Activities of Medical Consultants
CHAPTER II
Service Commands
Hugh J. Morgan, M.D.
There could hardly have been found any group of Army officers of the same age and grade with more original and independent attitudes and patterns of behavior than the group selected to be service command consultants in medicine (figs. 26 and 27) by The Surgeon General on the recommendation of his chief medical consultant. However, the group had certain attributes in common. Each was distinguished in civilian medical practice and medical education; each was a loyal patriotic American, eager to serve his country; and each became a dedicated officer in the Medical Department of the Army.
A prerequisite to their selection was that the consultants be sufficiently imaginative and resourceful to grasp in broad outline a concept of the role a professional consultant might play in the Army. After commission, however, the consultants were provided with little more than officer grade and a very vague job definition for support to establish themselves and make their way in a sometimes hostile and frequently indifferent headquarters.
The role of theprofessional consultant in civilian internal medicine was a familiarone to thesemen. The knowledge, resourcefulness, tact, and perseverance which theyrequired in civilianpractice were essential also for their role as consultants in the Army.They went into their newassignments encouraged by The Surgeon General and his representativesto do for sick soldiersand the medical officers who cared for these soldiers what theseconsultants knew well how todo for patients and practitioners in civilian life. This assignmentrequired not only professionalability but also ability to evaluate and manipulate professionalpersonnel, to create anenvironment in Army hospitals conducive to high professional standards,to encouragecontinuing medical education in the Army, to stimulate promptadministrative disposition ofconvalescent patients, and, in every other way, to keep the Armynoneffective rate from diseaseat the lowest possible level.
The effectiveness of themedical consultants in the earliest assignments to service commandsencouraged surgeons of other commands to experiment with this new kindof officer. 1 Theassignments were not mandatory. The Surgeon General had no suchauthority over servicecommand surgeons. Following the prompt and conspicuous success of theconsultants who wereassigned to the Fourth, Seventh, Eighth, and Ninth Service Commands inAugust 1942, other
1 Col. Henry M. Thomas,Jr., MC, was assigned to the Fourth Service Command on 1 Aug.1942; Col. Walter Bauer, MC, was assigned to the Eighth Service Commandon 19 Aug. 1942.Col. Verne R. Mason, MC, was assigned to the Ninth Service Command andCol. Edgar vanNuys Allen, MC, to the Seventh Service Command somewhat later in thesame month. The Firstand Third Service Command surgeons were the last to request consultantsin medicine. Officers were assigned to these service commands inJanuary 1944.
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FIGURE 26.-Consultants in medicine, Service Commands.
(Left) Col. George P. Denny, MC, Consultantin Medicine, Office of the Surgeon, First ServiceCommand.
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FIGURE 27.-Consultants in medicine, ServiceCommands.
(Right) Col. John Minor, MC, Consultant inMedicine, Office of the Surgeon, Third ServiceCommand.
(Left) Col. Johnson McGuire, MC, Consultantin Medicine, Office of the Surgeon, Fifth ServiceCommand
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commands requested consultants, despite thefact that early in the war no position vacancyexisted for them in thie allotment of medical officers for servicecommand headquarters.Consequently, the presence of a consultant used a position vacancydesigned for other purposesand blocked promnotions.
It should be pointed outthat the success of the consultant system in the Zone of Interiorduringthe early training phase of the war paved the way to a large extent forits adoption later withinthe communications zones and finally by the armies within the varioustheaters of operations. Aconspicuous exception was the consultant system adopted quite early inETOUSA (EuropeanTheater of Operations, U.S. Army). Under the guidance of Maj. Gen. PaulR. Hawley, ChiefSurgeon, ETOUSA, and Col. William S. Middleton, MC, and Col. (laterBrig. Gen.) Elliott C.Cutler, MC, Chief Consultants in Medicine and Surgery, ETOUSA,respectively, theredeveloped consultant coverage that was ready for and kept pace with therapidly expandingEuropean Air and Ground Forces in World War II. The professionalconsultant system reachedits fullest development and maximum efficiency in the European theater.
The names of the medicalconsultants in the Zone of Interior and the service commands in whichthey served are listed in appendix A (p. 829).
In the preparation of thischapter, full use has been made of the service command consultants'final reports which were prepared at the request of the MedicalConsultants Division, OTSG(Office of the Surgeon General), at the termination of the fighting andjust prior to the separationof the consultants from military service. All of the reports have beenhelpful, but special mentionshould be made of the report, Activities of the Medical Consultants inthe United States,prepared by Col. Walter Bauer, MC, Consultant in Medicine, EighthService Command, fromAugust 1942 to August 1945.
DUTIES OF MEDICAL CONSULTANTS
The service commandsvaried greatly in size, from the relatively small First Service Commandof the northeastern seaboard to the huge western Ninth Service Command(map 1). Because ofthe geographic area included in the more extensive commands,consultants found it almostimpossible to visit even the larger hospitals with any frequency.Problems encountered incommands with large areas and populations and the means used formeeting these problemswere discussed in the final report of Colonel Bauer. He summarized thescope of the activities ofthe service command consultants as the consultant program evolved inthe different commands.Also, he commented on the jurisdictional conflict regarding medicaladministrative authority,which plagued The Surgeon General and the Air Surgeon and their officesduring the war andwhich was brought into sharp focus by the medical consultants, whosechief concern was theimprovement of the quality of medical
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MAP l.-Service Commands, Zone of Interior,during World War II.
care received in military hospitals.2 The following paragraphs summarize his observations andrecommendations.
The magnitude of the taskto be performed by a service command consultant in a given servicecommand depended on the wishes of the service command surgeon, the sizeof the area, theavailable transportation facilities, the number and type ofinstallations, and the total troopstrength. In one of the larger service commands, the surgeon desiredthat the consultant beresponsible for the supervision of internal medicine, including allsubspecialties exceptneuropsychiatry. He was to serve all fixed Medical Departmentinstallations within thegeographic limits of the service command, including Army Air Forceinstallations, inductionstations, reception centers, replacement centers, internment camps,and, when necessary, Army-owned or Army-operated industrial plants.Even though the consultant worked rapidly, it wasimpossible for him to visit approximately 150 installations in a year'stime. Experience soondemonstrated that, unless he could visit each installation at leastevery 2 months, he could notachieve maximum professional effectiveness. This assignment was inmarked contrast to thoseof the smaller service commands, where it was possible to maintain thedesired schedule withrelative ease.
In the event of anothernational emergency, every effort should be made to correct such grossdiscrepancies. One or more additional consultants should be provided inthe table of organization(manning tables) of at least the larger service commands. Designationof an assistant by the
2 In fairness to Air Forcehospital commanders and hospital staffs, it should he said thatproximity to patients diminished the intensity of feeling whichcharacterized higher echelons. Ifleft to themselves at the operational level in the field, the servicecommand medical consultantsand the Air Force hospital commanders and staffs functioned togetherwell with benefit to thepatients and everyone else concerned.
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consultant, with the approval of the service command surgeon, wouldassure harmony. Thisarrangement would increase the frequency of hospital visits and providefor the continuouspresence of a qualified professional consultant at headquarters.
Since no provision wasmade for additional service command consultants, a substitute plan wasdeveloped by the Eighth Service Command in 1944. Each of the regionaland general hospitals,with the approval of the Surgeon, Eighth Service Command, designated acompetent internist,usually the chief of the medical service, to serve as consultant to itssatellite stations. By havingthese regional consultants visit the smaller hospitals every 8 weeks,it was possible to providebetter supervision of clinical activities, more intimate associationwith the parent institution, andmore frequent consultations. Once this plan was in effect, the servicecommand consultant wasable to maintain the desired contact with those installations (general,regional, and large stationhospitals) responsible for the care of most of the service commandpatients. His association withthe medical officers of the satellite hospitals continued through themedium of educationalexercises held at the time of his visits to the parent institution. Ata later date, the morecompetent service command specialists in radiology, dermatology,neuropsychiatry,ophthalmology, and otology were also directed to visit the largerhospitals. These augmentationsof the consultation service proved very effective and were adopted byseveral other servicecommands. The chief advantages were more frequent visits to allhospitals, greater exchange ofprofessional experiences, and, most important of all, higher quality ofmedical service for everysick soldier regardless of his location.
The consultants, havingbeen instructed to visit all medical installations in their servicecommands, rightfully assumed that their relations with the Army AirForce hospitals were to bethe same as with installations of the Army Service Forces. They were atthe outset. However, inMarch 1944, the Commanding General, Army Air Forces, specificallyrequested that the servicecommand consultants visit the Army Air Force installations only uponrequest and then for thesole purpose of teaching and holding clinics. This action marked thetermination of the initialplan except in the Eighth Service Command, where the surgeon of thatcommand insisted thatthe consultant continue as before or discontinue all contact with theArmy Air Forceinstallations. In a few of the other service commands, the visits werecontinued on a limited scalebut only because medical officers assigned to the Army Air Forcehospitals urgently requestedthat this profitable medical experience be continued. In retrospect,this action by the Army AirForces appears very unwise, since no substitute for the service commandconsultant wasprovided until the closing months of the war and then only on arestricted scale. This and similarexperiences at the ports of embarkation indicate the need fordefinitive statements of policyregarding the function of the consultant in the other installationsunder separate commands (fig.28). The needed integration of all the medical services located in aservice command cannot beachieved otherwise.
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Each consultant was freeto adopt the methods of procedure that he deemed suitable to the needsof his own service command. Helpful suggestions were received from manysources, the mostimportant being the service command surgeons; the Chief Consultant inMedicine, OTSG, andhis staff; fellow consultants; and the commanding officers and staffsof many of the hospitalsvisited. The yearly conferences of the consultants afforded themexcellent opportunity to discussmutual problems.
The scope of theconsultants' activities as finally evolved included supervising theprofessionalactivities of the medical services and the allied specialtiespreviously mentioned; advising theservice command surgeon on all professional matters; maintaining closeliaison with the chiefconsultant in medicine in the Surgeon General's Office; assigningmedical officer personnel;fostering educational programs; coordinating medical consultantactivities with those of theconsultants in surgery, neuropsychiatry, and orthopedic surgery;consulting frequently with theother divisions of the medical branch; reviewing clinical records andautopsy protocols;performing the necessary editorial duties; aiding in the control ofepidemics; and being availableon request by the commanding officers of hospitals as consultants onunusual or complicatedcases.
Many of the consultants'fields of activity overlapped; the time devoted to each depended on itsrelative importance. Initially, the consultants were
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concerned primarily with the professional needs of the medical servicesin the servicecommands. In those service comniands where the augmented consultationsystem wasintroduced, these professional duties required only 75 percent of theirtime; the remainder wasspent at headquarters.
Another appraisal of medical consultants'duties as they evolved with the passage of time isprovided by Col. F. Dennette Adams, MC, Consultant in Medicine, FourthService Command,from September 1943 to December 1945. Colonel Adams observed in hisfinal report that duringthe earlier months following the initiation of consultants' service inhis command, theconsultant's activities were limited almost exclusively to matterspertaining directly to the careof the patient. He was cimarged with the following duties:
1. To advise the Surgeon,Fourth Service Command, concerning all matters relating to thediagnosis and medical treatment of disease and the professionaloperation of medical andlaboratory services in all service command hospitals.
2. To maintain liaisonwith the chief consultant in medicine in the Surgeon General's Officeonmatters of a professional nature and those pertaining to key personnel.
3. To visit all servicecommand hospitals, survey the medical and laboratory services and makerecommendations to the chiefs of services and the commanding officer ineach installation aswell as to the service command surgeon, and prepare a report of eachsurvey for channeling toThe Surgeon General.
4. To hold teaching roundsand clinics at installations visited.
5. To serve as consultantfor chiefs of medical service within the hospitals of the servicecommand and advise them regarding professional problems.
6. To evaluateprofessional qualifications of medical officers serving at eachinstallation.
7. To be available to act,on the request of the commanding officer of a hospital, as a consultanton any unusual or complicated case under his jurisdiction. (In someinstances, this involved apersonal visit to the hospital; in others, the chief of medical serviceor other qualified officerfrom a nearby general, regional, or station hospital was designated toact for the consultant.)
As the elapsed, theconsultant's duties were broadened to include the following:
1. To survey professionalqualifications of officers assigned to the medical and laboratoryservices in order to recommend proper professional classification andcoding.
2. To assist the personnelbranch of the service command surgeon's office in the properassignment of medical officers.
3. To review all cases ofdeath occurring in the service command to detect possible errors indiagnosis or treatment and to make recommendations aimed at preventingsimilar mistakes in thefuture.
4. To review, edit, andapprove or reject, prior to dispatch to The Surgeon General for finalreview and action, articles written by medical officers in the commandand intended forpublication in professional journals.
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5. To prepare articles oftimely professional interest for publication in the monthly MedicalBulletin of the Surgeon, Fourth Service Command.
6. To encourage otherofficers in the command also to contribute appropriate articles to thisbulletin.
The service commandconsultants were not bureaucrats. Not more than one-third of theirtime,and usually less, was spent in headquarters. A summary of ColonelAdams' observations onmedical consultant activities in the Fourth Service Command gives adetailed, intimate view ofhow one medical consultant carried out his mission.
In general, the consultantspent 75 percent of his time in the field amid the remaining 25 percentat headquarters. Days at headquarters were devoted to administrativework, such as writingreports of his visits, familiarizing himself with current WarDepartment directives, discussingpolicies with the service command surgeon so as to be qualified tointerpret them properly toofficers in the field, reviewing papers submitted for publication, anddiscussing with the MedicalPersonnel Branch, Headquarters, Fourth Service Command, changes ofassignments to bringabout better distribution of the more proficient officers and soencourage a higher level ofmedical care.
The consultant usuallyspent from 10 to 20 days on each trip to the field, visiting from 3 to6installations, depending on their size. Such trips were alternated withperiods of from a week to10 days at headquarters. Until March 1944, Army Air Force hospitalswere included in theitinerary. Subsequent to this time, because of changes in WarDepartment policy, an Armymedical consultant visited an Air Force hospital only at the commandingofficer's specificrequest that the consultant come for the express purpose of consultingon all individual case or ofparticipating in a clinic or in ward rounds. These requests were notcommon.
It required from 4 to 6days to accomplish a mission in a hospital with a large number ofmedicalbeds and from 1 to 3 days in a smaller hospital. Usually, rounds wereheld on every ward on themedical service or on at least one ward of each officer assigned to theservice. The chief orassistant chief of service together with the section chief and wardofficer concerned wereexpected to accompany the consultant. Other officers were alwaysinvited but never ordered toattend and, in most installations, rarely did so despite the fact thatrounds were modeled aftersimilar rounds held in civilian teaching hospitals. However, in a fewinstallations, notably thosein which the ward officers were young and appeared eager to learn,attendance was gratifying.Once in a ward, the consultant made it a point to see each patient.Word spread rapidly throughevery hospital that a consultant from headquarters was making wardvisits. Patients who werenot given some attention felt neglected, perhaps resentful. Timepermitted detailed considerationof only the more difficult or serious problems, but each record wasread and the soldier brieflyquestioned, often encouraged.
In surveying a case, theconsultant reviewed the history with great care, noting especially thelength of the patient's stay in hospital, the adequacy of
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the history, progress notes, and details oftreatmnent. Where indicated, a physical examinationwas performed. In a friendly way, the ward officer or section chief wasquestioned concerninghis diagnosis and treatment, in an effort to contribute constructiveteachiing as well as to gaugethe officer's ability. Care was taken neither to embarrass any officerby a thoughtless remark norto weaken the confidence of the patient in his physician. Freediscussion without regard to rankof the medical officers participating was encouraged.
An estimate of eachofficer's ability, industry, and judgment was always recorded in theofficialreport and became the basis of a recommendation pertaining to MOS(military occupationalspeciality) number and letter designating proficiency in the specialty.
A profitable opportunityfor gauging the quality of professional work and judgment was affordedby attendance at meetings of the officers' disposition board,certificate of disability for dischargeboard, and other boards concerned with the final evaluation anddisposition of patients. Here, inaddition to estimating judgment and proficiency, the consultant oftenwas able to help withdecisions and interpret War Department disposition policies.
It was planned to give atleast one talk or clinic to the medical staff or the entireprofessionalstaff at each installation visited. In certain hospitals, theconsultant was always requested to doso; in others, it was necessary for him to ask the commanding officeror chief of medical serviceto arrange a meeting. Interesting or problem cases discovered on thewards were presented anddiscussed, a talk on some timely subject was given, or aclinicopathologic exercise wasconducted. In many instances, the officers appeared alert, interested,and anxious to learn; inothers, apathy was the keynote; in still others, the staff seemed toregard attendance as justanother chore. As would be expected, those medical officers most inneed of instruction were theleast likely to attend.
The following deficiencieswere frequently encountered during surveys of the medical services:
1. Failure of the chiefand assistant chief to make proper ward rounds sufficiently often tomaintain familiarity with their cases. Sometimes this could beattributed to either lack of drive orlack of self-assurance. More often, however, especially in the largerinstallations, it was thedirect result of the heavy load of administrative work. Where thehospital commanding officerwas sympathetically interested in the actual care of the sick soldierand clearly recognized theneed for careful clinical supervision by his chief of service, he madeevery effort to reduce thisadministrative load. If sufficient personnel were available, heprovided the chief of service withone or more able Medical Administrative Corps assistants and capableenlisted personnel. Wherethe hospital commander placed primary emphasis upon administrativedetails, the chief ofservice was overburdened with annoying and time-consuming non-clinicaltasks. In fact, it wasnot uncommon to encounter a commanding officer who habitually, severaltimes a day, calledhis chief of service to his office to discuss minutiae that could havebeen covered in a routinedaily conference.
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In so doing, he interrupted rounds or otherwisehampered professional work. The consultantalways made the effort to have Medical Administrative Corps assistantsassigned to the chiefs ofservice and to dissuade commanding officers from calling upon thechiefs for such duties asSaturday inspections, investigations, and membership on administrativeboards and councils.Shortage of personnel was the reason most often given by hospitalcommanders for failure tocarry out such recommendations.
2. Failure of wardofficers and section chiefs to take adequate histories. When this wasencountered, it sometimes reflected lack of interest but more often wasdue to lack offundamental medical training and knowledge of symptomatology inrelation to disease entities.Often, the history was a record merely of what the patient said; itshowed no indication of anattempt to run down symptoms, to follow leads, or to unearth facts thatmight point toward thecorrect diagnosis. In urging for better histories, the consultantemphasized not only these pointsbut especially the need for an account of the patient's performance andadjustments in civil andmilitary life. Carefully taken, such performance histories oftenbrought out emotional limitationsresponsible for the symptoms and were valuable in estimating thepatient's suitability for futuremilitary duty.
A social history wasrarely taken on the medical service. Here was the cause of the backlogofneuropsychiatric consultations encountered in many hospitals. Theneuropsychiatric specialistwas forced to spend one or more hours taking the emotional and socialhistory on each patientsent for consultation from other services.
3. An excessive number ofintersection consultations and the thoroughly established precedent ofregarding each specialist's opinion as infallible. Once a so-calledclearance had been obtainedfor any section, the decision was regarded as final. Personalconsultations and discussion ofcases at the bedside were infrequent. Too much emphasis was placed onwritten reports.
4. Thoughtlessrequisitioning of unnecessary laboratory and X-ray studies. A completebloodcount was ordered when white count, hemoglobin, and differential countwould have beensufficient. Sedimentation rates often were a matter of routine, orderedwithout consideration oftheir diagnostic value. Gastric analyses were performed when by nostretch of imagination couldthey have been helpful. The unnecessary load on the laboratory resultedin hurried work. Thesame can be said of X-ray examinations, electrocardiograms, and otherspecial procedures.
5. Lack of attention todetail in prescribing treatment and failure to ascertain that treatmentwasgiven properly. This applied particularly to feeding problems and toadministration of fluids,especially in patients treated with sulfonamides. Often, orders werewritten sketchily or onlygiven verbally to the nurse. A sense of obligation to follow up andconfirm was lacking.
6. Too free use ofsulfonamides. Particularly true in the earlier stages of the war, thisbecameless noticeable as education and experience was accumulated. Coryza,mild sore throat, andfever of undetermined cause were treated with sulfonamides without dueconsideration of thepotential dangers and
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limitations of these drugs. This was avoidedin time case of penicillin by proper instruction priorto its release for general use.
7. Tendency to label as apsychoneurotic any patient in whom routine examination failed toestablish the existence of structural disease.
8. Prolongedhospitalization of patients with minor ailments, especiallyneurocirculatoryasthenia, functional gastric disorders, chronic headache of emotionalorigin, and other likedisturbances. Psychoneurotics not only were made worse but many wereactually created inhospitals. If promptly and properly handled at the start, a good shareof them could have beensaved for some useful military purpose.
9. Failure to performrectal examinations.
10. Failure of the wardofficer or his superiors to establish proper rapport with the patient,toencourage a close physician-patient relationship and to exhibitevidence of genuine interest. Themost common complaint heard from soldiers was, 'They ain't done nothingfor me. They ain'ttold me nothing.'
The consultant continuallyemphasized these deficiencies on his rounds. They became somewhatless noticeable in the later months of his tour of duty.
PERSONNEL MANAGEMENT
In World War II, aftermedical officers were commissioned, they were assigned to The SurgeonGeneral's pool for redistribution to Army Ground and Service Forces andto the Air Forces aswell until the independent procurement program of medical officers forthe Air Forces came intobeing early in the war. The Surgeon General assigned officers (1) tothe Army Ground Forces,where they were reassigned by the surgeon of the Ground Forces tomobile medical units and tocombat units, or (2) to the Army Service Forces. Personnel wereprovided directly to thoseinstallations under the control of The Surgeon General, such as generalhospitals in the Zone ofInterior (excluding Walter Reed General Hospital, Washington, D.C.,until after April 1943), theArmy Medical Museum, the Army Medical Research Laboratories, the ArmyMedical ServiceSchool, and other Class II installations. The service commands wereprovided personnel forreassignment by the service command to station hospitals and otherservice commandinstallations such as induction stations, reception centers,redistribution stations, anddispensaries.
The extent to whichservice command consultants influenced or controlled the management ofpersonnel responsible for the care of the sick was usually a measure ofthe consultants'effectiveness. The service command surgeons and personnel officerslearned quickly that themedical consultants, constantly moving about the command visiting andworking with hospitalstaffs, often for several days at a time, were the best informedofficers in the command regardingprofessional personnel. In most instances, after the assignment of aconsultant to a servicecommand, there was no great delay before his counsel and advice weresought in personnelevaluations and assignments. Exceptions were few, conspicuous, and nottolerated in the latermonths of the war.
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A discussion of a service command consultant's viewon personnel problems based uponextensive experience and many conferences witim fellow consultants wasprovided by ColonelBauer. The following paragraphs summarize his observations.
The most difficult problemconfronting the consultants upon their arrival in the servicecommands was that of personnel, so basically important to good medicalpractice. The personnelneeds were never adequately filled, either numerically orprofessionally. The situation becamemore acute as the need for well-qualified officers in the varioustheaters of war increased. Manyof the difficulties that did arise could have been avoided had theservice command surgeonsdelegated their authority for personnel assignment to the consultants,once the latter werethoroughly acquainted with the medical officers and the needs of theindividual installations.This method of procedure or some modification thereof was finallyadopted by most of theservice commands. The consultants then sought the most equitabledistribution of medicalofficers on the basis of their qualifications, the total needs of theservice commands, and theindividual requirements of each hospital. An attempt was made to havethe appropriateconsultant interview every new medical officer before assignment in theservice command, butthis was not possible when the consultants were in the field. Theconsultant's appraisal of theintrinsic qualifications of a medical officer and decision as to theofficer's correct MOS numberwas postponed until after personal contact on ward rounds. Proceedingotherwise resulted in toomany injustices.
The reassignment ofmedical officers, particularly chiefs of service, within the servicecommandwas always difficult because of the obstructive tactics employed bymany of the commandingofficers. Sometimes they opposed the transfer of favorite incompetentofficers as much as thetransfer of competent specialists. In such instances, it was the dutyof the service commandsurgeon to intercede. Without such support, the consultants were unableto utilize the availablepersonnel properly.
The conception prevailedin some quarters in 1942 that every medical officer was capable ofperforming any type of professional service. Accordingly, newlyassigned consultants oftenfound highly trained specialists serving in assignments for which theywere not qualified andmen with inadequate training in positions of responsibility. Oncecorrection of suchmalassignments had been achieved, the transfer of key personnelthereafter was not permitted-orshould not have been-without the consent of the consultants. Seriousdisruptions of medicalservice would have resulted without this agreement, particularly whenthe transfer of strongchiefs of service was involved.
It is also important thatthe consultants be permitted to maintain close liaison with the chiefmedical consultant in the Surgeon General's Office regarding needs forqualified specialists,whether undersupplied or, possibly, oversupplied. The help receivedfrom this source, thoughnecessarily limited, was extremely valuable.
The unequal distributionof medical personnel between Army Service
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Forces and Army Air Force hospitals was unfortunate and, whileimpossible to correct at thetime, should not be allowed to occur again. To go from one hospitalwith 5 medical officerscaring for 1,200 medical patients to another in the same area with 15physicians and a totalhospital census rarely exceeding 100 was disturbing. It was equallyregrettable that so manywell-trained specialists were concentrated in the small Army Air Forcehospitals, where therewas little need for such talent because well-staffed regional andgeneral hospitals were withineasy reach. The service command medical services would have beenstrengthened materially bythese officers, could the officers have been transferred to theseservices. These specialists couldhave been replaced with well-trained general practitioners. Moreregular assignment of officersfrom numbered medical units, in training but without patients, tonearby service commandhospitals would have brought similar, though relatively temporary,benefits.
The type of medicalpersonnel assigned to a hospital governed its professional success,unless itwas hampered too greatly by the commanding officer. The presence of anable clinicianpossessing teaching and administrative abilities as chief of medicinematerially influenced theprofessional development of the officers assigned to the medicalservice. Initially, many of thechiefs of service, not being of this caliber, had to be replaced.
Professional developmentwas enhanced on those medical services organized along the linessuggested by the Surgeon General's Office; namely, chief of service,assistant chief, chief ofsection, and ward surgeon. This arrangement permits the delegation ofresponsibility to a groupof individuals each of whom is directly responsible to his immediatesuperior, and it allows forpromotion on the basis of merit. If well organized, the arrangementalso affords the chief ofservice sufficient time to supervise closely the clinical activities ofhis service. However, manychiefs of service did not function in this manner because of a heavilyimposed or self-assumedadministrative load. This was remedied in most instances by assigningMedical AdministrativeCorps officers and Medical Department enlisted men trained inadministrative matters.
U.S. Army medical officersrepresented a cross section of the Nation's medical profession. Theyvaried greatly in their professional competence. Some of them lackedthe qualities befitting truephysicians, including interest in patients as human beings. In the Zoneof Interior, many medicalofficers were reluctant to work more than 8 or 9 hours a day anddesired to be free on Sunday.This lack of sense of duty was all too frequently reflected in theirwork. It was difficult tounderstand the willingness of many officers to entrust their moreseriously ill patients to theofficer of the day. However, some commanding officers and chiefs ofservice were successful inimpressing upon their medical officers that in care for seriously illpatients there can be no suchthing as duty hours.
These and other observeddeficiencies indicate the need for a short course of basic training attheArmy Medical Service School followed by a period of from 3 to 6 monthswith troops in trainingbefore assignment to a hospital.
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Without such experiences, medical officers havelittle conception of the physical and mentalrequirements of a soldier. With a properly conducted period ofindoctrination, medical officerswould come to appreciate that their most important duty in the Army isto keep the noneffectiverate as low as possible. They would also gain a better understanding ofthe importance ofpreventive psycimiatry and the psychology of leadership in Armymedicine.
It is only fair to pointout that many medical officers on duty in hospitals were unable todevoteas much time to professional work as they desired because ofassignments to bivouac areas, timespent accompanying troop trains and patients, overseeing ward property,and similar activities,with in addition, many admimmistrative duties. These difficulties weregradually overcome insome of the installations by assigning well-qualified MedicalDepartment enlisted men for theduties mentioned, by making Medical Administrative Corps officersresponsible for property,and by providing messenger service, adequate secretarial aid, andDictaphones.
The number of highlytrained specialists was decidedly limited as was the number of generalinternists qualified as chiefs of service or section. As might beexpected, the personnel records ofeducational training and postgraduate medical experience were not sureguides to medicalproficiency. For instance, certain medical officers with a wide rangeof medical knowledge,some of whom had been qualified by an American specialty board, lackedconservative, soundclinical judgment or the necessary qualities of leadership. Conversely,other medical officerswith little postgraduate training, who had maintained an activeinterest in scientific mattersduring years of general practice, were fully qualified to be chiefs ofa medical service at a 250-or 500-bed station hospital. The better internists and specialists,when present, were thebackbone of the medical organization and contributed as well to thetraining of physicians.Physicians of average training and ability formed the largest singlegroup of medical officers.The majority of them made every effort to compensate for their lack inskill and training bydiligence and willingness to learn. Much credit is due these officerswho carried large clinicalloads. There were others who, because of lack of training and ability,could not be trusted withthe care of the sick without supervision. A small number of officersentered upon active dutywith more rank, or shortly acquired it, than was consistent with theirprofessional ability. Theywere a constant source of dissatisfaction to the consultants becausethese officers could not beutilized in positions commensurate with their rank. Thoughreclassification of such officers wasfrequently suggested, rarely was it effected.
A shortage of officers wascommon, particularly in late 1944 and 1945. This shortage could havebeen alleviated to some extent by greater expedition and efficiency inallocation of the largenumber of medical officers in Medical Department replacement pools.Some of these officersremained unassigned for months.
Some physicians came intothe Army with great enthusiasm and a deep desire to serve, even at asacrifice. Many others came in under stress of
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various kinds and were subsequently poorly prepared for the entirelynew life. As time passed,many of them became discouraged or disgruntled because of theirinability to adjustsatisfactorily to Army life, failure to resolve other personalproblems, malassigment, injustices inpromotion, the rigidity and lack of understanding of certain hospitalcommanders, dissatisfactionwith efficiency reports, time wasted in orientation courses that werenot pertinent to professionalactivity, continued drilling and physical training after assignment toa hospital, and unnecessarilypoor living quarters and mess facilities. The consultants wereparticularly impressed with thefact that, despite all these difficulties, groups of heterogeneousdoctors gathered from the fourcorners of the United States were assimilated so readily that thesedoctors could function ascoordinated staffs in a remarkably short period of time.
This process ofassimilation was most readily accomplished in the Air Force stationhospitalsbecause the staffs were smaller and composed of younger men who wereapproximately thesame age and more nearly comparable to one another in their medicaleducation, training, andthinking. The Air Force station hospitals had an additional advantage.The commanding officerswere younger and more recently removed from professional work, with theresult that most ofthem were as interested in the professional activities of theirhospitals as in administrativematters. A commanding officer with these dual interests frequently madepossible a moreintegrated and efficient institution.
Medical officers assignedto airfield dispensaries and similar posts suffered from the effects ofisolation. An active rotation system would have corrected this.
The following paragraphsare a summary of comments on personnel by Col. Johnson McGuire,MC, Consultant in Medicine, Fifth Service Command, from 7 July 1944 toDecember 1945.
The assignment of medicalofficer personnel within the Fifth Service Command was made bythe service command surgeon through the service command personneldivision. In practice, thisauthority was delegated to the assistant surgeon and constituted alarge part of his duties. Untilthe medical consultant had been on duty for several months, there wasrelatively littleopportunity to discuss assignments to specific hospitals when officerswere offered to the FifthService Command by the Surgeon General's Office. This lack ofdiscussion was due in part tothe frequent visits of the medical consultant to the field and in partto the remarkable knowledgeof the assistant surgeon of personnel problems in each hospital. Theassistant surgeon thereforethought it unnecessary to discuss assignments with the medicalconsultant.
After approximately 4months, the assistant surgeon consulted with the medical consultantbefore making assignments of medical officers to key positions, and, bythis time, the medicalconsultant was sufficiently familiar with the problems in each hospitalto make specificrecommendations, which were usually accepted.
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With the permission of theSurgeon, Fifth Service Command, the medical consultant kept theChief Consultant in Medicine, OTSG, constantly informed of the needsfor replacement of keypersonnel within the Fifth Service Command. Such information wastransmitted informally bypersonal letter. The cooperation of the chief consultant's office wasoutstanding, and, withinrelatively short periods of time, replacements were made available.
The chiefs of service ofthe general hospitals of the Fifth Service Command had an MOS of A- orB-3139 without exception, and, during the period covered by thishistory, these officers wereuniformly capable and efficient. Outstanding assistant chiefs ofservice were disappointingly fewin number and difficult to obtain. Section chiefs, as would beanticipated, varied from superior tomediocre clinicians. The latter were replaced when better officers weremade available.
Ward officers were, inmany instances, mediocre. Most of the young and healthy officers hadbeen assigned overseas, leaving only middle-aged general practitionerswith relatively littlepostgraduate training in internal medicine for assignment as wardofficers in the Zone of Interior.
The effect of the size ofthe service command and of the attitude of the surgeon toward his ownrole and toward that of his consultant on the type of personnel programwhich could besuccessful in a service command, as well as certain points of view ofthe consultant, werediscussed in the report of Col. Alexander Marble, MC, who, after longservice in the Pacific, wasassigned as Consultant in Medicine, Sixth Service Command, from March1945 to September1945 and as Consultant in Medicine, Eighth Service Command, fromSeptember 1945 toDecember 1945. Colonel Marble reported, in essence, as follows:
The matter of personnelwas handled differently in the Sixth and in the Eighth ServiceCommands. In the Sixth Service Command, rather than having a group ofofficers whose soleduty was attending to matters of personnel, the service command surgeonacted largely as hisown personnel officer, seeking the suggestions and advice of theconsultants when indicated. Hisdecisions were carried out through an officer of the general staffpersonnel divisions ofheadquarters. The latter had his office on another floor of thebuilding and so was not an intimatepart of the office force of the surgeon.
The Surgeon, Sixth ServiceCommand, had requested that, when medical officers were assignedto the Sixth Service Command, they not be sent directly to specifichospitals but that they firstreport to service command headquarters. Thus the service commandsurgeon together with theappropriate consultant had an opportunity to see and talk with the man,thereby making possiblea better decision as to an appropriate assignment. It is possible thatin a large service commandthis plan would not be feasible, but it worked very well in the smallerSixth. Of course, those fewofficers who were sent by the Surgeon General's Office for definiteassignments were giventhem, but, even in the case of these men, it was an advantage to havean opportunity to meet andtalk with them before they reported to their duty stations.
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Throughout thisconsultant's service in the Sixth Service Command, there was a more orlessconstant plea by almost every installation for more personnel of everytype (fig. 29). The lack oftrained personnel was at times very real in some installations, but, byand large, there was anadequate number of officers to do the work. It is fair to say that mostmedical officers did notwork any harder at their assignments in the Army than they had beenaccustomed to working incivilian practice. There were a few notable exceptions in certainspecialties; for example, thepathologists in the larger hospitals were often overworked and badly inneed of trainedassistants, who could not be obtained because of the small numberavailable. Some pathologistsworked week after week until midnight in order to keep current withtheir work.
Shifting of medicalofficers from one installation to another was not done thoughtlessly orcarelessly. Due consideration was given to the effect of the transfernot only on the installationconcerned but upon the officer and his family. At times, however,military necessity outweighedall other considerations.
CLINICAL PROBLEMS
This is not the place fora detailed discussion of the clinical aspects of the diseasesencountered,but, from material available in reports from several of theconsultants, a general picture can bedrawn of the clinical problems that engaged the interest of theseconsultants during their tours ofduty.
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Colonel Adams provides abroad view of the trends of disease as he observed them in the FourthService Command during the training period and, later, when patientsinvalided home fromoverseas began to arrive. Colonel Adams reported generally as follows.
During 1942, 1943, and theearly part of 1944, when training activities were at their height,hospital admissions for disease were largely due to (1) upperrespiratory infections; (2)pneumonia, especially atypical pneumonia; (3) meningococcic infection;(4) diarrheal diseasesoccurring in epidemnics; (5) dermatologic disorders, especiallydermatophytosis and othereruptions on the feet; (6) venereal disease; (7) asthma and otherallergic disturbances; and (8) ill-defined symptoms for which noorganic causes could be found and which were usually thoughtto be psychoneurotic. The last group included a large number ofindividuals designated'inadequate.'
Acute ripper respiratorydiseases and the run of contagious diseases posed no particularproblem,except for loss of time from training. The sulfonamides were prescribedmuch too freely in theupper respiratory cases, but, as medical officers became increasinglyaware of the indications forand against their use, this practice diminished.
Meningococcic infectionfirst appeared in this command in epidemic form in December 1942and for several months created a serious situation. The first epidemicbegan at Camp Sibert, Ala.,in late December 1942; at about the same time, cases began to bereported from other camps.Immediately, a letter was sent by the service command surgeon to allpost surgeons, invitingtheir attention to the need for watching closely for outbreaks of thedisease, describing the signsand symptoms (especially the earliest), and outlining a plan oftreatment. The medical consultanton his visits to each camp gave talks on this disease. This educationalprogram is believed tohave led to early diagnosis and more prompt and vigorous treatment,which may havecontributed to a lower mortality rate. The following figures for thiscommand were compiled:For December 1942 and January 1943, 317 cases with a immortality rateof 8.8 percent; and forFebruary and March 1943, 761 cases with a immortality rate of 2.1percent.3
Cases of atypicalpneumonia also appeared in large numbers. Here again, an educationalcampaign was waged. Little was understood about this disease. Mostmedical officers were notfamiliar with its manifestations. The officers were instructedregarding the clinical picture.Especially emphasized was the fact that the disease could exist in asevere form without physicalsigns, the diagnosis depending chiefly upon chest roentgenograms. Asexperience was gained,officers on the respiratory wards, especially in large stationhospitals, became extremelyproficient in recognizing this disease. At first, sulfonamides were toofreely administered; theeducational campaign reduced their unwise use.
3 Thomas, H.M., Jr.: Meningococcic Meningitis and Septicemia; Report of Outbreak inFourth Service CommandDuring Winter and Spring of 1942-1943. J.A.M.A. 123: 264-272, 2 Oct.1943.
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Explosive outbreaks of diarrhea occurred in severalorganizations, usually those on bivouac,especially during the early periods of training. Investigation revealedthat these epidemics mostoften were due to lack of recognition by line commanders of thenecessity for rigid fieldsanitation. As officers and troops became more experienced, importantoutbreaks ceased.
An allergy program,sponsored by Col. Sanford W. French, MC, Surgeon, Fourth ServiceCommand, was well conceived and managed (fig. 30). Patients in thecommand suffering fromany allergic disturbances received the best possible diagnostic andtherapeutic care. However, ifa soldier was transferred to another command or overseas, uniformity oftherapy could not beguaranteed. Hence, the impracticability of Armywide application of theprocedures standardizedin this command limited the overall value of the program. Few soldierswith allergicdisturbances were restored to full (general service) military duty, butmany were enabled torender useful (limited) service when assigned to fixed installations.
Admissions to generalhospitals during the first 2 years in large part consisted of difficultdiagnostic problems and cases requiring long-terms came or seriousoperative procedures. InJune 1944, the large station hospitals were designated regionalhospitals and were charged, inaddition to previous assignments, with the care of such Zone ofInterior patients as formerlywould have been transferred to general hospitals. (This was done inorder to free beds for thereception in the named general hospitals of patients from overseas.)Thus it became necessary tostrengthen promptly the staffs of regional hospitals. This augmentationwas rarely satisfactorilyaccomplished because of the shortage of specialists.
Although designated forZone of Interior patients, the regional hospitals also received afairlylarge quota of patients with diseases that had been acquired overseas.These soldiers were in theUnited States as a result of rotation or, having been returned aspatients, had been dischargedfrom general hospitals to duty in this country. Malaria, amebiasis,allergic states, peptic ulcer,residuals of hepatitis, intractable dermatologic diseases, andpsychosomatic disturbances were most commonly encountered in this group.
As the load of patientsfrom overseas increased, the following categories of illnesses werepredominant in the general hospital medical wards: (1) Recurrentmalaria; (2) acute or chronichepatitis; (3) peptic ulcer; (4) allergic disorders, especiallybronchial asthma; (5) trenchfoot; (6)amebiasis; (7) rheumatic fever, rheumatoid arthritis, and other formsof musculoskeletal disease;(8) psychosomatic complaints in soldiers who had been screenedimproperly and sent to medicalservices of hospitals in the Zone of Interior instead of toneuropsychiatric centers orconvalescent hospitals; (9) skin diseases, especially atypical lichenplanus and dermatitis inpatients from the Pacific areas; and (10) various tropical disease,especially filariasis andschistosomiasis (Moore General Hospital, Swannanoa, N.C., only).
The peptic ulcer caseswere often difficult. Many soldiers were encountered in whom thisdiagnosis had been established in theaters of operations.
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On the soldiers' return to this country, perhapsbecause of relief from combat tension andtreatment in oversea hospitals, they exhibited no clinical orroentgenologic evidence of ulcer.Most of them had mild gastric complaints, but it was impossible todetermine how many of thesecomplaints were the result of an unconscious desire to be relieved frommilitary duty and howmany the result of persistence of the disease. Chiefs ofgastrointestinal sections had difficulty indeciding whether the patients actually ever had peptic ulcers and inevaluating their patients'current condition. Early in the war, many of these patients were sentto limited duty, but it soonwas learned that they would not do well.
The proper disposition ofgeneral hospital patients returned to the Zone of Interior fromoverseaspresented a difficult problem. In the early stages, the emphasis wasplaced upon returning thesepatients to duty. However, it is doubtful if many were able tocontribute effective service exceptwhen a real desire to remain in the Army existed. Later, there appeareda growing tendency todischarge oversea patients from the service.
The following is a partiallist of cases of unusual interest reported from the stations noted:
| Cases | Station |
| Sarcoidosis | Battey General Hospital,Rome Ga.; RegionalHospital, Fort Benning, Ga.; Regional Hospital, FortMcClellan, Ala.; and others |
| Histoplasmosis | Foster General Hospital,Jackson, Miss; ReionalHospital, Fort Benning, Ga.; Regional Hospital, FortJackson, S.C. |
| Spontaneous rupture ofspleen | Foster General Hospital,Jackson, Miss. 9duringmalaria therapy for neurosyphilis); and RegionalHospital, Fort Benning, Ga. (During attack ofmononucleosis). |
| Leprosy | Stark General Hospital,Charleston, S.C.; and RegionalHospital, Camp Blanding, Fla. |
| Actinomycosis | Several hospitals |
| Coccidioidomycosis | Do. |
| Amebic abscess of liver | Do. |
| Endemic typhus fever | Several hospitals,chiefly in Southern Georgia andAlabama |
| Tuleremia | 50 cases at StationHospital, Camp Forrest, Tenn.,during Tennessee maneuvers in 1942-43 (fig.31); fromhospitals in Mississippi and elsewhere |
| Bacteroidesfunduliformis infection | Regional Hospital, FortBenning, GA |
| coarctation of aorta | Do. |
| Heat stroke | Several hospitals,especially in southern training camps |
| Anculostomabrazilense ( creping eruption) | Regional Hospital, CampBlanding, Fla.; StationHospital, Camp Rucker, Ala; and southern camps |
| Poliomyelitis | Sharp outbreak of 17cases with 3 deaths, in March andApril 1945, Regional Hospital, Fort McClellan, Ala. |
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Col. Henry M. Thomas, Jr.,MC, Consultant in Medicine, Fourth Service Command, fromAugust 1942 to August 1943, reported on clinical problems in militaryhospitals in 1942. Hisviews are of special interest in relation to later developments indermatology, venereal diseases,and neuropsychiatry. He commented, in general, as follows:
1. Dermatology.-Dermatologyshould be a separate service; separate, that is, from venerealdiseases, with which it was so often combined. There was a surprisingdearth of well-traineddermatologists. In retrospect, it seems it would have been worthwhileto collect a few superiordermatologists and send them around to the various hospitals asinstructors. Perhaps, schools ofdermatology could have been established, but Army dermatology is ratherstereotyped and doesnot cover a very wide field. A basic dermatologic training given to allofficers on medicalservices would be valuable, particularly in tropical areas. The medicalconsultant always visitedthe dermatologic cases; however, he contributed notiming butencouragement and interest.
2. Venereal diseases.-Insome hospitals, syphilis and dermatology were treated on themedicalservice and gonorrhea on the surgical service; in others, syphilis andgonorrhea were both treatedon the surgical service; and, in still other hospitals, syphilis andgonorrhea were both treated onthe medical service. It is a matter of some importance that theresponsibility for therapy shouldbe uniform. In this consultant's opinion, syphilis is entirely amedical disease,
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and gonorrhea is a medical disease with avery rare surgical complication. It is true that a certainnumber of genitourinary surgeons specialize in the treatment ofgonorrhea, while it is difficult tofind any officers on the medical services who have had experience withtreatment of gonorrhea.Furthermore, chiefs of medical services take very little interest ingonorrhea cases. Theseofficers have learned about the disease in this war, and, from now on,gonorrhea will become amedical disease.
3. Neuropsychiatry.-Oneof the most generally neglected phases of therapeutics in theleadingmedical schools of the country is so-called psychosomatic medicine. TheOslerian school treatedthese cases with a characteristic wave of the hand and pat on the back,went to the next patientwith a heart murmur, and from there went to the pathology laboratory.The usual teacher ofclinical medicine finds it difficult to crowd into the small number ofhours the amount oflearning essential to the fundamentals of diagnosis. When it comes tothe time-consuming andsomewhat subtle exposition of the patient as a whole and the part thepsyche plays insymptomatology, the clinical teacher often feels himself at adisadvantage and avoidsundertaking a complicated role. It was the medical consultant'sexperience that, by and large, theward officers in the station hospitals in the Fourth Service Commandhad very little conceptionof the patients' worries and the psychologic aspects of the patients'treatment. This consultant,early in his Army experience, became interested in the functionalaspects of duodenal ulcer casesand referred to this subject in discussions of the wider field ofpsychosomatic symptomatology.4This, however, cannot be taught by Army consultants alone andactually is the responsibility ofthe medical school curriculum. In the Army, the consideration of thepatient as a whole involvesthe morale of the patient as a soldier.
The greatest help wasobtained from Lt. Col. (later Brig. Gen.) William C. Menninger, MC,Consultant in Neuropsychiatry, Fourth Service Command, who frequentlymade rounds on themedical ward and discussed the many borderline psychiatric cases thatabounded in all wards. Alarge percentage of medical patients have such problems, and theresponsibility rests clearly onthe chief and other members of the medical service. Theneuropsychiatric consultant cannot seeevery patient, but he can function through the medical officers. Duringthis war, the MedicalDepartment went a long way in combining activities of theneuropsychiatric and medicalservices. The medical consultant was extremely interested inoccupational therapy, both on theward and in the workshop (fig. 32). Since there was no occupationaltherapy in most of thestation hospitals, it became necessary to try to get the American RedCross to provide thisvaluable service (fig. 33). Later, on visits with the neuropsychiatricconsultant, it became acontest as to which consultant would get the most cooperation from theRed Cross department.Actually, the neuropsychiatric consultant could have kept two Red Crossdepartments busy ateach hospital.
4 Thomas, H. M.Jr.: Peptic Ulcer in the Army. South, M.J. 36: 287-291, April 1943.
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FIGURE 33.-American RedCross arts and crafts program, Station Hospital, Fort Hayes, Ohio,March 1944.
Colonel Bauer, in a report on the weakness of the educational andtraining program of physiciansin relation to Army psychiatry, the importance of proper psychiatricmanagement in Armyhospitals, and urgent problems concerning the proper and promptdisposition of patients, madethe following observations.
Neuropsychiatry remained under medicine in most of the Army hospitals,although a few of theconsultants favored its being a separate service. Experiencedemonstrated that neither schemenecessarily provided successful management of medical patients withpsychoneurotic andpsychosomatic disorders. More important than operational arrangementsare physicians who,because of their attitudes, skills, and mutual respect for oneanother's disciplines, are capable offunctioning as members of a highly cooperative and coordinated team.Unfortunately, there werevery few such diagnostic and therapeutic groups. If they had been morenumerous, there wouldhave been less disagreement concerning the location of patients, thephysician responsible fortherapy, and the relation of neuropsychiatry to medicine.
Neverhas the need for physicians to recognize and manage psychoneurotic andpsychosomaticcomplaints and disorders been more clearly demonstrated. It reflectsthe greatest deficiency inAmerican medical education in recent years and also emphasizes theevils of specialization.Evidently, the effort to train physicians to recognize and treatphysiologic and organic disorders
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has resulted in failure to stress theimportance of personality functioning and psychopathology.
The defects of suchmedical training were readily apparent in the service commandhospitals.Too many patients were admitted; too much was done to them; they stayedtoo long; they weresubjected to much indecision and received little or no psychotherapy,and their disabilities wereeither prolonged or increased. Under such conditions, the number ofindividuals salvaged forsoldiering was disappointingly small. In many cases, treatment at thedispensary or outpatientlevel would have been more successful.
These patients wereessentially the same as their brothers in civilian life. The approachto themshould have varied little. Carefully taken histories usually revealedthe basic nature of thedisorders. Well-trained medical officers who could handle their ownanxiety and demonstratefriendliness, sympathy, and warmth to the soldiers as well as sinceredesire to help had littledifficulty in determining the patient's personality makeup, pastperformance, and relation tosymptom formation. The failure of medical officers to function in thismanner led to suchlabeling as 'gold-brick,' which resulted in increasing, unrelievedemotional tension and theprecipitation of neuroticisms and psychoso in atic complaints.
A prolonged period ofobservation and study of neurotic patients is not only wasteful of timeandmoney but is also harmful to the patient, since the persistent effortof the physician to find anorganic cause and failure to do so tends to aggravate the patient'sbelief that lie has an obscuremalady. Furthermore, the inexperienced physician, overimpressed by aminor deviation fromnormal in some physical finding or laboratory test, adds to thepatient's anxiety. Reliance on thismethod of procedure-diagnosis on the basis of exclusion-should bediscouraged if not prohibited.
Some of the difficultiesthat arose were attributable to administrative uncertainty andindecisionas to the proper disposition of these patients. Under the pressure ofan increasing manpowershortage, the administrative position changed from one of excludingthem from the Army to oneof retaining all but the most severe cases. With this change, however,there was no adequatesystem for assigning patients to suitable types of duties. During 1943,thousands of usefulsoldiers were discharged from the Army to their own detriment as wellas to that of the service.As the regulations governing these discharges were tightened, thehospitals faced otherdifficulties. When these men were returned to duty, they found scantwelcome in theirorganizations. The unit commanders found it easier to return the men tothe hospitals than to finda place for them in the original unit or to follow the procedurenecessary to have the menproperly assigned elsewhere. Consequently, they were returned to thehospitals again and againby their commanders in an effort to get rid of these soldiers. Thispractice not only added greatlyto the burden of the hospitals but also confused the medical officersand reacted disastrously onthe soldiers. In no other instance in the Medical Department of theArmy was there greater needfor formulation and execution of a policy than in the
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management and disposition of soldiers withpsychoneurotic and psychosomatic complaints.
LABORATORY ACTIVITIES
The Laboratory Division,Preventive Medicine Service, OTSG, exercised supervision overmedical laboratories in the Army. In the United States, elaborateservice command laboratoriessupported those of the general and station hospitals, and thedispensaries. Laboratory personnel,equipment, and supply were administered separately from the clinicalservices of hospitals inspite of time fact that the laboratories operated in hospitals almostexclusively in support of theclinical services. Of course, important laboratory work was done forpreventive medicine andpublic health, especially in the service command laboratories.
In the best hospitals,there was the closest liaison between the medical service, thelaboratoryservice, and the consultants in medicine. Wise clinicians and wiseclinical pathologists saw tothis. The interest and support of the professional consultants wasimportant to the properfunctioning of the hospital laboratories, since otherwise, in theopinion of many observers, theyhad limited supervision and advice from other sources. In many, if notmost instances, theclinical laboratories would have functioned in professional vacuums hadit not been for theconsultants in medicine and the chiefs of medical services and sections.
A critical appraisal ofthe utilization and operation of the laboratory facilities in a largeservicecommand was provided in Colonel Bauer's report. His views aresummarized in the followingparagraphs.
A satisfactory laboratoryservice requires a director capable of coordinating its activities withthose of the clinical services. It also requires properly trainedpersonnel, suitable space, adequateequipment, and a workload adjusted to the size and ability of thelaboratory staff. Directors whowere competent pathologists and interested in clinical pathology andteaching contributed greatlyto the intellectual atmosphere of hospitals. When such men were flankedby competent SanitaryCorps officers trained in biochemistry, immunology, and bacteriology,the clinicians wereassured that the laboratory work would be carefully supervised and wellexecuted.Unfortunately, such laboratory services were all too rare.
The hospital laboratorieswere sufficiently well equipped eventually to perform practically allthe examinations which are done in the better civilian hospitals. Themaintenance of adequatetechnical staffs, however, was always difficult because the enlistedmen were poorly trained andrapidly transferred. The resulting vacancies were of necessity filledby civilian technicians whowere inadequately trained. Generally speaking, the bacteriology andimmunology sections werethe weakest.
The abuses of laboratoryservices attributable to the clinicians were many and resulted incountless numbers of unnecessary determinations, which further impairedthe efficiency of thework. This misuse of laboratories, common
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in civilian as well as military hospitals,was undoubtedly accentuated in the Army by the absenceof the cost factor. Clinicians without firsthand knowledge oflaboratory procedures were mostfrequently responsible for excessive requisitioning of laboratorystudies. In some hospitals, theadditive effect of all these factors was great enough almost to nullifyt he laboratory'scontribution to diagnosis and treatment.
The consultantscontinuously impressed upon the medical officers the rational use oflaboratoryprocedures as diagnostic aids and therapeutic guides. The consultantsalso urged the chief of thelaboratory to meet with the chiefs of medicine and surgery immediatelyfollowing thecompletion of each monthly report, in order to promote full discussionof matters pertaining tothe efficient functioning of the laboratory. Supervision of thelaboratories by the medicalconsultants was reasonably satisfactory when they had experience insuch matters and could allotthe necessary time. The assignment of an additional consultant inmedicine, with suitabletraining, would have strengthened this objective of the consultantsystem, particularly in thelarger service commands.
In some hospitals, thelaboratory was established as a separate service. This had theadvantage ofplacing the director on an equal footing with the other chiefs ofservice and enabling him toperform his duties more easily and satisfactorily.
The service commandhistopathology service, the Army Medical Center, and the Army MedicalMuseum discharged their responsibilities extremely well, consideringthe many duties theseinstallations were called upon to perform. The work done by some of theservice commandlaboratories did not justify their large staffs and annual expenses.Many of the directors failed intime particularly important duty of maintaining helpful contact withthe staffs of the hospitallaboratories. The function of the service command laboratories shouldbe reexamined andredefined. They should be required to submit test specimensperiodically to all service commandhospitals. This arrangement would provide an additional check on thequality of laboratory work.
Colonel Thomas, the firstservice command medical consultant to go on duty, reported onobservations in the Fourth Service Command. The following paragraphssummarize hiscomments.
There should be alaboratory consultant in each service command and theater. He would beoneof those rarest of all medical officers, an excellent clinicallaboratory man. By and large, thelaboratory service was the worst in the hospital. There were not enoughgood, general, clinicallaboratory men to go around nor nearly enough technicians. Later, thisshortage was partiallyfilled by Army schools for technicians (fig. 34), but this deficiencystill reached into the theatersof operations, where it was even more noticeable.
When the medicalconsultant to the Fourth Service Command found a laboratory problem,he,with the chief of the medical service and the ward officer involved,would go directly to thelaboratory service. There a
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discussion would be undertaken on theindications for laboratory examinations, the results, thetechniques, and other pertinent information. It was a very rare thingto find a medical wardofficer who went directly to the laboratory with his problems. On theother hand, the laboratoryalmost always sent a rather poorly trained technician to the ward tohandle specimens. The resultwas that many tests were unreliable, specimens were mishandled, andthere was no closecooperation between the clinical laboratory and the ward. This problemwas taken up regularlyin each of the hospitals with the chief of the medical service, thechief of the laboratory service,and with the two of them together.
It was discovered early invisits to hospitals that a great deal of useless routine laboratoryworkwas being ordered for and performed by laboratories that were oftenalready over-loaded. Forinstance, at Fort Jackson, S.C., it was found that some 300 completeblood counts were beingrequested on peak days. When this was brought to the attention of thesurgeon of the servicecommand, an order was immediately circulated forbidding routinelaboratory work and directingthat each test would be ordered according to its own merit.Surprisingly enough, this seeminglysimple directive caused confusion and was interpreted by some medicalofficers to mean that nocase should be thoroughly studied.
The Fourth Service CommandLaboratory, Fort McPherson, Ga., was a splendid servicecommand laboratory (fig. 35). It was the habit of the
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FIGURE 35 -Section of Fourth ServiceCommand Laboratory, Fort McPherson,Ga., February1943.
medical consultant to send an account of thelaboratory service at the various hospitals he hadvisited to the commanding officer of this laboratory. This servicecommand laboratory sent testspecimens to the various hospital laboratories for analysis. In thisway, the reliability andaccuracy of a laboratory in question could be checked. The locallaboratories sent in specimensthey had analyzed to be checked in the central laboratory. In addition,the service commandlaboratory gave refresher courses for technicians and for laboratoryofficers. This was verysatisfactory. However, in addition to this, the need for a laboratoryconsultant was clearlyevident. An assistant medical consultant should be appointed withduties confined to clinicallaboratory work. This laboratory consultant should function in theprofessional consultantssection in the office of the service command surgeon.
AUTOPSY PROTOCOLS
It became an importantfunction of service command medical consultants to review autopsyprotocols in medical cases originating in the service command. This wasa direct outgrowth ofexperience with the procedure in the Eighth Service Command, concerningwhich ColonelBanner commented substantially as follows.
Beginning with the firsthospital visited, the Eighth Service Command consultant reviewedcopies of all autopsy protocols on file. The information gained was sopertinent to good medicalcare that the Surgeon, Eighth Service
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Command, soon issued a directive requesting that all autopsy protocolsbe forwarded to servicecommand headquarters for review by the appropriate consultant. On theadvice of Brig. Gen.Hugh J. Morgan, Chief Consultant in Medicine to The Surgeon General,this procedure was lateradopted by the other service commands.
Each of these autopsyprotocols included a complete abstract of the clinical findings,clinicalcourse, final clinical diagnosis, gross and microscopic pathologicdescriptions, final pathologicdiagnosis, and a paragraph summarizing the sequence of events that werethought to have led todeath. Three mimeographed copies were forwarded to the service commandheadquarters, twofor filing and one for review by time consultant. Others weredistributed to the medical officersof the hospital, preferably at a clinical conference following receiptof the consultant'scomments. The quality of the protocols, which varied greatly, furnishedinformation regardingthe ability, energy, and integrity of both pathologist andclinician. It was the consultant's duty toforward written comments pertaining to errors of omission andcommission as well as tocommend excellency of performance. This procedure proved extremelyvaluable to theconsultant as well as to the hospital staff and served as a furthercheck on the quality of carebeing rendered. It also had anticipatory value in that it was generallyunderstood that the clinicalrecord of any seriously ill patient might eventually be scrutinized inthe surgeon's office. Themost serious and frequent diagnostic and therapeutic errors disclosedby the protocols were oftendiscussed by the consultants at subsequent visits.
POSTGRADUATE EDUCATIONAL AND TRAINING PROGRAMS
From the outset, thoseresponsible for the initiation and development of the consultant systembelieved that an active professional educational program would be thebest stimulant to highstandards of medical practice in the Army. The following is a generaldescription of the medicaleducation programs provided the Sixth and Ninth Service Commands underthe direction of Col.Irving S. Wright, MC, medical consultant to each of these commands atdifferent times.
It appeared early to themedical consultant that continued medical education and training werevital to the maintenance of superior medical care, especially if thewar was to be a long one.There were many methods, most of which were tried by the consultant ineither the Sixth orNinth Service Commands. They were not equally successful and some thatwere successful inone hospital failed in another. The following techniques were utilized:
Ward rounds by the consultant.-Visitsto wards by the consultant appeared to be a very usefulform of medical education and training. It was the consultant's policyin hospital visits to spendbetween 80 and 90 percent of his time on the wards examining patientswith members of thestaff.
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The objective usually was not only thesolution of the problem of a particular patient but also theuse of that patient's problem as a stimulus for consideration of bothscientific and administrativeprinciples.
Field trips.-Visits to the field installations, made withcivilian consultants in medicine who wereoutstanding teachers, were also beneficial to all concerned. Thesevisits probably constituted thehighest form of medical teaching and were popular with and greatlyappreciated by the hospitalstaffs.
Unfortunately, the numberof medical officers benefited during any one trip with a civilianconsultant was small. Nevertheless, the employment of the civilianconsultants in this fashionwas important, for it introduced new attitudes and fresh points of viewfrom medical schools andcivilian hospitals.
Wartime graduate medicalmeetings.-The principle of wartime graduate medical meetings wassound. There existed factors that militated against success in some ofthe service commands.Certain requisites were essential, as follows:
1.A consultant whobelieved in the program and was willing to work for it.
2. One or more civilians who believed in the programand who were dynamic and self-sacrificingenough to activate it on the civilian side.
3.A sufficient number of medical schools oroutstanding hospitals to provide men of highprofessional caliber to act as speakers for the programs. For example,the small Sixth ServiceCommand with its many medical schools and hospitals was an idealcommand for this type ofteaching, whereas the Pacific Northwest in the Ninth Service Commandnever achieved asatisfactory program.
After some experimentationin areas where the program was feasible, one meeting every 2 to 4weeks was arranged. The speakers arrived in adequate time to permitbedside teaching throughward rounds and consultations. Papers for the formal program wereusually brief, and anopportunity was provided for discussion and questions from the floor.The wartime graduatemedical meetings in the Sixth Service Command were available to all ofthe personnel in theservice command hospitals once or twice each month.
Conferences of chiefs of services.-It was helpful for the chiefsof the medical services of servicecommand hospitals to come together at regular intervals for theexchange of ideas andexperiences and for the consideration of recent advances in the fieldsof medicine that were ofpractical importance. This type of meeting was not sufficiently used.Some service commandsmanaged to achieve one conference during the entire war. Such aconference should be held atleast once a year. The program of a conference in the Ninth ServiceCommand is included in thisvolume as appendix D (p. 841).
Clinicopathologic conferences.-Material for clinicopathologicconferences was made availablethrough the courtesy of the Massachusetts General Hospital at Boston,Mass., and the New YorkPostgraduate Medical School of Columbia University, New York City.Arrangements were madein the Sixth and Ninth Service Commands for the protocols to arrive atregular intervals at eachlarge hospital.
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The success of suchconferences depends upon certain factors. The chief of the laboratoryservice must be a competent pathologist who enjoys teaching andunderstands the technique forpresenting the material. Since it was noticeable that in hospitalswhere the staff waspredominantly surgical the conferences were not very popular, it wouldseem that members ofthe medical services appreciate this type of teaching to a greaterdegree.
Probably the mostimportant type of pathologic conference is the autopsy. Unfortunately,attendance was not required in some hospitals, although this consultantconsistentlyrecommended that it be made mandatory.
Temporary duty assignments fortraining.-A very important means of comparing experiencesand gathering information was the detailing of certain officers totemporary duty in otherhospitals where they could learn certain techniques or observe specialprocedures. For example,when the consultant found that the use of the classification ofrheumatic fever was quite differentin two of the rheumatic fever centers-namely, Torney General Hospital,Palm Springs, Calif.,and Birmingham General Hospital, Van Nuys, Calif.- he arranged for thechief of the medicalservice at Birmingham to visit Torney and later for the chief of themedical service at Torney tovisit Birmingham. They studied patients and went over charts togetherand were able to resolvedifferences in the use of the classification.
Editorial duties.-The consultantreviewed many papers prepared by medical officers. This was apleasant task, which seemed worthwhile and especially helpful to young,inexperienced authors.Numerous papers severely criticized in their original form either havereappeared later, muchbetter because of further thought and revision, or have been includedin the authors' souvenirs ofwar experiences where they rightfully belong.
In summary, then althoughthere would probably be some obstacles to continued medicaleducation and many nonreceptive medical officers, such education isunquestionablyfundamental to the maintenance of proper medical thought and practicein any hospital systemduring times of peace or war. The programs described in theseparagraphs were not entirelysuccessful in every detail in the two service commands considered inthis report, but they didappear to have been helpful to the majority of officers on the medicalservices of hospitals inthese commands.
The postgraduateeducational program developed in the Eighth Service Command was mostcarefully planned and executed. A summary of Colonel Bauer's reportfollows.
It is generally concededthat the strength of any institution for the care of the sick isdirectlyrelated to educational facilities which exist therein. However, it wasnot until the establishmentof the consultant system that the educational possibilities of Armyhospitals received properemphasis.
The consultants soonrecognized that fostering a strong educational program was the bestmethod of improving the medical services. They further agreed thatbringing to the hospital asystem of postgraduate education would benefit the largest number ofmedical officers.
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The consultants' wardrounds and clinics served as educational exercises and stimulatedbetterprofessional performance. However, as visits were too infrequent tohave the desired continuingeffect, the chiefs of service were urged to establish strongeducational programs. These usuallyincluded weekly medical staff meetings, clinicopathologic conferences,clinical X-rayconferences, and biweekly hospital staff meetings. In addition, some ofthe medical servicesestablished journal clubs for reviewing the current medical literature.The smaller stationhospitals conducted educational programs on a smaller scale.
The staff meetings wereoften time basic educational activity. Generally speaking, they werewell conducted. The cases selected for presentation were well chosenand the available pertinentliterature thoroughly reviewed. A few of the abler and more energeticchiefs of service preferredward conferences from 2 to 3 times a week, attended by the entiremedical staffs. Theseexercises, if properly conducted, encouraged free discussion, furtheredprofessional thought, andserved to unify diagnostic and therapeutic procedures.
The clinical X-rayconferences were very successful when well conducted, as evidenced bythelarge weekly audiences. When the participation by both the clinicianand the radiologist wasactive, such conferences were extremely informative and contributedgreatly to the intellectualatmosphere of the hospital.
The general hospital staff meetings varied greatly both in quality and purpose. In many of the installations, the major services-surgery, medicine, neuropsychiatry, and radiology-were responsible for one meeting each month. These meetings were usually devoted to a formal presentation of some topic of general interest. In some hospitals, the meetings were held only rarely or not at all because of the lack of cooperation between the medical and surgical services. Thus was most unfortunate because such meetings, if well organized, aided materially in unifying the purpose of the hospital staff.
The other educationalopportunities afforded medical officers were the wartime graduatemedicalmeetings sponsored by the American College of Physicians, servicecommand conferences forchiefs of service and their staffs, special postgraduate and refreshercourses in civilian and Armyhospitals, temporary duty assignments, and an intern program.
The first of these wasvery successful in several of the smaller service commands having manymedical schools and energetic, enthusiastic regional chairmen; forexample, the Sixth ServiceCommand. Lack of success in other service commands was attributable tofailure to have theregional area correspond geographically with that of the servicecommand, the long distancebetween the Army hospitals and the medical centers, the lack ofdynamic, self-sacrificingregional chairmen, and the absence of sufficient medical schools andoutstanding hospitals toprovide properly qualified teachers. Effective wartime graduate medicalmeetings required theutmost cooperation between the regional chairman and the servicecommand surgeon and hisconsultant. Without this cooperation, the meetings were notsufficiently well integrated to meetthe needs.
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A model program shouldfurnish one or more civilian consultants to each service commandhospital at least once a month. The participants should remain for atleast 1 day, spending thegreater part of their time on the wards with the medical officers. Iftalks are permitted, theyshould be confined to appropriate topics and be sufficiently brief toallow ample time fordiscussion and questions from the floor. The aim of these wartimegraduate medical meetingswas sound.
During the first 2 yearsof the war, many medical officers were sent to various specializedschools operated either by the Army or for the Army in civilianhospitals and medical schools.The benefits derived from these courses depended upon the individualsassigned, their ability,diligence, and interest in the subject. Too often, poorly qualified andindifferent officers wereindiscriminately ordered to these schools in order to fill the requiredquota. Therefore, in manycases, neither the individual nor the Army profited from the experience.
The refresher courses meldat some of the service command hospitals varied greatly in theiraccomplishments. Many of the courses were too ambitious considering theteaching staff thatwas available. Those courses of a more limited scope were the mostsuccessful and the only typethat should be permitted.
Assignment of medicalofficers temporarily to service command hospitals in order to acquireneeded techniques and other information proved to be a very helpfulmeans of strengtheningcertain hospital staffs.
Intern teaching programswere established in order to provide additional instruction forrecentlygraduated physicians entering the service. These young officers wereassigned as assistants totine best qualified ward officers. They accompanied the chiefs ofservice on their rounds andreceived 1 hour or more of didactic instruction each day. The majorityof these young physicianswere enthusiastic, energetic, receptive to instruction, and helpful inthe operation of the wards towhich they were allocated.
During this emergency, thespace, fixtures, and equipment apportioned for libraries were ofteninadequate. In some hospitals, the libraries were so dissipated byinformal loans to service andsection chiefs as to be of little value to other staff members. In theinstitutions where they werereadily accessible, attractively furnished, and well managed, thelibraries played important roles.The number of current medical journals received by the larger hospitalsrepresented an excellentcross section of the better periodicals. However, the quota of booksoriginally supplied wasinadequate both numerically and qualitatively. This inadequacy was dunelargely to unnecessaryduplication, such as from 6 to 8 volumes of Christopher's Textbook ofSurgery, Cecil'sTextbook of Medicine, Dorlammd's Medical Dictionary, Useful Drugs, andother books to alesser degree. Later, the libraries were supplemented by additionalbooks and purchases fromspecifically allotted funds. In addition, books and periodicals wereloaned by the Army MedicalLibrary, medical
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schools, and societies, whose generouscooperation enhanced the education of medical officers.
The educational program inthe Eighth Service Command was more comprehensive than that ofother commands because the surgeon and the consultants obtained asubstantial yearly grantfrom the Rockefeller Foundation. These additional funds made possiblebetter libraries, thedistribution of clinicopathologic conference case material, and theactive participation of visitingprofessors in the teaching program.
Considerable time wasdevoted to the selection of the volumes needed to provide each hospitalin the Eighth Service Command with a library sufficiently complete tofurnish definitiveinformation concerning all medical and surgical diseases. The bookswere then purchased anddistributed. This undertaking not only profited the hospital staff butalso served to demonstratethat small civilian hospitals could have reasonably comprehensivelibraries without spendinglarge sums of money.
The use of case teachingby means of chinicopathologic conferences, first introduced in theEighth Service Command through the grant-in-aid from the RockefellerFoundation, was verywell received. The numerous requests for this material finally led thefoundation to make itavailable to all service commands. Selected case reports of the typepublished in the NewEngland Journal of Medicine were obtained from the MassachusettsGeneral Hospital for theseconferences. Two such case reports were distributed to each servicecommand installation eachweek. The hospital staffs were urged to conduct these conferences inmuch the same manner asis done at the Massachusetts General Hospital. The success of theconferences depended in largepart on the ability of the hospital pathologist to teach and to invitediscussion. Participation inthese conferences by the staff members necessitated reading the medicalliterature and keepingin touch with the newest developments in medicine and surgery. Inaddition, the conferencesserved to maintain interest in those diseases not encounteredfrequently in Army hospitals.
Case records pertaining tothe major psychoses, psychoneuroses, psychosomatic disorders, andneurologic diseases were distributed to all hospitals. These were usedin much the same manneras the clinicopathologic caseteaching material. They were well receivedand stimulated interestin neuropsychiatric disorders.
Another and extremelyimportant feature of the educational program in the Eighth ServiceCommand was the provision for the active participation of eminentteachers. The annual budgetwas sufficient to permit nationally known internists, surgeons,neuropsychiatrists, orthopedicsurgeons, and, for a time, radiologists to visit the service commandhospitals. Once suchspecialist accompanied the corresponding consultant on his monthly tourof hospitals. Eachvisitor spent 2 or 3 weeks in the service command, depending upon thelength of leave grantedby his medical school. The foundation grant paid his traveling expensesand provided him with amodest honorarium. The invited
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guest joined the service command consultantin making ward rounds, holding clinics, and inroundtable discussions. Formal lectures were not featured with anyregularity because of thedesire to have the visiting physician demonstrate, by actualperformance, good medical practice.
Initially, the consultantsand their visiting specialists visited all types of service commandinstallations. With the institution of the regional consultant system,visits were confined to theregional, general, and large station hospitals. The continuedparticipation of the staffs of thesatellite stations in such exercises was made possible by having thecommanding officer of theparent or host institution invite the staff members to attend. Thisthey did with great regularityNot infrequently, the staff members requested aid in the solution ofsome of their more recenttherapeutic and diagnostic problems, and occasionally they presentedcases While at the parenthospital, the consultant and his visitor were available forconsultation to the satelliteinstallations.
Seeing the visitingprofessors intimately and in action had a most stimulating effect uponthemedical officers They appreciated brushing shoulders with these leadersand eminent authoritiesof the profession, submitting cases to them, and having the benefit oftheir experiences andopinions. The give and take of the ensuing discussions provided themedical officers withprofessional experiences of great and lasting value rarely to be had inprivate practice.
An unexpected result ofthese educational programs was their effect on the visiting professors.The two impressions most frequently discussed by the civilianconsultants are worthy ofrecording. First, the consultants were of the opinion that, concerningdiagnostic facilities andtechnical equipment, military medicine was at a very commendable level.Second, they wereagreed that most of the graduates of American medical schools had notbeen taught sufficientpsychiatry to enable these graduates to practice comprehensivemedicine. Several of thedistinguished consultants returned to their medical schools determinedto make changes inteaching methods. One wrote that his tour of military hospitals hadopened his eyes to the role ofpsychosomatic medicine and convinced him of the importance of teachingthe fundamentalprinciples of psychiatry not only in the department of psychiatry butin every division of themedical school.
Many, especiallycommanding officers of hospitals, argued that the institution ofeducationalexercises of the type just described would interfere seriously with thedischarge of the medicalofficers' routine duties. Experience soon demonstrated that thebeneficial effects more thancompensated for the time required The most important direct result ofthe educational programswas better medical care for sick soldiers. In addition, the programsfurnished needed instructionfor medical officers who came directly to the service after longperiods of practice, and theseprograms continued instruction for the more recent medical schoolgraduates.
If the Army Medical Corps is to provide the bestpossible medical care, it must fulfill certaineducational obligations. In the of war, this obligation willnecessitate greater discrimination inthe use of the affiliated hospital staff
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members,5 the Army's greatestsource of clinical teachers. The assignment of most of theseofficers to key hospital positions and the establishment of systematicrotation of ward surgeonswill provide excellent opportunities for the development of physicians.
ADEQUACY OF MEDICAL CARE IN ARMY HOSPITALS
This subject is one ofprime importance to the historian. The discussion that followsrepresentsthoughtful, thoroughly objective treatment of the subject. It is asummary of an appraisal writtenby Colonel Bauer, a service command consultant whose knowledge andexperience rendered himexceptionally qualified for the task.
The medical care providedsick soldiers in Army hospitals was, in most instances, superior tothat previously received in civilian life. This care was made possiblethrough the organizationand supervision of clinical activities, the unification of diagnosticand therapeutic procedures,better placement of medical officers, and continued education.Nevertheless, unnecessaryfatalities did occur.
In criticizing Armymedical care, it is important to stress that many of the deficienciesreflectedmore upon the undergraduate arid graduate training of physicians thanupon military medicine.Physicians often did not adjust well as members of disciplined teams,nor did they always acceptunusual assignments graciously. The majority of offices, however,executed their responsibilitiesto the best of their ability despite handicaps such as newsurroundings, unaccustomedadministrative procedures, and unfamiliar professional duties.
Deviations from the basicprinciples of good medical practice were frequently observed in theform of poor doctor-patient relationships, unnecessary hospitalization,inadequate histories,absence of personality evaluation, incomplete physical examination,delayed clinical evaluation,institution of therapy before establishing a diagnosis, paucity ofprogress notes, inadequatetreatment, and indecision in diagnosis, therapy, and disposition. Theseshortcomings wereconsciously or unconsciously compensated for by superfluous laboratorytests, radiologicexaminations, consultations, clearances, and treatment. Such practicesoften bespoke eitherinadequate medical training or a feeling of insecurity on the part ofmedical officers andconstituted some of the ictrogenic factors to which soldiers wereexposed. Such factors furtherincreased an already staggering neuropsychiatric rate.
Full documentation ofother breaches and deficiencies would not justify the time and spacerequired. It is sufficient to cite a few examples regularly observed,such as limited knowledge ofcommunicable diseases; meager understanding of the principles ofchemotherapy; unwarrantedreliance on laboratory procedures; and lack of clinical judgmentconcerning the variedmanifestations
5 Experienced teachers in medical units formed by asponsoring medical school or hospital.
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of rheumatic fever, infectious hepatitis, diphtheria, infectiousmononucleosis, malaria, anddiseases incurred in tropical regions.
The adequacy of medicalcare depended upon the professional qualifications, attitude, andperformance of the chief of service and his fellow officers and also ontheir relationship to oneanother. It was demonstrated repeatedly that even with personnel ofaverage ability a capablechief of service elevated medical care above the level of mediocrity byconstantly striving forimproved diagnoses, therapy, and disposition. In order to achieve this,he had to avoid beingsaddled with a heavy administrative load. Good leadership not onlypromoted better performancebut also invited a more critical attitude and a free expression ofopinion on all professionalmatters by medical officers, irrespective of rank. This atmosphereimproved rather thandiminished esprit de corps.
CLINICAL RESEARCH
At the outbreak of thewar, the policymakers of the Medical Department of the Army were notfavorably disposed to clinical research in Army installations. Theseadministrators werepreoccupied with the many and important problems involved in planningfor supplies, hospitals,personnel procurement and management, and operations for the huge andsteadily expandingArmy; and, at the same time, they were concerned with the efficientoperation of the MedicalDepartment in relation to pressing current problems. Not only didclinical research fail to receiveencouragement at this time, but attempts to carry out original studieswere actively discouraged.
In time, this attitudechanged. The influence of the consultants was of the greatestimportance inbringing this about. They understood the Army's need for additionalknowledge in order betterto support the combat training program in the Zone of Interior and,later, the combat strength oftroops in the line. This responsibility made research a very practicalmatter for the MedicalDepartment. Many questions had to be answered. What disposition to makeof patients withhepatitis? What treatment to employ for malaria? How to prevent andtreat properly cold injury?How to prevent and treat meat exhaustion? These and innumerable otherquestions could beanswered only after study, and often the studies could be made onlywith troops. As time passed,the attitude of the Medical Department in the Zone of Interior changedfrom one of activeresistance to clinical research to one of passive acquiescence and,rarely, to one of wholeheartedacceptance.
Only in isolatedinstances, however, was it possible to obtain the necessary prioritiesin material,transportation, and especially personnel. if priorities could beobtained at one echelon ofcommand, it was common experience to have them denied at another.Nevertheless, clinicalresearch developed in a modest way in certain places. In some of thehospitals designated for thecare of special disorders and, less frequently, elsewhere, researchactually flourished toward theend of the war.
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The following commentsregarding clinical research in three service commands are based onobservations of the medical consultants who served in these commandsand who often initiatedand supervised studies. A summary of Colonel Thomas' experience in theFourth ServiceCommand follows:
There were severalclinical research projects in some of the hospitals. Some officersturned out agreat many papers; a few of them were quite good. Whenever the medicalconsultant saw aninteresting and unusual case or a well-studied group of cases, heencouraged the chief of medicalservice and ward officer to prepare a report for publication. TheFourth Service CommandLaboratory was interested in various studies including dysentery andmeningococcic infection.
The influenza commissionwas established at Fort Bragg, N.C., where primary atypicalpneumonia was studied. Members of the staff of that commissioncontributed to the program of aconference held in the service command and distributed informationconcerning their work. Thelarge epidemic of meningococcic infections presented an opportunity forcareful clinical andtherapy studies. At Fort Bragg, Lt. Col. (later Col.) Worth B. Daniels,MC, studied an outbreakof a rare disease, which inc called pretibial fever. On the whole, themedical personnel in thehospitals in the Fourth Service Command were not trained for clinicalresearch. There were anumber of cardiologists who collected rare forms of cardiac arrhythmia,and thegastroenterologists made valuable contributions in the study of pepticulcers. The work on theuse of prophylactic sulfonamides in aborting a meningococcic epidemicwas of great value, andthe studies along this line performed by the Fourth Service CommandLaboratory personnel wereoutstanding.
A summary of a report byColonel Adams, also concerning the Fourth Service Command, ispresented in the following paragraphs.
The following studies andinvestigations were made in this command:
Location Study
Battey General Hospital, Rome, 1. Clinical studies on acute pericarditis. Ga.
2.Comparison of vaccine products and Brucellergen intradermal tests in brucellosis.
Finney General Hospital, Thomas- 1.Malaria therapy in neurosyphilis.
ville, Ga. 2.Penicillin therapy in neurosyphilis.
3.Spinal-fluid Wasserman reaction during the course of and subsequent to malaria treatment of neurosyphilis. 4.Studies on penicillin concentration in spinal fluid.
5.Value of Thio-Bismol (sodium bismuth thioglycollate) in quartan malaria.
6.Value of gastric analysis in the diagnosis of duodenal ulcer.
7.Survey of bronchial asthma in soldiers
8.Studies in histamine-stimulated fractional gastric analysis.
9.Statistical study of 200 cases of arthritis.
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Location Study
Foster General Hospital, Jackson, 1.Clinical studies on rheumatic fever and rheumatic
Miss. heart disease.
2.Value of salicylate therapy in rheumatic fever.
3.Effect of various adjuvants (such as sodium bicarbonate, ammonium chloride, and aluminum hydroxide gel) on blood salicylate levels.
4.Penicillin therapy in chronic bronchial asthma.
5.Clinical study of asthmatics returned from overseas.
Kennedy General Hospital, Mem- 1.Evaluation of certain drugs is the treatment and control of malaria
phis Tenn.
2.Studies on palmar sweating.
3.Clinical study of asthmatics returned from overseas.
Lawson General Hospital, Atlanta, 1.Comparative value of liver-function tests in hepatitis.
Ga 2.Gastroscopic studies in acute hepatitis.
3.Electrocardiographic studies in various forms ofheart disease.
4.Effect of amputation of the extremities on the electrocardiogram
5.Evaluation of penicillin in treatment of skin disease.
Moore General Hospital, Swannanoa, 1.Comparative evaluation of different drugs in treatment and suppression of malaria
N.C.
2.Clinical studies on filariasis.
3.Comparative evaluation of different drugs in treatment of schistosomiasis.
4.Evaluation of certain antigens in the diagnosis of schistosomiasis .
5.Comparative evaluation of different drugs and dosage in the treatment of kala-azar
6. Clinical studies on hookworm infections.
7. Clinical studies of various forms of treatment inatypical lichen planus and cezematoid dermatitis.
8.Histopathology of atypical lichen planus.
9 Relationship of Atabrine (quinacrine hydrochloride) administration to atypical lichen plants
10.Clinical studies of dermatologic and faucial diphtheria.
11.Study of metabolism of antimony by use of radioactive tartar emetic (in conjunction with the U.S. Public Health Service, Department of Zoology, National Institutes of Health).
Oliver General Hospital, Augusta, 1.Combined penicillin-heparin therapy in subacute bacterial endocarditis
Ga.
2.Evaluation of various forms of treatment in atypical lichen planus.
3.Recurrence rate of malaria treated without specificdrugs. Diagnosis of Strongyloides stercoralis infestation by duodenal drainage.
4.Statistical studies of the incidence and types of asthma in the Army.
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Location Study
Oliver General Hospital, Augusta, 5. Evaluation of Anthiomaline (antimony sodium thiomalate malate) in granulma inguinale
GA
6.Evaluation of intrathoracic penicillin treatment of empyema.
Regional Hospital, Camp Blanding, 1.Studies on heat stroke.
Fla. 2.Loeffler's syndrome in eases of Ancylostoma braziliense (creeping eruption).
Regional Hospital, Fort Benning, 1.Evaluation of immune globulin in the prevention of mumps orchitis
Ga.
2.Gastroscopic studies in infectious hepatitis.
3.Evaluation of antistreptolysin titer in differential diagnosis of rheumatic fever.
4.Evaluation of sulfonamide drugs in the prophylaxis of gonorrhea.
5.Studies to determine the optimum dosage of penicillin in acute gonorrhea
Station Hospital, Camp McCain, 1.Evaluation of sulfonamide drugs in the prophylaxis of meningococcic
Miss. infection (in cooperation with the Fourth Service Command Laboratory).
Station Hospital, Camp Wheeler, Ga.1.Evaluation of sulfadiazin prophylaxis in the control of respiratory diseases and meningococcic infection.
Thayer General Hospital, Nashville, 1.Malaria therapy in neurosyphilis.
Tenn. 2. Penicillin therapy in neurosvphilis.
3.Effect on propylene glycol aerosol in barracks on the incidence of respiratory infection.
United States Army General Hospi- 1.Studies on trenchfoot, including biopsy material,
tal, Camp Butner, N.C. fluorescein studies of circulation, and mycologic studies of skin complications.
2.Value in hepatitis of the coagulation band, the Watson quantitative urobilinogen, and the quantitative methylene blue tests.
Welch Convalescent Hospital, Day- 1.Studies on antiamebic drugs in diarrheal patients admitted by transfer with the diagnosis of
tona Beach, Fla. functional gastrointestinal disease.
Regional Hospital, Fort Bragg, N.C. 1.Clinical and laboratory studies on pretibial fever.
2.Clinical, laboratory, and epidemiologic studies on an outbreak of bacillary dysentery (in conjunction with the Fourth Service Command Laboratory).
3.Intensive arsenotherapy of syphilis.
4.Penicillin therapy of syphilis.
5.Evaluation of Frei antigen.
6.Therapeutic value of penicillin-beeswax-peanut oil mixture in various infections, including gonorrhea,early syphilis, tonsillitis, pneumonia, and others.
7.A comparative study of penicillin and sulfadiazine in the treatment of pneumococcic pneumonia.
8.Studies to determine the optimum dosage of penicillin in acute gonorrhea.
Regional Hospital, FortMcClellan, 1.Use ofestrin in the prevention of mumps orchitis.
Ala.
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Location Study
Regional Hospital, Fort Jackson, 1.Evaluation of sulfonamide drugs in the prophylaxis of meningococcic infection (in cooperation with the
S.C. Fourth Service Command Laboratory).
Station Hospital, Camp Forrest, 1.Clinicalstudy of an epidemic of tularemia.
Tenn.
An extensive study ofmethods for preventionand treatment of dermatophytosis was conductedat Fort Benning, Ga., from August 1942 through December 1945 by theDivision of WarResearch of Columbia University, under contract with the Committee onMedical Research ofthe Office of Scientific Research and Development. The project wasdirected by Dr. J. GardnerHopkins, Professor of Dermatology, College of Physicians and Surgeons,Columbia University.He was assisted by four trained mycologists and several technicians.Office and laboratory spacewere first provided at the regional (then station) hospital; later abarracks building was allocatedby the post surgeon for a laboratory and clinic. Troops for surveys andtesting of prophylacticmeasures were made available from various infantry regiments and otherorganizations on thepost. Treatment clinics were held in two of the post dispensaries. InJuly 1945, the scope of theproject was extended to include a study of penicillin therapy in alltypes of skin infection,including those secondary to dermatophytosis. A special ward in theregional hospital wasallocated for these cases, and a trained Medical Corps dermatologistwas placed in charge of theclinical work.
The following problemswere investigated: (1)Incidence of fungus infection in infantry troops;(2) types of fungi and bacteria concerned in these infections; (3)effectiveness of prophylacticmeasures, including footbaths, powders, ointments, and special types ofshoes in preventingdermatophytosis; (4) evaluation of new fungicides, including a numberof antibiotics, in thelaboratory; (5) evaluation of new fungicides in treatment of mycoticinfections; (6) evaluation ofantiseptics and the sulfonamides in treatment of secondary infections;and (7) effectiveness ofpenicillin in pyodermas and time frequency of sensitization resultingfrom its use.6 As a result ofthese studies, a new fungicidal ointment containing undecylenic acidwas added to the supplytables. Methods for treatment of dermatophytosis and secondaryinfections were published in theArmy Medical Bulletin. Close cooperation existed between timepost surgeon, the hospital staff,and Dr. Hopkins and his group. The latter freely gave their services inconsulting with thehospital staff on difficult dermatologic cases.
The Commission on AcuteRespiratory Diseases,1 of the 10 commissions activated by the ArmyService Forces Board for the Investigation and Control of Influenza andOther EpidemicDiseases in the Army, reported to Fort Bragg on 19 October 1942. Itsgeneral objectives were:(1) To maintain continuous
6 A detaileddiscussion of theseinvestigations appears in Medical Department, United StatesArmy. Preventive Medicine in World War II. Volume V. CommunicableDiseases TransmittedThrough Contact Or By Unknown Means, chapter VII. [In press.]
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observations of respiratory diseases as theyoccurred at Fort Bragg and to investigate theirepidemiologic, etiologic, serologic, clinical, and prophylacticaspects; (2) to maintain a constantwatch for the occurrence of influenza and to study any outbreaks ofthis disease; (3) to carry onstudies of primary atypical pneumonia, with particular emphasis on itsetiology; and (4) toconduct field investigations as directed by The Surgeon General.
This commission had itsspecial laboratory inthe regional hospital and had access to all clinicalmaterial. Its investigations were carried on with the full cooperationof the hospital staff. Themembers of the commission were most helpful to this hospital as well asto other installations inthe command in performing special laboratory tests and in freely givingtheir expert clinicaladvice whenever called upon.
A summary is presented ofan informativestatement about research in the Fifth ServiceCommand. The statement was included in a report by Colonel McGuire. Theexperiences at theWakeman General Hospital, Camp Atterbury, Columbus, Ind., illustratesome of the notinfrequent obstacles to well-planned investigations.
There were two majorefforts to carry onwell-planned investigations within the Fifth ServiceCommand. One was a study of physiologic alterations in the circulationconsequent toarteriovenous fistulas. This investigation was planned by Lt. Col.(later Col.) Daniel C. Elkin,MC, Chief, Surgical Service, Ashford General Hospital, White SulphurSprings, W. Va.; a groupof clinicians who were members of or selected by the National ResearchCouncil; representativesof the Surgeon General's Office; and the Fifth Service Commandconsultants in surgery andmedicine. The study was conducted at Ashford General Hospital.7 Acivilian clinicalinvestigator, Dr. Eugene A. Stead, Jr., trained in the technique ofmeasurements of circulatoryphysiology, was placed in charge of this project. Technicians and thenecessary apparatus werebrought to Ashford, where an extraordinarily large number of patientswith arteriovenous fistulaswere being prepared for surgical treatment. In a careful and thoroughmanner, alterations inblood volume and cardiac output and other changes in cardiovascularphysiology before andafter operation were investigated. Measurement of peripheral blood flowdistal to fistulas wasplanned but abandoned following V-J Day.
The second investigationwas a careful studyof the nutritional status of the paraplegic patients atWakeman General Hospital.8 This study was planned by thenutritional consultant, the chief ofthe surgical service, and the medical and surgical consultants of theFifth Service Command. Theproject was first formally presented to The Surgeon General in May 1945but was returned withthe comment that the patients to be studied were definitely surgical
7 Elkin, Daniel C.: Arterial Aneurysms and Arteriovenous Fistulas Circulatory Effects of Arteriovenous Fistulas. In Medical Department, United States Army. Surgery in World War II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955, pp. 181-205.
8 MedicalDepartment, United States Army.Surgery in World War II. Neurosurgery, Volume II.Washington: U.S. Government Printing Office, 1959, p. 151.
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and therefore the project should be carriedon under thee direction of the surgical consultant andthe chief of surgery at Wakeman General Hospital. The project was thenresubmitted inaccordance with this suggestion, and formal approval was received underdate of 11 July. In theinterim, the conditions under which the project had been originallyconceived were markedlyaltered. The cessation of hostilities in Europe diminished the flow ofparaplegics to the hospital,reducing the supply of the more acutely ill patients. Personnelshortages made it difficult for thehospital to organize and properly staff a special ward for the care ofthe patients underobservation. The construction and equipment of a laboratory for theconsiderable volume ofanalytical work required was deferred by the increasing emphasis on theenlargement of thereception-station and separation-center facilities which were locatedat Camp Atterbury, for itwas through the camp administrative channels that approval of suchconstruction had to pass.Such was the status of the project when V-J Day arrived. Shortlythereafter, it was recommendedthat the project be abandoned, and, with the concurrence of the servicecommand headquarters,The Surgeon General gave authority to discontinue it in October 1945.
Col. Thomas Fitz-Hugh,Jr., MC, Consultant inMedicine, Third Service Command, from May1944 to January 1945, provided the following comment on clinicalresearch.
One of the highlights ofthis war has beenthe output of excellent clinical research publicationsby many medical officers. A great deal of valuable material has beenaccumulated under difficultand trying circumstances. The medical consultant is dutybound toencourage and aid suchendeavors. By the same token, it is his duty to be critical of poorlyorganized, repetitious, andnon-contributing publications.
RECONDITIONING
The delay in thedevelopment of areconditioning program by the Army Medical Departmentwas principally due to indifference in the Surgeon General's Office toa need which had beenrecognized by medical officers in the field installations. Stimulationfrom the field, andespecially from the splendid Air Force program instituted by Col.Howard A. Rusk, MC,eventually led to reconditioning in Army installations. The need forsuch a program was evidentfrom the single fact that medical officers in hospitals were ordered toretain their convalescentpatients in hospitals until they could be returned to their units infull-duty status.
The interest of theservice command medicalconsultants in the reconditioning units whichultimately came into being varied greatly. The consultants were almostto a man extremely busyand preoccupied with important matters for which they were directlyresponsible. Once aseparate program for reconditioning became established, the medicalconsultants usuallyconsidered themselves relieved of responsibility in the matter.
Col. George P. Denny, MC,Consultant inMedicine, First Service Command, from January 1944to December 1945, commented in his final report
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on the reconditioning program for thatcommand. The following paragraphs summarize hisobservations.
The usual reconditioningprogram at generaland station hospitals for class I, II, III, and IVpatients was in operation at the time of this consultant's assignmentto the service command.This was set up and operated in accordance with Circular Letter No.168, dated 21 September1943, OTSG, U.S. Army. In March 1944, the medical consultant attended ameeting forreconditioning consultants of all service commands at Schick GeneralHospital, Clinton, Iowa.
U.S. Army Medical Center at Camp Edwards
In April 1944, areconditioning center wasset up at Fort Devens, Mass., and patients in classes Iand II were sent there from all hospitals in the First Service Command.This center was a part ofLovell General Hospital, Ayers, Mass., and, because of the complexityof the program, thedifficulty of obtaining machinery and materials, and the work necessaryto adapt the barracksbuildings available, the program got under way slowly. About the timethings were workingwell, the whole activity was uprooted and moved to Camp Edwards, Mass.,where in January1945, it became a part of the U.S. Army Medical Center at Camp Edwards.This center wasdesigned to take care of 6,000 men with the idea of freeing hospitalbeds for patients evacuatedfrom overseas. Beds were quickly filled to capacity by class I and IIpatients, and many morepatients were carried on furlough.
The original, primaryobject ofreconditioning was to return as many men to duty as possible andto fit the remainder for return to civilian life. As the programprogressed, it was found that only asmall percentage could be returned to duty of any type, and the centerbecame a vast waitingroom of men who knew they were on their way out of the Army and who didnot take kindly tothe various moral, mental, and physical methods of improving theircondition. This impressionwas derived from personnel observation and talks with the officersconcerned. The ideal ofreconditioning was worthy and high but so complex and diffused that itappeared to choke itself.
At first, there was atendency on the part ofhospitals to transfer patients who could not by anystretch of the imagination be benefited and who should have beendischarged at the hospital oforigin. This procedure was gradually corrected, but reconditioningremained in part a dumpingground used by hospitals needing to free beds for anticipated newpatients. Many men were sentdirectly to the reconditioning center from debarkation hospitals, somewith either no records orvery scanty ones and requiring examinations that could only beaccomplished in the generalhospital or by consultations. Finally, a consultation service and X-rayand clinical laboratorieswere established within the reconditioning unit, and, although medicalofficers in variousspecialties from the general hospital were still called upon, thehospital load was greatlylightened.
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There were not more thantwo companies ofmedical patients (exclusive of neuropsychiatricpatients). The usual medical census was only about 300 from a total of6,000 in the center.Chronic skin disease represented about 50 percent of this group. Othercommon conditions werethe residuals of acute infectious hepatitis, recurrent malaria, and theusual gamut of indefinitegastrointestinal complaints without definite organic disease. Littlecould be done for thedermatoses, but the gastrointestinal and malaria patients usually werereturned to limited duty.Rehabilitation of patients with the residuals of hepatitis had beengiven special attention in 1942and 1943 with little or no success, and the same was found true at theCamp Edwards center in1945. No special diets were available, time assumption being-andrightly so-that if a man werewell enough to be reconditioned, he should be able to eat at a generalmess. It became commonpractice to dispose of these men by providing them 90-day furloughswith the hope of sufficientimprovement at home to permit their ultimate return to duty-a fairlyslim hope, as it turned out.
Each company had a medicalofficer in chargewho saw all of his patients every day, if he couldcatch them between classes; and medical consultants from theprofessional service visited thecompanies routinely and on request of the officer in charge. If a manbecame sick, he was sent tothe dispensary by the company medical officer where one of three thingswas done: (1) He wasgiven appropriate treatment and returned to barracks, (2) He wasreferred to the U.S. ArmyGeneral Hospital, Camp Edwards, Falmouth, Mass., for study andtreatment, or (3) he wasreferred to the convalescent hospital professional-service consultingstaff for their opinion andadvice. The professional consulting service usually determined the typeof disposition to bemade.
Viewed from a realisticpoint of view, theconvalescent and reconditioning hospital was essentialfor the freeing of hospital beds for patients evacuated from overseas,but its complex andunwieldy system of reeducation hardly merited the vast effort andexpense put into it.
Colonel Bauer also hadextensive experiencewith problems of convalescence and rehabilitationin service command hospitals. A summary of his comments onreconditioning follows.
In December 1942, one ofthe largest servicecommands, without the consent of higher authority,established detachments at three posts. Their purpose was the physicalreconditioning ofconvalescent patients and the physical and mental rehabilitation ofselected soldiers withneuropsychiatric complaints, to the end of saving training days andreducing the number ofsoldiers receiving certificates of disability for discharge. Thesedetachments, located somedistance from the hospitals, were independently operated under thedirection of the postcommanders and surgeons. If these three detachments achieved theiraims, it was planned toestablish similar units at all posts. Although their value wasdemonstrated in approximately 3months, higher authority ordered that they be discontinued. Some monthslater, in September1943, the previously mentioned Circular Letter No. 168 directed
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the establishment of reconditioning units at all larger service command hospitals. These units were maintained for the duration of the war (fig. 36).
The program held promiseof contributing tothe military knowledge of the care of convalescentpatients, for the good of both the Army and the soldiers. It wasobvious from the outset that theprogram's success would depend upon a sound plan, executed withintelligent enthusiasm by theservice command surgeons, the post surgeons, and the personnel inimmediate charge of eachunit. Failure to develop a satisfactory program more rapidly was due tomany causes. There wasinsufficient coordination and direction from higher command, and a lackof understanding of theprinciples mind purposes of reconditioning by hospital commanders andclinicians alike and,save for noted exceptions, no real, enthusiastic desire to do the job.Initially, with no extrapersonnel allotment, there was a shortage, particularly of trainedindividuals. However, this wascorrected by creating a table of organization and by assigning anucleus of trained men.Reconditioning units with intelligent, well-trained personnelaccomplished a great deal. Whensuch personnel was lacking, reconditioning became something to betolerated. Where unitsoperated in this atmosphere, lip service was usually given in the formof mimeographedschedules issued weekly showing exactly what patients in the fourdifferent classes weresupposed to be doing hour by hour, day by day. Close scrutiny of suchunits frequently revealedmany omissions and deviations from the printed schedule.
Although it is notdirectly related to theproblem under discussion, attention should be directedto the problem of conditioning or hardening new troops. Many admissionsto hospitals werenecessary because of failure to adjust the physical training program inthe Army to the materialat hand. Usually, no difference was made in what was requiredphysically of the college athleteor farm boy as contrasted with the clerk or bank teller. Lame backs,sore feet, and generalphysical exhaustion were often causes of hospital admissions and thebasis for the activation ofunderlying neuroses.
DIETETICS
During the war years, noproblem relative toprocurement of food supplies for the Armyhospitals in the Zone of Interior was experienced, nor was thererationing for U.S. soldiers inthese hospitals. The only problems in the Zone of Interior were thosehaving to do with thepreparation and serving of the abundant rations which were alwaysavailable (fig. 37). Thehospital soda fountains and candy counters made their usual inroadsupon the balanced dietsprovided by hospital dietitians. The medical consultants, with otherArmy officers in similarpositions, showed the traditional concern about the quality andquantity of food available for thesoldiers for whom they were responsible, but actually the only realproblem in the servicecommand was to get the soldiers to eat the good food provided them.Poor hospital messesexisted in service command hospitals but not for long. Dietetics in Army
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FIGURE 36.-Continued. C. Water therapy inpool. D. Carefully supervised activities ingymnasium.
FIGURE 37.- Food service at Madigan General Hospital, Tacoma, Wash. A. Messhall. B. Kitchen.
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FIGURE 37-Continued. C. Serving line withsteam tables and huge automatic toaster (center rear).
hospitals, exclusive of the special dietsprescribed in certain diseases (such as diabetes, gout,nephritis, hepatitis, and acute infections) was of little concern tothe medical consultants.
The TM (War DepartmentTechnica1 Manual)8-500, Hospital Diets, dated March 1945, wasprepared in large part under the supervision of Col. Garfield G.Duncan, MC', who was ontemporary duty in the Medical Consultants Division, OTSG.
MEDICAL SUPPLIES
Fortunately, medical supplies in abundant quantity were practically always available promptly to Army medical installations in the United States (fig.38). Such shortages as were encountered were usually because of faulty implementation of the Army system of requisitioning, faulty interpretation of the function of a given hospital, and, therefore, faulty distribution of the supplies appropriate and available to that hospital. The procurement or distribution of medical supplies for general and station hospitals in the United States was never a problem, and the consultants had little occasion to deal with supply problems, except when acting as personal representative of a hospital commander to the service command supply officer or vice versa.
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FIGURE 38.-Well-stocked pharmacy at Percy Jones General Hospital, Battle Creek, Mich
This role was a common one for the professional consultants, not only with relation to supplies but also in relation to many other matters, for they visited and actually were familiar with the medical units functioning within the boundaries of the service command in a way that was unique and, to a degree, rarely approached by any other headquarters officer.
NURSING CARE
Interesting comments onnursing in theservice commands were submitted in the consultants'final reports. Col. John Minor, MC, Consultant in Medicine, ThirdService Command, wroteapproximately as follows:
Nursing in the servicecommand hospitals wasa very minor concern of the medical consultant.Medical officers, even in command positions in large hospitals, haveminimal jurisdiction overnursing problems. In fact, except for inquiries as to the adequacy ofcare in case of sick patientsor in supervision of special wards, the medical consultant hadpractically no contact with nursingproblems.
Also concerning the ThirdService Command,Colonel Fitz-Hugh noted that the chief problem inregard to nursing care which he encountered was occasional numericalinadequacy. However,this shortage was not serious. In general, the nursing care wasexcellent.
Col. Edgar van Nuys Allen,MC, Consultant inMedicine, Seventh Service Command, fromAugust 1942 to December 1945, reported in general that
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FIGURE 39.-Senior cadet nurses in training
nursing care was usually adequate except whenthere was a numerical shortage of nurses.Experience indicated that wardmen could be trained to discharge manynursing duties in asatisfactory manner. In general, nurses served in a supervisorycapacity, except in the case ofseriously ill patients.
Colonel Marble reported onnursing in theSixth Service Command. The following paragraphssummarize his comments.
The inauguration of thesystem of cadetnurses put into operation a plan which apparentlyworked excellently. For all practical purposes, a nurse who had had 2 ?years' training or itsequivalent in an accelerated program in a civilian hospital was ascapable as one who had spentthe full 3 years and was fully qualified to do her share of the nursingwork in an Army hospital.The fact that she was obliged to stay only 6 months and the fact thatthe majority of cadet nurseschose not to remain in the Army was offset by the fact that when the 6months' term of duty forone group of nurses was up, that of another group began. Although thisconsultant does not claimto know much about the Cadet Nurse Corps and the actual resultsachieved, in his opinion, theidea is an excellent one, which in another emergency should certainlybe used in order to providea sufficient number of nurses for the Zone of Interior (fig. 39).
Until the time of theestablishment of theCadet Nurse Corps, it was an almost universalcomplaint that there were not enough nurses in any of the hospitals.This was more or less true,but the whole situation was confused by various administrativeprecedents. In some hospitals,what seemed to be an unwarranted number of nurses were kept atadministrative work in theoffice of the principal chief nurse. It was thought by some that thenurses could have been ofmore help doing professional work on the wards. A constant source ofaggravation was thecontinual shifting of nurses from one ward or one section
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of the hospital to another. Upon inquiry, itwas always stated that the shifting of nurses wasnecessary because of two reasons: (1) An unbroken rule that at regularintervals every nursemust take her turn at night duty, and (2) the number of nurses actuallyavailable for duty fromday to day was constantly changing as the result of leave, illness,days or afternoons off, andtransfers in and out of the installation. Whatever the cause, theshifting of nurses when they hadjust become used to a given ward and trained in a specialized techniquewas a decided nuisanceand resulted in a poorer quality of care for patients.
One complaint made bynursing supervisors wasthat in the average Army hospital there werenot enough real nursing problems to challenge the capabilities of thenurses. As a consequence,over a period of time the nurses became less alert and less interestedprofessionally. It is true thatin the average Army hospital there are fewer patients who are acutelyill and who needspecialized nursing care than are found in the average civilianhospital. The consequence oftenwas that the nurse in charge of the ward spent most of her time doingclerical and administrativework. It will be interesting to observe what effect this practice hashad upon the performance ofthese nurses on their return to civilian life.
COORDINATION WITH OTHER CONSULTANTS
The medical, surgical,orthopedic, andpsychiatric consultants assigned to a service commandhad much in common. Their ultimate aims as medical officers wereidentical. They worked inthe same administrative setting, employed the same channels ofcommunication, often occupiedadjoining offices in service command headquarters, and sharedtransportation on field trips. It isnot likely that any other officers of the headquarters group possessedas much personalknowledge of the general medical activities of the command as did theconsultants. Therelationship between the consultants themselves and between them andthe service commandsurgeon was often intimate, to the great advantage of all concerned.The following summary ofcomments by Colonel Adams, of the Fourth Service Command, provides apicture of how themedical, surgical, psychiatric, and orthopedic consultants coordinatedactivities amongthemselves, with the officers of other headquarters divisions andservices, and with their chief,the service command surgeon.
The consultantsrepresenting the four majorspecialties-medicine, neuropsychiatry, surgery, andorthopedic surgery-coordinated their efforts closely and worked inperfect harmony. Friction wasnonexistent. Whenever possible, two or more of them made tripstogether, reviewed theirsections of the hospital separately, and compared notes in theevenings. As a general rule,because of the inevitable interruption of work, hospital commandersregarded it as undesirable tohave visits from more than three consultants at any one time; mostpreferred not more than two.By mutual agreement, whenever one consultant observed a situation thatneeded correctionwithin the sphere of another's activities, he always reported it to hisconfrere. Such problems
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or deficiencies otherwise might have escapedattention because of infrequent visits to a particularinstallation.
When two or moreconsultants visited aninstallation simultaneously, they sometimes conductedjoint clinics or teaching rounds or together studied problem cases. Itwas hoped that suchdemonstrations with the free discussions that always occurred in theconferences would serve topromote similar interservice joint consultations with free discussionand to discourage solereliance upon formal, written opinions.
Again, in the consultants'relationship withthe officers of the other divisions and services in thesurgeon's office, friendliness and close cooperation were the rule. Itwas the policy of theSurgeon, Fourth Service Command, that members of his staff returningfrom the field shouldreport directly to the appropriate officer any observed deficienciesthat fell within the scope ofother divisions or branches. For example, if unsanitary conditions in acamp, a mess, orelsewhere were encountered, the chief of preventive medicine branch wasnotified. Thediscovery of any minor epidemics or threats of epidemics were similarlyreported. Shortage ofsupplies or some special need, as for an instrument, for example, wasreferred to the chief ofsupply section. This system of direct reporting led to the more promptcorrection ofunsatisfactory situations.
A close and friendlyrelationship existedbetween the consultants and the officers in the MedicalPersonnel Branch, Military Personnel Division, Headquarters, FourthService Command. In spiteof this, the consultants were often unable to advise the personnelofficer regarding theassignment of medical officers as effectively as was desirable. Thenecessity for quick action andthe established policies of the Military Personnel Division made itimpossible for the medicalpersonnel officers consistently to obtain the advice of the consultantswhen the latter were awayfrom headquarters. A more generous use of telephone would have resultedin more effectivedistribution of the better trained officers within the command.
SERVICE COMMAND INSTALLATIONS OTHER THANSTATION AND GENERALHOSPITALS
The relationship of themedical consultant tononhospital medical operations within his servicecommand depended in large part upon the attitude of the service commandsurgeon toward theseinstallations and toward his consultant and the interest displayed bythe consultant. Thus, in theThird Service Command, Colonel Minor made no visits to inductioncenters, reception centers,replacement centers, dispensaries, or outpatient clinics. He pointedout in his report manyweaknesses with regard to professional care and professional personnelmanagement that couldhave been avoided or rectified by cooperative action of the servicecommand surgeon, thesurgeon of the ground forces, and the post surgeon.
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The following detailedcomment upon thesubject as it affects all service commands is basedupon a report from Colonel Bauer, whose extra-hospital interests andactivities were lively andwho speaks from a fund of experience and knowledge of the consultantsystem in the servicecommands. The discussion includes the effects of improved ambulatorymedical care of thesoldier in training camps upon the noneffective rate and the effect ofproper professionalpersonnel management upon the morale of Medical Department officers.
The service commandsurgeons' policyaffecting the relationship of the consultants to variousservice command installations governed the consultants' activities inthe installations. Someservice command surgeons considered the supervision of the care of thesick time consultants'sole function. Others regarded the consultants as their professionalrepresentatives and directedthem to aid in the coordination of all medical activities of theservice command. The latter policyis a most desirable one, but it cannot be realized until the requisiteauthority is delegated to TheSurgeon General and the service command surgeons. When this is granted,it will be possible forthem, with the aid of their professional consultants, to establish theproper type of integration ofthe Medical Department's activities at all Army levels. Such actionwill not only strengthen theMedical Department but also will really contribute to militaryplanning, training, and operation.If such a scheme is ever effected, additional service commandconsultants will be needed tosupervise and integrate properly the activities of the installationswhich are considered in thefollowing paragraphs.
Inductionstations. - In a few of the service commands, the consultantsvisited the inductionstations frequently. The deficiencies most often observed wereinadequate and poorly arrangedquarters, workloads too large for the doctors to handle efficiently,insufficient social serviceinvestigation and psychologic examination, and a paucity of goodneuropsychiatrists, competentradiologists, and qualified specialists to serve as consultants. Themedical officers lacked theauthority necessary for the proper execution of their duties. The mostcommon infringement wasdictation by line officers as to the number of rejectees permitted in agiven period. Manycertificates of disability for discharge, pensions, lost training days,and much hospitalizationwere directly attributable to poor screening at the induction stations.
Receptioncenters. - Many of the induction station errors could have beenunearthed at thereception centers if rescreening had been allowed. However, separationfrom the service orchecking the work of induction stations at this level was eitherdiscouraged or prevented. Neithersufficient time nor personnel was allowed for the proper classificationand assignment of themen received. These important decisions were made on the basis of quotademands and theinductees desire rather than on qualifications and aptitudes (fig. 40).In future mobilizations,reception centers should be charged with a greater responsibility inthe classification andassignment of inductees. Detailed reports pertaining to improvedselection and job assignment,based on excellent studies, are available.
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For a time, the treatmentof venerealdiseases at reception centers was not satisfactory. This wasdue to a lack of the necessary facilities.
Replacementtraining centers.- The establishment of psychiatric consultationservices in thereplacement training centers was of immense value and represented areal advance in themedical program of the Army. The better psychiatrists demonstrated mostimpressively the roleof educational, preventive, and treatment methods in the assignment andtraining of soldiers. Theline officers were cooperative and appreciated the help received. Theefficiency of thesepsychiatric consultation services was impaired at times because of lackof clinical psychologists,social service workers, interviewers, and stenographic and clericalassistants.
Campdispensary and outpatient services. - During the trainingperiod, the sick soldier wasfirst seen in a company, regimental, or camp dispensary (fig. 41). Inretrospect, it is apparent thatfailure to organize and integrate the medical facilities at each campmade it impossible toprovide adequate ambulatory medical care. There is little to be gainedfrom a lengthy expositionof the evils of isolated dispensaries, furnishing only crude medicinein most instances; crowdedhospital outpatient departments, where the harassed medical officerscould only guess as to thecause of symptoms; and abuse of the hospital receiving office function,where proper selectionwas not permitted,
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and, as a result too many admissions wereallowed and unnecessary hospitalization, with itsattendant evils, was encouraged. The institution of an ideal campmedical service requires thatthe post surgeon be delegated full responsibility for the health of allsoldiers on the post.
The first essential for anadequate campmedical program is a strong dispensary service. Theassistant chief of the station hospital medical service, who alsoserves as chief of the campdispensary service, should therefore be an energetic, well-trainedinternist with a workingknowledge of or interest in psychiatry. Once the proper organization iseffected, supervision ofthe dispensary would not require more than 50 percent of the chief'stime. On visiting thedispensary not less than every second day, he should demonstrate byexample that adherence tothe basic principles of good medical practice accomplishes the desiredgoal.
Unfortunately, the Armyfailed to stress thatthe dispensary surgeon is the key person ineffecting the lowest possible noneffective rate. Dispensary surgeonsmust realize theirimportance to the Army, be vested with the necessary authority, haveprotection against unduepressure by command to hurry with sick calls, receive support andsupervision of their clinicalactivities, be included in the professional and social activities ofthe hospitals, and share in a justrotation system. In many instances in World War II, these conditions
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were not met, and this explains thedevelopment of many bitter, disillusioned, ineffectivemedical officers, who did more harm than good.
Because of assignmentpractices and notionsconcerning the prestige and the relative importanceof work done, there was a regrettable and erroneous overevaluation ofthe hospital staffpositions. This misinterpretation merits special attention byresponsible leaders in the ArmyMedical Corps, since a good dispensary physician is much more valuablethan a hospital wardofficer. The scope of tine physician's activities is much wider anddemands infinitely moreenterprise, social skill, arid emotional and administrativeadaptability, for he is physician to alarge group of men and the logical source of advice on all matterspertaining to health andmorale. Due to his position and special vantage point, he can do muchto help line officers fulfilltheir obligations as leaders. There is literally nothing in thesoldiers' lives which may not be ofconcern to command and hence to the dispensary surgeon who should be asensitive observerand an accurate transmitter of information to responsible officers.
The dispensary service isthe most strategiclocation for the management of psychosomaticcomplaints. Therefore it is important that the dispensary surgeonsappreciate that most of thesoldiers seen on sick call are suffering either from relatively minorillnesses or from concernover personal health and welfare. The majority of these patients canand should be treated on anambulatory basis. On the on hand, if these individuals are returnedfrom the dispensary levelwithout adequate examination, treatment, and reassurance, they willcontinue to worry abouttheir health, will lose confidence in the Medical Corps and become lesseffective in theirassignments. On the other hand, if they are unnecessarily referred tothe consultation clinic orneedlessly hospitalized, they are very apt to assume that thedispensary surgeon is in doubt orthat their symptoms indicate the presence of serious disease. Suchpractices increase theneuropsychiatric casualty rate and loss of training days as well asmake it evident to soldiers thatdisability is an asset. Most of them ask such questions as: 'What haveI got?' 'Will it getworse?' 'Can I take a 20-mile mike?' Some semblance of an examinationat this time and anexplanation as to the cause of the symptoms, assurance, and simplepsychotherapy frequently areall that are needed. Fulfilling these requisites keeps at a minimum theall too common gripes:'He thinks I imagine it.' 'He called me a 'gold-brick' ('screw-ball,''eight-ball').' 'All I everget at the dispensary is the brush-off.'
The dispensary surgeon'smultitudinous andimportant duties prevent him from personallyundertaking detailed diagnostic studies. Therefore, he must have accessto a strong hospitaloutpatient clinic and good camp and hospital psychiatric services. Ifthe consultations are to beof maximum benefit to the soldier, the dispensary surgeon must maintaingood liaison with thepeople who provide them in the outpatient clinic and should inform themregarding the soldier inhis Army environment. Such consultation privilege must be used withdiscrimination. It isextremely important that
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the responsibility for the patient remainprincipally with the dispensary surgeon and that allpersonal problems be referred back to the dispensary surgeon and thescene of conflict, usuallythe soldier's platoon, company, battalion, or regiment. In order toavoid unnecessaryhospilitization, there must be adequate facilities for soldiers treatedon quarters status.Dispensaries, properly designated barracks, or the convalescent annexescan be used for thuspurpose. Reconditioning should be made available for ambulatorydispensary patients if quartersstatus is not desirable or permitted.
Station hospitaloutpatient clinics, whenproperly organized and directed, were of great value tothe dispensary surgeon. In these clinics, soldiers were furnished withgood professional care, andunnecessary hospitalization was prevented. The effectiveness of theoutpatient service in stationhospitals was one of the best indexes of the quality of medical carerendered by these hospitals.In the future, the importance of good outpatient clinics should bestressed.
The functioning of thecamp dispensaryservice and hospital outpatient clinic in the mannerdescribed necessitates their inclusion in a complete camp medicalservice. This facilitates therotation of all camp medical officers, except for key personnel,through the dispensary servicefor a period of not more than 4 months. This type of duty wouldacquaint the majority of medicalofficers with the importance of good ambulatory care in maintaining thelowest possiblenoneffective rate. Regular rotation of medical officers removes theonus of discrimination andpunishment, so frequently associated with indeterminate assignments tothe dispensary service;encourages better performance of duty; and permits greater professionaldevelopment.
The number of officersassigned to adispensary will depend upon the number of soldiers served.If two are required, selection and assignment should be so effectedthat the ranking officer is themore competent physician.
A camp medical service soorganized affordsmaximum performance and effectiveness of itsmedical facilities, provides proper preventive medicine, and gives allmedical officers a greatersense of responsibility with keener appreciation of the many campmedical problems. Inaddition, it makes possible better qualified, more efficient, andhappier medical officers.
Ports ofembarkation. - The medical activities at ports of embarkationshould have been moreclosely integrated with those of the service commands. This cannot beaccomplished until theformer are under the jurisdiction of the service command surgeons.Though the hospitals alwayswelcomed them, there was too much division of authority to enable theconsultants to be ofmaximum aid to the port surgeons in the solution of many problems thatarose.
Separationcenters. - The process of separation mirrored the inductionexamination with all itshandicaps (fig. 42). It was readily apparent that most
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separation centers would have functionedbetter if measures similar to those recommended underinduction stations had been instituted.
Other service commandinstallations which maybe of interest to the medical consultant arediscussed in the following paragraphs.
Hospital centers for special diseases.- Theestablishment and operation of these centers havebeen discussed on pages 33-39.
Debarkation hospitals. - Thisdesignation wasgiven hospitals used for the reception of patientstransported from overseas by water and air. These hospitals weregenerally administered well,but it must be said that the compulsion to evacuate patients tohospitals located inland, in orderto have empty beds available, often made difficult proper triage andtreatment of patients intransit (fig. 43). The lack of judgment with regard to this matter wason occasions incredible.Transportation and evacuation seemed to become the end and not themeans-the empty hospitalbed the goal and not a facility - for providing necessary treatment forthe sick and injured. Thisunsatisfactory situation was clear to medical consultants, and theyoften fought the tendency toimpersonal decisions, group management, and the premature movement ofoversea patients inthe evacuation chain to their ultimate hospital destinations in theUnited States.
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CONSULTANTS' EVALUATION OF THE CONSULTANTSYSTEM
Summaries of evaluationsof the consultantsystem, its weaknesses and strengths, its failures andaccomplishments, as formulated by a representative sample of theopinions of the medicalconsultants to the service commands are herewith presented. Theirstatements were preparedsoon after V-J Day. They were formulated in a spirit of thoughtful,constructive criticism byindividuals of great competence and of complete loyalty to the UnitedStates Army and itsMedical Department and also to the highest ideals of medicine.
First, are presented theviews as generallyexpressed by Colonel Adams, medical consultant tothe Fourth Service Command from September 1943 to December 1945. Hiscomments aresummarized, as follows:
It is believed that theconsultant system asset up in the service commands contributed definitelyto the welfare of the patients. In anticipation of this report, aquestionnaire was sent to the chiefsof medicine of every hospital in this command. With one exception, thereplies indicated that theconsultants' visits were helpful mind stimulating but too infrequent.
The following is a summaryof Colonel Adams'criticisms of the consultant system as it operatedduring World War II:
1. In a large servicecommand, such as theFourth, one consultant in each major branch was notenough. Each consultant should be able to visit an installation atleast once from every 3 to 4months instead of from every 8 to 12 months. This arrangement could beaccomplished byassigning assistant consultants, who could be responsible for bedsidevisits and personnelevaluations in a specified group of hospitals. Then, the servicecommand consultant, using theinformation provided by his assistant, could cover the command morerapidly and frequently,concentrate on trouble spots, and devote more time to teaching,personnel assignments, andgeneral supervision.
2. The suggested plan ofhaving the chief ofservice in each large hospital visit nearby smallerstations was not practicable. The chief of service in any largeinstallation usually has more dutiesthan he can discharge adequately. To send him away for several dayseach month to visit otherstations would result in increasing the backlog of his own work.
3. To execute his missionproperly, theconsultant should have a grade commensurate with hisduties and with his relative importance as an officer of the MedicalDepartment of the Army.
Next, a summary of theopinion of ColonelDenny, medical consultant to the First ServiceCommand from January 1944 to December 1945, is presented:
The uses and possibilitiesof the servicecommand consultant can be illustrated by a visit to thenorthern bases in Newfoundland, Labrador, Iceland, and Greenland madeby the First ServiceCommand consultants at the request of the Eastern Defense Command. Mostof the medicalofficers in these isolated stations had been on such duty from 2 to 3years without a
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visit from a medical officer who wasprimarily interested in the clinical work being done. Thehospitals were small and not active when visited in May 1945 andprobably not much wasaccomplished professionally by the visit, but the interest andgratitude of the medical officerswas, in many instances, almost pathetic. Physical and professionalisolation lowers medicalinterest and general morale. Visits by consultants much earlier in thewar would have been ofreal value to these medical officers, almost all of whom werewell-trained and conscientious menwho by reason of their isolation had come to feel that no one in higherauthority took any interestin their professional work. Given sufficient authority consultantsmight well have been able torotate such officers before dry rot set in.
Colonel Fitz-Hugh, medicalconsultant to theThird Service Command from May to December1944, expressed primarily the following views in his evaluation:
1. The medical consultantsystem as itoperated during World War II was fundamentally soundand necessary. Some of the difficulties and problems inherent in itwere no doubt unavoidable;some could be corrected.
2. The autonomy of theservice command andthe necessity of going through channels at timesimpaired the relationship of the service command consultant to thechief consultant in theSurgeon General's Office. Higher authority in the service command attimes resented directcommunication between the service command consultant and the chiefconsultant in the SurgeonGeneral's Office. If possible, this conflict should be resolved.
3. The autonomy of theservice command alsomade it difficult for an overall adjustment of keypersonnel needs. The office of the chief consultant in the SurgeonGeneral's Office is the onlyqualified central authority possessing the necessary knowledge ofpersonnel qualifications andinstitutional needs. Therefore, in the future, the authority and powerof the central authorityshould be increased.
4. The service commandconsultants' concernwith professional personnel should be moreeffectively implemented. The consultants should, through the office ofthe chief consultant in theSurgeon General's Office, be given more real authority over assignment,transfer, andreassignment of professional personnel. If this authority is consideredunwise, then theconsultants should be instructed to keep out of personnel problems andto confine themselves tothe task of trying to improve the personnel of each installation asthey find it.
5. The selection ofconsultants in the recentwar was generally well done. In the opinion of thisconsultant, the service command consultants should always be men whoare fully qualified andhave proven themselves adequate as consultants and teachers in civilianlife. The outstandingqualities of General Morgan were no doubt responsible for much of thebest that came out of theconsultant system in this war. All consultants should not only be goodenough to rank as fullcolonels but should have this rank. If an inflation of grade occurs inthe next war, then theconsultants' grade should also be comparably inflated.
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6. Finally, the MedicalCorps of the Army, ingeneral, was undergraded and promotions were tooslow and too few. Improvement in this important aspect of militaryservice would result in muchbetter morale.
Colonel Minor, medicalconsultant to theThird Service Command from December 1944 toDecember 1945, summarized his opinion of the consultant system,generally, as follows:
The medical consultantservice was animportant addition to the Medical Department and servedvery well the functions for which it was planned. These functions were(1) to assist inestablishing and maintaining professional staffs as well qualified andas stable as possible inhospitals and other installations; (2) to oversee the general pictureof medical professional carein the command medical installations, to keep tine staffs informed ofrecent advances, and tobring the practice of medicine to as high a level as possible; and (3)to furnish consultation ofprofessional and often personal nature for the medical officers,develop educational programs,stimulate special study projects, and minister in these important waysto the total professionalmorale of the medical officers.
A corollary to thesefunctions was, ofcourse, the maintaining of close relationship with thesurgeon, by making suggestions and preparing directives aboutprofessional matters for hissignature. An additional function was the correlation of activitieswith the surgical andneuropsychiatric consultants.
The consultant functionedto a very largedegree on a personal basis because duties of theposition, while of evident importance, were not officially integratedinto the preexisting planningfor the Medical Department. The consultant's activity, therefore, andhis ability to accomplishhis objectives depended first on his relationship to the surgeon andthe amount of confidence andrespect he earned from his direct superior and, secondly, on the samefactors in the commandingofficers and the key professional officers of the hospitals with whomInc worked. In other words,it was necessary for the consultant to sell himself as a useful andcompetent individual withsomething to offer before he could function effectively, there being norecognized or officialstatus for his job. As a result, success in accomplishing his missionwas largely dependent ondeveloping such relationships.
It was Colonel Minor'sopinion that thequality and amount of interest taken by the servicecommand surgeon in the professional matters that were the prime concernof the medicalconsultants was a determining factor in the effectiveness of theconsultant system. Theconsultant was clearly responsible to the service command (through thesurgeon) and had onlyan associated relationship with the Surgeon General's Office. Alladministrative power wasplaced in the hands of the service command headquarters; that is, inthe hands of thecommanding general. It was therefore necessary to sell one's wares tothe commanding generaldirectly, when possible, or indirectly through the surgeon or otherofficers. In this command, thepolicy of complete control of all installations on a post by thecommanding officer of the postraised many serious difficulties in the allocation and shifting ofmedical personnel. All the
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methods that could be used by the consultantsto bring about needed changes sometimes failed toovercome the opposition or passive resistance of the commander of apost, who might be aninfantry officer with mo knowledge and little interest in the realmedical problems at hand.Similar difficulty was occasionally encountered with medical officerscommanding hospitals, butin large part these officers were cooperative. A point of view notinfrequently encountered wasthat one medical officer was the same as another, and this withoutregard to special professionaltraining or ability. This viewpoint might be called the 'doctrine ofthe body.' However, as timepassed, there developed realization among even the most reactionarymedical officers thatspecial men were required for special jobs.
The most effective portionof Colonel Minor'swork was visiting the hospitals in the servicecommands. It was necessary at the start to make clear that these visitswere not inspections in theusual Army sense. When the professional staff realized that tineconsultant was interestedprimarily in good work, in the advancement of competent men and theirproper assignment, andalso sincerely interested in their personal problems, little oppositionor resentment wasencountered. The more time spent in visiting, the more effective wasthe consultant. With rareexceptions, the consultant was made welcome and was able to establishsatisfactory liaison withthe various officers, administrative and professional, who operated thepost.
The promotion ofeducational activities andthe holding of formal and informal discussions withmembers of the staffs to consider professional problems of importancefurnished an opportunityfor free interchange of ideas, which was mutually beneficial.
Ward rounds were of greatimportance fromthree standpoints: (1) They afforded the bestopportunity for the consultant to evaluate and to know the officers ona service; (2) theyprovided an overall view of the management of patients and of diseases,as for example,diabetes, rheumatic fever, hepatitis, syphilis, gonorrhea, arthritis,pleurisy, and others; and (3)they made possible a review of problem cases by the consultant, whichwas an interesting andinstructive exercise and often contributed directly to improvedmanagement of the case at hand.
In the preparation ofreports of visits, aneffort was made to give a general picture of theoperation of the hospital from a professional angle; to evaluate withfairness and frankness thevarious officers; to describe important professional problems and themethods by which theywere handled; to make recommendations as to the proper classificationof officers by MOSnumbers; and to recommend promotions when deserved.
The relationship of themedical consultant tothe Surgeon General's Office was as close as waspermitted by the organization described. It was, of necessity, largelyon a personal basis, as theSurgeon General's Office was unable to implement its plans with regardto personnel or methodwithout the consent of the service command. In the case of the ThirdService Command,nearness to the Surgeon General's Office and the warm personalrelationship
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existing between the officers there and allthe service command consultants made possible thesolution of many personnel problems. Also, questions of policy andprocedure were readilyironed out by means of this direct, personal contact.
The medical consultantservice in the ThirdService Command earned its way and proved itself amost valuable addition to the organization of the Medical Department.In the long view and fromthe standpoint of promotion of the best in medicine, it can only becalled an essential element tothe proper functioning of the Medical Department. In spite offrustrations, difficulties inadministration, and the reliance on personal relationships to achieveends that could be attainedonly in that way under the existing system, the medical consultant planachieved importantsuccess and was of great benefit to tine practice of medicine in thecommand and to thedevelopment and proper use of professional personnel.
Colonel Marble, medicalconsultant to theSixth Service Command from March to September1945 made, generally, the following observations:
1. There is no doubt thatthe consultantsystem is worthwhile. It is imperative, particularly duringtimes of expansion of the Army, that medical officers with thenecessary professionalqualifications be assigned to service command headquarters to advisethe service commandsurgeon on professional matters and, by visits to medical installationsthroughout the commandand by other contacts with medical officers, to promote and maintainhigh standards ofprofessional care.
2. It is desirable thatthe position of theconsultant in the service command headquarters andthroughout the service command be clarified so that administrativedifficulties may be avoidedand the carrying out of professional policies expedited.
3. Some plan should beworked out wherebyfree and informal contact by the consultant withhigher authority (Medical Consultants Division, OTSG) and medicalofficers throughout theservice command may be possible on purely professional matters, withoutarousing concern thatadministrative channels have been bypassed.
4. One of the greatestfields of usefulnessof the consultant is in his advice to the servicecommand surgeon and the headquarters personnel officer regarding theproper placement ofmedical officers. By his personal professional contacts, the consultantafter a period of timecomes to know the professional qualifications of medical officers andthe professional needs ofvarious installations in the service command better than any otherofficer on the staff.
5. The next greatest fieldof service of theconsultant lies in the teaching and professionalencouragement of medical officers by frequent and prolonged visits tohospitals and othermedical installations.
Colonel McGuire, medicalconsultant to theFifth Service Command from July 1944 toDecember 1945 summarized his endeavors, in general, as follows:
1. To be of assistance tothe service commandsurgeon and the chief
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consultant in medicine in the SurgeonGeneral's Office by keeping both constantly informed ofprofessional and personnel problems on the medical services of thegeneral and station hospitals.
2. To be of assistance tothe chiefs of themedical and laboratory services of service commandhospitals by: (1) Presenting their personnel problems to the attentionof the service commandsurgeon; (2) conducting teaching ward rounds and attempting tostimulate the section chiefs andward officers to carry on their professional duties at the highestpossible level; (3) stimulatingclinical research; (4) encouraging scientific meetings of high quality;(5) recommending transferof mediocre medical officers; (6) recommending changes to improvephysical location andadministrative procedures of medical libraries; and (7) obtainingclarification of confusingadministrative procedures for chiefs of medical service from theservice command surgeon andthe Surgeon General's Office.
Colonel McGuire statedfurther that, if theconsultant system should be needed in the future, aclearer definition of the consultant's responsibility to the servicecommand surgeon as comparedwith his responsibility to the chief consultant in medicine in theSurgeon General's Office,would be of value. In the Fifth Service Command, no problem arose,since there was perfectcooperation between the service command surgeon, the chief medicalconsultant, and the servicecommand consultant. However, it may be difficult to serve two masters,and, unless theconsultant's fundamental responsibility be more precisely defined, itis clear that on occasion hisposition will be ambiguous.
To preventmisinterpretation of the functionof a professional consultant and to avoid beingregarded as an inspector, the professional aspects of the consultant'sfunction should beemphasized and the administrative aspects minimized. However, since thebest availablepersonnel are essential to the maintenance of the highest professionalstandards, it was theopinion of this medical consultant that assignment of key personnel tothe medical services ofhospitals should be made only on the recommendation of the servicecommand consultant.
Finally, in a summary andcritique preparedin 1945, Colonel Bauer, medical consultant to theEighth Service Command from August 1942 to August 1945, presented theviews expressed inthe following paragraphs.
Regardless of theaccomplishments orshortcomings of individual consultants, there can be littledoubt that the consultant system has favorably influenced the medicalservice of the Army andtherefore should be included in its permanent organization. It hasserved particularly to focusattention on the primary importance of the professional aspect ofmilitary medicine.
The problem now [1945] isnot so much thefuture of the consultant system as what to do aboutthe future medical service of the Army. The high standards ofprofessional care attained in thiswar must be maintained and advanced. The way must be opened for capableand ambitiousyoung officers to progress in their profession. Postgraduateopportunities must be made availableto a
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sufficient number of officers of the MedicalCorps to furnish the Army a group of qualifiedspecialists in the various branches. These men should receiverecognition in the form of rank andpay commensurate with their eminence in their profession and the weightof the duties that theywill be required to perform.
The benefits of theexperience gained by thegroup of men who have acted in the capacity ofconsultants in the service commands during this war should not be lostto the Army. Throughthis experience, they have acquired an insight into the practicalworkings of the Army MedicalCorps. This, joined with their professional knowledge in variousspecial fields, fits them for thetask of evaluating the future needs of the medical service of the Army.
Colonel Bauer made thefollowingrecommendations: 9
1. That the MedicalDepartment be representedon the Army staff at the departmental levelinstead of being relegated to a subordinate position such as was thecase in the Services ofSupply and Army Service Forces reorganizations during World War II.This representation ofthe Medical Department at the highest level will provide betteropportunity for the integration ofmedical activities throughout the Army and restore to the MedicalDepartment more prestige andautonomy. It is hoped that the changes in staff organization at alllevels implicit in thisrecognition of the responsibility of tine Medical Department willpermit it to make a greatercontribution to all military planning, training, and operations.
2. That the MedicalDepartment formallyrecognize different career patterns for medical officerswho are primarily interested in staff and command functions from thosewho are primarilyinterested in the professional practice of medicine or in research andprovide appropriatetraining, assignments, and rewards to each group.
3. That the consultantsystem, as evolvedduring the present conflict, be retained and extended.
9 The originalrecommendations made by Dr.Bauer were revised in a letter from Dr. Bauer to Col.J. B. Coates, Jr., MC, Director, The Historical Unit, U.S. Army MedicalService, 9 Nov. 1956,and a letter from Col. Coates to Dr. Bauer. 19 Nov. 1956.
