituted such a problemthat the Emergency Medical Service was forced to set up numerous unitsdevoted entirely to its treatment. The high incidence was clearly related tothe severe dislocation of civilians, to overcrowding, and to the disruption ofhygienic facilities caused by German bombing raids.
The increased incidence of scabies in the British civilianpopulation was soon reflected in the British Armed Forces. The incidence inthe U.S. Army in the United Kingdom never reached particularly high levels, butthe number of cases, from 3.8 to 8.35 per 1,000 per year for the period 1942-45,was accompanied in the early years by delays in diagnosis and by therapeuticmismanagement that led to complications and required unnecessary
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hospitalization for many patients. In 1943, ward rounds instation and general hospitals invariably revealed that from 20 to 30 percentof all admissions on dermatology services were for scabies and for complicationsof it that were entirely preventable and that would not have developed if thediagnosis had been made promptly and if adequate treatment had beeninstituted.
An intensive campaign was undertaken to remedy thesituation. Brigadier MacKenna was extremely helpful, as was Dr. KennethMellanby, whose studies, which were of great value, had been carried out withthe support of the British Medical Research Council.48 It was notonly important to train medical officers in the early recognition of scabies(figs. 95, 96, and 97), which many of them had seldom observed in theircivilian careers, but it was also necessary to discontinue useless and outmodedmethods of disinfestation of clothing and gear, frequently by techniques thatwere destructive to both. Treatment in 1943 also differed sharply frommethods recommended in most standard texts.
The regulation methods of diagnosis and treatment wereoutlined in Circular Letter No. 77, Office of the ChiefSurgeon, Headquarters, ETOUSA,
48Mellanby, K.: The Transmission of Scabies. Brit. M.J.2: 405-406, 20 Sept. 1941.
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FIGURE 96.-Scabies, with louseinfestation and malnutrition.
8 May 1943. The basis of treatment was the use of benzylbenzoate, but the shortages of shipping delayed the receipt of the emulsion inwhich it was used, and sulfur ointment had to be substituted. Sulfur therapy wasentirely satisfactory if a strength of 10 percent rather than USP 15 percent wasused and if the specified details of application were scrupulously adhered to.The film on scabies, prepared under the auspices of the British Medical ResearchCouncil, was widely used in the instruction of medical officers.
Once the correct principles and practices were put intooperation, disability from the complications of scabies decreased sharply andhospital admissions for this condition became uncommon.
Southwest Pacific Area.-Most of thescabies seen in U.S. troops in New Guinea occurred in men returning from leavein Australia. The incidence was high in Japanese prisoners of war; one groupshowed a 25-per-
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FIGURE 97.-Scabies, withsecondary infection, malnutrition, and edema.
cent infestation. Dr. Hopkins pointed out in his March 1945report to General Denit that scabies was likely to be a more serious problem inthe Philippines and in other populated areas. He believed, however, that thesuccessful results obtained with benzyl benzoate in the European theater couldbe duplicated in the Southwest Pacific Area.
OTHER DERMATOSES
Zone of Interior.-Experiences with miscellaneous dermatosesin the Zone of Interior did not differ materially fromexperiences in civilian practice (figs. 98, 99, 100, and 101). At FitzsimonsGeneral Hospital, for instance, six patients were encountered with chronicdiscoid lupus erythematosus, together with two with acute disseminated lupuserythematosus and one with subacute disease.49 The incidence wasconsidered somewhat
49See footnote 20, p. 588.
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FIGURE 98.-Psoriasis of soles.
FIGURE 99.-Congenitalkeratosis plantaris occurring at site of pressure.
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FIGURE 100.-Psoriasis of palms.
FIGURE 101.-Circinate tinea of buttocks.
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lower than would be encountered incivilian life, probably because, as Dr. Hopkins pointed out in commenting onthe few cases he had observed in the SouthwestPacific Area, medical officers were dealing with a selected populationof healthy young men. He had seen no instances ofgranuloma fungoides or of pemphigus and had seen only a very few cases of severepsoriasis and chronic urticaria, probably for the same reason.
Dermatophytid was a fairly frequent admission diagnosis at FitzsimonsGeneral Hospital, but it was seldom supported by clinical and laboratoryfindings. At this hospital, the minimum criteria for diagnosis were:
1. A proved fungal infection, almostalways inflammatory and acute.
2. A positive trichophytin test.
3. A symmetrical, erythematous, maculopapular or vesiculareruption compatible with the diagnosis.
4. Disappearance of the id eruption on elimination of theprimary focus of infection.
Tuberculosis of the skin was important on the dermatologyservice at Fitzsimons General Hospital, as well as interesting, because this hospital served as atuberculosis center. All patients on the tuberculosis wards who presented anytype of skin disease were seen routinely in consultation with the dermatologyservice. It was considered significantthat tuberculous adenopathy was observed in only threepatients, all from racial groups (Negro,American Indian) peculiarly susceptible to tuberculosis, and that the onlythree cases of lichen scrofulosus observed at this hospital all occurred in Negropatients with pulmonary tuberculosis. Tuberculosis verrucosacutis, the rosacea-like tuberculid of Levandowski, and lupus miliaris disseminatusfasceii were seen in one case each. Papulonecrotic tuberculids wereinfrequent, and no instance of lupus vulgaris was observed.
Mediterranean theater-Atopicdermatitis (neurodermatitis disseminata),along with allergic dermatitis, was not frequent in theMediterranean theater but was a causefor prolonged andrepeated hospitalization when it was encountered. The final disposition of mostpatients was reclassification or return to the Zoneof Interior. Dermatologists in this theater shared the opinion of manydermatologists in the Zone of Interior as to the unwisdom of sending overseasany men with a background of allergic skin disease and eczema. Inability tocontrol such causative factors as diet, inhaled and contact allergens, andemotional stress made it impossible for most of them to be useful soldiers.
In the Mediterranean theater, a large proportion ofthe patients admitted to dermatology services had eczematoid dermatitis.Their lesions were either localized or diffuse. They might have been produced by scabicides, fungicides, or sulfonamides, though most of the timethe exact cause was not apparent. Psychic tension often predisposed to, or resulted from, dermatitis in this category.
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Therapy consisted of simple, soothing remedies, such ascompresses, calamine lotion, crude coaltar, and Lassar's paste, plus protection of the lesions.Superficial X-ray was often useful, but ithad to be employed judiciouslyand administered only by qualified personnel.
Infectious eczematoid dermatitis, which was rebellious to treatmentand accounted for many hospital admissions, was secondary to infected wounds,draining sinuses, chronic otitis media, otitis externa, and other septic foci.It responded to elimination of the local focus, penicillin parenterally, andlocal compresses of penicillin solution in concentrationsof 250 to 2,500 units percubic centimeter.
Southwest Pacific Area.-Warts (figs. 102, 103, 104, and105) were surprisingly frequent on the hands in the Southwest Pacific Area. Theywere less frequent on the feet, but there they could be extremely painful and practicallydisabling. They responded well to X-ray therapy, but ithad to be given with great caution to prevent damage.
Exfoliative dermatitis was infrequent in the SouthwestPacific Area, but a sufficient number of severe casesoccurred to make it of medical importance. Fatal sepsis or aplastic anemiadeveloped in a number of patients. The use of plasma to combat hypoproteinemiathat often resulted from voluminous exudation was strikingly successful, as wasthe use of penicillin parenterally to combat secondary infection. The absence offatalities in uncomplicated cases was,in Dr. Hopkins' opinion, "a striking tribute to thetherapy employed."
LICHENOID AND ECZEMATOID DERMATITIS (ATABRINE DERMATITIS, ATYPICAL LICHENPLANUS)
In the latter part of 1943, medical officers inthe Southwest Pacific Area began to call attention to a characteristic cutaneoussyndrome beginning to be observed in men who were serving in New Guinea andadjacent islands or who had been evacuated from these areas.50The condition was termed, provisionally, "atypicallichen planus," because of resemblances of the lesions to those of lichenplanus or lichen planus hyptertrophicus. Most of these patients, however, alsohad skin lesions with other morphologic characteristics, particularly certaineczematoid characteristics, while some patients with these eczematoid lesionsdid not have any lichenoid lesions (figs. 106, 107, 108, and 109).
50As a convenience for the reader, references to theperiodical literature are listed whenever official reports of observations or investigations are known to have been published. In addition, the followingare presented as a matter of interest: (1) Agress, C. M.: Atabrine as a Cause ofFatal Exfoliative Dermatitis and Hepatitis. J.A.M.A. 131: 14-21, 4 May 1946;(2) Bereston, E. S., and Saslaw, M. S.: Complications of Lichenoid Dermatitis:Glomerulonephritis and Severe Pigmentary Changes in Exfoliative Stage ofLichenoid Dermatitis. Arch. Dermat. & Syph. 54: 325-329, September 1946;(3) Ginsberg, J. E., and Shallenberger, P. L.: Wood's Fluorescence Phenomenonin Quinacrine Medication. J.A.M.A. 131: 808-809, 6 July 1946: (4) Livingood, C. S., and Dieuaide, F. R.: Untoward Reactions Attributable to Atabrine. J.A.M.A. 129: 1091-1093, 15 Dec. 1945; (5) Rosenthal, J.: Atypical LichenPlanus. Am. J. Path. 22: 473-491, May 1946; (6) Sugar, H. S., and Waddell,W. W.: Ochronosis-Like Pigmentation Associated With the Use of Atabrine.Illinois M. J. 89: 234-239, May 1946.
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FIGURE 103.-Wart on plantarsurface of great toe.
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FIGURE 104.-Condyloma acuminatum of penis.
FIGURE 105.-Painful X-ray atrophyand ulceration following excessive radiation for plantar wart.
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FIGURE 106.-Lichenoid dermatitis with secondary infection.
FIGURE 107.-Lichenoid dermatitis with secondary infection.
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It seemed reasonable at this time to conclude that thelichenoid lesions were only part of a multiforme complex and also to assume thatcertain cases of eczematoid dermatitis in which no lichenoid lesions werepresent probably fell into the same etiologic group.
Realization that this group of dermatoses represented anew and hitherto unknown disease developed only gradually, as did therealization that the frequency of the condition might make it a significantmilitary problem, not only in itself but because of its relation to Atabrine,the drug by which the devastating effects of malaria were being held in check.51Once the existence of the new syndrome was recognized, it became thesubject of
51Medical Department, United States Army. Preventive Medicine inWorld War II. Volume VI. Communicable Diseases: Malaria. Washington: U.S.Government Printing Office, 1963.
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FIGURE 109.-Lichen planus affecting lip.
more reports and publications than any other cutaneousdisease encountered in World War II.
Evolution of the Concept
The account of this new syndrome might profitably beginwith the overall report made to General Denit in March 1945 by Dr. Hopkins afterhis survey of dermatologic conditions in the Southwest Pacific Area. He foundthat three groups of cases, symmetrical eczematoid dermatitis, atypical lichenplanus, and blue nails, constituted, numerically, the major dermatologicconditions encountered in this area. Blue nails had no clinical significance(p. 582), but the other two conditions constituted major military problems. Dr.Hopkins had not observed any of these dermatoses in his previous (very wide)experience, and he regarded them either as three new entities or asthree separate phases of a new entity.
The eczematoid eruption, as he observed it in his movementsabout the Southwest Pacific Area,usually began on the hands (fig. 110) but frequentlyinvolved the arms, feet, legs, and sometimes the entire body. The most strikingfeatures of the disease, to him, were the remarkable bilateral symmetry ofthe lesions; the frequent involvement of the nail bed and the
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FIGURE 110.-Eczematoid Atabrine dermatitis. A and B. Bilateral symmetrical involvement of hands.
skin of the nail fold; and the frequent exfoliation of thenails in the absence of true suppurative paronychia. The involved areas,particularly those in which dry involutinglesions were present after acute vesiculation had subsided, often presentedthe bluish tinge common in many skin lesions in the theater (p. 661). Anotherstriking feature was the appearance of dermatitis in a band extending along theradial side of the index finger and the ulnar aspect of the thumb; the firstlesions were often observed in these locations. Thevesicles on the fingers seemed larger, deeper, and less fragile than those typicalof contact dermatitis or dermatophytids.
The involvement of the hands, in itself, made this disease ofmilitary importance, for even relatively slight eruptions disqualified men forfull military duty. Moreover, Dr. Hopkins found that no curative treatmenthad been devised, relapse was almost certain after return to duty, and it hadalready become clear that prompt evacuation to the Zone of Interior was the besttherapeutic policy.
At the time he made his survey, Dr. Hopkins considered theetiology of symmetrical eczematoiddermatitis entirely obscure. Fungi were demonstrable inthe cases he examined in only a single instance: Capt. P. A. Beal, MC, at the27th Medical Laboratory, had isolated a Monilia, apparently M.albicans, from the nail of this patient. The finding was probablycoincidental, but in view of the paucity of other leads, it seemed worthfollowing up. A small series of patients had been tested for hypersensitivityto Monilia, Staphylococcus, and trichophyton, but the uniformly negative results were
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regarded as unreliable because the extracts used in the testhad been exposed for a long period to room temperatures. Much more careful andmore systematic work wouldbe necessary before it could be said with certaintythat these lesions were not the result of sensitivity to bacteria or fungi,though no evidence existed that they were.
The absence of interdigital lesions on the feet in manypatients was strongly against the then prevalent assumption that these lesionswere dermatophytids. In most instances, no history of an external irritant orallergen could be obtained, and while the theory that this was a contactdermatitis could not be excluded, it was a remote possibility, if onlybecause of the sharp circumscription and striking symmetry of the lesions.
Both of these latter features pointed to some internal cause.The single clue to this assumption was the fact that thelesions Dr. Hopkins observed were frequently seen inpatients with atypical lichen planus and that many patients with atypical lichenplanus described inflammatory lesions on the
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dorsum of the hand or on the fingers as the firstmanifestation of their disease. Although it might be that the etiology ofatypical lichen planus and symmetrical eczematoid dermatitis was the same, thefact that patients with eczematoid dermatitis seemed to recover more promptlythan patients with atypical lichen planus was against the supposition thatAtabrine was the causative factor. It would be profitable, Dr. Hopkins thought,to run control studies, continuing Atabrine in one group of patients but keepingthe other group off it long enough to permit its complete eliminationfrom the body. Results would determine whether the withdrawal of Atabrine wasessential for cure.
As time passed, it became quite clear that Atabrine was theresponsible factor in both symmetrical eczematoid dermatitis and atypical lichenplanus, and it did not seem advisable to make a sharp distinction between them,for many of the same patients exhibited lesions of both types. In the 118 cases,for instance, observed by Maj. (later Lt. Col.) Charles L. Schmitt, MC, at the27th General Hospital (table 103), a small number of patients had only lichenoidlesions, a larger group had both lichenoid and eczematoid lesions, and a stilllarger group had only eczematoid lesions. Exfoliative dermatitis could occur inany of these groups.
Site | Number of cases | Percent |
| Thighs and legs | 31 | 26 |
| Hands and fingers | 31 | 26 |
| Arms | 25 | 21 |
| Torso | 24 | 20 |
| Buttocks | 20 | 17 |
| Eyelids | 17 | 14 |
| Feet | 17 | 14 |
| Penis | 13 | 11 |
| Neck | 11 | 9 |
| Ears | 10 | 8 |
| Waistline | 10 | 8 |
| Scalp | 7 | 6 |
| Groins | 7 | 6 |
| Scrotum | 6 | 5 |
| Face | 6 | 5 |
| Listed as generalized | 37 | 31 |
Source: Collected in the Southwest Pacific Area by Maj. Charles L. Schmitt,MC, 27th General Hospital.
Incidence and Etiology
Southwest Pacific Area
No doubt many of the earliestcases of atypical lichen planus were overlooked becausethey were classified under such diagnoses as dermatitis,
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unclassified, or trichophytosis corporis. While it isimpossible to state positively when the first case occurred, in retrospect itseems likely that two patients evacuated from New Guinea to the Zone of Interiorin March 1943, with the diagnosis of dermatitis, chronic,lichenoid, might have had atypical lichen planus. In July 1943, two patients whowere later found to have had atypical lichen planus (though it was not thendiagnosed under that terminology) were evacuated from the same area, one fromthe 4th and the other from the 118th General Hospital. At least nine additionalpatients were evacuated during the remainder of this year with the samecondition.
Meantime, reports were being received concerning theincreasing frequency of this new disease. In November 1943, Maj. (later Lt.Col.) Robert B. Palmer, MC, reported (verbally) that he had seen a remarkablenumber of patients with hypertrophic lichen planus. The station hospital at PortMoresby received 14 patients with severe lichenoid disease between September1943 and February 1944. In January 1944, Major Ambler observed 16 cases in histours of various hospitals in the Southwest Pacific Area. In April 1944, hereported on 28 cases he had observed in forward areas. By July of this year, hehad personally observed 130 cases, and by December, the number had risen to 200.52
Several comprehensive reports on the condition were preparedfor The Surgeon General through the Surgeon, SWPA, by Maj. Thomas W. Nisbet, MC,in June and again in August 1944, covering the cases observed at Milne Bay,New Guinea;53 by Major Schmitt, in collaboration with Capt. George Chambers, MC,and Maj. O. Alpins, MC, of the Australian Army;54 and by Major Ambler, Dr.Hopkins, and Col. Maurice C. Pincoffs, MC.55Numerous other reportscovered smaller numbers of cases and less extensive observations.
The possible relation of Atabrine to this new syndrome, inwhich both eczematoid and lichenoid manifestations wereoften present in combination, seems to have been mentionedfor the first time in the Southwest Pacific Area in November 1943, when theConsultant in Dermatology for the Australian Army, at a meeting of the SydneyMedical Society, presented a patient with severe lichenplanus, which he attributed to this drug. Major Nisbet andMajor Schmitt were the first U.S. Army Medical Corps officers to point out, inseparate official reports to The Surgeon General, that Atabrine was probably theessential etiologic factor in this new type of dermatitis.
52Report, Maj. John V. Ambler, MC, to the Theater Surgeon,Southwest Pacific Area, 15 Dec. 1944, subject: Statistical Survey of 200 Casesof Atypical Lichen Planus.
53Nisbet, T. W.: A New Cutaneous Syndrome Occurring in NewGuinea and Adjacent Islands: Preliminary Report. Arch. Dermat. & Syph. 52:221-225, October 1945.
54Schmitt, C. L., Alpins, O., andChambers, G.: Clinical Investigation of a New Cutaneous Entity. Arch. Dermat.& Syph. 52: 226-238, October 1945.
55Minutes of the Conference on Atypical Lichen Planus, Boardfor the Coordination of Malarial Studies, 6 June 1945, exhibit V thereto,"Atypical Lichen Planus: Present Status of the Problem."
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These officers based their conclusions on the observations(1) that all patients with this new skin disease had taken suppressive Atabrine;(2) that their skin lesions had progressed as long as they were on the drug; (3)that improvement or complete healing had followed its withdrawal; and (4) thatin some instances new lesions appeared when the medication was resumed. MajorNisbet also called attention to the occurrence of fixed eruptions of exfoliativedermatitis and the occasional development of aplastic anemia in these patients;both of these manifestations were suggestive of a drug etiology. He also statedthat until Atabrine was introduced into the Southwest Pacific Area, he couldfind no record of any such cases at Mime Bay or elsewherein New Guinea.
When the mounting number of cases of atypical lichen planusindicated that the disease might become a serious military problem in relationto suppressive Atabrine, the use of which was considered essential,56 26patients with the disease were assembled, in July 1944,for study by a group of officers of the Malarial Research Unit attached to the3d Medical Laboratory at Base B (Oro Bay, New Guinea). The group consisted ofMaj. (later Lt. Col.) Abner M. Harvey, MC, Capt. (later Maj.) Frederik B. Bang,MC, Lt. (later Maj.) John M. Myer, MC, and Lt. Nelson G. Hairston, SnC.57Maj. A. M. Pappenheimer, SnC, was later assigned to the project, to conduct nutritionalstudies. These 26 patients, who had both lichenoid andeczematoid manifestations, were kept under constantobservation for a 5-month period. In addition to studies of the skin lesions inrelation to the administration and withdrawal of Atabrine, laboratory studieswere carried out to determine the levels of the drug in skin and plasma. Vitaminsaturation tests were also carried out.
These studies showed that in 18 of 22patients kept on Atabrine after hospitalization, the original lesions continuedto progress and new ones appeared. The condition of threeother patients in this group remained unchanged. The remaining patient showedsome improvement.
In another test, Atabrine was discontinued in 19 patients, 15of whom then showed improvement. Two showed noimprovement, and the other two, both of whom had had bismuth injections, hadprogressive lesions.
When Atabrine was readministered to nine patients whoselesions had begun to heal after it was discontinued, sevenhad acute exacerbations of the disease within 24 to 72 hours.
A significant finding in this study was the appreciableamounts of Atabrine found in the skin of the patients, from 7 to 9weeks after the drug had been discontinued, although atthese times there were no detectable amounts in either urine or blood.
56See footnote 51, p. 642.
57Minutes of the Conference onAtypical Lichen Planus, Board for the Coordination of Malarial Studies, 6 June 1945, exhibit IV thereto, "Clinical andLaboratory Studies on Atypical Lichen Planus With Particular Reference to theRole of Atabrine."
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Mediterranean Theater of Operations
All of the data presented up to this point concern the Southwest PacificArea. Informal communications from medical officers in the South Pacific BaseCommand also described patients with atypical lichen planus but commented on itsinfrequency.
Meantime, cases were being reported from both the Mediterranean and theChina-Burma-India theaters. In July 1944, Capt. (later Maj.) Lawrence M. Nelson,MC, reported from the Mediterranean theater two cases of a characteristic typeof eczematoid dermatitis without lichenoid lesions.58 He attributed theeruption to Atabrine.
In January 1945, Maj. (later Lt. Col.) R. N. Buchanan, Jr., MC, reportedfrom the same theater five cases of symmetrical, generalized eczematoiddermatitis that subsided when Atabrine was discontinued and recurred when itsadministration was resumed.59 In July of this year, Major Nelson reported sixcases of atypical lichen planus apparently caused by Atabrine; all the patientshad acquired the disease late in 1944.60 For the last several months,evacuees with this condition had been reaching the Zone of Interior from theMediterranean Theater of Operations. Available evidence indicates, however, thatthe incidence of both the lichenoid and the eczematoid syndrome was much less inthe Mediterranean theater than in either the Southwest Pacific Area or theChina-Burma-India theater.
China-Burma-India theater
The first three cases of atypical lichen planus in the China-Burma-Indiatheater were recognized and reported to The Surgeon General through the theatersurgeon by Major Livingood in November 1944.61 Later reports indicated thatthe incidence of this condition in this theater was perhaps as high as it was inthe Southwest Pacific Area.
In March 1945, in view of thedata that he had accumulated since this condition was first recognized, MajorLivingood recommended that suppressive Atabrine be discontinued not only in menwith lichenoid dermatitis but also in those with characteristic prodromaleczematoid lesions. He made the same recommendation for sulfathiazole, thearsenicals, and other potentially sensitizing drugs.62
58Report, Capt. Lawrence M. Nelson, MC, to The Surgeon General, through theSurgeon, Mediterranean Theater of Operations, U.S. Army, 3 July 1944, subject:Eczematoid Dermatitis Due to Atabrine.
59Report, Maj. R. N. Buchanan, Jr., MC, to The Surgeon General, through theSurgeon, Mediterranean Theater of Operations, U.S. Army, January 1945, subject:Dermatology in an Army General Hospital Located in a Theater of Operations.
60Report, Maj. Lawrence M. Nelson, MC, to The Surgeon General,through the Surgeon, Mediterranean Theater of Operations, 20 July1945, subject: An Unusual Dermatitis Simulating Lichen Planus and Lichen Corneus Hypertrophicus.
61Letter, Maj. C. S. Livingood, MC, to The Surgeon General, November 1944,subject: Report of the Occurrence of an Unusual Skin Disease.
62Report, Dr. Clarence S. Livingood, 14 Feb. 1951,subject: Lichenoid and Eczematous Dermatitis Syndrome Due to Atabrine.
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In July 1945, Maj. James M. Flood, MC, reported his observations on therelation between atypical lichen planus and Atabrine in the 20th GeneralHospital.63 They covered not only patients but the 800 officers,nurses, and enlisted men on the staff and in the personnel. He considered theevidence for the relationship convincing for several reasons:
1. There was a large number of troops in the theater between March 1943 and November 1945.
2. No cases of this syndrome were observed between March 1943 and March 1944.Suppressive Atabrine was not used during this period.
3. After March 1944, Atabrine therapy was used in two distinct programs.Between March 1944 and 15 February 1945, it was used in selected troops in theforward area, and so-called Atabrine discipline was poor. Scattered cases ofatypical lichen planus began to occur about 6 weeks after the program wasinstituted. Between 15 February 1945and 1 November of that year, all troops in Assam and north Burma receivedAtabrine, and discipline in respect to its use was reported excellent. By April1945, the number of cases of atypical lichen planus had begun to increasesharply.
4. Patients with this syndrome were observed only in Assam and north Burma,the only sections of the theater in which suppressive Atabrine medication wasused.
5. All other factors in the theater, including climate, working conditions,and diet were approximately the same during the entire time except for aconsiderable improvement in diet later in the period.
Major Flood's and Major Livingood's studies, as already indicated, coveredthe 800-member personnel of the 20th General Hospital.Most of them had been in the same area and worked under the same conditions forabout 20 months before suppressive Atabrine therapy was instituted. During thisperiod, not a single individual acquired cutaneous lesion in any way suggestiveof either atypical lichen planus or eczematoid dermatitis. Within 5 months afterthe regimen had been instituted, seven persons had acquired the complex. Most ofthe lesions improved when Atabrine was discontinued, but new lesions appeared insome cases when it was reinstituted.
Investigations in the Zone of Interior
The study of atypical lichen planus in the Zone ofInterior was facilitated by concentrating the patientswith this syndrome first at hospitals designated as tropical disease centers andlater at Moore General Hospital and Harmon General Hospital, which weredesignated as dermatology centers. Here they were studied by a routine devisedby the Medical Consultants Division, OTSG, with thecooperation of the civilian consultants and the Board for the Coordination ofMalarial Studies.
63Letter, Maj. James M. Flood, MC, to Commanding General, 20th GeneralHospital, APO 689, 27 July 1945, subject: Atypical Lichen Planus.
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At Moore General Hospital, Maj. James M. Bazemore, MC, andhis associates studied intensively 51patients who were selected because their lesions werepredominantly lichenoid and had involuted after withdrawal of Atabrine forvarying periods.64 When suppressive therapy was reinstituted, twodistinct reactions were observed:
1. Five patients developed an eczematoid type of eruptionthat began characteristically as a generalized pruritus and was followed byerythema of the skin, most marked in the antecubital and popliteal spaces, theanterior aspect of the neck, and friction points. In the most severe cases, theeruption became red and generalized and went on to scaling. The time ofdevelopment after the first dose of Atabrine given after the period ofwithdrawal varied from 4 hours to 7 days. All five patients, all of whom had tobe dropped from the study group, had positive patch tests to Atabrine.65
2. The second type of reaction observed at Moore GeneralHospital was a clear-cut exacerbation of the lichenoid lesions, manifested byrecurrences at the sites of previous lesions and development of new lesions. Theearliest recurrences were observed 23 days after the reinstitution of Atabrinetherapy; the majority occurred between 40 and 63 days afterward. Only two of thenine patients who manifested this second type of reaction had positivepatch tests.
The proportion of patients in the experimental group whodeveloped exacerbations of their lesions within 3 months after the reinstitutionof Atabrine therapy was practically identical with theproportion who had developed the syndrome within a similar period afterbeginning suppressive Atabrine. This particular phase ofthe investigation at Moore General Hospital explains why some observers reportedno exacerbations of the original lesions when Atabrine wasreadministered for short periods of time. On the otherhand, all investigators in oversea theaters who had theopportunity to readminister the drug to patients with atypical lichen planus oreczematoid dermatitis reported a higher incidence of exacerbations than were observedwhen experimental readministration was carried out in patients who had beenevacuated to the Zone of Interior.
Geographic Distribution and Incidence
The more careful investigation that was possible after thewar left no doubt that atypical lichen planus and eczematoid dermatitis occurredin all areas and commands in which suppressive Atabrine was in general use. Itwas recorded in New Guinea and neighboring islands on the north coast;
64Bazemore, J. M., Johnson, H. H., Swanson, E. R., andHayman, J. M., Jr.: Relation of Quinacrine Hydrochloride to Lichenoid Dermatitis(Atypical Lichen Planus). Arch. Dermat. & Syph. 54: 308-324, September1946.
65Capt. Harvey Blank, MC, Chief of Dermatology andSyphilology, 69th General Hospital, informed the writers of this chapter that inthe 33 cases he personally observed, patients with typical lichenoid lesionswere generally patch-test negative to Atabrine while those with the eczematousand exfoliative types were likely to be patch-test positive.
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Bougainville; Guadalcanal; Green Island; the Carolines; NewBritain; Morotai Island; the Solomon Islands; the Admiralty Islands;the Trobriand Islands; Okinawa; Assam; north Burma; the Philippine Islands;parts of Australia; and Italy.
No data are available on the incidenceof atypical lichen planus and eczematoid dermatitis inrelation to troop strengths in the various areas in which these diseases wereencountered. The largest numbers of cases are known to have occurred in NewGuinea and adjacent islands and in the Assam-Burma area. Major Ambler estimatedthe incidence in the Southwest Pacific Area at 2 or 3 per 1,000 per year,which most observers considered too low. Colonel Schmitt, basing his estimateson his experience in a general hospital in New Guinea, estimated the incidenceat 11-14 per 1,000 per year, and Major Flood, using his experience in ageneral hospital in Assam, estimated the incidence at 10 per 1,000 per year.
Contributory Factors
The fact that the incidence of this syndrome was so muchhigher in New Guinea and adjacent islands, and in Assam and north Burma, than inother areas suggests that factors other than Atabrine might also playcontributory roles in its causation.Some investigations substantiated this theory, at least to a limited degree.
Major Ambler and his associates,66 MajorLivingood,67 Lt. Col. Donald J. Wilson, MC,68 and otherspresented evidence that indicated that various forms of cutaneous traumacontributed to the onset and localization of the lesions, particularly duringthe eczematoid phase of the eruption. The assumption was that something happenedto the skin of a certain proportion of men who were taking Atabrine regularlythat made them particularly vulnerable to irritation and infection. As a result,they developed an increased tendency to acquire chronic eczematoid dermatitis oncontact with external allergens. It naturally followed that a larger proportionof men on suppressive Atabrine would develop cutaneous eruptions in hot, humidclimates such as New Guinea, Assam, and north Burma, than in other parts of theworld, where the skin was less subject to trauma, infection, and inflammation.
Dietary deficiencies and psychosomatic factors were alsoinvestigated as possible principal contributory causes of this syndrome. MajorHarvey and his group found a slightly lower nutritional status in patients withthis disease than in a control group, but they did not implicate dietarydeficiency as a cause. It was emphasized by Col. Benjamin M. Baker, MC,Consultant in
66See footnote 55, p. 647.
67See footnote 62, p. 649.
68Wilson, D. J.: Eczematous and Pigmentary Lichenoid Dermatitis: Atypical Lichen Planus.Arch. Dermat. & Syph. 54: 377-396,October 1946.
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Medicine, in the South Pacific Area,69 that a greater varietyof fresh vegetables and fruits, as well as larger quantities of milk and eggs,was available in that area than in the Southwest Pacific Area. These facts mightexplain the much lower incidence of the syndrome in the Solomon Islands than inNew Guinea and its adjacent islands, although the use of suppressive Atabrinewas approximately the same in both regions.
A number of observers analyzed theavailable data in reference to race, sex, age, andcomplexion. The only finding of any possible statistical significance was thatpatients with the lichenoid and eczematoid dermatitis syndromes were in asomewhat higher age group than the average military population.
Virus studies carried out at Moore General Hospital,70 aswell as cultural studies for fungi and bacteria carried out here and elsewhere, producedno significant data.
Clinical Considerations
It was the combination of various types of lesions in acharacteristic fashion, plus their occurrence in large groups of individualsunder similar circumstances, that made this syndrome a new entity. All observersagreed that the lesions were polymorphous and that they appeared in manydifferent combinations. At the same time, they emphasized also that thesepatients reacted dermatologically in a highly characteristic fashion and thatthe clinical picture soon became unmistakable, even to medical officers withlittle or no experience in dermatology.
Initial manifestations.-The disease almost invariably beganwith a prodromal inflammatory cutaneous eruption thatvaried in character and distribution. The most typical initial manifestation wasa rather sharply marginated, patchy, eczematoid eruption,either exudative or nonexudative, most frequently on the dorsal surfaces ofthe hands, feet and legs, and in the crural region. The wrists, eyelids, ears,and neck were other sites of predilection.
Other clinical manifestations seen early in the illnessincluded an eruption resembling seborrheic dermatitis in the scalp, eyebrows,bearded region, axilla, and suprapubic region; discreteand confluent erythematous, pinhead-size vesicles andpapules that resembled miliaria; and flat, erythematous patches that soonbecame scaly and sometimes exfoliative. Often, the eczematoid and intertriginouslesions became impetiginized; in such instances, they wereapt to extend more rapidly.
As this description indicates, these early eruptions often soclosely resembled other forms of eczematoid dermatitisthat an exact clinical diag-
69Baker, Benjamin M.:South Pacific Area. In Medical Department, United States Army. InternalMedicine in World War II. Volume I. Activities of Medical Consultants.Washington: U. S. Government Printing Office, 1961, pp. 569-623.
70See footnote 64, p. 651.
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nosis was difficult. So-called nummular eczema, contactdermatitis, seborrheic dermatitis, pyoderma, tineal infections, miliaria, anddermatophytids all had to be excluded. It was sometimes necessary to follow theeruption from day to day in order to detect the lichenoid lesions upon which thediagnosis of atypical lichen planus was based. In other cases, the symmetry,distribution, and violaceous color of the initial lesions were sufficientlycharacteristic for an experienced dermatologist to make the diagnosis very earlyin the course of the disease.
The personally collected data of Major Ambler on 200 cases inthe Southwest Pacific Area71 (table104) and of Major Schmitt and his group on 118 cases in the same area72(table 103) closely parallel the observations of MajorBazemore and his associates on 302 cases at Moore General Hospital in respect tothe initial sites of cutaneous involvement.73 Opinions differed,however, as to the significance of these early, antecedent eruptions. Somedermatologists regarded them as unrelated dermatoses that predisposed tolichenoid lesions. There was some evidence to support this opinion; trauma ofvarious types, sunlight, and mechanical and chemical agents unquestionablypredisposed to the development of lichenoid lesions. Other observers pointed outthat eczematoid patches, crusted plaques, and
Sites | Number of cases | Percent |
Dorsum of hands | 152 | 76 |
Lower legs | 137 | 69 |
Lips | 127 | 64 |
Eyelids1 | 114 | 57 |
Dorsum of feet | 102 | 51 |
Forearms | 99 | 50 |
Ears1 | 86 | 43 |
Buccal mucosa | 70 | 35 |
Palms | 70 | 35 |
Penis | 63 | 32 |
Manubrial region | 56 | 28 |
Scalp | 51 | 26 |
Soles | 49 | 25 |
Buttocks | 49 | 25 |
Face | 39 | 20 |
1Originally, only 1.5 percent of these patients hadlesions of the eyelids and only 3 percent lesions of the ears. The percentagesshown in this table were a later development in each instance.
Source: Report, Maj. John V. Ambler, MC, to the Theater Surgeon, Southwest Pacific Area, 15 Dec. 1944, subject: Statistical Survey of 200 Cases of Atypical LichenPlanus.
71See footnote 52, p. 647.
72See footnote 54, p. 647.
73See footnote 64, p. 651.
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severe intertriginous dermatitis frequently developed in thepresence of lichenoid lesions. Whatever the causation, it seems probable thatthe initial lesions, even though they occurred independently and in advance ofthe lichenoid eruption, were still part of the lichenoid complex.
Later manifestations.-The lichenoid lesions characteristicof atypical lichen planus assumed a variety of forms, as follows:
1. Annular, scaling violaceous lichenoid papules occurredsingly or in sharply outlined patches of varying sizes. Pigmentation (melanin)that became deeper as time passed regularly accompanied some of these lesions74(figs. 111 and 112). The papules resembled those seen in lichen planus ruber butwere not angular and their surfaces were not ordinarily shiny. Wickham'sstriae seen in true lichen planus were only occasionally observed.
2. Hypertrophic and hyperkeratotic lichenoid plaquesrepresented another secondary manifestation of the syndrome (fig. 113). Large,elevated plaques and nodules began as such; they were not the result ofcoalescence of small papules. These plaques, which were either annular orlinear, ranged in diameter from 0.5 to 5.0 centimeters.They were often elevated 0.5 cm. or more above the surfaceof the skin, but they did not usually infiltrate it deeply. Initially, theircoloration varied from erythematous to a deep violaceous hue. Later, theyassumed a dark brown or slate-gray color. Extremely dense, grayish scales wereseen in lesions that became verrucous. This variety, as well as lichenoidpapules, usually developed at the sites of healing eczematoid lesions. Whilethey might occur almost anywhere on the face, trunk, orextremities, they were most often localized on the dorsal surfaceof the hands, the extensor surface of the forearms and legs, and thedorsal surface of the feet. These lesions, in general, resembled those seen inlichen planus hypertrophicus.
3. Lichenoid lesions of the mouth (fig. 114) involved thevermilion borders of the lips, the buccal surface of the cheeks, and the dorsalsurface of the tongue. They took the form of whitish or violaceous-tinged,slightly elevated, reticular leukokeratoses that resembled true lichen planusexcept that the involvement was usually more extensive. Erythema and some degreeof erosion were quite common. Major Nisbet described several instances of severestomatitis, with bullous lesions.75
Concomitant lesions.-In addition to the lichenoid lesionsjust described, the fully developed syndrome included a wide variety of otherlesions, not all of which were observed in all patients, though the lesions werealways polymorphous. Among these lesions were the following:
1. Pigmented patches, which were frequently at sites otherthan those of the earlier lichenoid or eczematoid lesions (figs. 115 and 116).The coloration varied from violaceous to slate-gray, dark brown, or almostcoal-black.
74Lutterloch, C. H., and Shallenberger, P. L.: UnusualPigmentation Developing After Prolonged Suppressive Therapy With Quinacrine Hydrochloride. Arch. Dermat. & Syph. 53: 349-354, April 1946.
75Nisbet, T. W.: Dermatitis Due to Quinacrine Hydrochloride("Atabrine"). J.A.M.A. 134: 446-450, 31 May 1947.
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These patches resembled, in some respects, the fixed drug eruptions caused byphenolphthalein and other compounds.
2. Faintly erythematous, scaling, papulosquamous lesions with an axialdistribution not unlike that of pityriasis rosea (figs. 117 and 118).
3. Flat, squamous, well-demarcated geographic plaques on the trunk, axilla,and groin, which resembled fungal lesions.
4. A diffuse, exfoliative type of generalized eczematoid dermatitis (fig.119), with increased involvement and marked weeping of the intertriginous sites,the flexors of the knees and elbows, the inner surfaces of thethighs, and the neck.
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5. Follicular involvement, which took the form of either (1) a patchy or adiffuse keratosis pilaris or (2) papular lesions in the hair follicles. Theselesions were most frequent on the buttocks, shoulders, back, arms, and legs.
6. A scaling, erythematous, eczematoid dermatitis of the eyelids (fig. 120). This was a very common finding.
7. Hyperkeratosis, superficial fissuring, and pigmentation of the vermilionborder of the lips (fig. 121); fissures at the angles of the lips; and,occasionally eczematous cheilitis with edema, fissuring, and oozing.
8. Erythematous and violaceous-tinged, oozing, scaling, eczematoid plaques,well demarcated in some instances and ill defined in others.
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FIGURE 111.-Continued. C. Lichenoid, verrucous-like lesions on anterolateral surface of foot.
9. Oozing intertriginous dermatitis of the groins,axillas, and intergluteal surfaces.
10. Scaling, hyperkeratotic papules of the palms and soles. The entire areawas occasionally so greatly thickened, fissured, and glazed as to suggest ahyperkeratotic eczema.
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11. Scaling, bilateral, dry dermatitis of the ears, especially the tips ofthe auricles, or a weeping dermatitis involving the entire auricle and theretro-aural folds. The lesions observed in these cases resembled seborrheicdermatitis with secondary streptoderma.
12. Diffuse, adherent, thick scaling of the scalp, with or withouthyperkeratotic plaques, usually accompanied by diffuse or patchy alopecia.Alopecia occurred in some instances, however, without lesions of the scalp.
13. Crusted pyogenic lesions, which in some instances went on to generalizedpyoderma and septicemia. These were extremely serious complications.
14. Ecthymatous ulcerations, which were in part the result of excoriation ofthe hypertrophic nodules and plaques just described. In the strictly
660
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accurate sense of the word, it seems more logical to classifythe various types of pyoderma observednot as an integral component of atypical lichen planus butrather as secondary complications.
15. Abnormalities of the nails, which took various forms(fig. 122), including separation of the distal margin withaccumulations of whitish, cellular debris under it; roughening or destruction ofthe nail near the matrix; linear striation and transversedepression; brittleness; pitting and lackof luster; and, in some cases, subacute paronychial infections. All of thesevarieties of nail involvement occurred more frequently when the hands, feet, orboth had been involved in the process for some time.
In his trips about the SouthwestPacific Area, as already mentioned, Dr. Hopkins was greatly impressed by thefrequency of a blue discoloration of the nail beds in men in the area. The firstsuch cases he observed were in patients with atypical lichen planus, whofrequently had pigmented plaques elsewhere in the body which resembled the fixederuption caused by phenolphthalein. The nail anomaly appeared as a wide,transverse band, ranging from slate-colored to violet. The band, which wasusually located in the mid zone of one (or more) of the nails on the fingers orthe toes did not shift as the nail grew. Small macules of the same color weresometimes seen beneath the nails. Itwas reported to Dr. Hopkins, though it was no more than arumor, that some men with blue nails had similar pigmented areas elsewhere onthe body. Some lesions were said to resemble argyria,
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but he himself saw no such cases, and he doubted the accuracyof the description. The discoloration of the nails gave rise to no symptoms, andsoldiers seldom sought medical attention except to satisfy their curiosity.
One patient observed by Capt. William D. Wolfe, MC, at the35th General Hospital, presented a wide zone of deep violet pigmentation acrossthe anterior aspect of the neck and extending onto theupper chest, where it ended sharply. Except for itsextent, it suggested (as did the first cases observed by Dr. Hopkins) aphenolphthalein reaction. Biopsy revealed a strip of lymphocytic infiltration inthe papillary zone of the cutis. The violet color was explained by the presenceof numerous chromatophores stuffed with melanin.
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FIGURE 116.-Pigmented patches in Atabrine dermatitis.
Dr. Hopkins conceded that the occurrence of blue nails withlichen planus might be no more than a coincidence. Many other skin lesions inthe Southwest Pacific Area, especially ecthyma, showedpuzzling blue to violet tinges and scars, sometimes whenthere was no other evidence of skin disease. He believed that the problem shouldbe investigated but confessed that he could see no approach that offered anypromise.
16. Cutaneous sequelae, including the pigmentation alreadydescribed; atrophy of the skin, varying from slight tomarked and occurring after involution of some of thelichenoid nodules and plaques; the development, in some cases, of paper-thinskin, mottled with areas of pigmentation and depigmentation and usuallyoccurring on the dorsal surfaces of the feet and hands; alopecia; exfoliation ofthe nails; and, in severe cases, generalized and localized anhidrosis thatexempted the forehead and axillas.
Figures collected by Major Schmitt and Major Ambler (tables103 and 104) show the respective anatomic distribution of lesions in the fullydeveloped lichenoid and eczematous complex and of lichenoid papules and nodules.It is notable that the distribution of the lichenoid papules differs from thatof combined lichenoid and eczematoid lesions.
Symptoms.-Pruritus was present in all cases, but variedgreatly in severity. As a rule, it was severe initiallyand then moderated. Acute inter-
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FIGURE 117.-Atabrine dermatitis, with papulosquamous lesions resembling pityriasis rosea.
triginous lesions caused pain on movement, and lesions on thehands interfered with useful work.
Constitutional manifestations.-The majority of patientswith uncomplicated diseases had little evidence of systemic involvement, andmany with serious lichenoid lesions appeared wellnourished and in excellent general health. Major Ambler,however, and a number of other observers noted significantlosses of weight in about half of their cases. Patients with extensiveexfoliative dermatitic complications usually suffered from malaise, asthenia,fever, and lymphadenopathy, though the proportion of such manifestations was nogreater in this syndrome than in generalized cutaneous eczematoid eruptions fromother causes.
In very occasional cases, aplastic anemia, other severe blooddyscrasia such as agranulocytosis, and severe acute hepatitis occurred inassociation with the lichenoid-eczematoid syndrome. Similar complications,however, were occasionally observed in men taking Atabrinewho did not develop skin lesions. The case fatality rateof hematopoietic complications was very high. The relationbetween them and the skin disease was not clear, but the association wasstriking.
Chronology and course.-The sequence of events in atypicallichen planus and eczematoid dermatitis, as well as the types and combinations
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FIGURE l18.-Atabrine dermatitis, showing closeup of lesions which resemble pityriasis rosea.
of lesions, varied from patient to patient, though manyreports emphasized that most men who developed the syndrome had been onsuppressive Atabrine therapy for relatively long periods before the diseaseappeared. Lesions sometimes occurred abruptly, in the form of a widespreaderuption, and attained a lichenoid appearance within a week. In many othercases, the prodromal lesions were present for weeks and the lichenoid lesionsdeveloped insidiously.
In the cases analyzed at Moore General Hospital,76 only 20percent of the patients developed the disease within 3 months after institutionof Atabrine therapy, as compared with 70 percent within 6 months and 90 percentwithin 10 months. In the 200 cases analyzed by Major Ambler (table 104), theonset of the lichenoid lesions was sudden (within 2 weeks) in 126 cases andgradual in the remainder. In the 118 cases studied by Major Schmitt (table 103),the initial eruption appeared within 1 and 3 months after suppressive Atabrinetherapy was begun. The largest number of cases developed in the fourth and fifthmonths; 85.3 percent of the
76See footnote 64, p. 651.
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eruptions became evident within the first 8 months, and only3 percent appeared after a year.
Major Harvey's group,77 as well as otherobservers, thought that, when daily doses of Atabrine were larger than theroutine prescribed dosage (0.1 gm.), the percentage of cutaneous reactions wasunusually high. Numerous patients were observed who tolerated routinesuppressive therapy for long periods and who acquired the lichenoid andeczematoid syndrome only when the suppressive dosage was increased or whenmalarial symptoms required therapeutic dosages.
In many instances the general course of the disease wasslowly progressive, with enlargement of old lesions and the appearance of newlesions
77See footnote 57, p. 648.
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in other locations. It was often many weeks before thecomfort and efficiency of the patient were seriously affected. In other cases,however, there was rapid, generalized development of eczematoid lesions, and theclinical picture was almost identical with that ofexfoliative dermatitis except that the skin was less uniformly involved andthere was less infiltration. These generalizedexacerbations, which could occur at any time during the course of thedisease but which were likely to occur early, were always serious and werepotentially fatal. When the lesions involuted, the eruption became dry and scalyand often progressed to the development of pigmented flat or hyperkeratoticlichenoid lesions on the sites of former eczematoid plaques.
In some instances, there was definite evidence ofphotosensitivity, with lesions on the face, the anterior surface of the neck,and the dorsal surface of the hands. In other instances, no reactions of thiskind were seen, even after prolonged exposure to sunlight.
In general, the lesions persisted for weeks and months,depending upon a number of factors, some of which werepoorly understood.
To summarize the clinical course: A fewpatients had a gradual or rapid onset of lichenoid lesions, either preceded oraccompanied by eczematoid lesions. A large group presented prodromal eczematoidor inflammatory lesions of one type or another, followedby gradual or rapid onset of lichenoid lesions that developed primarily or atthe sites of the eczematoid lesions. In these cases, the eruptions were amixture of lichenoid and eczematoid lesions, with one typeor the other predominating. Still another group of patients had an almostconcomitant onset and development of lichenoid and eczematoid lesions. Somepatients had eczematoid lesions followed in a short timeby explosive generalized exacerbations suggestive of exfoliative dermatitis; whenthe eczematoid-exfoliative reaction subsided,
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there was an onset of lichenoid papules and plaques. Finally,some patients had lesions that remained primarily eczematoid throughout thecourse of the eruption, with the lichenoid phase limited to relativelytransitory lesions of the mucous membranes.
The degree and rate of improvement also varied. In themajority of the cases studied at Moore General Hospital,78improvement progressed to a point at which the lesions became flat, erythemasubsided, and, at the end of 6 to 9months, pigmentation was the only evidence of the disease.
Although precise data on comparable groups of cases are notavailable, it seems clear that improvement was much morerapid when patients were removed to a temperate climatefrom the hot, humid climate in which their disease had developed. On the otherhand, their lesions sometimes cleared up completely even when they werehospitalized in the Tropics.
81See footnote 64, p. 651.
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Laboratory Investigations
The reports of the laboratory studies on this syndromecarried out by various observers and groups in the SouthwestPacific Area were collected and analyzed by Major Ambler and his associates.79They included urinalysis, blood counts, blood sedimentation rates, serumprotein determinations, serologic tests, and examinations for fungi. All resultswere negative except for (1) leukocytosis and increased sedimentation rates,both of which, when they occurred, could be attributed to secondary pyogenicinfection, and (2) low serum protein levels in patients with exfoliativedermatitis and extensive exudation.
The (summarized) report that follows concerns the results ofmultiple tests of hepatic function carried out on 24 patients who had contractedthe disease in Assam and north Burma by Maj. Thomas E. Machella, MC.80
1. Definite evidence of abnormalities in the role of theliver in carbohydrate metabolism was found in patients with active skin lesionsof atypical lichen planus. There was evidence of impairment of glycogenolysis inall cases; increased tolerance toglucose in 11; and decreased tolerance to it in 2.
79See footnote 55, p. 647.
80Letter, Maj. Thomas E. Machella, MC, 20th General Hospital, to TheSurgeon General, War Department, Washington, D.C., through the CommandingGeneral, 20th General Hospital, Advance Section, U.S. Forces in IBT, APO 689, 6 Aug.1945, subject:Atypical Lichen Planus.
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2. Impairment of the ability of the liver to removebromsulphthalein from the bloodstream was found in 16of the more severe cases of atypical lichen planus and in 3of those with mild lesions or lesions that had involuted.
3. The mean total serum proteins were low normal or actuallylow, with the albumin fraction decreased. The lowest values occurred in thosepatients with the more severe skin lesions who also had disturbances incarbohydrate metabolism and excretory function.
4. No significant disturbances were found in cholesterol orthe cholesterol esters, the plasma fibrinogen, or the detoxifying function ofthe liver.
5. The disturbances observed in these cases in carbohydratemetabolism, serum protein levels, and excretory hepatic function were comparablewith the abnormalities that may occur when a liver is low in glycogen and highin fat. They were such as might occur when the sympathetic nervous system is notfunctioning properly.
The liver function tests performed on 35 patients at MooreGeneral Hospital81 included hippuric acid synthesis, bromsulphthalein retention,cephalin-cholesterol flocculation, icterus index, and prothrombin time. Three ofthese tests were abnormal in 1 patient, 2 were abnormal in 7, and 1 was abnormalin 6. It should be emphasized that these studies were made in a hospital in theZone of Interior weeks and months after the onset of the disease, in contrast toMajor Machella's studies, which were carried out in anoversea theater a few weeks after the onset.
Therapy
Recognition of the fact that Atabrinewas the basic etiologic factor in eczematoiddermatitis and atypical lichen planus pointed to the basictherapeutic measure, withdrawal of the causative drug.Majors Schmitt, Ambler, Nisbet, and Harvey promptly arrived at this conclusionin the Southwest Pacific Area, as did Major Livingood andothers in China-Burma-India. It was also soon learned, asalready mentioned, that these patients were likely to clear more rapidly if theywere removed to a cooler climate and that relapse was likely to occur if theywere returned to the Tropics.
Time-honored textbook remedies for lichen planus, such asbismuth and arsenic, had no effect onthe course of this new syndrome, and on theoretical grounds,these drugs were strictly contraindicated. These patients would not tolerateirritating local treatment, such as salicylic acid and tincture of iodine.In fact, the commonest mistake in the treatmentof the eczematoid phase of the eruption was the use ofstrong fungicidal measures.
Penicillin, used parenterally and locally, was beneficial,and was sometimes lifesaving, in the treatment of secondary pyogenic infection,particularly of exacerbations in the form of generalized exfoliative dermatitis.
81See footnote 64, p. 651.
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Other useful measures in generalized involvement were plasmaand glucose infusions, vitamin therapy, and liver extract.
Major Machella pointed out, in view of the abnormalitiesfound in the liver function studies made, that correctionof these dysfunctions should be an integral part of thetherapeutic regimen.82 An important component of treatment was a diethigh in protein and carbohydrate but low in fat. A vitamin supplement was alsorecommended.
In the 118 cases studied by Major Schmitt and his Australianassociates,83 well over half of the patients experienced improvementwithin a month after Atabrine wasdiscontinued, but 20 percent noted no improvement for 2 to3 months. About 10 percent began to improve while theywere still in New Guinea and still taking Atabrine. Of thepatients not taking Atabrine when improvement began, 57 were in the UnitedStates, 20 were en route there, and 7 were still in New Guinea.
Administrative Action
Administrative action in this matter had to be undertakencarefully. Widespread dissemination of information concerning the relationbetween Atabrine and lichenoid and eczematoid dermatitis would have resulted ina sharp decrease in the use ofsuppressive malaria therapy. The increased malaria ratethat would inevitably have resulted might have seriously impairedthe military effort in both the Southwest Pacific Area and the China-Burma-Indiatheater. For these reasons, as soon as the causal relation was recognized, everyeffort was made to avoid open discussion of the subject, and The Surgeon Generalplaced a RESTRICTED classification on all oral and written communicationsconcerning it. On the otherhand, it was essential that medical officers in the theaters and areas affectedshould have the information. It was widely disseminated by appropriateconsultants, but the restriction was so effective that many medical officers didnot learn of the relation of Atabrine to the lichenoid-eczematoid syndrome untilafter the war.
The increasing proof that Atabrine was the basic etiologicfactor in this new syndrome, the evident magnitude of the problem, and therealization that many medical officers were aware of thedata that had been accumulated prompted the MedicalConsultants Division, OTSG, to issue a RESTRICTED letteron the subject which was eventually disseminated to all theaters and commands.84In substance, this letter contained the followinginformation:
82See footnote 80,p. 669.
83See footnote54, p. 647.
84Restricted Letter, Office of The SurgeonGeneral, U. S. Army, to Surgeons, allmajor oversea theaters, all Army Service Forces servicecommands, and the Military District of Washington, 14 Aug.1945, subject: Reactions Attributed to Atabrine.
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1. The military value of Atabrine in suppressing vivaxmalaria and in attacks of falciparum malaria far outweighs the untowardeffects that have been attributed, with reason, to the use of this drug.
2. Suppressive doses greater than 0.7 gm. per week should notbe employed routinely. This amount has been shown to provide adequate protectionagainst clinical attacks of malaria if Atabrine discipline is strictly enforced.In the clinical treatment of malarial attacks, the routine dosage of Atabrineshould not exceed 2.8 gm. over a 7-day period.
3. Suppressive Atabrine medication should be discontinuedpromptly, and Atabrine should not be used therapeutically, if troops develop anyof the following conditions: Atypical lichen planus; unexplained chronic eczematoiddermatoses;unexplained toxic erythematous eruptions; exfoliative dermatitis; severeleukopenia, agranulocytosis, and aplastic anemia; acute hepatitis (not includingdisturbances believed to be caused by malaria) ; and any toxic psychoses that,after careful clinical study, can be reasonably attributed to Atabrine.
4. Quinine is available for the treatment of individuals whoare known to be sensitive to Atabrine or to be seriously intolerant of it.Quinine should not be used, however, for units or organizations as a whole.
5. When, after thorough study, it is concluded that anindividual is definitely sensitive to Atabrine (or quinine), an appropriateentry should be made, as in the case of other drugs, on WD AGO Form 8-117(Immunization Register).
6. Caution should be exercised in attributing diseaseconditions to Atabrine until careful and complete studies over a period of timehave established the relation. Because of the widespread use of this agent, itsadministration inevitably coincides with the existence of many diseases withwhich it has no connection. Even if a connection is established between Atabrineand any given untoward effect, the connection must be evaluated in relation tothe military value of Atabrine. Since suppressive Atabrine therapy came intogeneral use, clinical attacks of falciparum malaria have been almost eliminatedand deaths from malaria have become extremely uncommon. There is no questionconcerning the general superiority of Atabrine over quinine, both forsuppression and for clinical treatment of malaria.
7. Detailed information and instructions in regard to thepossible toxic effects of Atabrine and the management of men for whom it isconsidered contraindicated should be disseminated to medical officers,especially those in direct charge of patients. In all discussions of thetoxicity of Atabrine, its great military usefulness and the low incidence of alltypes of serious reactions to it should be emphasized. Discussions of its rolein various disease conditions should be avoided in the presence of patients.Public discussions should be discouraged. At this time, the relation betweenAtabrine and the atypical lichen planus complex is classified as RESTRICTED.
8. It is recommended that the contents of this letter becommunicated to medical consultants and that they be instructed to inform andadvise all medical officers concerned.
Prognosis
The prognosis of both atypical lichen planus and eczematoiddermatitis was excellent, especially when Atabrine was discontinued and thepatient was hospitalized and evacuated from the Tropics. Once these facts wereappreciated and acted upon, the period of recovery was significantly shortened.Patients with severe eczematoid dermatitis were prone to relapse, especially iftreatment was delayed until the lesions were well established onthe hands, feet, or both, Perhaps 5 to 10 percent wereleft with a semipermanent increased sensitivity to trauma and externalallergens.
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Cases complicated by blood dyscrasia, severe hepatitis, orsepticemia were usually fatal. These complications, which fortunately wereuncommon, tended to occur in patients with severe generalized exfoliativedermatitis. Patients who recovered from them always had protracted courses.
Alopecia and sweating abnormalities cleared up spontaneouslyin almost all cases, though in some patients with deepobstruction of the sweat glands, severe intolerance toheat and apparently permanent anhidrosis developed. It was thought that thehyperpigmentation (fig. 123), which was frequently strikingand sometimes disfiguring when the patients were receivedfrom overseas, would eventually disappear entirely, an expectation that has beenlargely fulfilled.
