Activities of Medical Consultants
CHAPTER I
Medical Consultants Division
Office of the SurgeonGeneral
Hugh J.Morgan, M.D.
The Army of the United States in World War II wasby and large a citizen's army administered at the higher levels by arelatively small number of professionalsoldiers. This was true for practically all arms and services,including the Medical Department which was primarily responsible forhealth services. A small groupof career officers of the Army Medical Corps administered thecomplicated affairs of the Medical Department. Consultants wereappointed by The SurgeonGeneral and assigned to his office to develop medicine, surgery, andpsychiatry in the Medical Department of the Army and, in a limited way,to superviseprofessional performance in these special fields. With few exceptions,these men were recruited from civilian life and were not from among theRegularEstablishment.
The history of the development of the MedicalConsultants Division, OTSG (Office of the Surgeon General), and theprojection of its influence throughout theArmy is a story of civilian participation in military medicine. Theconsultant system, beginning in the Surgeon General's Office with theassignment of the chiefconsultants, extended into the service commands in the Zone of Interiorduring the mobilization and training period and overseas with theestablishment oftheaters of operations. Finally, its representatives were utilizedtoward the end of the war by armies, corps, and divisions in combat. Inthis history, it would beinappropriate and unrealistic to disregard the difficulties that arosethrough the consultants' lack of experience with the military and themilitary's failure tounderstand clearly what the consultants had to offer. On the one side,the special problems of military medicine and, on the other side, thevalue of specializedmedical services in hospitals and in the field had to be learned beforethere could evolve the system of medical, surgical, and psychiatricsupervision that existedat home and in the theaters of operations at the end of the fighting in1945.
In the pages that follow, the author breaks manytimes with the conventions of military reporting. This is inevitable,since he and his immediate associates andpractically all of the medical consultants throughout the Army wereproducts of civilian medicine. It is thought that the value of thisvolume will be enhanced if itreflects accurately both failures and achievements, both helps andhindrances, at the inception and during the development and operationof the medicalconsultant system in the Surgeon General's Office and in the Army FieldEstablishment.
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FIGURE 1.-Brig. Gen. Charles C. Hillman, Chief, Professional Service Division, Office of the Surgeon General, 13 April 1942.
BEGINNING OF THE CONSULTANT SYSTEM
Chief Consultant in Medicine
On 1 January 1942, Dr. Hugh J. Morgan received a communication from Col. (later Brig. Gen.) Charles C. Hillman, MC (fig. 1), Chief, Professional Service Division, OTSG, inviting him to become a member of the Professional Service Division with the title of Chief Consultant in Medicine to The Surgeon General in the grade of colonel. The letter outlined the duties of this assignment as follows: "With the increased tempo of military matters, expansion of the Professional Service Division to provide for separate subdivisions of medicine, surgery, and neuropsychiatry appears desirable. It is contemplated that the Chief of each subdivision will be the Chief Consultant and Coordinator in matters pertaining to his field of medicine throughout the Army." On 11 February 1942, Colonel (later Brigadier General) Morgan and his personally selected assistant, Capt. (later Col.) Harrison J. Shull, MC, reported for duty to Maj. Gen. James C. Magee, The Surgeon General, and were assigned to the Professional Service Division.
Although he was strongly supported by his immediate superior, General Hillman, it was necessary for Colonel Morgan to make his way in the Surgeon
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FIGURE 2.-Brig. Gen. W. Lee Hart (seated, center) and key members of his Eighth Service Command medical staff.
General's Office. He participated in certain problems immediately, assisting in the formulation of physical standards for induction into the Army and in the selection of new drugs and special items of medical supply. He attended meetings of committees of the National Research Council concerned with internal medicine. In those early days, however, the professional consultants were expected to confine their duties rather narrowly to clinical problems. There was slow acceptance of the concept that they should recommend the duty assignments of Medical Corps specialists or should take initiative in matters directly affecting medical care, such as medical supply and hospitalization policy. Time and effort had to be expended in a process of mutual enlightenment between the newly commissioned consultants and the seasoned Medical Corps officers in the Surgeon General's Office. The latter, although experienced in the ways of the Army, were not always cognizant of the ways in which professional consultation could best be used, either in administrative medicine or at the bedside.
The peacetime Army of the thirties had recognized no need in its medical operations for a consultant service, although such a service had functioned in World War I. Revival of position-assignments by General Magee met with the indifference, occasionally the frank opposition, of many officers in pivotal positions outside the Surgeon General's Office and of some inside it. There were notable exceptions, and to these early supporters the professional consultant system, as it finally evolved, owed much. Col. Sanford W. French, MC, Surgeon, Fourth Corps Area (later Fourth Service Command), and Col. (later
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Brig. Gen.) W. Lee Hart, MC (fig. 2), Surgeon, Eighth Corps Area (later Eighth Service Command), set an example for other surgeons of major commands. The prompt and enthusiastic cooperation of these two officers hastened the end of inertia.
Certainly no one in the Surgeon General's Officein February 1942envisaged the magnitude and importance of the consultant system as iteventually functionedat the time of victory in Europe and in the Pacific. Colonel Morgan'sinitial staff consisted of two Medical Corps officers and one civilianclerk, housed in onesmall room and having no representation in any major command either inthe Zone of Interior or overseas. In each of the major commands, thereappeared intime as consultants in medicine an informally organized group ofexceptionally qualified officers. These men had been carefully chosen,most of them by TheSurgeon General with the advice of his chief consultant in medicine. Ina practical sense, they were usually recognized by the MedicalDepartment asrepresentatives of the Surgeon General's Office, although they were, infact, directly responsible to the surgeon of the command or theater orarmy and wereseparated from The Surgeon General and his chief consultant in medicineby zealously guarded command channels.
The mission of the Medical Department of the Armyin time of war isto prevent disease and injury and to provide optimum treatment, to theend of maintainingthe lowest possible noneffective rate. With this as his primaryobjective--to reduce time lost from duty--Colonel Morgan attempted toencourage, in every waypossible, prompt, accurate diagnosis and optimum therapy; to expediteadministrative procedure; and to help accelerate the convalescence andreturn of thesoldier to his military assignment physically and emotionally fit. Itsoon appeared that this broad concept of his functions required theestablishment of broadprinciples governing the practice of medicine in the Army and thecontrol of specialized personnel responsible for relating theseprinciples to the care of patients.
In the formative days, great assistance wasrendered The SurgeonGeneral and his professional consultants by the various committees ofthe National ResearchCouncil. These committees provided facts and expert opinion which couldserve as the basis for formation of policy regarding clinical andadministrativepractices. Later, Colonel Morgan established, in his own organization,branches representing important subspecialties in military medicinearid assigned expertsas their chiefs. Civilian consultants in medicine to the Secretary ofWar and to The Surgeon General were also helpful.
Much of the time of the chief consultants wasoccupied by manymatters which were not, strictly speaking, included in their functions.For example, their earlyefforts to encourage an aggressive attack by hospital staffs upon theproblem of excessively prolonged hospitalization after recovery fromdisease and injurycontributed greatly to the official recognition of the importance ofthis matter and to the eventual establishment of a comprehensive,well-organized program forthe management of convalescence and rehabilitation.
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Command, Theater, and ArmyConsultants
It was evident from the beginning thatdelegationof responsibilityby the chief consultant in medicine in the Surgeon General's Office wasnecessary, if themission assigned him was in any real sense to be executed. This becameobvious to all when hospitalization plans for the future weredisclosed. There were inactual operation in the Army approximately 209 station hospitals, with71,459 beds, Plans called for an additional 145 station hospitals, with86,843 beds. The 15general hospitals, with 14,912 beds, then in operation were to beaugmented by 15 additional installations with 20,988 beds. Thus, inearly 1942, firm plans forhospitals in the United States provided for a total of 384 station andgeneral hospitals, with 194,202 fixed beds. The futility of any attempton the part of thechief consultant in medicine to affect significantly the practice ofmedicine in so many hospitals scattered so widely throughout thecountry merely by issuingdirectives and bulletins from the Surgeon General's Office wasapparent. Moreover, there was no provision for detailed control ofassignments to key positions inthese hospitals. Finally, the division of the United States into corpsareas (later service commands), each a separate military command, madeeffective centraladministration of medical activities from the Surgeon General's Officeimpossible, since authority for centralized control did not exist.
Accordingly, on the recommendation of the consultants of the Professional Service, OTSG, The Surgeon General recommended the assignment of consultants to the surgeons of corps areas.1 It was proposed that these officers "shall act in an inspectional and consultative capacity, and that their duties shall include the evaluation of the professional qualifications of medical personnel, appraisal of new therapeutic methods and agents, and the coordination of professional practice by local discussion with hospital staffs of such special problems as may present themselves. It is contemplated that the consultants selected shall be outstanding and nationally recognized in their respective fields."
Headquarters, Services of Supply (later Army Service Forces), approved in principle this recommendation but refused the accompanying request that corps areas be authorized an increased medical officer allotment in the grade of colonel for this purpose. Shortly thereafter, the following service command consultants in medicine were assigned: Lt. Col. (later Col.) Henry M. Thomas, Jr., MC, to the Fourth Service Command; Lt. Col. (later Col.) Walter Bauer, MC, to the Eighth Service Command; Lt. Col. (later Col.) Verne R. Mason, MC, to the Ninth Service Command; and Lt. Col. (later Col.) Edgar van Nuys
1 (1) Letter, The Surgeon General to Commanding General, Services of Supply, 28 May 1942, subject: Coordination of Medical Service (Professional) in Corps Area Installation, with 1st Indorsement thereto. (2) Letter, The Surgeon General to Commanding General, Services of Supply, 23 June 1942, subject: Coordination and Supervision of Medical Service in Station Hospitals. (3) Letter, The Surgeon General to Commanding Generals, Service Commands, 28 July 1942, subject: Coordination and Supervision of Professional Medical Service Under Service Commands. (4) Letter, The Surgeon General to Commanding General, First Service Command, 25 Jan. 1943. subject: Assignment of Professional Consultants.
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Allen, MC, to the Seventh Service Command. In due time, as hospital beds increased in number, consultants were assigned to tine remaining service commands. Manning tables contained no position vacancies for consultants, and some service command surgeons were loath to accept new colonels and lieutenant colonels who would have to be absorbed in the rigidly fixed staff allotted to the surgeon's office. Moreover, the concept of a consultant in medicine, whether from a military or a professional viewpoint was new and unattractive to some service command surgeons.
Great patience and forbearance were required of some of the eminent physicians chosen to serve as consultants. Their response attests to their tolerance and devotion to duty. In rare instances, it was actually necessary to prove to the surgeon of a service command that the consultant was not a busybody, troublemaker, or impractical reformer but a physician able to help the surgeon provide optimum medical care and medical administration for the patients under his jurisdiction. To their credit, these consultants made themselves so valuable in their commands that their subsequent placement in over-sea theaters and with the armies met with little or no obstruction and in some instances was insisted upon by the surgeons concerned.
Service command, theater, and army consultants were usually recommended for thieir assignments by the Surgeon General on the advice of his chief consultant in medicine. They were judged to be eminently qualified to organize and administer the mission entrusted to them. A loose, informal, unofficial relationship between the chief consultant and his associates in the field was the only type possible, because of command boundaries. In such a large undertaking, decentralization was, in fact, desirable. It was the duty of the consultant in the field so to relate himself to his command surgeon as to insure implementation of the policies of The Surgeon General and his chief consultant in medicine for the care of medical patients. Once assigned, he was in complete control of the development of his mission and of procedures by which to carry it out under the authority of the surgeon of the command. Inevitably, the consultants' activities in the various commands varied according to local circumstances.
The record attests to the efficiency and effectiveness with which the consultants related themselves to their missions. By precept and example, formal and informal talks and demonstrations, laborious and painstaking indoctrination of military superiors and subordinates, amazing industry, tact, patience, forbearance, and ingenuity, they carried out their missions. In some instances, regional- and subordinate-command consultants were appointed on the recommendation of the consultant in medicine to the command surgeon. An outstanding example of this type of organization in the field existed in ETOUSA (European Theater of Operations, U.S. Army), under the direction of Col. William S. Middleton, MC, Chief Consultant in Medicine, ETOUSA, and Maj. Gen. Paul R. Hawley, Chief Surgeon, ETOUSA.
From time to time, reassignments were made to carry the experience gained in one command over into another. Examples are to be found in the
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assignments of the following medical consultants: Colonel Thomas who was the first service command consultant appointed and who served in the Fourth Service Command and later in the Southwest Pacific Area; Lt. Col. (later Col.) Herrman L. Blumgart, MC, who served in the Second Service Command and later in the India-Burma theater; Colonel Mason who served in the Ninth Service Command and later in the Pacific Ocean Area; Lt. Col. (later Col.) Roy H. Turner, MC, who served in the Third Service Command, in the Surgeon General's Office, and finally in the Southwest Pacific. There were similar changes in the assignments of Lt. Col. (later Col.) Walter B. Martin, MC; Lt. Col. (later Col.) Irving S. Wright, MC; Lt. Col. (later Col.) F. Dennette Adams, MC; Lt. Col. (later Col.) Alexander Marble, MC; Lt. Col. (later Col.) Eugene C. Eppinger, MC; Lt. Col. (later Col.) Garfield G. Duncan, MC; Lt. Col. (later Col.) Benjamin M. Baker, MC; Colonel Shull; and Lt. Col. Myles P. Baker, MC.
In addition to changes of assignments as part of a long-term program, devices used to disseminate professional information and to meet specific local problems as they arose included assignment of consultant from one command to temporary duty in another, and sometimes exchanges between theaters were arranged. Temporary-duty assignments to the Surgeon General's Office were often requested. For example, Colonel Marble and Colonel Duncan were assigned to OTSG to assist in preparing TB MED (War Department Technical Medical Bulletin) 168, June 1945, entitled "Diabetes Mellitus," and TM (War Departnient Technical Manual) 8-500, March 1945, entitled "Hospital Diets," respectively. Similarly, Col. Maurice C. Pincoffs, MC, and Col. Benjamin M. Baker from the Pacific area, and Lt. Col. (later Col.) Perrin H. Long, MC, from thie Mediterranean theater, were assigned to the Surgeon General's Office to give information and exchange views with staff members on particular problems in their commands. An unusual temporary-duty assignment was that of Colonel Bauer, who was sent to Sweden when the Swedish Government requested the U.S. Government to send an Army internist to discuss with the Swedish medical profession advances made in medicine during Sweden's relative isolation because of the war.
Medical Corps officers who served as consultants in medicine in various commands are listed in appendix A (p. 829). Not all were assigned on a full-time basis. In certain of the smaller commands, an exceptionally well trained chief of medical service in a hospital might also serve as consultant in medicine for the command. This dual role was not always a satisfactory substitute for the full-time service of a professional consultant. The following commands were served by part-time consultants: Bermuda Base Command, Persian Gulf Service Command, Middle East Service Command (formerly Delta Service Command), mind U.S. Army Forces in the South Atlantic (fig.3).
When the consultants were appointed, it was anticipated that they would use different approaches and techniques in their assignments. Therefore, they were selected with the greatest care possible. The fact that the consultants held important posts in civilian medical education and practice added
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FIGURE 3.-Continued. C. Headquarters, Delta Service Command, Heliopolis, Egypt, February 1943.
to the obligation and responsibility of The Surgeon General and his representatives in selecting their assignments. The success of the assignments was dependent in large nneasure upon mutual understanding and trust between the consultants and the Surgeon General's Office. The enviable record attained by the Medical Department in the field of internal medicine during the war and the lasting appreciation of the men with whom they worked in the field are convincing and enduring testimonials to the medical consultants.
EVOLUTION OF MEDICAL CONSULTANTS DIVISION
Organization
The evolution of the Medical Consultants Division, OTSG, was slow. Reorganizations of the office, wholly or in part, were frequent. 2 As a result, the actual development of the organization of the chief consultant in medicine in the Surgeon General's Office into a group adequate in number and with sufficient support to function properly did not take place until late in the war.
The Medicine Subdivision, Professional Service Division, OTSG, was created on 21 February 1942. The unit, headed by the chief consultant in
2 The reorganizations discussed in this section are based on (1) 0ffice Orders, OTSG, U.S. Army, No. 87, 18 Apr. 1941, No. 340, 31 Mar. 1942; No. 444, 12 July 1943; No. 4, 1 Jan. 1944; and No. 175, 25 Aug. 1944; (2) Manual of Organization and Standard Practices, OTSG, Army Service Forces, 15 Mar. 1944; and (3) Organization Charts, OTSG, U.S. Army, 21 Feb. 1942, 26 Mar. 1942, 24 Aug. 1942, 10 July 1943, 3 Feb. 1944, and 24 Aug. 1944.
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medicine, had to function under the Professional Service Division. This arrangement was not satisfactory. Problems exclusively professional in nature, such as policies concerned with diagnosis and treatment, arose constantly as the tempo of the war increased and the Army expanded. All communications and memorandums to or from the Medicine Subdivision relative to these matters had to pass through the administrative channels of the Professional Service Division before reaching either The Surgeon General or other divisions of the office. Although the officers of Professional Service Division were cooperative and sympathetic, the mechanics of this arrangement retarded decisions and administrative actions.
On 26 March 1942, in a general reorganization of the Surgeon General's Office, the Professional Service Division became the Professional Service, and the Medicine Subdivision became the Medicine Division with an organizational chart providing for branches in tropical diseases, tuberculosis, general medicine, and specialized medicine. These branches were not actually put into operation, with qualified personnel assigned to them, until much later.
Another general reorganization took place on 24 August 1942. Five main services were created, including one designated Professional Services. The Medicine Division was redesignated Medicine Branch of the Medical Practice Division, which in turn functioned as one of the divisions of Professional Services. Medicine Branch retained as sections its former branches, and Colonel Morgan remained its chief, while continuing his duties as chief consultant in medicine in the Surgeon General's Office. On 4 November 1942, Col. Arden Freer, MC, who had been Chief, Medical Service, Walter Reed General Hospital, Washington, D.C., was appointed Director, Medical Practice Division, OTSG. In spite of Colonel Freer's consideration and understanding, this addition of still another administrative echelon was a further complication. Colonel Morgan repeatedly sought to obtain for the Medicine Branch a position of greater independence, one having more direct approach to The Surgeon General and thus being better able to meet promptly the pressing needs of the growing Army.
On 12 July 1943, Lt. Col. (later Col.) Esmond R. Long, MC, who had become Chief, Tuberculosis Section, Medicine Branch, and Chief Consultant in Tuberculosis to The Surgeon General, was appointed Chief, Medicine Branch. This change was designed to give the chief consultant in medicine in the Surgeon General's Office greater freedom from routine administration and easier access on professional matters to the chief of Professional Service and to The Surgeon General. General Morgan continued to initiate and direct the overall policies of the Medicine Branch. On 1 January 1944, as part of another general reorganization, the Medicine Branch was designated the Medicine Division, with General Morgan as director.
Finally, on 25 August 1944, the Professional Service was dissolved, and the Medicine Division was renamed Medical Consultants Division and placed in an independent status functioning directly under The Surgeon General. At this time, the division was composed of four branches: General Medicine
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Branch, Tuberculosis Branch, Tropical Disease Treatment Branch, and Communicable Disease Treatment Branch, the last named having been established in lieu of the Specialized Medicine Branch. A final addition to the organizational setup was the position for a consultant in dermatology, which was filled in March 1945. With this structure and direct relationship to The Surgeon General, the division continued its activities through V-E and V-J Days.
Thus, in order to carry out the mission of the chief consultant in medicine in the Surgeon General's Office, with the many routine administrative responsibilities which had been made a part of his mission, a staff which in the beginning had consisted of two medical officers had been gradually enlarged to six. It was clear at the outset that the activities for which the chief consultant was held responsible could be performed only by men specially trained in such activities. As need became urgent, trained men were usually found but not without delay or, occasionally, out-and-out obstruction.
Obstructions can be explained to some extent by the fact that Services of Supply, under which the Medical Department operated, controlled medical personnel with an iron hand. The Surgeon General's Office was handicapped on many occasions by edicts defining the exact personnel-allotment ceiling under which its operation had to be carried out and by the fact that these edicts originated from an authority which, one is forced to conclude, was often poorly informed if not completely ignorant of the needs of the Office.
The Medical Consultants Division had more than its share of difficulties. For example, there was delay in excess of 6 months in obtaining an officer thoroughly familiar with tropical medicine, although the need for expert guidance in this field had been long foreseen and repeatedly urged. Another delay, in obtaining a position vacancy for an officer to act as chief of a communicable disease treatment branch, at one time threatened the very existence of the Medical Consultants Division as it was at that time constituted. In addition, one may cite the extraordinary way in which the management of venereal disease treatment was handled.
In the field, the treatment of venereal diseases, with their high noneffective rate, was an enormous problem and, because of the rapid developments in therapy, urgently required proper direction. The Venereal Disease Subcommittee of the National Research Council was one of the most active, effective, and important organizations in contact with The Surgeon General. It became mandatory that the Surgeon General's Office place the responsibility for the care of venereal diseases in the hands of those professional men best equipped to master the new methods and techniques recommended to the Army by the Venereal Disease Subcommittee and guide these men in their application of the newer knowledge as it became available. Colonel Morgan took the position that the treatment of venereal diseases was, in fact, a problem of internal medicine; that the local treatment commonly employed at the time was harmful; and, therefore, that the responsibility for treatment should be given to medical rather than to surgical (urological) experts. This position was readily agreed to by Col. (later Brig. Gen.) Fred W. Rankin, Chief
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Consultant in Surgery to The Surgeon General, and in due time The Surgeon General enunciated this as official policy. Nevertheless, it was impossible to obtain approval for the assignment of an officer who was a specialist in this field. Since the Preventive Medicine Service, Office of the Surgeon General, on the other hand, had the personnel available, the Surgeon General, on the recommendation of Colonel Morgan, in November 1942 created a venereal disease treatment section in the Venereal Disease Control Branch of the Preventive Medicine Service,3 and throughout the remainder of the war this clinical activity was adnministered in that service.
Fortunately, Lt. Col. (later Col.) Thomas B. Turner, MC, Director, Venereal Disease Control Branch, OTSG, recognized that it would be impossible for his field representatives actually to supervise treatment. Most of the venereal disease control officers had had public health training and little or no clinical experience. Therefore, the consultants in medicine in service commands, theaters, and armies served as agents for implementation of venereal disease treatment policy enunciated by Colonel Turner and Colonel Morgan. The Medical Consultants Division participated in all relevant activities, such as publication of official policy in War Department circulars and TB MED's; establishment of treatment centers for neurosyphilis; clinical trials of various methods of management of gonorrhea, including duty-status treatment; and treatment of syphilis and gonorrhea with penicillin. In the field, the medical consultants, in their regular visits to Army hospitals and other Medical Department installations, consulted on the clinical management of venereal disease. Excellent Armywide liaison in the important functions of control and treatment existed between venereal disease control officers and medical consultants, and the lowered noneffective rate from venereal disease achieved during World War II represented a triumph in military medicine. Nevertheless, The Surgeon General's organization for the supervision of venereal disease treatment was a glaring example of administrative inconsistency and improvisation (p.24).
These references to some of the organizational difficulties which General Morgan encountered in the Surgeon General's Office are not cited in a spirit of criticism of the Medical Department. They arose usually because of the position of the Medical Department in relation to the Army as a whole. They were the result of restrictions and controls imposed upon The Surgeon General by higher authority, which, often enough, was uninformed and unsympathetic. That The Surgeon General was held responsible for prevention and optimum treatment of disease and injury in the Army but was not provided the authority with which to carry out this mission is an incontrovertible fact. It will be attested to by experienced medical officers throughout Army. As a partial explanation of this situation, suffice it to say that the physician and surgeon, conditioned to professional and social relation
3 (1) Memorandum, Brig. Gen. Charles C. Hillman for The Surgeon General. 3 Nov. 1942, subject: Additional Function for Venereal Disease Control Branch. (2) Office Order No. 466, OTSG, U.S. Army, 12 Nov. 1942, subject: Venereal Disease Treatment Transfer Functions.
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ships as they exist for the doctor in civilian life, often found the military setting a trying one in which to practice their profession. In fact, it can be said that the Medical Department as a whole experienced similar difficulties in its relationship to the Army which it served.
Personnel
The problem of personnel as part of the overall problem of organization has been indicated in broad outline as it existed in the Surgeon General's Office and as it was gradually resolved. It had been clear at the beginning that the Medicine Subdivision, to function fully, required experts in several medical specialties to collect and collate information, outline policies in diagnosis and treatment, initiate and supervise research, and aid in dissemination of recently acquired knowledge. As early as March 1942, a memorandum had been sent to the Executive Officer, OTSG, stating the minimum requirement to be five officers. Nevertimeless, expansion of the staff and activities of the Medicine Subdivision never kept pace with the expanding needs of the huge army in training.
Tuberculosis Branch.-It was recognized early by General Hillman that tuberculosis was an extremely important problem for the Army despite careful screening at induction centers. Therefore, Dr. Esmond R. Long, Director, Henry Phipps Institute for the Study, Treatment and Prevention of Tuberculosis, Professor of Pathology, University of Pennsylvania, Philadelphia, Pa., and Chairman, Subcommittee for Tuberculosis, Division of Medical Sciences, National Research Council, was asked to accept a commission in the Army, and on 1 July 1942, was assigned to the Professional Service Division, OTSG, as chief of the Tuberculosis Branch, Medicine Subdivision, with the rank of lieutenant colonel. The Tuberculosis Branch was concerned with all problems related to the diagnosis, treatment, and disposition of military personnel with tuberculosis. In a memorandum to The Surgeon General dated 13 July 1942, the urgent need for an assistant to Colonel Long was outlined. None was assigned. Finally, in October 1942, through an informal arrangement with the Army Medical Center, Walter Reed General Hospital, one of its medical officers, Capt. (later Lt. Col.) William H. Stearns, MC, was placed on special duty in the Tuberculosis Branch, OTSG, while he was still assigned to the Center. It was not until 17 Marchi 1943 that Captain Stearns was officially assigned to the Surgeon General's Office. Such expedients were necessary because The Surgeon General lacked full control in the management of medical personnel and was thus obliged to operate under fixed ceilings as to numbers and rank.
Tropical Disease Treatment Branch.-In the Pacific areas, many U.S. troops were certain to be exposed to various tropical diseases. Although malaria was the outstanding problem, other diseases common in time Tropics were expected to affect significant numbers. On 21 July 1942, in a memorandum to the Executive Officer, Professional Service Division, OTSG, Colonel Morgan asked that a specialist in the clinical aspects of tropical medicine be assigned to the Medicine Subdivision. No action was taken. On 2 November
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1942, Colonel Freer, at Colonel Morgan's request, sent a memorandum to General Hiliman requesting the assignment and outlining the reasons for urgency. On 18 November, General Hillman repeated the request in a memorandum to Time Surgeon General. No action was taken. Efforts to obtain appointment of a suitable officer were renewed on 5 February 1943, when war in the Pacific was very active and malaria had become an enormous problem in New Guinea. Urged by General Morgan, Colonel Freer again wrote a memorandum requesting the assignment of a specialist aid suggesting Dr. Francis R. Dieuaide, then Clinical Professor of Medicine, Harvard Medical School, Boston, Mass., and formerly Professor of Medicine, Peking Union Medical College, Peking, China. The request was granted 8 months after its initiation, and, on 22 March 1943, Dr. Dieuaide was finally commissioned lieutenant colonel and was assigned to the Medical Practice Division, OTSG, as chief of the Tropical Disease Section, Medicine Branch.
There were now five officers assigned to the Medicine Branch of the Medical Practice Division. These were General Morgan, director; Colonel Long, Tuberculosis Section chief; Captain Stearns, assigned to the Tuberculosis Section; Colonel Shull, General Medicine Section chief; and Colonel Dieuaide, Tropical Disease Treatment Section chief (fig. 4). On 1 January 1944, the Medicine Branch was redesignated the Medicine Division of Professional Services. When Colonel Long became chief consultant in tuberculosis functioning directly under the chief of Professional Services, Captain Stearns became chief of the Tuberculosis Branch. The other sections, now called branches, remained unchanged.
Communicable Disease Treatment Branch.-When Colonel Long left the Medicine Division, a numerical vacancy was opened. To fill this vacancy General Morgan proposed appointment of a chief of a communicable disease treatment branch. On 2 February 1944, in a memorandum to The Surgeon General, General Morgan outlined the functions of such a branch and indicated the need for it, mentioning the problems in relation to infectious hepatitis, rheumatic fever, gonococcal infections, and other communicable diseases. He named Col. Roy H. Turner then Consultant in Medicine, Third Service Command, and formerly Associate Professor of Medicine, Tulane University Medical School, New Orleans, La., as his choice to fill the position. No action was taken, and on 28 February 1944, the recommendation was made again but was disapproved by The Surgeon General. On 15 April 1944, another memorandum to The Surgeon General sought to have Colonel Turner assigned to the Medicine Division. The request, at first refused, was finally approved on 19 April 1944, and Colonel Turner was assigned as Chief, Communicable Disease Treatment Branch, Medicine Division, OTSG, on 4 May 1944.4
Consultant in Dermatology.-Diseases of the skin were common throughout the Army, especially in the Tropics. In a memorandum dated 29 November 1944, General Morgan requested that a consultant in dermatology be assigned
4 Office Order No. 94, OTSG, U.S. Army, 4 May 1944, subject: Chief, Communicable Disease Treatment Branch Medicine Division.
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to the Surgeon General's Office. This request was approved, and Maj. (later Lt. Col.) Clarence S. Livingood, MC, (fig. 4) then assigned to the 20th General Hospital, located in Ledo, Burma, reported for duty in the Medical Consultants Division, OTSG, on 30 March 1945.
The appointment of Major Livingood brought to six the number of officers assigned to the Medical Consultants Division. The number remained the same until demobilization began although several changes were necessitated by the policy of making officers of the division available for oversea assignments. Major Stearns was released on 2 January 1945, to become chief of the medical service of a numbered general hospital, and Capt. John S. Hunt, MC, replaced him as Tuberculosis Branch chief. Colonel Shull was released on 22 May 1945, to become Consultant in Medicine, Sixth U.S. Army, then in the Pacific, and was replaced by Maj. (later Lt. Col.) Frederick T. Billings, Jr., MC, as General Medicine Branch chief. Colonel Turner was released on 12 July 1945, to become Consultant in Medicine to the Surgeon, Army Forces, Western Pacific, and, later, Chief Consultant in Medicine to the Surgeon, U.S. Army Forces, Pacific. He was replaced by Colonel Eppinger as Communicable Disease Treatment Branch chief. Colonel Dieuaide remained in the Medical Consultants Division and became its deputy director. He continued to serve as chief of the Tropical Disease Branch.
CLASSIFICATION AND ASSIGNMENT OF PERSONNEL
Appropriate allocations of personnel with special qualifications, essential in maintaining high standards of medical care, required familiarity with the requirements of the position vacancies to be filled and accurate knowledge of the qualifications of the men available. Early in the program, difficulty was encountered in assigning specialized personnel in Zone of Interior general hospitals, which were under the direct control of The Surgeon General. It was also difficult to assign specialists to the service commands for reassignment to station hospitals and other service conmmand installations.5 Thus difficulty resulted from the apathy of some officers in the Personnel Service, OTSG, in regard to specialization in the practice of medicine. The Personnel Service was engaged in the enormous job of assigning general medical officers for the rapidly expanding Army. Moreover, no standardized Armywide classification of medical officers as to specialties existed in early 1942, and no use was being made of a classification of civilian internists furnished by civilian medical organizations.6
5 As soon as service command consultants were appointed, the general hospitals located in their command received from them as much attention and consultation and personnel management as the station hospitals. Efforts were made to establish close liaison between the service command consultant in medicine and the Medical Consultants Division, OTSG, to maintain coordination and integration in all matters, including the assignment of specialized personnel.
6 Before the outbreak of World War H and as part of preparation for the emergency, the Committee on Medicine of the National Research Council, in cooperation with the American College of Physicians, provided The Surgeon General of the Army with a carefully prepared list of the internists in the United States. This classification furnished a professional evaluation of each person as to his potentialities for assignment as, ward officer, section chief, assistant chief, or chief of service. On his arrival in the Office of the Surgeon General, Colonel Morgan procured this list from the files of the Personnel Service. The Medical Consultants Division and the Personnel Service also made extensive use of it during the early months of the war.
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Colonel Rankin and Colonel Morgan, in 1942, participated actively in The Surgeon General's officer-procurement program. They visited civilian medical society meetings and insisted upon the careful, considered assignment, by The Surgeon General, of the specialized personnel procured. These personnel functions were included in the duties of the chief consultants in the official definition of the functions of the Medicine and Surgery Subdivisions, as stated in Office Order No. 87, OTSG, U.S. Army, 18 April 1942. This order read in part as follows: * * * approval, by liaison with the Military Personnel Division, of selection of personnel for key professional positions." Gradually, these personnel functions gained the support of the Personnel Service. The fact became recognized in the Surgeon General's Office and, subsequently, in service commands and theaters that only through control of specialized personnel could the consultants perform effectively the duties assigned them. Where this principle had the wholehearted support of the surgeon of the command and of his personnel officer, it yielded the greatest returns in improved medical care.
The final acceptance by The Surgeon General of the proposition that the Medical and Surgical Consultants Divisions should cooperate with the Personnel Service in the assignment of all individuals with special qualifications in their respective fields was basic to their success in the Surgeon General's Office and throughout the Army. Finally, the Personnel Service invited the Medical and Surgical Consultants Divisions to cooperate in establishing a classification based on evaluation of professional qualifications. Out of the deliberations which ensued, there developed, albeit belatedly, the method of placing all medical officers initially into 1 of 4 categories--A, B, C, and D--according to arbitrarily defined standards of professional training and experience. Subsequently, at appropriate intervals, the classification of each officer was to be reviewed on the basis of demonstrated ability in the Army.7 Because of administrative difficulties, much time was lost in instituting this method of professional evaluation. Nevertheless, the adoption and use of the classification led to great improvement in personnel managenment during the latter part of the war. The consultants in service commands and in oversea theaters were in an ideal position to assume responsibility for the continuing evaluation and reevaluation of medical officers to keep the classifications current.
The responsibilities of the chief consultant in medicine with regard to appropriate assignments to position vacancies were defined and accorded official recognition in Office Order No. 175, OTSG, U.S. Army, dated 25 August 1944, which stated: "Assignments of key personnel will be made only with the concurrence of the appropriate Service or Division particularly concerned with or possessing special knowledge as to the qualifications of the officers and the requirements of specialty assignments." The Surgeon General encouraged the same attitude regarding the responsibilities of consultants in medicine in service
7 TM 12-405, 30 Oct. 1943, Officer Classification; Commissioned and Warrant, Appendix B, Classification of Medical Corps Officers.
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FIGURE 5.-Continued. E. 120th Station Hospital at Tortworth Courts, Falfield, Somerset, England. A castle is shown in the distance, 5 August 1943.
commands and in oversea theaters. The degree to which this responsibility was given to the consultants in the various commands at home and overseas varied considerably. It is believed that the Medical Consultants Division, OTSG, and the medical consultants in the field best served their intended functions when they were permitted to participate directly and in a detailed fashion in the classification, evaluation, and duty asignment of the specialists in internal medicine available within their command. Experience in the war has shown that, wherever the consultant was most active in this regard, the quality of medical care was usually superior.
Tables of organization.-Early in the emergency, the Medical Consultants Division was not invited to take part in the formulation or revision of tables of allotment, as the Division was concerned with specialists in internal medicine. Gradually, however, as the value of the Division's contributions to personnel management in internal medicine became recognized, consultation and advice regarding the quantitative need for specialists in the varied types of Medical Department organizations were requested.
In retrospect, it is clear that the allotment of officer personnel for medical installations of World War II placed too much emphasis upon the need for internists in the fixed hospitals, especially the general hospitals in the Zone of Interior, and too little emphasis upon needs of station hospitals in the Zone of
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Interior and in mobile units in theaters of operations. The Medical Consultants Division held that the most important contribution of internal medicine, in terms of maintaining the effective strength of the Army, was the successful treatment and prompt return to active duty of the acutely ill patient. In theaters of operations, these patients normally received their initial definitive treatment in station, field, and evacuation hospitals. This fact was not given proper consideration in the staffing of these hospitals. Station hospitals in the Zone of Interior and mobile and fixed hospitals overseas that cared for actually ill patients should have received a larger number of well-trained internists (fig.5). In time, this mistake was corrected in large measure in the station hospitals of the Zone of Interior. However, overseas, particularly in the Pacific areas, the tables of organization were adhered to. Late in the war, the resulting deficiencies were in process of being corrected by local arrangement in sonic evacuation and field hospitals.
CLINICAL SERVICES IN ARMY HOSPITALS
Organization of the Medical Service
At the beginning of the emergency, it was generally believed that the organization of professional services conventionally employed in civilian hospitals would function effectively in Army hospitals. The major services of medicine and surgery were outlined in TM8-260, Fixed Hospitals of the Medical Department (General and Station Hospitals), dated 16 July 1941. The medical service of large hospitals contained sections for general medicine, communicable diseases, gastrointestinal diseases, cardiovascular diseases (fig. 6) and neuropsychiatry. Later, the section for venereal diseases was assigned to the medical service. These sections were commonly housed in separate wards and headed by medical officers, who were designated chiefs, serving under the direction of the chief of the medical service. In addition, separate sections had to be maintained for officers and for enlisted men, in accordance with Army customs, and for women. Experience indicated the desirability of a section for dermatology, although one was not provided for in the organizational chart in TM 8-260. The Medical Consultants Division, OTSG, attempted to provide for the selection and assignment of personnel qualified to function in hospital staffs so organized.
As a rule, neuropsychiatry was organized as a section of the medical service in Army hospitals in the early part of the war (fig.7). As the Army grew and neuropsychiatric conditions increasingly contributed to the noneffective rate, the Neuropsychiatry Consultants Division, OTSG, felt that the establishment of separate neuropsychiatric services in Army hospitals, identical in status with medical and surgical services, should be considered. This separation was effected in some of the large general hospitals in the Zone of interior, and these hospitals became specially designated for the care of neuropsychiatric patients. However, for the most part, neuropsychiatry sections remained a
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FIGURE 6.-Cardiac clinic, Lawson General Hospital, Atlanta, Ga., July 1942.
FIGURE 7.-Patient on neuropsychiatry ward, Percy Jones General Hospital, Battle Creek, Mich.
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FIGURE 8.-Scene on ward at neurology center, Ashburn General Hospital, McKinney, Tex
part of the medical service in Army hospitals. The Medical and the Neuropsychiatry Consultant Divisions, OTSG, and the consultants in the field were in complete agreement that the care of patients with somatic and psychic disturbances was the common responsibility of internist and psychiatrist and that the closest cooperation was indicated. Neurologic diseases were officially designated the responsibility of the neuropsychiatrists, and, in a few hospitals designated as neurology centers, separate and independent services were established (fig. 8). In general, however, cooperation between the internist and the neurologist was considered so essential to proper treatment as to discourage organizational trends to separate them.
Management of Diseases
The treatment of diseases in Army hospitals was under continuous scrutiny by the Medical Consultants Division, OTSG. Publications based on the best available knowledge concerning the management of various diseases were prepared in the division for publication and prompt distribution. Their effect upon practice was immediate and Army wide. Only two examples will be cited.
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The time-honored and often complicated schedules of therapy for malaria were replaced with more simple regimes, after careful evaluation of the results of controlled experiments.8 In the management of gonorrhea, evidence of the existence of sulfonamide-resistant gonococci led, in July 1942, to the employment of artificially induced fever combined with sulfonamides.9 This treatment, however, though satisfactory in many instances, was accompanied by appreciable danger and was abandoned in February 1944 in favor of penicillin, 10 which had been shown to be highly effective. These radical changes in the treatment of two important diseases were brought about promptly throughout the entire hospital system of the Army. Policy governing these and many other therapeutic procedures was formulated in the Medical Consultants Division. The medical consultants throughout the Army supervised implementation of the policy.
Diphtheria.-In the Pacific, it was observed that a disturbance involving the peripimeral nerves frequently occurred in the presence of certain persistent ulcerations of the skin. Diphtheria bacilli were suspected, and careful bacteriological studies proved them to be inhabitants of these ulcerations. These and similar observations from the India-Burma theater shed new light upon the diagnostic criteria, clinical course, and therapeutic management of cutaneous diphtheria. The Medical Consultants Division, OTSG, prepared a comprehensive discussion of this subject for distribution to officers throughout the Medical Corps.11
Hepatitis.-Clinical and laboratory studies, carried out in the Army and among civilians, made it possible, in November 1945, to publish TB MED 206, Infectious Hepatitis, which contained an evaluation of the clinical criteria and laboratory procedures used in the diagnosis and management of this disease.
Tropical diseases.-Descriptions of the clinical features, laboratory findings, and therapeutic management of many clinical disorders encountered in the Army, particularly in the field of tropical disease, resulted from observations which were correlated under the guidance of the Medical Consultants Division.
Venereal diseases.-General Morgan's opinion regarding the management of venereal diseases in the Army led to an important and difficult policy decision on the part of The Surgeon General. In the peacetime Army, as in civilian practice, the care of venereal diseases, especially gonorrhea, was assigned to the urologist. In gonorrhea, the conventional procedures were urethral
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8 Circular Letter No. 153, OTSG, U.S. Army, 19 Aug. 1943, subject: The Drug Treatment of Malaria, Suppressive and Clinical.
9 (1) Circular Letter No. 74, OTSG, U.S. Army, 25 July 1942, subject: Diagnosis and Treatment of the Venereal Diseases. (2) Circular Letter No. 86, OTSG, U.S. Army, 15 Aug. 1942, subject: Fever Therapy in the Treatment of Gonorrhea. (3) Circular Letter No. 97, OTSG, U.S. Army, 12 May 1943, subject: The Use of Combined Fever and Chemotherapy in Sulfonamide Resistant Gonorrhea; and General Consideration on the Therapeutic Use of Physically Induced Fever.
10(1) TB MED 9, 12 Feb. 1944, subject: Penicillin. (2) TB MED 16, 6 Mar. 1944, subject: Penicillin Treatment of Resistant Gonorrhea.
11 TB MED 143, February 1945, subject: Cutaneous Diphtheria.
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irrigations, the frequent use of prostatic massage, urethral sounds, and bladder irrigations. Genitourinary wards equipped with batteries of specially designed irrigation commodes were provided as standard equipment for hospitals. All of this was outmoded when it was found that sulfonamides by mouth promptly cured gonorrhea in the vast majority of cases and that local irrigations and manipulations caused the complications which plagued therapists and enormously increased the noneffective rate in the Army by increasing the duration of the disease. These revolutionary developments made it quite clear that gonorrhea, as well as the other venereal infections, should become the responsibility of physicians rather than of surgeons. Recommendations to this end by the chief consultant in medicine were received without enthusiasm in many quarters. It appeared to be especially difficult for Regular Army officers, whose experience with gonorrhea and its complications had been long and dismal, to accept the new doctrine. It was pronmptly accepted by the Surgical Consultants Division. The official announcement of policy by The Surgeon General came only after the loss of much time.12 The remarkable effectiveness of the sulfonamides in treatment of acute gonorrhea and the disappearance of complications when local treatments were abandoned soon became apparent to all. Here, indeed, was arm extraordinary episode in the history of military medicine. No other development during the war contributed so significantly toward lowering the ineffective rate.
Drugs
The selection and distribution of new drugs and of new preparations of old drugs for use by the Medical Department was an important function of the Medical Consultants Division. The drug list in the Medical Department Supply Catalog, U.S. Army, was reviewed frequently. The division actively participated in planning and observing clinical trials of many drugs, notably penicillin, the production and clinical use of which were in the experimental stage.13 in the selection of a therapeutic agent for use in Medical Department installations, the fullest consideration was given not only to its efficacy but also to the dangers involved in its use. Treatment with proprietary preparations which were not on the Medical Department Supply List was discouraged. The Surgeon General, upon recommendation of the Medical Consultants Division, established policy prohibiting the use of drugs not included in the Army Service Forces Medical Supply Catalog, the United States Pharmacopoeia, or the National Formulary, or accepted by the Council on Pharmacy and Chemistry of the American Medical Association or the Council on Dental Therapeutics of the American Dental Association, unless prior approval of The Surgeon General or the appropriate theater surgeon was obtained.14
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12 (1) Circular letter No.195, OTSG, U.S. Army, 1 Dec. 1945, subject: Treatment of Venereal Disease in Army Hospitals. (2) TM 8-262, 1 July 1945, ch. 1, sec. 21, Medical Service.
13 (1) See footnote 10, p.24. (2) TB MED's 106, 11 Oct. 1944; 196, 20 Aug. 1945; 198, 20 Aug. 1945; and 172, June 1945.
14 (1) War Department Circular No. 321, August 1944, sec. II, Use of Medicinal Agents. (2) War Department Circular No. 264, 1 Sept. 1945. sec. VII, Use of Medicinal Agents.
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Chest Examinations
Roentgenographic examination of the chest of every inductee was essential during mobilization, for the protection both of the individual and the military service. Examinations with the conventional 14- by 17-inch X-ray film were cumbersome, time consuming, and expensive. Civilian equipment and personmnel were frequently employed, sometimes at great expense. The Medical Consultants Division, through Colonel Long, Chief, Tuberculosis Branch, was instrumental in establishing photoroentgen units using 4- by 5-inch film in all induction stations. It thus became possible to make routine chest X-ray examinations without burdening local civilian X-ray facilities and with great financial saving to the Government.
Clinical Laboratories
The Medical Consultants Division, OTSG, had only an indirect part in the establishment and organization of clinical laboratories in Army hospitals. The Preventive Medicine Service, OTSG, was charged with thus responsibility. Although in the Surgeon General's Office the relationship with the Laboratories Division of the Preventive Medicine Service was always one of cooperation, difficulties resulted here and in the field because of administrative separation. The experience of World War II leads to the conclusion that a more direct participation in the planning and supervision of laboratory work by the Medical Consultants Division and by the clinicians assigned to the medical service of hospitals would be helpful to the actual operation of clinical laboratories in the field. The evaluation of routine and special laboratory procedures in Army hospitals or in special laboratories in support of Army hospitals is believed to be, to a large extent, although not exclusively, the function of the clinician for whose assistance the laboratory, in large part, exists. In the service commands and in oversea theaters, consultants in medicine interested themselves directly in the maintenance of high standards in the clinical laboratories (fig. 9). Thus was beneficial both to the laboratory and to the medical service.
The appropriate use of laboratory procedures by medical officers was the subject of special interest both to the Medical Consultants Division and to the medical consultants in the field.15
Convalescence and Reconditioning
The Medical Consultants Division, OTSG, took an early and continuing interest in measures designed to shorten the hospital stay for the sick and at the same time to return the soldier to duty in the best possible condition. The great number of patients who were hospitalized with minor illnesses and the length of time they spent in hospitals contributed heavily to the non-
15 Circular Letter No. 193, OTSG, U.S. Army, 30 Nov. 1943, subject: Elimination of Unnecessary Laboratory Work.
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effective rate. Soldiers had to remain in hospitals until they were fit for full duty. In 1942, there was no organized effort in hospitals to utilize time available in the convalescence phase of illness to improve the soldiers' physical status and morale prior to his return to duty. The Medicine Division took the initiative in this matter. Through visits to the field and informal correspondence, an effort was made to develop a program to shorten the time spent in convalescence and to make better use of this time (fig. 10). As a result, War Department Memorandum W40-6-43 of 11 February 1943, entitled "Convalescence and Reconditioning in Hospitals," was published; thus memorandum marked the official initiation of a definite program for the rapid and complete rehabilitation of the disabled soldier. Although the program was far from satisfactory, it terminated the attitude of indifference toward the matter. The service command consultants in medicine encouraged and, in many instances, helped initiate reconditioning programs in hospitals under their professional supervision. In late 1942, General Morgan and Brig. Gen. (later Maj. Gen.) David N. W. Grant, the Air Surgeon, conferred informally with Maj. (later Col.) Howard A. Rusk, MC, Chief of the Medical Service, Army Air Force Station Hospital, Jefferson Barracks, Mo., on the subject of convalescence and rehabilitation. Major Rusk promptly organized a reconditioning program at the Jefferson Barracks Station Hospital and put it into operation. This marked the beginning of the extraordinarily effective program developed by Major Rusk for all Air Force medical units. Subsequently, greatly stimulated by this successful program in Air Force hospitals, The Surgeon General established a reconditioning division to administer such programs.
ADMINISTRATIVE AND CLINICAL ADVANCES DURING WORLD WAR II
At the close of the war in 1945, the Director, Historical Division, OTSG, U.S. Army, requested the Medical Consultants Division to provide in outline a statement of general advances in medical treatment during World War II. The following comments are taken from the reply to this request. They are presented without editing and represent attitude and opinion as of 24 September 1945.
1.Effective utilization and supervision of specially qualified medical personnel.-Largely through the services of a small group of expert consultants in The Surgeon General's Office, Service Command Headquarters, and Theater Headquarters, the varied specialized skills of medical officers have been effectively used and supervised both in the United States and overseas. A system of hospitals has been created with selected staff and equipment for the treatment of special military medical problems. In general, professional care has been standardized at a high level. The results are reflected in shortened periods of hospitalization and reduced fatality rates. Days lost because of disease averaged 13 for 1942-44, against 18 days for 1917-19. Deaths from disease were 0.6 per 1,000 cases in 1942-44, against 15.6 per 1,000 cases in 1917-19.
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2. Effective development of sulfonamides and penicillin as chemotherapeutic agents-The application of penicillin was developed in a small fraction of the time that would have been required in peacetime. The success of the use of sulfonamides and penicillin is reflected in periods of hospitalization and low fatality rates for many infections, specific examples of which are given below:
a.Meningococcus infections, including meningitis and septicemia.-Sulfadiazine was proved to be an extremely effective treatment, far superior to any previous method, even in extremely severe cases which occurred in large numbers at various times during the war. Later, penicillin was shown to be almost equally effective. The case fatality rate in World War II was approximately 4 percent (to be compared with 38 percent in World War I).
b. Bacillary dysentery.-Sulfaguanidine, the drug of choice at the start of the war, was replaced by sulfadiazine which was found to be the most effective treatment available. Although a great many cases occurred, the case fatality rate in World War II was about 0.05 percent, whereas in World War I it was 1.6 percent.
c. Pneumonia-The types of pneumonia which occurred in the two World Wars differed to a considerable extent. Nevertheless, it is noteworthy that the case fatality rate in World War II was 0.7 per cent, as against 28 per cent in World War I.
d. Acute upper respiratory infection.-It was shown that in the presence of an epidemic of this disease the daily administration of small doses of sulfadiazine decreases materially the incidence of complications which are commonly associated with colds and which are usually due to streptococcus invasions. As a corollary, it was found that certain types of streptococci become resistant to sulfadiazine.
e. Venereal diseases.-The use of penicillin has revolutionized the treatment of gonorrhea and syphilis. Days lost by soldier patients because of gonorrhea in 1944 averaged 7, whereas the average in 1939 was 42.
f. Skin diseases due to bacterial agents.-Medical Department studies have shown that various methods of using penicillin greatly improved the treatment of many of these infections, especially impetigo, furunculosis, and ecthymatous ulceration.
3. Streptomycin.-This recently discovered drug is still under study. It has already been shown, however, to be effective in certain diseases that are resistant to treatment with other agents, notably certain otherwise intractable infections of the urinary bladder.
4. Effective treatment of malarial attacks.-Largely through the application of improved methods of using Atabrine (quinacrine hydrochloride) and by the prompt institution of treatment, malarial attacks have not caused chronic physical disability and deaths from malaria in 1943 and 1944 amounted to only 180, although there were recorded about 320,000 attacks (0.06 deaths per 100 admissions). In 1917 - 19 there were 36 deaths due to malaria among 15,600 admissions for malaria (0.02 deaths per 100 admissions).
5.Higher fatty acids in the treatment of certain superficial fungus infections.-It has been shown that preparations of undecylenic acid and propionic acid are both effective drugs in the treatment of troublesome superficial fungus infections, including "athlete's foot." In addition, these agents cause many fewer sensitivity reactions than drugs formerly in use.
6. Podophyllum.-Just before World War II began civilian physicians found that podophyllum was effective in the treatment of verrucae of the genitalia. During the war medical officers confirmed this finding, obtaining spectacular results in the treatment of this condition.
7. Advances in knowledge of the course and general management of important diseases.-In a number of instances important advances were made in the knowledge of the course of serious but poorly known diseases and at the same time the general management of patients with these diseases was greatly improved, although in these instances effective specific chemotherapeutic agents are not now available. The following instances deserve special mention.
a. Infectious hepatitis.-Important advances were made in the diagnosis and prognosis. Much new information was obtained concerning the significance of numerous
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tests of liver function. Early and prolonged rest in bed and dietary management, especially the use of high protein feedings, were shown to be the more important available methods of treatment.
b. Filariasis.-Experience to date has shown that infection of soldiers when limited in duration by prompt evacuation to nonendemic areas is rarely, if ever, followed by permanent disability or significant lasting bodily changes. Psychological management and reconditioning are important aspects of treatment.
c. Schistosomiasis.-Late in the war, a number of soldiers contracted this little known disease in the Philippines. Much has been learned about the course of the infection. The drug treatment is still a matter of research.
d. Coccidioidomycosis.-As a result of the infection with this disease of many soldiers in the western part of the United States, a great deal has been learned about its course and management.
e. Skin diseases associated with the tropics.-Soldiers in various parts of the tropics have acquired cutaneous diphtheria, cutaneous leishmaniasis, atypical lichen planus, and generalized hyperhidrosis. Such conditions were previously little understood, especially in the United States.
8. Convalescence.-The importance of systematic management of convalescence was stressed early in the war and methods of proper management were developed.
SPECIALIZATION IN ZONE OF INTERIOR HOSPITALS
In the United States, the trend toward specialization 16 in medical practice was very strong, long before World War II. It was carried over into the Army by The Surgeon General with the assignment of medical and surgical specialists to supervise the care of the seriously ill and injured soldiers and to assist programs of prevention.
The framework for the assignment of individuals in the various specialties and subspecialties of internal medicine was, for the most part, already established in the organization of the medical services of Army hospitals at the outbreak of World War II. Of course, nothing of the sort was feasible or desirable in the assignment of medical officers to troops in the field, where general practice was the order of the day.
In addition to the policy of assigning specialists, whenever possible, where they could work in their respective fields, there developed, during the war, the use of hospitals especially manned and equipped to deal with certain
16 Documents which implemented the Medical Department's policy of specialization during World War II, as discussed in this section, are (1) War Department Army Regulations 40-600, 6 Oct. 1942, pars, 7b and 13; (2) War Department Memorandum W40-14-43, 28 May 1943, subject: General Hospitals Designated for Special Surgical Treatment; (3) Letter, Headquarters, Army Service Forces to Commanding Generals, All Service Commands and Commanding Generals Military District of Washington, 17 Dec. 1943, subject: General Hospitals Designated for Specialized Treatment; (4) Letter, Medicine Division, OTSG, to Surgeons, All Service Commands, 7 Aug. 1944, subject: New Overall Hospitalization Plan as It Affects the Medical Services of Hospitals; (5) Memorandum, Brig. Gen. Hugh J. Morgan for The Surgeon General, 11 Nov. 1943, subject: The Treatment of Malaria; (6) Memorandum, Medicine Division for Chief, Operations Service, 18 Mar. 1944. subject: General Hospitals Designated for Specialized Treatment; (7) Memorandum, Brig. Gen. Hugh J. Morgan for Chief, Operations Service, 29 May 1944, subject: Recommendation for the Designation of a General Hospital for Specialized Treatment of Tropical Diseases; (8) Memorandum, Maj. Clarence S. Livingood, MC, for Brig. Gen. Hugh J. Morgan, 23 June 1945, subject: Hospitalization of Dermatologic Patients; (9) Memorandum, Director, Resources Analysis Division for Medical Regulating Officer, 26 July 1945, subject: Revision in Authorized Patient Capicities; (10) War Department Circular No. 347, 25 Aug. 1944, subject: General Hospital-Designated for Specialized Treatment; and (11) Army Service Forces Circular No. 456, pt. II, 29 Dec. 1945, subject: Hospital Establishment of specialized Center for Tuberculosis at Moore General Hospital
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diseases or groups of diseases. The concentration of large numbers of patients with similar disorders in these hospitals--designated "centers" for special treatment--favored optimum care for the sick soldier, while it assured more economical use of highly specialized medical officers and gave them an opportunity for intensive clinical experience. Carefully planned clinical studies, including the trial of approved therapeutic measures, were possible in a few selected medical installations.
The Medical Consultants Division, OTSG, recommended the designation of certain hospitals as centers for tuberculosis, arthritis, vascular diseases, neurosyphilis, tropical diseases, rheumatic fever, and dermatological diseases, and for the cure of general medical problems in patients evacuated from overseas late in the war under the special designation of "medicine." The developments leading to this designation are discussed in the following paragraph.
General medicine.-In all theaters, during 1944, there was increasing need for Medical Corps officers qualified in internal medicine. At this time, it was difficult to provide full staffs for the medical services in 59 general hospitals operating in the Zone of Interior. However, a survey indicated that provision had been made in these hospitals for a large number of medical patients that were being sent to them either from station hospitals in the Zone of Interior or from overseas. On the other hand, beds for surgical patients were in short supply. It was proposed that the number of general hospitals receiving medical patients in the Zone of Interior be reduced. A full staff of internists would be provided each hospital designated to receive medical patients. A smaller but adequate number of qualified internists would be assigned to each of the remaining hospitals, in which the surgical services would expand as the medical service contracted. The purpose and details of this plan were explained by General Morgan in letters to each service command surgeon on 7 August 1944. The official designation of certain hospitals simply as specialty centers for medicine was announced in August 1944 (fig.11). Objections were voiced from time to time because of the limited number of specialists in internal medicine allotted to hospitals not so designated. However, it is believed that this redistribution of patients and specialists met the overall problem by providing superior care in internal medicine in general hospitals at home, while it made available specialists to the oversea theaters where they were badly needed.
Tuberculosis.-The peacetime Army had for many years maintained a center for the care of tuberculous patients at Fitzsimons General Hospital, Denver, Col. (fig.12). This designation was continued throughout the war. The numerical increase in patients from the greatly enlarged Army and the prolonged period of hospitalization required for treatment made additional beds necessary. In August 1944, Bruns General Hospital, Santa Fe, N. Mex., was designated a tuberculosis center, and its medical staff was supplemented with officers specially qualified in this field. In December 1945, Moore General Hospital, Swannanoa, N. C. (fig.13), was similarly designated and manned.
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FIGURE 12.-Fitzsimons General Hospital, Denver, Colo.
Arthritis.-Before World War II, the Army had utilized the special physiotherapy facilities of Army and Navy General Hospital, Hot Springs, Ark., for the care of patients with rheumatic diseases. This hospital was officially designated an arthritis center in December 1943. However, in both the Zone of Interior and various theaters of operations, there were found large numbers of arthritic patients requiring specialized therapy and prolonged periods of hospitalization (fig.14). To provide additional beds and a better opportunity to evaluate methods of treatment and disposition, a second arthritis center was established at Ashburn General Hospital, McKinney, Tex.
Vascular diseases.-The initial designation of hospitals in the United States for the treatment of vascular diseases was made in December 1943, on the recommendation of the Surgical Consultants Division, OTSG. However, many patients seen at these centers required medical rather than surgical management. Therefore, internists with special interest and experience in vascular disorders were found and assigned to these hospitals early in 1944, and the official designation was changed from "vascular-surgery centers" to "vascular centers." Here, on the medicine services, clinical investigation of a high order was carried out in relation to trenchfoot, immersion foot, and frostbite. Optimum methods of treatment and disposition were defined. Physicians with special knowledge of the physiology of the circulatory system cooperated closely with surgeons of similar training and interest, to the great advantage of both.
Neurosyphilis.-By the spring of 1944, the number of patients with manifestations of neurosyphilis had begun to mount considerably. It was difficult to assure uniform and optimum management when patients were admitted
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FIGURE 13.- Moore General hospital, Swannanoa, N.C.
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FIGURE 14.-Therapy used in treatment of arthritic patients. A. Creeper device used to develop range of motion. B. Arthritic patient in pool working upper arms while attendant gives proper exercise to lower limbs
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indiscriminately to any of the Army general hospitals. Therefore, in June 1944, seven general hospitals located conveniently throughout the Zone of Interior were specially staffed and designated for care of neurosyphilis patients.
Rheumatic fever.-Two needs--one for uniform management of patients with rheumatic fever in a favorable climate, the other for increased knowledge regarding all aspects of the disease--suggested the establishment of specially staffed centers. However, air transportation of acutely ill rheumatic fever patients created special problems. Again, plans to coordinate clinical st udies with similar studies carried on in hospitals under the direct supervision of the Air Surgeon were difficult to administer. Discussions begun in the early spring of 1944 did not produce the actual designation of hospitals until August 1 944, when the establishment of three rheumatic fever centers was announced. These were Foster General Hospital, Jackson, Miss., Birmingham General Hospital, Van Nuys, Calif., and Torney General Hospital, Palm Springs, Calif.
Tropical diseases.-Clinical problems in tropical diseases were difficult and numerous. In particular, reliable information regarding prognosis and optimum treatment was lacking for malaria, filariasis, and schistosomiasis. The Medical Consultants Division, OTSG, recommended early in 1943 the establishment of centers, both in the United States and overseas, for the observation, study, and special treatment of patients with tropical diseases. Since at that time malaria was the only tropical disease occurring with troublesome frequency and since higher authority in the Surgeon General's Office was unsympathetic to the project, no action was taken. On 11 November 1 943, the establishment of a number of malaria treatment study units, both in the United States and overseas, was again recommended. The Surgeon General responded to this request by establishing, on 15 November 1943, the Board for Study of the Clinical Treatment of Malaria (p.50). This board used four general hospitals in the United States and studied the relative value of eight different plans of treatment. One definite conclusion arrived at was that Plasmochin naphthoate (pamaquine naphthoate) did not cure malaria caused by infections from Plasmodium vivax.
Believing that special study and special treatment facilities for tropical diseases were, in fact, mandatory, the Medical Consultants Division again recommended, on 29 May 1944, that at least one center be established and in this connection cited a simple administrative problem. At about that time, it had become necessary to make provision in one hospital for a large number of filariasis patients returning from overseas. The administrative requirement carried weight, and, on 25 August 1944, Moore General Hospital was finally designated a tropical disease center. Highly qualified clinical and laboratory staffs were assembled. Eventually, studies of filariasis, malaria, tropical skin diseases, schistosomiasis, and leishmaniasis were carried out under the direction of Maj. Harry Most, MC, chief of the tropical disease section Lt. Col. (later Col.) Joseph M. Hayman, Jr., MC, chief of the medical service, and Lt. Col. (later Col.) Frank W. Wilson, MC, commanding officer.
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Harmon General Hospital, Longview, Tex., had been selected by The Surgeon General's board on malaria in 1943 to try 1 of its 8 plans for treatment. After The Surgeon General's board filed its final report on the treatment of malaria on 26 March 1944, 4 months and 11 days after its organization, the malaria studies were taken over, continued, and expanded by the staff in medicine at Harmon General Hospital. Finally, in April 1945, Harmon also was designated a tropical disease center. The contributions of this hospital ex tended over a period of 2 ½ years and were of great value in connection with malaria, filariasis, schistosomiasis, and tropical skin disorders. Those chiefly responsible for this work were Maj. (later Lt. Col.) Harry H. Gordon, MC, chief of the tropical disease section; Colonel Marble and Lt. Col. (later Col.) Worth B. Daniels, MC, successively chiefs of the medical service; and Col. Gouverneur V. Emerson, MC, commanding officer.
Dermatologic conditions.-In the spring of 1945, after a careful survey of the problem in general hospitals in this country, Major Livingood of the Medical Consultants Division recommended that the management of patients with dermatological conditions be concentrated in seven general hospitals, where the small number of specialists then available could more adequately care for them. In a memorandum of 23 June 1945, this plan was described by Major Livingood, and it was officially adopted on 26 July 1945.
The results which accrued from the use of hospitals designated as special centers for the care of certain diseases or groups of diseases were impressive. The centers provided good patient care, efficient use of limited personnel with specialty qualifications, opportunities for clinical investigation, specialized programs for convalescent care and rehabilitation, and opportunities to plan the ultimate disposition of certain large groups of patients. It is clear in retrospect that the establishment of these centers earlier in the emergency would have been wise administration.
EXCHANGE OF PROFESSIONAL INFORMATION
A major interest of the Medical Consultants Division, OTSG, was the collection and dissemination of professional information throughout the Medical Department, particularly information concerned with recent advances in medical knowledge and techniques and with the development of new approaches based upon observations and study in the field. The Medical Consultants Division, in the highest echelon of the Medical Department, was strategically situated to encourage and direct this activity.
Early in the development of the Medical Consultants Division, a great deal of time was devoted to the study and manipulation of channels of communication through which important medical information could flow from field to headquarters. With the establishment of consultants in the service commands and oversea theaters, the interchange of professional news and opinion became a compelling necessity. The difficulties resulting from rigid adherence to command channels during the early days of the war were of such magnitude
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and importance that they should be mentioned. Those difficulties were not confined solely to prohibitions issued by officers of the line against the transmission of medical intelligence. Certain service command and theater surgeons, either of their own volition or because of orders from higher authority, forbade the forwarding of technical information by the service command or theater medical consultant to the chief consultant in the Surgeon General's Office. The conclusion is inescapable that much of the difficulty regarding interchange of technical information which characterized the early period of the war could have been avoided had line and medical officers alike adopted a sane commonsense attitude toward the interpretation of directives dealing with command channels and military security.
Reports, correspondence, and meetings.-The ETMD (Essential Technical Medical Data) reports initiated by the Medical Department in 1943 helped greatly to facilitate the interchange of professional news and opinion. These reports, gathered in the major oversea headquarters, contained data concerning the incidence and management of disease in the various subordinate units; the satisfactoriness of treatment agents, equipment, and supplies and the availability of qualified professional personnel. Though far from adequate for the needs of the Medical Consultants Division, these ETMD reports furnished one medium at least through which professional information could be exchanged between personnel in oversea theaters and the Zone of Interior.
Service command medical consultants in the Zone of Interior usually forwarded to the Medical Consultants Division carefully prepared reports of visits which they made to each medical installation within their command. These formal reports were frequently supplemented by personal correspondence. The service command consultants were encouraged to communicate freely when they felt that the Division could give assistance or that the Surgeon General's Office or the medical installations in other commands should be informed concerning professional matters. These personal letters permitted rapid transmission of news and ideas and free expressions of opinion.???
Annual meetings of medical consultants in the Zone of Interior were held, with programs divided between clinical and administrative topics (appendix B p. 831). In 1943, the meeting was held in the Surgeon General's Office (fig.15); in 1944, at Ashford General Hospital, White Sulphur Springs, W. Va. (fig. 16); and in 1945, at Thomas M. England General Hospital, Atlantic City, N.J. At the first of these meetings, in 1943, the neuropsychiatrists were in attendance. Subsequently, in 1944 and 1945, attendance was confined to the medical consultants from the service commands and the civilian consultants in medicine to The Surgeon General. The Surgeon General or his deputy and the chiefs of personnel and hospitalization services also attended. At the meetings in 1944 and 1945, it was possible to have representatives, temporarily in this country, from some of the oversea theaters.
In addition to encouraging exchange of information on professional matters throughout the Army, the Medical Consultants Division, OTSG, maintained liaison with other individuals active in the field of clinical investi-
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FIGURE l5.-Meeting of consultants in medicine, OTSG, 25-26 October 1943.
Left to right, first row, seated: Col. W. Bauer (Eighth Service Command), Col. A. Freer (Director, Medical Division), Brig, Gen. C. C. Hillman (Chief, Professional Service), Brig. Gen. H. J. Morgan (Chief Consultant in Medicine to The Surgeon General), and Lt. Col. V. R. Mason (Ninth Service Command).
Second row, standing: Lt. Col. E. R. Long (Chief, Medicine Branch), Lt. Col. F. D. Adams (Fourth Service Command), Lt. Col. H. L. Blumgart (Second Service Command), Col. W. B. Martin (Fifth Service Command), and Lt. Col. F. R. Dieuaide (Medicine Branch).
Third row: Lt. Col. R. H. Turner, Lt. Col. E. V. Allen (Seventh Service Command), Lt. Col. I. S. Wright, Lt. Col. G. P. Denny, Lt. Col. H. J. Shull (Medicine Branch), and Capt. W. H. Stearns (Medicine Branch).
gation. Members of the staff regularly attended important civilian medical meetings and meetings of appropriate committees of the National Research Council.
Publications-In the fall of 1942, representatives of the Surgical and Medical Consultants Division suggested to others in the Surgeon General's Office that a medical newsletter be established. Such a medium was made available in January 1943. Only two issues were published before the project had to be abandoned because of administrative difficulties.17 Further discussions within the Surgeon General's Office resulted in converting the quarterly Army Medical Bulletin to a monthly publication called the Bulletin of
17 (1) Circular Letter No. 8, OTSG, U.S. Army, 2 Jan. 1943, subject: Medical News Letter, 1 Jan. 1943, (2) Circular Letter No. 26, OTSG, U.S. Army, 15 Jan. 1943, subject: Medical News Letter No. 2.
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FIGURE 16.-(See opposite page for legend.)
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the U.S. Army Medical Department. In this bulletin, there appeared regularly through the remainder of the war both articles and news items relating to current problems in the field of medicine. The establishment of the bulletin was announced in Circular Letter No. 165, OTSG, U.S. Army, 15 September 1943, and the first issue appeared the following month. The chief consultants in surgery and medicine became member's of the editorial staff. Unfortunately, distribution of this bulletin, even in the Zone of Interior, constituted a major problem. Copies were never received by many medical officers in oversea installations, although direct mailing to officers at their APO's improved distribution to some extent.
Another medium for dissemination of official communications concerning diagnosis, treatment, and disposition of patients in Army hospitals was the circular letters of the Surgeon General's Office. These were discontinued on 31 December 1943. They were replaced by TB MED's and to a less extent, by War Department circular's, Army regulations, FM's (War Department Field Manuals) and TM's.
FIGURE l6 - Conference of military and civilian consultants in medicine, Ashford General Hospital, White Sulphur Springs, W. Va., 30-31 October 1944.
Left to right, first row, seated: Col. D. M. Pillsbury (Consultant, Dermatology, ETOUSA), Col. F. P. Strome (Surgeon, Third Service Command), Col. E. A. Noves (Surgeon, Fifth Service Command), Brig. Gen. H. J. Morgan (Chief Consultant in Medicine to The Surgeon General), Col. C. M. Beck (Commanding Officer, Ashford General Hospital), Col, A. Freer (Chief, Professional Administrative Service, OTSG), and Col. W.P. Holbrook (Chief, Professional Division, Army Air Forces).
Second row: Lt.. Col. T. H. Sternberg (Director, Venereal Disease Control Division, OTSG), Col. E. V. Allen (Consultant, Seventh Service Command), Col. T. Fitz-Hugh, Jr. (Consultant, Third Service Command), Col. W. Bauer (Consultant, Eighth Service Command), Dr. J. H. Stokes (Consultant, Dermatology), Dr. W. L. Palmer (Consultant, Gastroenterology), Dr. J. E. Moore (Consultant, Venereal Diseases), Col. I. S. Wright (Consultant, Sixth Service Command), Dr. M. F. Boyd (Consultant, Tropical Diseases), Dr. R. B. Watson (Consultant, Tropical Diseases), Lt. Col. H. J. Shull (Chief, General Medicine Branch, OTSG), and Dr. P. D. White (Consultant, Cardiovascular Diseases).
Third row : Col. V. R. Mason (Consultant, Ninth Service Command), Col. F. D. Adams (Consultant, Fourth Service Command), Dr. R. L. Levy (Consultant, Cardiovascular Diseases), Dr. C. B. Thomas (Consultant, Infectious Diseases), and Dr. R. A. Cooke (Consultant, Allergy)
Fourth row: Lt. Col. F. R. Dieuaide (Chief, Tropical Disease Treatment Branch, OTSG, Dr. C. M. Jones (Consultant, Gastroenterology), Lt. Col. H. L. Blumgart (Consultant, Second Service Command), and Dr. C .M MacLeod (Consultant, Infectious Diseases).
Fifth row: Dr. W. B. Wood, Jr. (Consultant, Infectious Diseases), Lt. Col. M. J. Farrell (Deputy Director, Neuropsychiatry Consultants Division, OTSG), and Maj. A. C. Vami Ravenswaay (Chief, Medicine Branch, Army Air Forces).
Sixth row: Col. B. M. Baker (Consultant, South Pacific Base Command), Lt. Col. J. McGuire (Consultant, Fifth Service Command), and Dr. H. W. Brown (Consultant, Tropical Diseases)
Seventh row: Dr. F. M. Rackemann (Consultant, Allergy), and Lt. Col. G. P. Denny (Consultant, First Service Command)
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Circular letters of the Surgeon General's Office and T B MED's were the usual vehicles for conveying useful clinical information and outlining professional procedures. Each of these publications, when written by the Medical Consultants Division, was the editorial responsibility of one member of the staff. Its contents expressed, in general, a summation of the best available information on the subject under discussion. Throughout the emergency, the Division's staff devoted much time and effort to the preparation of these publications. The circular letters, TB MED's and other publications which were prepared wholly or in considerable part by the Division are listed in table 1.
TABLE 1.-Publications prepared wholly or in part by the Medical Consultants Division 1
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TABLE 1- Continued - Publications prepared wholly or in part by the Medical Consultants Division 1.
It should be repeated that the distribution of professional publications was neither so prompt nor so complete as it should have been, especially in oversea theaters. Journals and books received at oversea depots had low priority ratings for distribution, and delivery to hospitals was often delayed or failed completely. Individual medical officers in forward units who might have profited most from the medical technical bulletins frequently did not receive them at all or received them only after great delay. Often, careless handling at medical installations delayed or defeated proper distribution.
Educational media.-General Morgan believed that the assignments of most physicians in the Medical Department provided them an opportunity
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for professional improvement. He also believed that the Medical Department was obligated to render all practical assistance possible to medical officers in their efforts to improve their professional knowledge. Consequently, procedures of educational value were encouraged in Medical Department installations. Medical consultants in the major commands, both in the Zone of Interior and overseas, were the pivotal personnel in this undertaking. Circular Letter No.27, OTSG, United States Army, 22 January 1943, and TB MED 210, December 1945, stressed importance of staff rounds and staff meetings in hospitals. The Medical Consultants Division was successful in its efforts to modernize and enlarge hospital libraries in respect to internal medicine. The Board for Review of Books and Periodicals, OTSG, theoretically made selections of professional texts and journals available to each medical installation caring for patients (p.49). Facilities of the Army Medical Museum were opened to all hospitals. To speed up the procurement of special information from medical literature, the Army Medical Library enlarged its facilities for the reproduction and distribution of microfilm for any medical officer or installation requesting it. Visits of civilian consultants to hospitals of service commands in the Zone of Interior were encouraged and assisted. Wartime graduate medical meetings were held under the auspices of the American College of Physicians and the American College of Surgeons, in cooperation with the Surgeons General of the Army and Navy. Medical Corps officers were encouraged to qualify themselves for certification by the American specialty boards and, wherever practical, to attend important medical meetings of both Army and civilian physicians.
Important contributions to the continuing education and training of Army medical officers were made by civilian organizations such as the American Medical Association, the State societies, the American College of Physicians, the American College of Surgeons, and other medical groups, the Rockefeller Foundation, and the Commonwealth Fund. Especially in the early months of the war, the Medical Consultants Division, OTSG, served as a coordinating agency between the Army medical officer's and these civilian organizations.
INTRAOFFICE AND INTEROFFICE RELATIONSHIPS
In the large and complex organization of the Surgeon General's Office, the operations of certain services and divisions were of special importance to the Medical Consultants Division.
Personnel Service.-It is obvious that accurate classification and proper assignment of professional personnel directly affects the quality of medical care furnished patients.
As has been noted (p. 17), the medical consultants' group cooperated actively in the procurement of immedical officers. Many civilian internists were personally acquainted with members of the staff of the Medical Consultants Division and, in the process of becoming commissioned, made their first contact with the Army in that Division. Through such contacts, Gen-
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eral Morgan assisted the Personnel Service, OTSG, by acquainting himself with the availability of individuals with special qualifications in internal medicine. Through personal knowledge of civilian physicians, he was able to select and procure for the Army, by informal means, individuals best suited to fill certain key positions. Generals Morgan and Rankin made frequent visits to civilian medical meetings in the interest of Medical Corps officer procurement during the early days of the war.
A close, effective relationship between the Medical Consultants Division and the Personnel Service was clearly essential to the proper utilization of internists by the Army. When this relationship finally received official approval, the Medical Consultants Division assumed one of its most important duties-- that of determining, by recommendation, the classification and assignment of medical specialists in Army installations. This activity involved constant exchange of information between the Personnel and Medical Consultants Divisions regarding the need for and availability of medical specialists, the continuing evaluation and classification of individual medical officer's with experience in internal medicine, and recommendations as to where these individuals could best be used.???
The information used by the Medical Consultants Division in personnel evaluation covered many aspects of an officer's qualifications but chiefly had to do with his participation in postgraduate education and training programs and his record of professional performance. The service command consultants regularly reviewed the classification of the internists assigned to their commands, evaluating their on-the-job performance.
The Civilian Personnel Division, OTSG, was important to the Medical Consultants Division because it provided not only secretarial and clerical personnel but also civilian consultants to The Surgeon General. The role of the latter is described elsewhere in this chapter (pp. 66-67). As to the former, the Medical Consultants Division was fortunate in having capable, industrious, and loyal office employees, whose work was essential to the success of the division.
Operations Service.-The Medical Consultants Division cooperated with the Operations Service, OTSG, and the Personnel Service, OTSG, in studying the need for medical officers qualified in internal medicine in the various types of Army medical installations. These studies formed the basis for the tables of organization for numbered oversea units and for the manning guides for the fixed installations in the Zone of Interior. Unfortunately, these tables and guides proved to be unsatisfactory in the light of actual field experience. Even when hostilities ceased, they had not been revised insofar as professional personnel was concerned.
The Hospital Division of the Operations Service designated hospitals to receive certain types of patients, recommended establishment of centers for the care of special disorders, and evolved and administered plans for the transfer of patients from one hospital to another. Under the leadership of the Hospital Division, group visits to selected hospitals throughout the Zone of Interior
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were made by representatives from the Medical Consultants Division, the Surgical Consultants Division, and certain other divisions within the Surgeon General's Office. The Hospital Division frequently requested the Medical Consultants Division to recommend administrative changes which would result in more efficient management of medical patients. The relationship between the Medical Consultants Division and the Operations Service was extremely cordial, to the greater effectiveness of both divisions in relation to the care of the sick. This was the state of affairs during the last 18 months of the war. It is unfortunately true that, during 1942 and 1943, opportunity for cooperative endeavor of this sort was very limited.
Supply Service.-In the earliest days of his assignment, Colonel Morgan was asked his opinion concerning medicinal agents for use in the Medical Department of the Army. To a somewhat lesser extent, he and his staff became concerned also with the distribution of medicines and items of equipment to the various medical installations in the Army. As the war continued, the Supply Service, OTSG, requested the Medical Consultants Division's cooperation in the review of tables of equipment with a view toward adding new items, immeluding medicinal agents, and deleting old ones no longer in demand. The Medical Consultants Division was often asked for an opinion on the misc of nonstandard medical items. From time to time, it provided background information and assistance in developing therapeutic agents and in expanding production. The development of production facilities for penicillin, streptomycin, and blood plasma was obviously a matter of great concern to the Division.
Other services and divisions.-The Medical Consultants Division and the divisions representing preventive medicine, surgery, and neuropsychiatry cooperated closely in the formulation of professional policies. This cooperation was essential to the planning of a balanced professional program. The Medical Consultants Division regularly gave assistance also to the Physical Standards Division, OTSG, in refereeing questions pertaining to borderline physical findings in military personnel. It cooperated actively with the editor of the Bulletin of the U.S. Army Medical Department in the preparation, approval, and editing of professional material for dissemination to the field and with the Technical Information Division, OTSG, in reviewing professional articles submitted for publication and also material to be released to public information mediums. In addition, the Medical Consultants Division was called upon from time to time to advise and assist other divisions of the Surgeon General's Office in the preparation of bulletins and manuals for dissemination to the Armed Forces. Such a publication was FM 21-11, First Aid for Soldiers, 7 April 1943. The Medical Consultants Division cooperated with the Surgical Consultants Division, OTSG, in preparing the manuscript and supervising the collection of data. A large part of TM 8-500, Hospital Diets, published in March 1945, was prepared under the Medical Consultants Division's direction.
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Special boards.-The Medical Consultants Division, OTSG, provided members for a number of special boards, five of which were of special interest to the Division.
1. Board to prepare, develop, and implement the medical portion of the War Department's program for aid to civilian populations in liberated countries.-This board was established on 28 June 1943, by Office Order No. 419, OTSG, U.S. Army. Colonel Dieuaide of the Medical Consultants Division, served on this board until after the end of the war. In many meetings, supplemented by individual interim study, comprehensive plans were developed for furnishing medical supplies to civilian populations in the countries to be liberated by Allied forces. Items to be included in various supply assemblies were carefully selected, and instruction sheets were prepared by Colonel Dieuaide outlining the purposes and recommended method of using these supplies, particularly drugs.18
2. Board for Review of Books and Periodicals.-The Medical Consultants Division was represented on this board by General Morgan and Colonel Shull, chairman and secretary respectively.19 The board provided reviews by appropriate professional authorities of all medical textbooks and periodicals submitted by publishers to The Surgeon General for purchase. It recommended to The Surgeon General medical textbooks and journals for the libraries of Medical Department installations of all types and, at regular intervals, revised the recommended list. The board also provided the Supply Service, OTSG, with authoritative opinion when requisitions were received for nonstandard books and journals.20 The consultants in medicine throughout the Army stimulated commanding officers to provide libraries in Army hospitals with adequate physical facilities and personnel and to supplement the supply of books where local funds were available for that purpose.
The actual delivery of journals to oversea installations remained a problem throughout the war (p.45). The Board for the Review of Books and Periodicals finally arranged for the direct mailing of journals by the publishers to the individual units. This was found to be an improvement in the theaters where it was tried, but no genuinely satisfactory method for the continuing and prompt distribution of current journals and books to Army libraries was developed during World War II.
The Board for the Review of Books and Periodicals also took a lively interest in a method, developed by the Army Medical Library, for the rapid transmission of professional data on microfilm to medical installations in the Zone of Interior and overseas. This very important aid to professional education and training was one of many successful efforts of the Army Medical
18 TB MED 149, 17 Mar. 1945, subject: Descriptive List of Drugs and Chemicals in Far East CAD Units.
19 Office Order No. 350, OTSG. U.S. Army, 4 June 1943, subject: Board for the Review of Books and Periodicals.
20 (1) Circular Letter No. 158, OTSG, U.S. Army, 27 Nov. 1942, subject: Medical Books. (2) Circular Letter No. 126, OTSG, U.S. Army, 16 July 1943, subject: Medical Books and Journals, Including Authorization for Limited Local Procurement. (3) War Department Supply Bulletin 8-3, 21 Mar. 1944, subject: Medical Department Professional Books, (4) Var Department Supply Bulletin 8-4, 21 Mar. 1944, subject: Medical Department Professional Journals. (5) War Department Supply Bulletin 8-20, May 1945, subject: Medical Department Professional Books.
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Library to project its influence into the oversea theaters and, in rare instances, even to individual medical officers assigned to combat units. Facilities were enlarged at the Army Medical Library for photoduplication, and projectors for reading the microfilms were made available to all Army installations.21
3. Board for Study of the Clinical Treatment of Malaria.-The initiation of clinical studies of malaria treatment was impeded by the opinion of a few medical officers in high position that sufficient knowledge was already at hand, based on prewar experience of the Army in the Tropics. Early attempts to modify this sentiment were unsuccessful. Finally, on 15 November 1943 in Office Order No. 890, The Surgeon General appointed a special board to surpervise studies in the field of malaria. Colonel Dieuaide served on this board. Trials of eight plans of treatment for malaria were conducted at Bushnell General Hospital, Brigham City, Utah, Kennedy General Hospital, Memphis, Tenn., Percy Jones General Hospital, Battle Creek, Mich., and Harmon General Hospital. Plasmochin naphthoate was one of the drugs especially studied in the hope of curing malaria caused by infection from Plasmodium vivax. The Plasmochin naphthoate method was unsuccessful, as indicated in the final report of the board, dated 26 March 1944. 22
4. Board for the Coordination of Malarial Studies.-Early in November 1943, an interservice Board for the Coordination of Malarial Studies was created by joint action of the Director, Office of Scientific Research and Development; the Director, National Research Council; and the Surgeons General of the Army, Navy, and U.S. Public Health Service. This board continued the functions of the Subcommittee on Malaria of the National Research Council and established means for direct collaboration with the services. It was brought into existence because the usual consultative arrangement with committees of the National Research Council was found inadequate in the face of the complexities and size of the malaria problem then confronting the armed services. Colonel Dieuaide, on the recommendation of General Morgan, was appointed by The Surgeon General of the Army as a member of this board and served until after the end of the war. The Malaria Board, as it was called, was a clearinghouse for all available information about malaria, as well as a forum for the discussion of plans and a directing body for the supervision of research in the field (fig.17). Through the Malaria Board, most of the planned studies of malaria treatment in the Army in the United States, and to a less extent overseas, were coordinated with research carried on outside the Army. The Board for Coordination of Malarial Studies published several volumes of malaria reports from 1943 to 1946. Of 600 numbered reports approximately 90 were contributed by various Army sources. Although the efforts of the board failed to disclose any new curative drug, several powerful and important new drugs
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21 (1) Monocular Microfilm Viewer. The Army Medical Library Microfilm Service. Bull. U.S. Army M. Dept. 74: 118-119, March 1944. (2) Journals Available on Microfilm. Bull. U.S. Army M. Dept. 75:12 Apr. 1944. (3) Microfilming Research Material. Bull. U.S. Army M. Dept. 79:29 Aug. 1944. (4) Microfilm Projector for Army Hospitals. Bull. U.S. Army M. Dept. 88: 62-63, May 1945.
22 Memorandum, Board for Study of the Clinical Treatment of Malaria for The Surgeon General, 26 Mar. 1945, subect: Final Report on the Treatment of Malaria.
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FIGURE l7.-Collecting mosquito larvae in the field for study, 8th Medical Laboratory, Australia, 1943.
were studied (including SN-7618 and SN-8713), and the routine treatment of malaria with the drugs then available was vastly improved. Important contributions included a definitive comparison of quinine and Atabrine, which demonstrated conclusively the superiority of the latter and the determination of the optimum methods for its use. 23
???5. Board to survey and evaluate the medical problems of repatriated American prisoners of war.-With the cessation of hostilities in the Pacific, a large number of American prisoners of war were released from Japanese prison camps. The length of captivity ranged from a few days to 3 ½ years. The environmental conditions had varied considerably but for the most part had been extremely poor (fig.18). Thousands died as a result of disease and starvation (fig.19). The Medical Consultants Division believed that a careful health survey of the survivors would be of value in planning their future medical care, in preventing the spread by them of communicable diseases to families and communities, and in providing a better understanding of the changes that take place in men during exposure to such hardships (fig.20). Accord-
23 (1) The Board for the Coordination of Malarial Studies. Wartime Research in Malaria. Science 103: 8-9, 4 Jan.1946. (2) The Suppressive Treatment of Malaria with Mepacrine (Quinacrine).J. A. M. A. 126: 1098, 23 Dec. 1944. (3) Quinacrine Hydrochloride (Atabrine) for Malaria. .J. A. M. A. 125: 977, 5 Aug. 1944. (4) Shannon, J. A., Earle, D, P., Jr., Brodie, B. B., Taggart, J. V., and Berliner, R. W.: The Pharmacological Basis for the Rational Use of Atabrine in the Treatment of Malaria. J. Pharmacol. & Exper. Therap. 81:307-330, August 1944.
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FIGURE 19-Typical picture of malnutrition in an American prisoner of war recovered in Japan.
ingly, in Office Order 218, dated 30 August 1945, The Surgeon General established a board to survey and evaluate the medical problems of repatriated American prisoners of war returning from the Far East. General Morgan served as president of this board, Colonel Wright as coordinator, and Captain Hunt as recorder. The work of the survey teams that made the study and the results of the undertaking are described in a published report.24
Army Air Forces-Contact between the offices of The Surgeon General, the Air Surgeon, and, to a lesser extent, the Surgeon, Army Ground Forces, was not close. This was a reflection of the separation by command boundaries and the compartmentation of responsibilities in the various fields of Army medicine which existed at the beginning of World War II. In spite of the inherent difficulties, the Medical Consultants Division attempted to serve the Air Surgeon and the Ground Surgeon, as well as The Surgeon General of the Army. The organizational and physical separation of the offices rendered the efforts difficult and, on the whole, unrewarding.
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24 Morgan, H. J., Wright, I. S., and Van Ravenswaay, A.: Health of Repatriated Prisoners of War from the Far East. J.A.M.A. 130:995-999, 13 Apr.1946.
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FIGURE 20.-Continued. C. Disinfestation of clothing. D. Taking a medical and social history.
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In the fall of 1942 and spring of 1943, service command medical consultants in the Zone of Interior regularly visited Air Force hospitals. However, autonomy of Air Force operations, coupled with misunderstandings which occasionally grew out of the consultants' suggestions designed to improve the quality of medical care or to change medical officer assignments, often resulted in friction. When friction occurred, it almost invariably involved administrative or command personnel rather than the professional personnel in hospitals. Because of such friction, medical consultants in certain service commands ceased visiting Air Force medical installations.
Fortunately, the value of these visits by professional consultants was apparent to Air Force clinicians. Therefore, the Air Surgeon established a svsteni of consultation within the Air Forces, with visits by the senior clinicians in Air Force regional hospitals to the smaller hospitals in their areas.25 The Air Surgeon also appointed consultants who functioned in his office much as did medical consultants in the Surgeon General's Office. The relationship between the consultants in the Air Surgeon's Office and those in the Surgeon General's Office was good, and many professional problems which would have been difficult to consider through regular channels were handled well on an informal basis. Examples of cooperative undertakings carried on in spite of administrative difficulties are clinical observations on atypical lichen planus, clinical trials of penicillin in certain infections, notably gonorrhea, and observations on the management of rheumatic fever and other diseases related to streptococcal infection. There was little cooperation between the two offices with regard to the assignment of specialists. During World War II, The Surgeon General of the Arniy had virtually no control over the professional personnel of the Army Air Forces.
Army Ground Forces.-In the Army Ground Forces, the importance of the quality of professional medical services was overshadowed in the early months of Army expansion by more pressing quantitative needs and the necessity for field training of medical officers. It is unfortunate that no professional consultants regularly visited Ground Force units in training in the Unted States. It was not until the early months of 1944 that the consultants divisions of the Surgeon General's Office participated in personnel selection and assignment to the professional staffs of numbered hospital units destined for oversea service with the Ground Forces. The training program for medical officers in these units emphasized physical conditionmg and practice in triage and transportation and evacuation of patients, especially the wounded, but little emphasis was placed upon the curative treatment of disease and injury with prompt return of the soldier to duty (fig. 21). Thus, the primary mission of the Medical Department in time of war--the maintenance of the lowest noneffective rate possible--was often neglected. The emphasis upon surgery
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25 This system was also in operation in certain Army Service Forces hospitals as a supplement to the consultation provided by the service command consultants.
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FIGURE 21-Training in triage and evacuation of wounded. Placards on trees announce (left to right): ''Capt. MC,'' ''1st Lt. Med. Officer,'' ''Litter wounded,'' and ''Water,'' Lawson General Hospital, Atlanta, Ga., September 1943.
in the manning tables for numbered hospitals destined to function with combat troops in the theaters of operations is understandable, but it often proved to be unrealistic (fig.22). The number of surgical patients returned to duty from hospitals in the theaters of operations was small indeed when compared with the number of medical patients returned. The greatest contribution to the maintenance of the lowest noneffective rate possible came from medical officers, who were concerned with the prevention and cure of disease,
American National Red Cross.-Contacts between the Medical Consultants Division and headquarters of the American National Red Cross and between consultants in medicine in the field and Red Cross field representatives were frequent, cordial, and mutually beneficial. The Medical Consultants Division, through Colonel Dieuaide, assisted the Red Cross in formulating lists of drugs to be included in packages for delivery to American prisoners of war in enemy hands. Accompanying these packages was a statement prepared by Colonel Dieuaide describing in lay terms the indications for dosage of these drugs.26
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26American Red Cross. Booklet of Instruction for the Use of Drugs Contained in the 100-man Unit of the Medical List for Allied Prisoners of War in the Far East, May 1944.
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FIGURE 22.-Emphasis on surgery during training. Actual operation under field conditions in a mobile hospital unit attached to Lawson General Hospital, Atlanta, Ga., January 1944.
RESEARCH
In the early days of the emergency, The Surgeon General, while urging full use of civilian research facilities, discouraged efforts to carry on planned and coordinated clinical investigation in the Army. This official attitude appeared to be due to a number of factors. There was enormous pressure to meet the practical medical needs of the rapidly expanding Army, and, although important scientific research had been done in the past by Army officers, the tradition of clinical research was not established in Army thinking. The function of the Medical Corps in time of war was generally judged to be the optimum application of knowledge already available, not research and discovery. Moreover, the National Research Council, which the National Academy of Sciences had established in 1916 for the benefit of Government agencies, was fully organized and geared to a high degree of activity.27 During World War II and the emergency period preceding it, the committees of experts of the National Research Council were available to the Medical Department for consultation and for the planning and actual execution of research projects.
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27 The National Academy of Sciences was a private nonprofit organization of scientists recognized by act of Congress and by President Lincoln in 1863 to further science and to advise the Federal Government in scientific matters upon request.
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As the war progressed, the need for answers to medical problems, both new and old, became increasingly urgent. The facilities of the National Research Council were used widely. It may be said that without this help the Medical Consultants Division, in relation to many problems, would have functioned often in a vacuum and almost always would have been less effective. The Committee on Chemotherapeutics and Other Agents, together with its special subcommittees, gave invaluable assistance, especially in regard to the sulfonamides, penicillin, and streptomycin. Also, the Committee on Medicine and each of its Subcommittees on Tuberculosis, Infectious Diseases, Clinical Investigation, Cardiovascular Diseases, and Medical Nutrition assisted the Medical Consultants Division in solving problems in these specific fields. The Subcommittee on Tropical Diseases initiated and coordinated investigations in its field. Upon official request of The Surgeon General, the following topics of special importance to the Medical Consultants Division were made the subject of study and reports by the appropriate committees: Amebiasis, schistosomiasis, leishmaniasis, filariasis, malaria, poliomyelitis, and tuberculosis; the treatment of ill effects of heat upon troops; the treatment of venereal diseases; the use of sulfonamide drugs; the use of penicillin and of streptomycin; and the management of fungus infections of the skin.
The facilities available to the National Research Council for its study of Army medical problems were confined, in large measure, to civilian institutions. As the Army was organized and administered in World War II, it was not practicable for the National Research Council systematically to carry on studies in military installations. Nevertheless, many of the problems facing The Surgeon General had special military aspects that could be studied only in Army installations.
???The need for such clinical studies, initiated and directed by the Medical Consultants Division, was evident when War Department technical bulletins were in preparation. These official publications were intended to guide medical officers throughout the Army in diagnosis, treatment, prognosis, and disposition of soldiers with certain unethical disorders. In many instances, information was not available for specific statements and directions regarding the particular professional problems seen by the Army. The choice of the Medical Consultants Division was either to depend upon impressions, guesses, and conclusions arrived at on hypothetical grounds or to make studies designed to provide the answers. It was extremely difficult to do the latter at any time during World War II.
The criteria for the early diagnosis of infectious hepatitis constitute a case in point. There was little information in the medical literature, and that little was not certainly applicable to time disease as it was experienced by the Army. It was soon apparent that time patient with hepatitis should have prompt and prolonged hospital care, but there were many uncertainties concerning diagnostic laboratory procedures. Even the piecemeal information available on these points reached the Medical Consultants Division by means so indirect and slow that the problem was never completely and satisfactorily solved,
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although useful information was obtained through civilian consultants and Army personnel in selected hospitals. Patients with naturally acquired infectious hepatitis were not seen in sufficient numbers in Zone of interior installations, nor were enough qualified investigators ever concentrated in one or more of the oversea commands to permit thorough study of the problem.
Such research as was undertaken in Army installations in the management of disease was often fragmentary and poorly coordinated. There was no established administrative machinery for carrying out these studies. The initiation of each project required special approval, special arrangements for equipment and personnel, special instructions to the commanders of the installations concerned, and the approval of several organizations within the Surgeon General's Office. It was difficult to get information about clinical research in oversea commands because early in the war there were no direct channels of communication between the field installations and the Medical Consultants Division. It is true that clinical investigation carried out both in the Zone of Interior and in oversea theaters was excellent, but investigations were often hampered and their accomplishments rendered less valuable to the Army as a whole because means of communication and coordination were tenuous or nonexistent. The Medical Consultants Division was especially sensitive to this serious handicap in relation to its problems with malaria, filariasis, schistosomiasis, hepatitis, and penicillin.
The following are examples of clinical research with which the Medical Consultants Division was actively concerned:
1. Hepatitis.-In the spring of 1942, numerous cases of infectious hepatitis occurred in soldiers who had been vaccinated for yellow fever. The Medical Consultants Division succeeded in obtaining the assignment of four medical officers to four separate Army hospitals to observe the chemical course and the effects of various forms of treatment. These studies provided early clinical experience in a problem that was to develop into one of great magnitude and importance.
The Division encouraged as best it could the extensive field studies on hepatitis which were carried out under difficult circumstances in the Zone of Interior.
???2. Tropical diseases.-Extensive and valuable clinical observations and therapeutic trials were made in the field of tropical medicine, especially at Moore and Harmon General Hospitals and in the Pacific. Such studies increased knowledge of filariasis and of schistosomiasis and gave information of the greatest practical value on the use of Atabrine in malaria. From the Southwest Pacific in 1944 and 1945, large numbers of patients were returned to this country with an unusual skin disorder, which came to be called atypical lichen planus. A concise, clear-cut clinical description eventually resulted from carefully organized studies of related groups of eases in hospitals in this country as well as overseas.
3. Trenchfoot.-Selected hospitals, manned and equipped for the purpose, made special studies of a great many trenchfoot patients returned from the
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European theater. These studies yielded useful information applicable throughout the Army.
4. Penicillin and streptomycin.-The Medical Consultants Division was active in planning and developing within the Army opportunities for studying the use of penicillin. Studies on the absorption, excretion, and methods of prolonging the action of penicillin were carried forward at two specially designated Army hospitals, Walter Reed General Hospital, and Fort Bragg Regional Hospital, Fort Bragg, N.C. As the war closed, extensive observations on the use of a newer antibiotic, streptomycin, were under way.
By the spring of 1945, there was fairly widespread acceptance of the concept that it is the province and duty of the Medical Department of the Army to pursue actively, by whatever means available, clinical research in Army hospitals and laboratories. There was increasing (but never complete) agreement in the Surgeon General's Office that it was sound and proper policy to establish facilities and assign medical personnel for this purpose. Earlier efforts made in this direction from time to time had met with resistance or failure. Members of the Medical Consultants Division and others contended that establishment of a special board, within the framework of the Surgeon General's Office, composed of Medical Corps officers with research interest and training, would facilitate research undertakings. Establishment of such a board, to be designated the Army Board for Clinical Research, was formally proposed by the Medical and Surgical Consultants Division in March 1945, with the belief that its creation would strengthen and extend administrative provisions then existing for the initiation, supervision, and coordination of research by The Surgeon General. The proposal was not approved during the war.
VISITS TO SERVICE AND OVERSEA COMMANDS
From the beginning, it was apparent that firsthand knowledge of the problems of medicine as encountered in the field was essential if a bureaucratic, theoretical approach was to be avoided. Experience strengthened this opinion (fig. 23). Accordingly, General Morgan, during his tour of duty in the Army, spent approximately one-half of the time in the field, including more than 8 months in oversea theaters, As the Medical Consultants Division, OTSG, grew, the chiefs of branches also made frequent field trips. This personal contact was maintained with the medical consultants assigned to service commands, theaters, and armies.
In 1942, General Morgan attended Army maneuvers in the California desert (fig.24). During this year and subsequently, he and members of his division made frequent visits to the nine service command headquarters and the medical units (general and station hospitals) in these commands (fig.25). In 1943, General Morgan visited the North African theater; the Middle East theater, including Egypt, Eritrea, Palestine, and the Persian Gulf Service Command; the China-Burma-India theater; the Southwest Pacific Area (Australia, New Guinea); and the Hawaiian Islands, Colonel Dieuaide visited the
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FIGURE 23 - Brig.Gen. Hugh J. Morgan visiting Col. Frank W. Wilson, MC, Moore General Hospital, Swannanoa, NC., 1944.
Pacific in 1943-44 to survey the tropical disease problems in general and malaria in particular. In 1944, Colonel Turner of the Communicable Disease Treatment Branch visited the Mediterranean theater to study infectious hepatitis. In the spring of 1945, General Morgan visited the European and Mediterranean theaters, and, after V-J Day, accompanied by Colonel Dieuaide, he visited the following commands: U.S. Army Forces, Pacific (including U.S. Army Forces, Western Pacific, and the Sixth and Eighth U.S. Armies, which were then occupying the Japanese islands), and the China theater.
The value of these visits to field headquarters and installations may be summarized as follows:
1. Through direct contacts between the chief consultant and his assistants and the medical consultants and command surgeons in the field, the visits promoted unity of purpose and mutual understanding and confidence.
2. They were a means for direct and immediate interchange of ideas and information that were often of Armywide significance.
3. They improved specialized personnel management within commands and between commands.
4. To some extent, they associated the Medical Corps officers in field assignments in remote places with The Surgeon General and his headquarters organization. At the least, they were interpreted as a token of the interest of The Surgeon General in all of the officers of the Medical Department.
5. They brought to the attention of the commanding officers of major
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FIGURE 24.- Maneuvers in California desert. Armored halftracks approach Blythe, Calif., 7 October 1942.
and subsidiary commands the functions of The Surgeon General and his office in relation to the Army as a whole.
6. They encouraged, by example, a continuing and lively interest in clinical problems. Time and time again, medical officers expressed appreciation for visits made by individuals from the Surgeon General's Office to the bedside of sick or injured patients. Inspections by men in high position in the Army often completely ignored the actual care of the sick or injured soldier and the clinical problems incident thereto. This care was the chief activity of the majority of medical officers, and they rightly viewed it as their primary mission. The morale and performance of these officers were improved when The Surgeon General or his representatives took a similar view.
7. They bridged the chasm which inevitably develops between the men in field assignments and the headquarters group.
8. They brought to the Surgeon General's Office the problems of the field for such contributions to their solution as could be provided.
???It should be stated that administrative duties in the Surgeon General's Office did not permit enough visitation by the staff to field units, whether in the Zone of Interior or overseas. In addition, visits to oversea installations were often discouraged by the War Department and, at times, by the oversea theaters.
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FIGURE 25.- Medical installation, Ninth Service Command. Hospital (foreground) of Desert Training Center, Calif., 1943.
CIVILIAN CONSULTANTS IN MEDICINE
Every effort was made by The Surgeon General to bring into the Medical Department of the Army the best personnel available and to choose from them military consultants for assignment to commands in the field. The demands of medical education, research, and practice in civilian life, however, were so great that many eminent specialists in medicine were required to remain at their civilian posts. Moreover, many who were anxious to serve in the Army could not meet Army physical requirements. Through membership in the National Research Council committees, the services of most of these specialists were made available to The Surgeon General. In the early years of the war, much good for the Army was accomplished by informal contacts and personal correspondence between the chief consultant in medicine and his staff and this group of physicians. In January 1944, General Morgan recommended, and The Surgeon General approved, the formal appointment of civilian consultants in medicine to The Surgeon General. These consultants were recognized authorities in the fields of gastroenterology, cardiovascular diseases, dermatology, infectious diseases, chemotherapy, allergy, tropical diseases, and tuberculosis. In subsequent months, as special needs arose, additional consultants in special fields were appointed, as follows: In November 1944, a consultant each in hepatic diseases and in tropical medicine; in January 1945, an additional consultant in dermatology; and in March 1945, a consultant in vascular diseases. The internists who served as civilian consultants to The Surgeon General during World War II are listed in appendix C, p. 839.
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General Morgan, his staff in the Surgeon General's Office, and the military medical consultants in the field were aided greatly by the civilian consultants. Through these consultants, both medical societies and individuals had direct access, through official channels, to The Surgeon General and the chief consultant in medicine, anti developments in civilian medicine were immediately available to the Army. Frequently, advice on urgent matters was asked by letter or telephone. The civilian consultants prepared material to be incorporated in War Department technical bulletins for Armywide distribution; they attended conferences with the Medical Consultants Division and the service command consultants; and they offered suggestions and recommendations regarding Medical Department administrative procedure and professional practices. In short, they provided a close and effective liaison between civilian medical practice and research and Army medical practice and research, to the great benefit of both. Occasionally, the civilian consultants were ordered on active duty as commissioned officers with the Army for a few days, following which they submitted comments and recommendations regarding the problem at hand. They visited Army hospitals in the Zone of Interior in company with the military consultant of the command. Such visits, made jointly by civilian and military consultants, were found to be stimulating to the morale and professional performance of medical officers on duty in hospitals. It should be recorded that each of these civilian consultants gave freely and willingly of time and knowledge. Their extraordinary competence and their availability made them a valuable source of advice and professional assistance for the Surgeon General's Office and for medical officers in the field. Their appointments were terminated as of 31 December 1945.
PLANS FOR THE POSTWAR ARMY
Planning for the Medical Department.-General Morgan and his colleagues in surgery and psychiatry devoted a great deal of thought and energy to plans for retaining an adequate number of properly trained general medical officers and specialists in the postwar Army in order to preserve the excellent wartime standards of professional care. The problem was the procurement of specialized personnel for the Army Medical Corps. Suggestions and recommendations were submitted as early as 1942 and were resubmitted periodically.28 These suggestions involved increasing the Army Medical Corps through admission of interested officers of ability who were either certified specialists or candidates for certification. During the war, these suggestions were considered impracticable because there were few, if any, vacancies in appropriate grades and it required an act of Congress to increase the size of the Army Medical Corps. Following cessation of hostilities, there was a sharp drop in interest on the part of both the Medical Department and the personnel under consideration.
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28 Memorandum, Chief Consultant in Medicine for Director, Historical Division, 14 Sept. 1945, subject: General Recommendations for the Medical Department in a Future Emergency.
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Plan to continue the consultants system.-The professional consultants system, as employed during World War II, had gained general acceptance throughout the Army. The following directive, War Department Circular No. 101, was published 4 April 1946, months after cessation of hostilities and at a time when demobilization of the Army was well under way. Indirectly, it is an appraisal of the consultant system in the form of a statement of what the Army had come to expect of it and how the Army planned for continued operation of the system in the postwar period.
III. PROFESSIONAL CONSULTANTS. 1. During World War II, The Surgeon General developed a system of utilizing professional consultants from which great benefit was derived (reference is made to paragraph 2d, section II, WD Circular 12, 1946). In order to insure the maintenance of the highest professional standards and to provide close liaison with leaders in the medical profession at large, this system will be continued and extended in the future. Professional consultants who are recognized experts in the medical and allied specialties, including internal medicine, surgery, neuropsychiatry, preventive medicine, dentistry, veterinary medicine, and other special medical fields, will be designated by The Surgeon General. Recommendations for appointments in connection with special subjects, such as dentistry and veterinary medicine, will be made by the senior officer in these fields. They may be either appropriate officers commissioned in the military service (Regular Army, Army of the United States, Officers' Reserve Corps, or National Guard of the United States) or qualified civilians selected to render consultant service (see par. 4). Although the provisions of this circular apply particularly to the United States, oversea commanders will utilize appropriate medical officers in their commands for similar duties or may procure professional advice from locally available civilian medical experts.
2. As representatives of The Surgeon General, the professional consultants are concerned essentially with the maintenance of the highest standards of medical practice. It is their function to evaluate, promote, and improve further the quality of medical care and sanitation by every possible means, and to advise in the formulation of the professional policies of The Surgeon General and to aid in their implementation. The proper performance of these functions necessarily involves an appraisal of all factors concerned with the prevention of disease and the professional care of patients, including particularly the organization and program of professional services in medical installations, the quality, numbers, distribution and assignment of specially qualified professional personnel, the diagnostic facilities including roentgenologic and laboratory procedures, the availability and suitability of equipment and supplies for professional needs, and the nursing care, dietary provisions, recreational and reconditioning facilities, and other ancillary services which are essential to the welfare and morale of patients. The professional consultants exercise their functions by assisting and advising The Surgeon General, the surgeons of major forces and commands, and the commanding officers of hospitals and other medical installations on all matters pertaining to professional practice and preventive medicine, by providing advice on professional subjects in general and on newer developments in prophylaxis, diagnosis) treatment, and technical procedures, by stimulating interest in professional problems and aiding in their investigation, and by encouraging and participating in educational programs such as conferences, ward rounds, and journal clubs, and by giving advice on matters pertaining to research and development. The execution of these functions involves periodic visits to medical installations and other types of units concerned with the medical care of military personnel. The functions of professional consultants vary somewhat according to their assignments.??????
a. Office of The Surgeon General. In addition to medical officers permanently assigned as professional consultants, other specially qualified individuals will be placed on temporary duty from time to time, for the purpose of rendering advice and assistance to The Surgeon
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General on broad problems connected with policy and practice in the prevention of disease, the care of patients, evaluation and maximum utilization of specialized personnel, medical research, postgraduate medical education, and other important professional matters throughout the Army both in the United States and overseas.
b. Lower echelon headquarters. Designated professional consultants will be placed on temporary duty from time to time in service commands, Military District of Washington, and air force command headquarters for the purpose of rendering expert advice to surgeons of these headquarters. It is desirable that such consultants be individuals with military experience. Their services will be utilized regularly in connection with problems within the command which relate to the care of patients and other professional matters as indicated above.
c. Army hospitals and other medical installations in United States. Professional consultants will be placed on duty from time to time in Army hospitals and other medical installations in the United States which are designated by The Surgeon General to provide graduate education for medical officers in certain medical specialties. Such consultants will have the particular duties in hospitals of furthering in every possible way the educational program for the advancement of medical officers in the specialties and of maintaining the highest standards on the professional services of the installations. They may, however, he called upon by the commanding officer for any professional advice or appropriate professional assistance he may desire of them. Their services will be utilized regularly. For further information regarding the educational program of the Medical Department in the medical specialties, see AR 350-1010. Professional consultants in the various medical and allied specialties will also be used in other types of medical installations, including especially those devoted to research and development.
3. At the completion of a special mission and at such other times as may be required, each professional consultant who has been on duty shall direct a communication to The Surgeon General dealing with the functions set forth in paragraph 2, including recommendations (if any). These communications, with appropriate indorsements including those of hospital commanders and surgeons of commands concerned, will be promptly forwarded through technical channels to The Surgeon General. Indorsements will show what action has been taken on consultants recommendations and will give an evaluation in terms of the consultants services.
4. Qualified individuals designated by The Surgeon General will be utilized as medical consultants in one of two capacities--that is, either by being ordered to active duty as officers commissioned in the Officers' Reserve Corps or the National Guard of the United States in accordance with War Department policy, or by being employed as consultants holding excepted civilian appointments under the authority of the Secretary of War. The consent of the individual concerned will be obtained prior to placing him on duty. The Surgeon General will maintain up-to-date lists and from time to time inform all concerned of the names, addresses, and qualifications of medical experts selected and approved for consultant duty. He will also furnish details regarding the procedures for placing consultants on duty.
5. The above instructions are equally applicable to dental and veterinary consultants.
6. These instructions do not relate to the provision of civilian medical care, specialized or otherwise, for individual military patients at public expense, as outlined in paragraphs 3 and 4, AR 40-505.
ROLE OF THE INTERNIST IN WORLD WAR II
Among many miscellaneous topics claiming General Morgan's interest was the relative importance of the internist in the Medical Department of the Army. The topic was forced into the foreground of attention by the tendency on the part of some to emphasize the Medical Department's surgical activities in such a way as to belittle the contribution of those who cared for the sick.
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This attitude on the part of laymen is not surprising, for, when their attention is directed to the Medical Department of the Army during wartime, it naturally focuses upon the wounded man and his care. Actually, the noneffective rate and the factors that affect it adversely are equally the concern of the Army Medical Department; they are, indeed, its chief concern in respect to its mission to help win wars. Viewed in this light, the wounded man, aside from the great emotional reaction experienced by all regarding his plight, of necessity assumes a position of secondary importance, for he is often noneffective for a very long time, if not permanently. Preventive and curative medicine are more immediately effective in reducing medical noneffectiveness, which fortunately constitutes the bulk of the problem of the Medical Department as a whole. In the Italian campaigns of World War II, 80 percent of noneffective soldiers returned to duty by the Medical Department were medical patients; only 20 percent were surgical. The internist, thanks to the developments in medical therapeutics since the early 1920's, has become the most effective therapist extant, and this fact is reflected in Army records.
Nevertheless, the traditional tendency in military medical planning and administration is to lay the greatest stress upon the surgical aspects of military medicine, often to the detriment or neglect of the medical aspects. General Morgan considered it one of his important duties as chief consultant in medicine to represent the professional interests and to emphasize the practical importance of the internist with the Army in the field in order to claim for himself, in the councils of the Surgeon General's Office, his proper place and to urge that he be properly recognized and adequately supported. In this position, General Morgan was strongly supported by many medical officers with field experience in the Ground Forces, notably Col, (Later Maj. Gen.) Joseph I. Martin, MC, Surgeon, Fifth U.S. Army. Nevertheless, the maximum exploitation of what internal medicine had to offer in reducing the noneffective rate of troops in the field was not undertaken during World War II. To do this, a revision of the tables of organization and equipment for Ground Forces medical installations would have been necessary. In the field of psychiatry, much was accomplished in this direction during the war, with notable returns in reduction of psychiatric noneffectiveness. The Ground Forces administration of problems in the field of internal medicine during World War II differed little from the practices of 1917-18, the management of the venereal diseases being almost the sole exception. Because Army Medical Department installations were planned and administered primarily for a surgical mission, inefficiency and improvisation characterized their performance with regard to medical problems. In the theaters of operations, the lack of specialized personnel in internal medicine and the paucity of beds for the care of the sick in installations under Army jurisdiction resulted in much unnecessary evacuation to the communications zones, prolonged hospitalization, and increased noneffectiveness. The assignment of medical consultants to field any headquarters in this war was an extremely important initial step in the direction of correction. Much still remained to be done when hostilities ceased.
