Activities of Medical Consultants
CHAPTER III
Mediterranean (Formerly North African) Theater of Operations
Perrin H. Long, M.D.
FUNCTION AND DUTIES OF A MEDICAL CONSULTANT IN AN OVERSEA THEATER OF OPERATIONS
The advent of World War IIfound the Medical Department of the U.S Army without aprofessional consultant group in either medicine or surgery. From themiddle of 1940 untilshortly after the entry of the United States into the war, an attemptwas made to overcome thisdeficiency by the establishment. of liaison, in strictly professionalmatters, between the variousnewly created advisory committees of the Division of Medical Sciences,National ResearchCouncil, and the Professional Service Division, Office of the SurgeonGeneral. Between theend of World War I and 1925, when the Professional Service Division wasformally established,the activities normally carried out by such a division had beenperformed by various professionaloffices or divisions of the Office of the Surgeon General.
Even after the Professional Service Division was set up in 1925, its scope had been limited and its functions poorly defined. It had been concerned chiefly with routine administrative matters, and its influence as a positive force in developing and guiding the professional aspects of medicine and surgery in the Army had been negligible.
As a consequence, when consulting services were established in World War II in the Office of the Surgeon General and in the service commands and the theaters of operations, a certain amount of education was necessary on both sides. Command and staff officers of the Medical Corps of the Regular Army, whose work, in the emergency, was necessarily chiefly administrative, had to learn the functions and the potential value of consultants in the maintenance of professional standards. For their part, the consultants, most of whom had been commissioned from civilian life, had to learn the complexities of their position in the Army and the extreme importance of what might be termed the administrative background of military medicine.
It was not until both theconsultants and the Regu]ar Army medical officers had learned--usuallyby trial and error--to define and comprehend their individual and jointresponsibilities that theconsultant system achieved real efficiency. Much time and effort wouldhave been saved inWorld War II if a consultant group had been maintained in the Office ofthe Surgeon Generalbetween the two World Wars. It would also have been helpful if, beforeany consultants hadbeen appointed, the nature of their duties had been clearly
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established in an official publication. For those who were fortunateenough to see it--and manywere not--the first official notice of the consultant's functions wascontained in TM (WarDepartment Technical Manual) 12-406, Officer Classification,Commissioned and Warrant,dated 30 October 1943. In this manual, under MOS (Military OccupationalSpecialty) 3117, theduties of a consultant are summed up in the following paragraph:
Renders special professional advice to various headquarters concerningthe medical service within the command.Visits various medical installations and advises the staff of theirmedical services as to methods of diagnosis,treatment, and operations, with special reference to professionalimprovements and new developments; conductsclinical-pathological conferences on unusual cases; reviewsprofessional aspects of work of medical services;develops methods for training junior medical officers; advises superiorofficer concerning professional policy onmatters pertaining to the practice of internal medicine within thecommand; transmits professional information andsuggestions between subordinate installations and higher echelons.
In the North African andMediterranean theaters, the medical section, which was a component ofAFHQ (Allied Force Headquarters) was always maintained at the theaterlevel. This gave theSurgeon direct access to the theater commander, the chief of staff, andthe chiefs of the generaland special staff sections; and it facilitated the Surgeon's entranceinto all subordinatecommands in the theater. The consultants division of the MedicalSection, AFHQ, was enabledto coordinate the professional aspects of medicine and surgery in thevarious echelons of thecommand more easily than would have been possible had the medicalsection been placed at thelevel of the communications zone or the services of supply. As a resultof this system, advice onall technical subjects emanated from the highest level in the theater;the various consultantsrarely experienced any difficulty in entering subordinate echelons suchas the field army, the airforces, or the communications zone; and coordination and correlation oftechnical subjectsbetween these commands were made relatively easy.
The need for consultantsin the professional fields of medicine and surgery was amplydemonstrated during World War II. The establishment of a consultantsdivision in the medicalsections in oversea theaters of operations freed the Surgeon and hisstaff officers fromperplexities arising in the practice of medicine and surgery andprovided the Surgeon with expertadvice concerning the care of the sick and wounded. It also providedhim with a channel forascertaining, and putting to the best use, the professional talents ofnon-Regular Army medicalofficers. At their peak employment, these officers composedapproximately 98 percent of theMedical Corps of the Army.
Professional Functions
Advisory functions. - The functions and duties of a medicalconsultant are many and varied andin practice are much broader than outlined in TM 12-406.In the firstplace, the consultant shouldalways remember that he is in an advisory capacity, and that, unless heis directed to do so by thetheater
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Surgeon, he will be at fault if he descendsto operational levels. His prime duty is to keep theSurgeon constantly and accurately informed of the standards ofprofessional care obtaining in thecare of the sick. This service cannot be rendered by sitting at a deskin headquarters. Theconsultant must spend at least two-thirds of his time in the field,observing and studying medicalcare at all levels, from the aid stations through the generalhospitals. He should be familiar withthe tactical and other conditions that affect the diagnosis andtreatment of disease and govern theevacuation and disposition of patients in all echelons of the comnmand.To accomplish thismission, the consultant must have easy access to all medicalinstallations, and he should beregarded as a friend and advisor to the Surgeon and medical officers ofall commands. It shouldbe well understood that the consultant's main interest is improvementin the care of the sick, inorder that patients may be returned promptly to duty. The consultantshould never assume thefunctions of, or be regarded as, an inspector.
Administration of professional personnel. - The second important function of themedicalconsultant is to advise the Surgeon upon personnel changes that may benecessary to insure ahigh level of professional efficiency. The Surgeon, as a rule, has nothad the training, nor has hehad the time, to evaluate medical personnel. He must have confidence inthe recommendationsmade by his medical consultant and should do his utmost to support themeven though, at times,reluctant commanding officers have to be brought into line. Otherwise,it would be best for theconsultant to ask to be relieved of his duties, so essential is thisfunction to his usefulness. Forhis part, the medical consultant must have accurate knowledge of theprofessional capabilities ofall medical officers directly concerned with the care of the sick. Heshould have understanding,as well, of officers' personalities and reactions to their environment.An individual may do betterwork if shifted from a particular situation to one to which he isbetter adapted. Again, a familyproblem may lower efficiency and can sometimes be solved or amelioratedby judiciousrecommendation of leave, rotation, temporary duty, compassionate leave,and other devices. Theconsultant in medicine should interest himself in the welfare of themedical officers, generalduty, MOS 3100, because these are the forgotten men of the MedicalCorps, and it is from thisgroup that many of the ward officers on the medical services willultimately be derived. Finally,it is the duty of the consultant in medicine to direct the Surgeon'sattention to meritorious oroutstanding services rendered by medical officers.
Professional education. - The consultant in medicine should bethe leader in initiating andguiding professional educational programs for the medical officersunder his advisorysupervision. Through the medium of clearly written circular lettersfrom the Office of theSurgeon, he should keep them constantly advised concerning medicalexperience within thecommand and concerning new developments in scientific and clinicalmedicine in the Zone ofInterior. He should see that medical officers receive all the textbooksand
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medical journals to which they are entitled,and if he thinks additional publications wouldbroaden their intellectual horizons, he should make the necessaryrecommendations to theSurgeon. When conditions permit, the consultant should assist inestablishing a medicalperiodical, in which local experiences in the prevention, diagnosis,clinical course, treatment,and other aspects of disease are recorded, for circulation to allmedical officers within thecommand. It is his duty to initiate staff conferences,clinicopathological and X-ray conferences,journal clubs, and other educational programs within hospitalinstallations. He shouldrecommend and assist in the formation of medical societies in the lowerechelons and should seethat medical meetings are held in which medical officers from allechelons of the commandparticipate. The consultant in medicine, being generally himself ateacher in civilian life, shouldalways revert to this capacity when making ward rounds in any medicalinstallations. He shouldplan and initiate a program through which medical officers assigned tofield service ornonprofessional duties could be rotated to hospital assignments, inorder to prevent theprofessional deterioration that frequently follows too long an absencefrom professional duties.
Medical research. - Research, havingfor its aim the better understanding of medical problemsand the more efficient care of the sick within the command, should befostered by the medicalconsultant. He should not be discouraged if his first efforts in thisdirection are rebuffed byadministrative or commanding officers with the reminder 'there is a waron' and the assertion'there is no time for research.' In reply, the consultant shouldoutline the problem clearly andshow how, with the resources available within the command, knowledgemight be obtained thatwould benefit the health of the command and save manpower. He shouldencourage and assistmedical officers who have initiated research problems on their own. Heshould criticallycorrelate and coordinate the various problems in order that the workmay progress in an efficientmanner. When results are obtained, he should see to it that they aremade available to thecommand and also to the Office of the Surgeon General for widerdissemination. In promotingresearch within a command, the consultant in medicine should endeavorto secure for it adequatepersonnel, supplies and equipment. Finally, if the problem appears towarrant extramural aid, heshould recommend to the Surgeon that investigators selected by TheSurgeon General be sentinto the command.
Care of prisoners of war. - The medical care of prisoners of warshould be carefully supervisedby the consultant in medicine. It is his duty to report to the Surgeonupon the expected needs forprofessional services in prisoner-of-war compounds and to recommendwhat should be done toinsure an adequate level of medical service among prisoners of war. Heshould visit suchinstallations and should supervise and advise upon care of the enemysick. If the latter are underthe care of their own medical officers, he should inform these officersof the prevailing theaterpolicies on the treatment of disease and should instruct them in theuse of U.S. Army medicalsupplies. At all times, the consultant in medicine should be on thelookout for violations of theGeneva,
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conventions in respect to protected enemypersonnel, and, if such are noted, he should makestrong recommendations to the Surgeon in respect to their correction.
Liaison and Staff Functions
Hospitalization and evacuation. - It is sometimes assumed thatthe consultant in medicine haslittle or nothing to contribute to the operational side of the MedicalDepartment. On the contrary,he can offer valuable aid in estimating bed needs, based upon hisknowledge of the prevalence ofand average duration of hospitalization for current diseases. Hisopinion is also of value inrespect to the ability of any given medical installation to handleoverloads of patients. His adviceon the triage of sick patients and their assignment to suitable medicalinstallations will be usefulto every operations officer. It should be the consultant's function torecommend to the Surgeonthe creation of special centers to facilitate and improve treatment. Heshould also recommend tothe Surgeon a plan for time evacuation and disposition of the sick thatwill meet existing needsand one that will insure uniformity in procedure throughout thecommand. In the course of actualtactical operations, the consultant in medicine can frequently be ofaid to the task force surgeon,by recommending holding policies for the sick. Often through hisefforts and influence, aconsiderable saving in manpower can be effected.
Medical laboratories. - Although laboratory services are underthe direction of the preventivemedicine service, the consultant in medicine should be cognizant of thefunctioning oflaboratories in all of the medical installations under his supervision.He should carefully checkthe diagnostic methods being used and the accuracy of the resultsobtained. If he believes alaboratory service could be improved, he should communicate his viewsto the preventivemedicine officer in the medical section of the headquarters and requestthe necessary action. Theconsultant should also ascertain time extent to which the ward officerson medical services relyupon laboratory tests, rather than upon clinical ability in making adiagnosis. If he thinks anexcessive amount of laboratory work is being requested, he shouldrecommend proper correctivemeasures to the chief of the medical service.
Medical supply. - Problems of medical supplies should rarely bethe concern of a medicalconsultant in the U.S. Army. To be sure, local shortages may develop,but these often can becorrected by dropping a friendly word to the officers in charge ofmedical supplies. Theconsultant's greatest concern should be the requests made by medicalofficers for nonstandardsupplies, which they have been accustomed to using in civilianpractice. It is his duty to instructmedical officers in the use of those preparations found on the ArmedForces supply table. Heshould constantly keep abreast of all therapeutic advances and makeappropriaterecommendations to keep the supply table up to date. In addition, heshould make allrecommendations concerning the acquisition of nonstandard items thatare deemed necessary forthe proper prosecution of clinical investigations.
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Interpersonal relations with the headquarters staff - Theconsultant in medicine should not lethimself become the headquarters staff or generals' doctor. He shouldrefrain from givingmedical advice or attention to his fellow staff officers unlessrequested to do so by the Surgeonor by the chief of medicine of the general dispensary at hisheadquarters. First, if he practicesmedicine at headquarters, he will find it next to impossible not todiscuss questions involvingmedical policy with members of other staffs; such discussions should beleft to the Surgeon orhis designated representatives. Secondly, his proper work will beconstantly interrupted, and histrips away from headquarters curtailed. It should be the policy of theconsultant in medicine torefer, politely and in a helpful manner, all questions relating tomedical treatment of staffofficers to those whose duty it is to practice medicine at aheadquarters.
Staff work. - The consultant inmedicine should become versed in staff work as rapidly aspossible. He should never forget that he functions in an advisorycapacity. He should learn theproper channels for communication, should avoid going out of channels,and refrain from anyactivities that might create the impression he is going over the headof the Surgeon. Staff work isnot too difficult if one remembers that every paper should becoordinated with all interestedparties within and without the office of the surgeon of theheadquarters before it is passed on bythe Surgeon. It is also less difficult if one remembers that, as aprinciple, established channels arethe most effective. A properly coordinated staff paper is rarely turneddown, if only because ithas been agreed to by all concerned before it is presented. Theconsultant in medicine should bein constant communication with the other consultants, the preventivemedicine officer, thesupply officer, the personnel officer, and, for that matter, with allother members of his section.Close liaison with other consultants is especially desirable because inmatters of broadprofessional policy a united front is generally irresistible. If theconsultant in medicine isfunctioning in an allied force, he should coordinate his professionalwork with his opposite alliednumber and should take every opportunity to visit the medicalinstallations of the ally. At thesame time, he should make certain that similar privileges are extendedto his allied colleague.
Visits in the field. - When theconsultant in medicine is visiting any medical installation, heshould visit an appropriate cross section of the patients on themedical service in company withthe chief of the medical service. During such visits, he should checkon the prevalence of variousdiseases, diagnostic methods, therapeutic measures, the condition ofpatients, and the policies inforce regarding disposition of patients. It is here, too, that he cando his best teaching--at thebedside of the patient.
The consultant in medicineshould remember to observe military courtesy each time he visits asubordinate echelon. After reporting to the office of the surgeon ofthe unit he is visiting, theconsultant should call upon the commanding officer of the echelon orhis designatedrepresentative and explain in general lay terms the purpose of hisvisit. This procedure should berepeated
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when the medical consultant leaves thecommand. Common courtesy demands that he inform thecommanding officer of the observations and conclusions made during thetour. When medicalinstallations are visited, the commanding officer or his representativeshould be seen first and thepurpose of the visit should be explained. At the termination of hisvisit, the medical consultantshould discuss with the commanding officer those points, both good andbad, that have beennoted. This permits the commanding officer to take such correctiveaction as may be necessary.It obviates filling out long reports, since no further action need betaken, unless the commandingofficer is either unwilling or unable to act upon the recommendationsof the consultant. Finally,it is important to remember that the consultant in medicine shouldallow other consultants, thechiefs of medicine, and the officers working on the medical services aconsiderable degree oflatitude in the performance of their duties, provided they stay withinthe bounds of theestablished principles of the practice of medicine. It is only by doingso that the spirit of mutualesteem, which is so necessary for the maintenance of high standards ofmedical service, can bepreserved.
Assignment and Arrival
On 20 November 1942, theDeputy Surgeon, AFHQ, informed Lt. Col. (later Col.) Perrin H.Long, MC, who at that time was the Scientific Liaison
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Officer, Office of the Chief Surgeon, ETOUSA(European Theater of Operations, U.S. Army),that he had put in a request to the Chief Surgeon, ETOUSA, for theservices of Colonel Long asconsultant in medicine (fig. 44) for the American branch of the MedicalSection, AFHQ. Thisrequest was refused by the Chief Surgeon, ETOUSA, but on 14 December1942 the followingradiogram was received: 'C in C directs that Perrin Long Lt. Col., MC,ETOSOS be relievedfrom present assignment and dispatched by first availabletransportation and assigned to AFHQ.'His new assignment was directed by a letter order dated 17 December1942, and passage wassecured for him in convoy K.M.S., 5, sailing from Glasgow, 26 December1942, and arriving inAlgiers on 3 January 1943. Reporting to AFHQ and being assigned to themedical section, by theauthority contained in paragraph 5, Special Orders No. 3, AFHQ, 3January 1943, heimmediately assumed his duties as consultant in medicine.
ORGANIZATION
Allied Force Headquarterswas the combined Allied command for all operations in the NorthAfrican theater and the later Mediterranean theater (map 2) 1NATOUSA(North AfricanTheater of Operations, U.S. Army) and MTOUSA (Mediterranean Theater ofOperations, U.S.Army) staff sections supervised strictly U.S. Army operations withinthe theater. Operational andtactical control remained with AFHQ. This control was exercised throughvarious task forces,British Army Groups, the Seventh U.S. Army and later the Fifth U.S.Army in Italy.
At its inception as afunctioning unit within the theater, the Medical Section, AFHQ, was acompletely integrated special staff section because, in the early days(until June 1944), Britishand American interests were interlocking as regards both tactics andlogistics. An officer of theBritish Army Medical Service (not the Royal Army Medical Corps) wasDirector of MedicalServices and Chief Surgeon, AFHQ. The Deputy Surgeon, AFHQ, was a U.S.Army medicalofficer. Within the Medical Section, AFHQ, British and Americancomponents were divided intoa British branch and an American branch. The American branch wasallotted five officer spaces,three in the grade of colonel and two in the grade of lieutenantcolonel. When the consultant inmedicine arrived at AFHQ, on 3 January 1943, this branch consisted ofthe Deputy Surgeon,AFHQ, and executive, dental, and preventive medicine officers. Theconsultant in medicinemade the fifth officer. In addition, Brig. Gen. (later Maj. Gen.)Albert W. Kenner was assignedto AFHQ as medical inspector, a position from which he reporteddirectly to General
1 When the Allied forcesinvaded North Africa on 8 November 1942, the region was, insofar asstrictly U.S. elements were concerned, a part of the European theater.NATOUSA. wasestablished on 4 February 1943 and included northwestern Africa, Italy,and portions of theMediterranean Sea. The theater was renamed MTOUSA on 1 November 1944and expanded toinclude all of the Mediterranean Sea, Greece, and the Balkan nations.On 20 November 1944,however, base sections in southern France were assignedto the European theater. Early in 1945,MTOUSA was further diminished by assigning its African territory to theAfrica-Middle Easttheater, On 1 October 1945, AFHQ was formally separated from MTO USAand, for all practicalpurposes, ceased to function.
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MAP 2. - Campaigns in North African andMediterranean Theaters of Operation 1942-45.
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Dwight D. Eisenhower, Commander-in-Chief,Allied Expeditionary Force, without reference tothe Director of Medical Services (Chief Surgeon) and the DeputySurgeon, AFHQ.
Most of the importantproblems facing the Medical Section, AFHQ, were settled by conferencesand committees with representatives of the British and Americanbranches meeting jointly andbringing in recommendations to the Director of Medical Services. TheAmerican consultant inmedicine, from the earliest period of his assignment to the MedicalSection, AFHQ, maintained aconstant liaison with his opposite number, the consulting physician inthe British branch,Brigadier Edward R. Boland, O.B.E. Throughout the war, therecommendations on professionalpractices that were made to the Surgeon, NATOUSA, were the joint andcoordinated effort ofthe British consulting physician and the American consultant inmedicine.
Later, as theparticipation and responsibilities of the French increased in the war,representativesfrom the office of the surgeon of the French Army in North Africajoined in these conferencesand committee meetings. Following the invasion of Sicily, the line ofdemarcation in respect totactics, logistics, and administration between the two components ofthe AFHQ began to takeform, and, from that time until the war ended, the actions taken by thetwo branches of theMedical Section, AFHQ, tended to become more unilateral. Hence, withthe exception of certainproblems involving the control of diseases (such as malaria), jointaction resulting from thedecisions of Anglo-American committees became increasingly less common.
The Medical Section,NATOUSA, came into existence in February 1943. It was not untilsometime later that a table of organization (chart 1) for this sectionwas approved. TheConsultants Division, Medical Section, NATOUSA, was purposelyrestricted to five officers,one each for surgery, medicine, orthopedic surgery, neuropsychiatry,and chemical warfaremedicine. The reason for restricting consultant spaces to five officerswas based on experiencegained in certain other theaters which tended to show that the need forconsultants in othermedical and surgical specialties, although definitely existent, was notalways great enough torequire the full-time services of a specialist. Moreover, it was knownthat a considerable numberof affiliated general hospital units were to arrive in the theater, andspecialists from these unitscould be used as consultants on a temporary duty status in the Officeof the Surgeon,NATOUSA, for such periods of time as were considered necessary. In theNorth African, andlater the Mediterranean theaters, this approach proved to be sound.Such medical specialties asdermatology, neurology, tuberculosis, and others were adequatelysupervised in this way withouttying up valuable personnel during the periods of relative inactivitycommon to all theaters. Anadded advantage was the fresh and enthusiastic outlook of the specialconsultants, unjaded byperiods of inactivity and the petty annoyances of normal administrativeroutine. No provisionwas made in the table of organization for a chief of professionalservices, because it was thoughtlikely that the addition of such an officer would increaseadministrative detail without
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serving any useful purpose. For the bestfunctioning of the division, it was thought that each oftime five consultants should have direct access to the Surgeon of thetheater.
Officers assigned to themedical sections of NATOUSA and later MTOUSA also were assignedto AFHQ. These officers served in dual capacities. When dealing solelywith problemsconcerning time operations of U.S. Army forces in the theater, theywould act in their staffcapacity as members of the medical section of NATOUSA or MTOUSA, butwhen planning,operations, or policy matters required joint action with the British,their staff actions would becarried out as members of the Medical Section, AFHQ.
Initially, an organizationentitled 'the Service of Supply' existed in NATOUSA, but thisorganization dealt solely with supplies and had no other service oradministrative functions.Later, in February 1944 when the name of Service of Supply was changedto theCommunications Zone, it was given true administrative, service, andoperational functions overthe various base sections, and at that time the American special staffsections at the Allied Force,NATOUSA-MTOUSA level became, in theory, advisory and planning sectionswith nooperational functions.2 This resulted in the organizationof large general and special staff sectionsat Communications Zone headquarters, which, at least insofar as themedical section at thetheater headquarters level
2 The organization of suchan intermediate headquarters between theater headquarters and thebase sections was necessary to coordinate activities of widelyseparated base sections inproviding logistical support for the opening of a new front in southernFrance. - J. B. C., Jr.
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was concerned, caused a considerable amount of administrative andoperational confusion inproblems involving the ground and air forces, and the CommunicationsZone. NATOUSA wasrenamed, effective 1 November 1944, MTOUSA, and within the month 3itsmedical sectionassumed the functions of the former medical section of theCommunications Zone in addition toits theater functions. This reorganization restored to the theatersurgeon all the responsibilities hehad previously, before February 1944, and added an important newfunction in the form of acomplex supply activity (chart 2). The medical section acting attheater and allied headquarterswas now responsible for all medical functions of theaterwide scope.
In late 1944, all theofficers then assigned to the Medical Section, MTOUSA were reassignedtoAFHQ.
CONSULTANT ACTIVITIES IN VARIOUS TYPES OFMEDICAL INSTALLATIONS
In time of war, andespecially in a newly established, active, oversea theater ofoperations, amedical officer is likely to have many tasks in addition to hisassigned duties, and the U.S.Consultant in Medicine, AFHQ, was no
3 The extensivecommunications zone organization in southern France, consisting ofSouthernLine of Communications, Continental Advance, and Delta Base Sections,was made a part ofETOUSA. With the loss of this area and the area commands, the MedicalSection, Headquarters,MTOUSA, again assumed direct operational control over medical mattersin the original basesections that had constituted NATOUSA before preparation began for theinvasion of southernFrance. - J. B. C.. Jr.
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exception to this rule. Initially, he was the representative of theDeputy Surgeon in allconferences and committees having to do with professional services ofall types, and, because ofthe illness and the subsequent transfer of the preventive medicineofficer to the Service ofSupply headquarters, he assumed the functions of the officer in chargeof venereal diseasecontrol for 2 months, those of the preventive medicine officer for 7months, and those of thetheater nutrition officer for 18 months. Summaries of the problems withwhich he dealt in theseother capacities can be found in other volumes of this history.
In the North African andMediterranean theaters, the function of the consultant in medicine waspurely that of an advisor to the Surgeon, except in those rareinstances in which, by command, hewas placed on an operational or at a command level. His prime duty wasto keep the Surgeonconstantly and correctly informed of the standards of professional carethat were being exercisedin the treatment of the sick. In addition, the consultant representedthe Surgeon in matterspertaining to the care of the sick, he advised the surgeons of lowerechelons in respect to medicalproblems within their jurisdiction; he prepared circular letters uponthe diagnosis, treatment, anddisposition of medical patients and prepared other educational matterfor medical officers; hesupervised the activities of the consultants in neuropsychiatry andchemical warfare medicine; headvised the Surgeon on problems of professional personnel in theMedical Corps; he attemptedto stimulate clinical research; he interpreted the policies of theSurgeon to members of themedical staff of the various hospitals in the theater; he consideredhimself the guardian of allmedical officers, general duty, MOS 3100; and he prepared that sectionof the monthly ETMD(Essential Technical Medical Data) report that dealt with medicine.These duties wereaccomplished by constantly observing professional work in medicalinstallations and by trying tomaintain a continuous contact with medical officers throughout thetheater. Because of theshifting nature of operations in the North African and Mediterraneantheaters, with the resultantrapid buildups and as rapid deflations of tactical units and basesections, it was not consideredexpedient to have subsidiary consultants in medicine, except for theFifth U.S. Army. Aconsultant was recommended, but not accepted by the surgeon of thatcommand until the closingdays of the war in Italy. As a result of this general policy, thetheater consultant in medicine wasaway from his headquarters on tours of visits during 67 percent of thetime in 1943, 74 percent in1944, and 69 percent in the first half of 1945. It was only by being inthe field that it waspossible for him to fulfill his duties to the Surgeon.
Initially, the activitiesof Colonel Long, Consultant in Medicine, AFHQ, were limited by theuncertainties surrounding the actual position and powers of theAmerican branch of the MedicalSection, AFHQ. This section had been established primarily as aplanning and advisory section;the operations of the Medical Department in the theater were to becarried out at the level of thebase sections, task forces, and air force. By December 1942, however,it had
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MAP 3.- Base Sections, North African Theaterof Operations, July 1944.
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become clear that the Medical Section, AFHQ,because of its position at the theater level, wouldhave to assume the additional function of coordinating the medicalactivities of its subordinateechelons. As this naturally meant that the American branch had to enterthe field of operations,which the original plan had not envisaged, certain administrativedifficulties arose between thatsection and the medical sections of the lower echelons of command.
This situation created, inturn, certain difficulties for the consultant in medicine. Surgeons ofsome base sections (map 3) accepted him at once. Considerable educationwas necessary beforethe surgeons of other sections fully accepted him or made real use ofhim. Generally speaking, aperiod of about 6 months elapsed before the surgeons in the theaterunderstood the duties of theconsultant in medicine well enough to permit him to function properlyin his assigned mission. Itis only fair to add that it also took the consultant in medicine acertain period of time to learnhow to function effectively within the framework of the Army in anactive theater of operations.
The activities of theconsultant in medicine in the North African and Mediterranean theaterswere practically always limited to those of an advisory nature becauseoperational and technicalcommand duties were sharply limited, within the medical branch, to theSurgeon and hisexecutive officer. The consultant advised the Surgeon, NATOUSA, and thesurgeons ofsubordinate commands concerning the problems discussed under thevarious headings thatfollow.
PERSONNEL MANAGEMENT
One of the most importantduties of both medical and surgical consultants was evaluation ofmedical personnel. Hospital staffs were frequently found professionallyunbalanced. Some ofthem, particularly the affiliated units, had a surplus of talent.Others had been constituted withoutdue regard for their special functions and the ability of theirprofessional staffs to carry them out.
It was the practice of theconsultant in medicine to review the professional attainments ofmedical officers assigned to the medical services of all hospitals assoon as possible after theirarrival in the theater. This was done (1) by studying thequestionnaires which all medical officerswere required to fill out and (2) by interviewing them individually assoon as opportunitypermitted.
Assignment and Reassignment of MedicalOfficers
If glaring errors ofassignment had been made in a unit, recommendations for reassignment ortransfer were made to the commanding officer immediately. Otherwise,recommendations werewithheld until the consultant in medicine had been able to review theprofessional work of theofficers in question after the unit was in operation. Then, ifdeficiencies were noted, appropriaterecommendations were made.
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It was sometimes difficultto convincecommanding officers of the need for these changes,particularly if the changes involved transferring officers of superiorability to build up weakerunits. In the North African theater, the general hospitals were allaffiliated units and weretherefore rich sources of medical and surgical talent. Officers withsuch qualifications wereseldom relinquished willingly, even when the new assignments might meanpromotions andpositions of greater responsibility for them.
At the other extreme,although the functionsof the consultant in medicine included the makingof recommendations for transfers, these changes were sometimesinitiated without reference tohis opinions and recommendations.
One difficulty which arosein the first daysof action in the North African theater was not entirelysettled until Api'il 1944. Because of certain command policies ineffect within the theater at thistime, it was not possible for representatives of the theater Surgeon tointerview replacements andunassigned personnel until their completed questionnaires had beenreceived at headquarters.This policy meant that medical officers sometimes remained inreplacememmt pools for a monthor more before assignment, a waste of medical manpower which thecircumstances of the theaterdid not warrant.
In a number of instancesin 1943, MedicalCorps personnel entered the theater and were assignedby G-1, NATOUSA, without reference to the Office of the TheaterSurgeon. This difficulty, likethe one just described, was not satisfactorily settled until April 1944.
Replacements
In March 1944, a furthercomplication wasadded when the Communications Zone commandtook over the personnel services in the base sections in addition toits already existing supplyfunction. Thus, an intermediate echelon was created between AFHQ andbase section levels,and, although the Surgeon, Communications Zone was always cooperativein respect to therecommendations of the consultant in medicine, this meant that everycontemplated change inMedical Corps personnel that affected base section units had to becoordinated with still anotherechelon of command. Then too, at this time, because of a shortage ofreplacements for medicalofficers in combat units, it was decided that all medical officers inbase section units who wereunder 35 years of age and physically fit were to be made available tothe Fifth and Seventh U.S.Armies as needed. The responsibility for making these officersavailable was given to thePersonnel Division, Medical Section, Communications Zone, which waspresided over by anonmedical officer of the Medical Department, who again had had littleor no training inpersonnel problems. This really made things difficult, and this officerhad to be watchedconstantly, because to him a captain in the Medical Corps was acaptain, and hence, regardless ofwhether he had had specialized training or not, was material of whichbattalion surgeons weremade. When chiefs of services or assistant chiefs of services (many ofwhom were diplomates ofAmerican Specialty
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Boards) were recommended for transfer tocombat units by time personnel section in the Officeof the Surgeon, Headquarters, Commnunjcations Zone, it was only thevigilance of theconsultants that prevented serious dislocation on certain services ingeneral and station hospitals.
In the Fifth U.S. Army,the chief of thepersonnel section in the Surgeon's Office was anonmedical officer until after the surrender in Italy, and thephilosophy of that office dictatedthat Medical Corps replacements, no matter how highly qualified theymight be professionally,should serve 6 months with combat troops before they could be assignedto hospital units withinthe Fifth U.S. Army. The extreme example of this type of thinkingoccurred in the winter of1944-45, when an officer who was a member of the American Board ofOphthalmology wasassigned to a general service combat engineer unit at a the when therewas a real need for well-trained ophthalmologists in the evacuationhospitals within Fifth U.S. Army.
In July 1944, Maj. Gen.Morrison C. Stayer,Surgeon, NATOUSA, having surveyed thesituation, took the steps necessary to establish central control in hisoffice of the initialassignment of Medical Corps personnel within the base sections and, toa certain degree, withinthe Fifth U.S. Army. To make this plan effective, he first arrangedthat all replacements andunassigned medical officers should be concentrated in a replacementdepot close to theaterheadquarters and that his office should be notified by telephone on theday any medical officersarrived at that depot. Then, through the personnel section of hisoffice, arrangements wereimmediately made for interviews with the newly arrived medicalofficers. When the professionalattainments of these officers had been ascertained, they were promptlyassigned by NATOUSA,and later by MTOUSA orders, to existing vacancies in medicalinstallations in the base sections,or they were sent to the Fifth U.S. Army with recommendationsrespecting the type of duty theycould best. perform. In effect, with this system placing the initialassignnment of these officers inthe hands of the consultant staff, there was mnore chance of theirbeing properly placed on thebasis of their professional abilities, and the time they had to remainin the replacement depot wascut from weeks to a matter of a very few days. It might also be addedthat, following theinstitution of this system of personnel placement, complaints arisingfrom alleged improperassignments were practically eliminated.
Redeployment
After V-E Day, theCommanding General,MTOUSA, directed that redeployment to the Zone ofInterior and the Asiatic-Pacific areas of Medical Corps personnelassigned to hospital units bethe responsibility of the Surgeon, MTOUSA. The Surgeon, in turn,delegated it to the consultantstaff in his office.
These officers laid downthe policy that theseventeen 500-bed station hospitals, the three 400-bed evacuationhospitals, the three field hospitals, and the two general dispensariesthat had to beredeployed by MTOUSA would be
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staffed with medical officers (1) whopossessed the proper MOS; (2) who had demonstrated theirability to fill their new assignments; (3) whose adjusted serviceratings were below 85 points;and (4) whose ages, whenever possible, were below 40 years. It was alsodecided that everyopportunity would be given for promotion this meant that assignmentswere not made in gradebut in one grade below that which was called for in the tables oforganization.
Although the theater wasshort of medicalofficers-in May 1945, it was operating on a basis of4.6 medical officers per 1,000 men-it was possible to completeredeployment upon the basis ofthe criteria just outlined.
Classification and Promotion
One of the outstandingadvances in the propermanagement of Medical Corps officers resultedfrom War Department Circular No. 232, dated 10 June 1944, which createdthe graded MOSnumbers. As the result of his long service in the North African andMediterranean theaters,Colonel Long was well aware of the professional qualifications of themajority of medicalofficers who belonged to field army or base section units. Inanticipation of the responsibility forgrading medical officers, he had, late in 1944 and early in 1945,interviewed chiefs of medicalservices of hospitals in the base sections and in the Fifth U.S. Army,as well as the majority ofbattalion medical officers in the Fifth U.S. Army, for the purpose ofreviewing once again theprofessional attainments of medical officers in MTOUSA. In the actualgrading, the status ofeach medical officer in the theater was reviewed before an MOS wasassigned. The consultant inmedicine was assisted in this task by Col. Donald S. King, MC, and Col.Marion H. Barker, MC,each of whom had a wide acquaintance with medical officers in thetheater. It is a pleasure to beable to state that the Office of the Surgeon received only one requestfor a change in MOS. Inthis instance, the purported error had resulted from an improperlyfilled out questionnaire. Therecan be little doubt that the possession of an accurate MOS contributedmore than any other factorto the proper assignment of individuals during the redeployment period.
In the Mediterraneantheater, as in othertheaters, the promotion of medical officers was always aproblem. The number of vacancies was limited, and the number of medicalofficers whodeserved promotion on the basis of their qualifications and performancewas many times thespaces available. It is to the credit of the officers who entered theservice from civilian life that,in spite of disappointments and actual injustices in this regard, theydid not let them affect theexcellence of their work, particularly when, as inevitably happened,less qualified officerssometimes received the promotions which they felt belonged to them orfor which they had beenrecommended. The question of promotions was a problem which theconsultant in medicine wasnever able to solve.
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FIGURE45.-Open storage of medicalsupplies, Naples, Italy.
MEDICAL SUPPLIES
The U.S. consultant in medicine in the North African and Mediterranean theaters was much more fortunate than his British colleague, in that he rarely had to be concerned with problems of medical supplies. Aside from certain unavoidable local shortages, medical supplies (fig. 45) were always abundant, and the supply officers in the theater were most cooperative in obtaining nonstandard items that were deemed desirable for the treatment of patients or for the pursuit of research.
DISEASES OF MEDICAL INTEREST
The problems that arose inthe North Africanand Mediterranean theaters in respect to themanagement of various diseases will be discussed sequentially.
Neuropsychiatric Casualties
Early in February 1943,the problem of thetreatment and disposition of neuropsychiatric battleand nonbattle casualties became pressing. Since December 1942,casualties of this type had beenentering British medical installations from the 18th Regimental CombatTeam (U.S.),Commando and
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FIGURE 46 -British hospital ship (inforeground) Algiers, North Africa.
Ranger units. When the II Corps was committedin southern Tunisia neuropsychiatric patientsbegan to flow into the evacuation and the surgical hospitals assignedto that Corps. Since thesehospitals did not have psychiatrists on their staffs, theneuropsychiatric patients were treated onthe medical wards. Because medical ward officers lacked knowledge andinterest in themanagement of such patients, the rate of return to duty in the corpsarea was very low, and mostof the patients were evacuated by air to the 95th General Hospital(British) in Algiers or toAmerican hospitals in the Oran area. By the first week in February, the95th General Hospital(British) was crowded with more than 70 U.S. neuropsychiatriccasualties. This groupconstituted a great additional load upon the already overworkedpsychiatrist in that institution,and, as this British general hospital did not possess the authority forthe final review anddisposition of American neuropsychiatric patients, they were steadilyaccumulating, despite thefact that American casualties were still being evacuated to the UnitedKingdom in Britishhospital ships (fig. 46).
At the request of theDirector of MedicalServices, AFHQ, the consultant in medicine reviewedthe situation at the 95th General Hospital (British) and made tworecommendations. The firstwas that a medical disposition board consisting of 2 British and 1American medical officer becreated and be empowered to pass upon the status of Americanneuropsychiatric patients, whilethe second dealt with the possibility of attaching an Americanpsychiatrist to the 95th GeneralHospital (British) for temporary duty. The first recommen-
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dation was immediately put into force by theDirector of Medical Services, who created a specialdisposition board of which Maj. (later Col.) Roy R. Grinker, MC, thepsychiatrist of the 12th AirForce, was the American member. This board immediately began tofunction, and it provided aneeded mechanism for the disposition of neuropsychiatric patientscoming to the rear in theBritish and American lines of evacuation. Because of a shortage inpersonnel, it was not possibleto attach an Anmerican psychiatrist to the 95th General Hospital atthat time.
On 12 February 1943,Colonel Long flew downto southern Tunisia at the direction of theSurgeon, NATOUSA, to investigate and make recommendations concerningthe treatment anddisposition of neuropsychiatric casualties in forward areas. Thesituation in the forward areaswas very interesting. Neuropsychiatric casualties were being treated,without segregation, on themedical wards of the surgical and evacuation hospitals by inexperiencedinternists. The resultwas that more gross hysterical and conversion manifestations weredeveloping than were evernoted before or subsequently in forward areas. Hysterical blindness,deafness, aphonia, and grosstics were common and were developing even in individuals who hadentered the hospitals withbut minor anxiety states. Treatment of these patients was neitherindividualized nor standardized,and there was ample evidence that the neuropsychiatric disturbanceswere spreading, in themanner of an infection, to other patients in the medical wards of thehospitals. After spending 6days in observing the management of these patients and collecting datain respect to them, theconsultant in medicine returned to AFHQ and rendered the followingreport to the Surgeon, on21 February 1943:
1.This report isbased on data obtained fromthe Medical staff of II Corps, and from interviewswith medical officers of the 9th and 77th Evacuation Hospitals.
2.The problem ofpsychotic, psychoneuroticand anxiety states in the personnel of the A.U.S. inNATOUSA is a real one, and is becoming more acute as relatively new anduntried troops areplaced on combat duty. Experience in this theater, which is derivedfrom reports of the CenterTask Force and II Corps show that when troops are in battle for thefirst time, a considerablenumber of psychiatric casualties may be expected. The curve of suchcasualties is a sharp onewhich will fall rapidly as troops become acclimated to combatconditions with the exception thata secondary rise in the curve will be noted when troops are kept underbattle conditions for longperiods of time, as has already happened in this theater (6thCommandos, Inniskilling Fusiliers,etc.).
3. For the sake ofconvenience, psychiatricconditions can be roughly classified as follows:
a. Psychotic States. Unfortunately, a number of individuals with histories of previous treatment in mental hospitals have been inducted into the Army. These men are having recurrences of their psychoses. The only problem in respect to such individuals is that the nature of their psychosis be promptly recognized by the Medical Officer and the proper disposition made of them. At the present moment, many of these patients are being sent to U.K. This is not desirable because one theater of operations should not throw such a burden upon another. Whenever it is possible, psychotic patients should be sent directly to the U.S.A.??????
b. Psycho-Neurotic States. The individuals who fall into this classification are those who generally have past histories which show that they were unstable in civilian life. They are the ones of whom it is frequently said, 'The Army will make a man out of him.'
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Unfortunately, the Army has its difficulties in such an endeavor, and has instead, a problem child on its hands. These individuals are especially hard to handle as members of combat units and, in desperation, unit commanders resort to all sorts of subterfuges to get them sent 'down the line' with diagnoses of 'shell shock,' 'gastric ulcer,' etc. Upon reclassification, a fair number of these individuals will he able to perform some type of base sector duties. However, a certain group will be complete misfits in whatever unit they are placed, and because of their inaptitude or other characteristics should be sent home to be discharged under the provisions of Section VIII [Inaptitude and Undesirable Traits of Character, AR 615-360], if this section is operative in this theater.??????
c. Anxiety States. Personnel suffering from these physiological and psychological disturbances should be the special concern of the Army, because with proper treatment many of them can be promptly rehabilitated for combat duty, and the majority of the remainder will perform well in the Base Sections. Individuals who are suffering from anxiety states rarely give histories of previous difficulties. The factors which produce these states are multiple. Among them are exhaustion, lack of food, equipment or munitions, poor leadership, and extremely difficult, immediate personal tactical situations. Suddenly, when these factors become operative, something happens to an otherwise balanced intellect, and an acute anxiety state is produced. Unfortunately, at the present time, the inception of these disturbances is frequently not being recognized by unit commanders or medical officers and the symptoms progress to become full blown. Then patients are frequently evacuated with a diagnosis of 'shell shock' on their Emergency Medical Tag. These patients all read their Emergency Medical Tags sooner or later, and when they see the diagnosis of 'shell shock' they have something that they know of, and a fixation of the psychological component of their illness frequently results. Much can be done for this group if the nature of their disturbance is understood and recognized, and the proper treatment is instituted and carried out in forward areas.
d. Exhaustion States. These disturbances areprimarily physiological in nature, but are frequentlymisdiagnosed by forward medical officers, and hence, personnel are sentdown the line ofevacuation improperly labeled as 'shell shock,' anxiety state, orpsychoneurosis. Individualssuffering from exhaustion, in practically every instance, can betreated in the far forward areasand returned to their units within a very short time.
4. Treatment ofAnxiety and ExhaustionStates. At the present time the treatment of thesepsychological and physiological disturbances in forward areas, franklyis not very good. Thereason for this is that many of the Medical Officers who deal withthese men really do notunderstand the nature of the disturbances. Sedation to the point oflight anesthesia is consideredby many psychiatrists to be the basis for the treatment of anxietystates, and it is not being used.None of the patients are arriving at the surgical or evacuationhospitals completely 'knockedout,' but instead, they are being given, for example,1? grains ofphenobarbital, 15 grains ofsodium bromide or, what is worse, morphine. Hence, with an evacuationline which is long (12to 15 hours), plenty of time in which a fixed neurosis can develop isbeing allowed to elapse. Theideal place for the treatment of these patients is in the evacuationhospitals, but there again, owing to the lack of a trainedpsychiatrist in such installations, thetrue nature of thesedisturbances is frequently missed, and imuproper therapy is instituted.There can be noqumestion but that the addition of a trained psychiatrist to thosehospitals would not only bewelcome, but also would pay large dividends in facilitating the propersorting of psychiatriccasualties and the proper treatment of anxiety and exhaustion states.As conditions exist atpresent, psychiatric casualties are spread over the medical wards ofthe evacuation hospitals, andthere is evidence that they are acting as foci of infection for thespread of neuroses to otherpatients. This is an unhealthy situation.
5. Availability ofPsychiatrists in NATOUSA.According to Major Grinker there is a dearth oftrained psychiatrists in this theater. Two are in the 12th Air Force.The 12th and 21st GeneralHospitals have trained psychiatrists. However, the senior psychiatrist
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in the 21st General Hospital has beentransferred to the 64th General Hospital. In addition tothese men, there are said to be three otherpsychiatrists in NATOUSA.
6. It is thereforerecommended on the basisof the situation as it now exists that:
a. A directive be issued stating that theterm 'shell shock' shall not be used as a diagnosis andthat the term 'anxiety state' be the sole diagnosis permitted onEmergency Medical Tag or FieldMedical Record of patients who are suffering from thephysiological andpsychologicaldisturbances described in paragraphs 3c of this report.
b. A psychiatrist be attached to eachevacuation hospital, in order that proper sorting andtreatment of psychiatric casualties can be carried out and properinstruction can be given tomedical officers in battalion aid and clearing stations in the initialhandling of these casualties.?????
c. Psychiatric casualties be segregated from other patients.
d. Sodium Amytal, for intravenous use in sterile 7 ? grain ampules, be provided for clearing stations.
e.Five additional trained psychiatrists beassigned to this theater.
The Surgeon, NATOUSA, accepted all of these recommendations. The Surgeon, II Corps, on being queried stated that he would be glad to have psychiatrists in his evacuation hospitals, and Maj. (later Lt. Col.) Louis L. Tureen, MC, and Capt. (later Lt. Col.) Frederick R. Hanson, MC, were assigned to II Corps, with understanding that Captain Hanson would work in the forward areas. This stipulation was made because of the latter's familiarity with actual battle conditions, which he had gained in the course of commando raids and in the landing at Dieppe. On 22 March 1943, Circular Letter No. 4, entitled 'Psychotic and Neurotic Patients, Their Management and Disposition,' was issued by the Office of the Surgeon, Headquarters, NATOUSA. Before the appearance of this circular letter, supplies of Sodium Amytal (amobarbital sodium) had been made available in all forward areas. Thus, the policy was initiated of treating neuropsychiatric casuahities as far forward as possible. The wisdom of this policy was demonstrated during the battles for Maknassy and El Guettar (fig. 47), in the course of which Captain Hanson returned more than 70 percent of 494 neuropsychiatric casualties to combat after 48 hours of treatment, and Major Tureen rapidly rehabilitated the majority of the remainder for duty in the base section.
At the beginning of thebattle for northernTunisia the consultant in medicine held a conferencewith the four psychiatrists in the II Corps (two new 400-bed evacuationhospitals having beenassigned to the II Corps). As a result of the conference, the II Corpscommander, Maj. Gen.(later General) Omar N. Bradley, issued, on 26 April 1943, thefollowing directive on thehandling of psychiatric casualties:
1. Evacuation Policy. - Psychiatric cases should be evacuated, treated and disposed of as rapidly as possible. The following evacuation policies will prevail for such casualties in hospitals in II Corps:
a. 11th Evacuation - 3 days
b.15th Evacuation - 3 days
c.48th Surgical - 3 days
d.9th Evacuation - 7 days
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FIGURE48.-Admission of 'exhaustion'casualties to clearing stations.
2. Selectionof Cases.
a. If any or all corps hospitals are acting as clearing stations, the psychiatrist shall be on duty in the receiving room, sorting and labeling psychiatric casualties and seeing that further sedation is given.
b. The following types of psychiatricdisorders will he immediately evacuated to E.B.S. [EasternBase Section:
(1)Moderate and severe hysteria.(2)Patients with a past history of nervousdisorders.
(3)All psychogenic repeaters.
(4)All psychoneurotic disorders such asneuro-circulatory asthenia, gastrointestinal disorders,sustained ties, etc.
(5)All psychoses.
3. All psychiatricor psychogenicdisturbances will he diagnosed as exhaustion in the battalionand, collecting, or clearing stations (fig. 48). The definitivediagnosis will be made in theevacuation hospitals.
4.Treatment.
a.The treatment of all psychiatriccasualties in corps area will be under the direction andsupervision of the psychiatrist (fig. 49) assigned or attached to thehospital.
b. In general, all psychiatric cases will besegregated for treatment.
c.Insofar as it is possible, patients willbe kept under sedation from battalion aid stations toevacuation hospitals.
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FIGURE 49.-Treatment of neuropsychiatriccasualty under supervision of psychiatrist.
d.Specific Therapy. - Battalion aidor collecting stations for all psychogenic or psychiatricpatients.
(1) By mouth - Initial dose: Sodium Amytal 6grains, or phenobarbital 4 grains, or Nembutal 41/2 grains.
(2) Subsequent dosage should be adjusted tokeep patients drowsy. Do not give more than 12grains of Sodium Amytal, or 6 grains of phenobarbital per 24-hourperiod in the line ofevacuation.
(3) Morphine or codeine will not be given toneuropsychiatric patients.
5. Disposition.- Psychiatric andpsychogenic cases should be disposed of as promptly aspossible and their disposition will be in the hands of thepsychiatrist. They will be sent direct toduty when possible, if not, to the replacement pool with a statementthat they must be returned toduty as promptly as possible.
It may be noted that inthis directive theterm 'exhaustion' was introduced for the first time. Ofthe possible diagnostic terms discussed this word was chosen because itwas thought to conveythe least implication of a neuropsychiatric disturbance, and probablyit came closest todescribing the way the patients really felt.
In the campaign innorthern Tunisia, theresults obtained again were excellent as approximately70 percent of neuropsychiatric casualties were returned to combat dutywithin the time periodsdefined in the directive. One of the prime objectives of treatment inthe North African theaterwas to reduce the period of hospitalization to the minimum consistentwith the rational care ofthe patient. When a neuropsychiatric patient was released from thehospital an attempt was madeto assign him to duty as promptly as possible. In the more severecases, under this system, not alltraces of anxiety were lost by the time the patients were assigned newduties in the base sections.It was noted
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FIGURE 50.-Brig. Gen. Frederick A. Bless?,Theater Surgeon.
by the consultant in medicine during timespring of 1943 that on many occasions reclassifiedneuropsychiatric casualties were given duties that frequently, oftenpromptly, resulted in theirexposure to enemy air raids. These raids produced a return of the acutesymptoms of anxiety inthese men, which necessitated further hospitalization. In an effort todefine more carefully thetypes of duty to which reclassified neuropsychiatric casualties shouldbe assigned in the basesections, Colonel Long made the following recommendations to Brig. Gen.Frederick A. Bless?(fig. 50), the Surgeon, NATOUSA, on 1 May 1943:
1. Experience isshowing that certain typesof neuropsychiatric casualties cannot be returned tocombat duty because they quickly deteriorate and have to be evacuatedto the rear.
2. Many suchcasualties when properlyreclassified and placed on duty in quiet areas such as theABS or MBS [Atlantic Base Section or Mediterranean Base Section] areable to fulfill theirduties in a satisfactory manner. The use of rehabilitatedneuropsychiatric casualties in the quietbase section also obviates the need for a certain number ofreplacements for such areas.
3.If, however, such rehabilitated casualtiesare placed in areas such as Algiers, etc., which aresubjected to bombing and hence AA fire, many will revert to theirneuropsychiatric state afterthe first bombing. It is therefore plain that such areas are not to beused for the placement ofrehabilitated neuropsychiatric casualties.
4.It is therefore recommended that astatement covering the types of and places for duty beprepared and signed by station and general hospital psychiatrists forall rehabilitatedneuropsychiatric casualties and that their statements he forwarded toreclassification boards withthe request that they be acted upon accordingly. If this plan iscarried out more useful work willbe gotten out of such individuals and the chance of them repeatingtheir neuropsychiatricsyndrome will be greatly lessened.
These recommendations wereaccepted by theSurgeon, and from that time a conscious attemptwas made to assign reclassified neuropsychiatric casualties to dutiesin quiet areas. Also, duringthe Tunisian campaign, Captain
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FIGURE51.-Reghaia swamp, Algiers area,North Africa, 1943.
Hanson made a brilliant record in the returnof neuropsychiatric patients to combat duty and inthe organization of the psychiatric facilities in the II Corps. Becauseof this, the consultant inmedicine recommended to the Surgeon, NATOUSA, that Captain Hanson bedesignated asconsultant in neuro-psychiatry for the North African theater. Thissuggestion was carried out bythe Surgeon early in June 1944, and subsequently the consultant inmedicine acted solely in anadvisory capacity insofar as neuropsychiatric problems were concerned.
Malaria
It became evident to theconsultant inmedicine shortly after his arrival in North Africa that, becauseof the frequency and severity of malaria in that area (fig. 51),special efforts would have to be madeto indoctrinate American medical officers in the need for promptsurvey, control (fig. 52), diagnosis,and treatment. In Circular Letter No. 6, entitled ''Treatment ofMalaria,'' which was issued on 10April 1943 by the Office of the Surgeon, Headquarters, NATOUSA, theimportance of earlyrecognition and treatment (fig. 53), was stressed, and it wasrecommended that the quinine-Atabrine-Plasmochin or theAtabrine-Plasmochin scheme of therapy be employed. The dosage systemrecommended was that advised in Circular Letter No. 135, 21 October1943, Office of the SurgeonGeneral. These methods of treatment were used during
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the summer of 1943 with the following averageperiods of hospitalization 15 days, aestivo-autumnalmalaria; 17.6 days, benign tertian malaria; and 20 days, clinicalmalaria.
In August, 1943, ColonelLong began to doubtthe necessity for the use of Plasmochin (pamaquinenaphthoate) in the treatment of malaria in U.S. Army troops in theNorth African theater. Hisreasons for this point of view were summed up in the following report,which was made to GeneralBless? on 2 September 1943:
Plasmochin hasvery little plasmodicidaleffect upon malarial parasites except in the gametocytestage.
It is the opinionof experiencedmalariologists in NATOUSA that, as a result of eliminating routinePlasmochin therapy in U.S. troops, adult gametocyte carriers will notincrease the present rate ofmosquito infection from troop sources.
The reportedreduction in malaria relapses inprimary cases by use of Plasmochin therapy has notbeen confirmed.
As Plasmochin ismore toxic than Atabrine orquinine and of limited therapeutic value, it should beused only in selected relapsing patients who possess a heavy gametocyteconcentration in their bloodand who cannot be adequately protected from anophehine mosquitoes. Itis recommended that theplan outlined in Circular Letter No. 6, Office of the Surgeon, Hq.NATOUSA, Paragraph 3a(1) forthe treatment of uncomplicated malaria be abandoned.
In addition, it wasthought that the timerequired for the hospitalization of malaria patients wouldbe decreased if the use of Plasmochin was discontinued. At the sametime, it was recommended that,if Atabrine (quinacrine
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hydrochloride) alone was used for thetreatment of malaria, the dosage schedule should be changedto 0.2 gm., three times daily, until the temperature was normal, then0.1 grn., three times daily, aftermeals for 5 days. This revision was motivated by the desire to build upthe concentration of Atabrinein the tissues early in the disease and then, when the infection wasknown to be under control, tomaintain an effective level of time drug over a period of days. Thequinine-Atabrine method oftreatment was left unchanged, as were also the directions for theparenteral use of quinine orAtabrine in severe forms of malaria. These recommendations wereaccepted and were published on3 September 1943 in Circular Letter No. 32, Office of the Surgeon,Headquarters, NATOUSA. Onthe day after this circular letter was published, reports were receivedfrom the National ResearchCouncil indicating that Atabrine was as effective, if not more so, inthe therapy of malaria thanquinine (a conclusion also arrived at in NATOUSA), and giving detailedinformation concerningthe pharmacology of Atabrine. On the basis of these reports and ofinformation received from theOffice of the Surgeon General, in addition to theater experience, itwas decided to abandon theroutine use of quinine and to recommend that Atabrine be used as thedrug of choice in the treatmentof malaria. This was done in section II, Circular Letter No. 34, issuedon 14 September 1943 by theOffice of the Surgeon, Headquarters, NATOUSA. In this circular letter,the pharmacology ofAtabrine was discussed, and a dosage schedule of 0.2 gm. of Atabrineevery 6 hours for 5 doses,followed by 0.1 gm. three times a day after meals for 6 days, wasrecommended for the treatnmentof malaria. This method of therapy, which resulted in a reduction inhospitalization required formalaria to an average of 11 days for all cases, was maintained as themethod of choice for treatingmalaria throughout the life of the theater, except that a temporarymodification was made in respectto the treatment of relapsing malaria in February 1944.
At this time, aconsiderable number ofpatients were being seen with three, four, or more relapsesof benign tertian malaria. After consultation with the theaterpreventive medicine officer and themalariologist, the following suggestions for the treatment anddisposition of patients ill withrelapsing malaria were published in section III, Circular Letter No.10, 15 February 1944, Officeof the Surgeon, Headquarters, NATOUSA:
Relapsing Malaria
1. Experience hasshown that despite varioustreatment regimes malaria is a disease prone to relapse,especially when the infection is caused entirely or in part by Plasmodiumvivax. This letter dealswith treatment of relapses and disposition of malaria patients to theZone of the Interior.
2. First andsecond relapses of malariashould be treated like a primary attack, using the system oftherapy outlined in Section II, par. a (1), Circular Letter, No. 34,Office of the Surgeon, Hq.NATOUSA, dated 14 September 1943.
3. Third andsubsequent relapses should betreated with quinine according to the following 10-dayregime:
a.Quinine sulfate 1.0 gram (15 grains) bymouth three times daily after meals for the first threedays.
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b. Quinine sulfate 0.32 gram (5 grains) bymouth three times daily after meals for the next sevendays.
4. The use ofadrenalin followed by Atabrineor quinine (so-called Ascoli method) is notrecommended because its value has not been demonstrated.
5. Every method of adjuvant therapy shouldbeemployed as indicated to restore the physicalcondition of malaria patients. Of special value are:
a.High caloric, high meat protein diets.
b.Multivitamin pills or capsules.
c.Transfusion when patient is very anemic.
d.Ferrous sulfate in appropriate doses.
6. It is notlogical to set up absolutecriteria for disposition to the Zone of Interior of personnel whohave had one or more attacks of malaria. Some patients are ill betterphysical condition after severalrelapses than other patients after a primary attack. Patients whodevelop chronic malarial cachexia,persistent splenomegaly, or recalcitrant anemia should be considered assubjects for evacuation tothe Zone of the Interior.
It is to be noted that inthis circularletter time use of epinephrine in the treatment of malaria was notrecommended-a move to counteract the influence of the teachings ofAscoli-and that a policy forthe disposition of patients ill with relapsing malaria was established.That part of Circular Letter No.10 that dealt with the use of quinine in the treatment of relapsingmalaria was rescinded in paragraph4e, Circular Letter No. 41, 29 July 1944, Office of the Surgeon,Headquarters, NATOUSA, after itbecame apparent that therapy with quinine did not alter the rate ofrelapse in malaria. In CircularLetter No. 41, the importance of the physical rehabilitation ofmalarial patients was again stressed,and a directive that all patients convalescent from relapsing malariashould receive 0.1 gm. ofAtabrine daily, for 7 days a week, regardless of whether they were in a'safe' or 'dangerous' area,was issued. No other changes in policy for the treatment or dispositionof cases of malaria weremade until after the surrender of the enemy in Italy in May 1944, whenit was recommendedverbally by the Surgeon, MTOUSA, that patients suffering fromfrequently relapsing malaria shouldbe sent to the Zone of Interior.
Dysentery
The threat ofdysentery-both bacillary andamebic-seemed great in the early part of 1943. As a resultof the recommendations made by Colonel Long, Circular Letter No. 9 wasissued on 6 April 1943by the Office of the Surgeon, Headquarters, NATOUSA. Diagnosis andtreatment were discussed
in this directive. The highpoints of thiscircular letter were the recommendations that sulfaguanidinewas the drug of choice for the treatment of bacillary dysentery andthat the course of emetinehydrochloride to be used in the therapy of amebic dysentery should beof 10 days' duration, ratherthan the customary 6 days. This latter recommendation was made upon theadvice of the Britishconsulting physician, who had had an extensive experience in thetreatment of amebic dysentery insoldiers in Egypt. It is believed that the wisdom of this advice wasborne out by the experience ofthe theater.
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In September 1943, inparagraph VIIb ofCircular Letter No. 34, the more extensive use ofsulfadiazine for the treatment of bacillary dysentery was advocated,and, in paragraph IIl.a(1) ofCircular Letter No. 24, 15 April 1944, Office of time Surgeon,Headquarters, NATOUSA, it wasstated that for time treatment of bacillary dysentery 'sulfadiazine isthe drug of choice withsulfaguanidine and sulfathiazole following in the order named.' Thisrecommendation was madebecause, under the conditions existing in the theater, it had beenfound that sulfadiazine was aneffective, practical drug. Time inference that it was therapeuticallysuperior to sulfaguanidine in thetreatment of bacillary dysentery could not be drawn, as both appearedto be equally effective, butsulfadiazine was easier to administer to patients because of thesmaller doses and less frequentdosage periods required for its use.
In the spring of 1944, during the offensive from the Hitler to the Gothic Line, the hospitals in Italy were very busy, and it became common practice to discharge from hospitals patients suffering from amebiasis, with instructions to take a second course of carbasone while on a duty status. As a consequence, the second course of carbasone frequently was not completed, and relapses often occurred. in paragraph 3 of Circular Letter No. 41, 29 July 1944, Office of the Surgeon, Headquarters, NATOLTSA, this practice was condemned, and instructions were given that all patients suffering from amebic dysentery should remain hospitalized until their treatment had been completed. It is unfortunate that a true evaluation of the effects of the recommended therapy for amebic dysentery in the North African and Mediterranean theaters could not be made because adequate diagnostic criteria for the disease could not be formulated, and relapses frequently could not be distinguished from possible reinfections. Curiously enough, probably because of good sanitation, amebic infection was never a real problem in NATOUSA or MTOUSA.
Poliomyelitis
In the summer and fall of 1943, 1944, and 1945, the question arose concerning the treatment and disposition of patients suffering from acute anterior poliomyelitis. The policy in respect to the treatment of such patients, based upon the recommendations made by the Conference on Poliomyelitis of the National Research Council-which did not recommend the Kenny Treatment -was laid down in Circular Letter No. 42, 1 November 1943, Office of the Surgeon, Headquarters, NATOUSA. Standard Drinker respirators were not requisitioned by the theater, because these could be borrowed from the British, and patients with paralysis that persisted after the acute phase of the disease were evacuated to the United States.
Infectious Hepatitis
The epidemic of infectioushepatitis, whichbegan in August 1943 and mounted rapidly to its peakin November of that year, caught the North
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African theater in a state of intellectualand physical unreadiness. All medical officers were familiarwith a disease called catarrhal jaundice, which in their clinicalexperience had been essentially amild disease occurring, without sequelae, in children and young adults.It was difficult for them tocomprehend what was happening-and this was true of others who did notwitness the epidemic-when, within 4 months, more than 14,000 cases ofhepatitis were admitted to hospitals. They soughtaid from their textbooks, from their elders, and from their consultantin medicine, to little avail,because this was something new in the experience of most medicalofficers. To be sure, a numberof them had witnessed numerous cases of jaundice following vaccinationagainst yellow fever in1942, but this naturally occurring disease appeared to be different.Also, none of the medicalofficers, with possibly two exceptions in the theater, had followedtheir cases of hepatitis in 1942,with the numerous correlations that are so necessary if the clinicalpicture of a disease is to beobtained. Thus, the fall of 1943 can be considered as a period inwhich medical officers began tolearn about infectious hepatitis at the bedside.
It was also a difficultperiod for thepatients, because with the successful assault on Italy, manyhospitals moved from North Africa to Italy, where it took time to setup these installations, with theresult that there was a constant pressure upon medical officers toreturn patients to duty in order thatbeds might be made available for additional sick and wounded flowinginto the base from the ArmyAir Forces and the Fifth U.S. Army. At the same time, the B ration hadbecome badly unbalancedowing to the substitutions and eliminations always made in that rationduring periods of stress. Thetotal situation was difficult-medical officers were dealing with adisease about which little wasknown, hospitals beds were at a premium, and the hospital ration wasunbalanced. In the course ofa tour of inspection of hospitals in PBS (Peninsular Base Section) andthe Fifth U.S. Army made inDecember 1943, Colonel Long noted that marked variations existed in thetherapy, period ofhospitalization, and disposition of patients ill with hepatitis. Therewas no unanimity of opinionamong medical officers concerning the management of the disease, and itappeared that unlessaction was initiated, a chance to make a fundamental contribution inrespect to management wouldbe lost. The Surgeon, Peninsular Base Section, requested the assistanceof the consultant in medicinewith this problem. The latter recommended that, as soon as the l2thGeneral Hospital arrived inNaples, Colonel Barker be given the task of assembling pertinentinformation concerning thediagnosis, treatment, and disposition of patients suffering frominfectious hepatitis. Thisrecommendation was made because it was known that Colonel Barker hadstudied the hepatitis thatfollowed vaccination against yellow fever in 1942 at Camp Custer, Mich.Colonel Barker began hiswork early in 1944 and obtained enough information to permit theconsultant in medicine to make
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the following report to the Surgeon, Peninsular Base Section, on 1 March 1944:
* * * * * * *
2. Within the pastfew weeks, recurrences ofhepatitis with and without jaundice, which are markedby anorexia, dyspepsia, fatigue, or enlarged, painful or tender liver,have become increasinglyfrequent. These recurrent manifestations of hepatitis are very similarto those noted in the course ofthe epidemic of hepatitis which followed inoculation with certain lotsof yellow fever vaccine. Todate, however, the severe instances of the disease marked by a rapidlyprogressing cirrhosis of theliver with ascites have been rare. Thus, it has become clear that inthe present outbreak of hepatitis,the sequelae which marked the jaundice following the yellow feverinoculation are being repeated.
3. It isimpossible to state exactly how muchof a role insufficient hospitalization and convalescentcare play in the production of the recurrences or relapses of hepatitisbecause adequate data uponthis point are not available. However, evidence is accumulating whichshows that many cases ofhepatitis appear to be discharged from hospitals, convalescentsections, and even from personnelcenters before the disease is completely arrested and as a result ofthese premature dispositions,recurrences or relapses of the disease are occurring.
4. If experiencerepeats itself, recurringwaves of hepatitis with and without jaundice may beexpected in this theater until troop dispersal is effected after thecessation of hostilities. It istherefore necessary to enunciate as promptly as possible, thosecriteria which will enable medicalofficers to dispose of cases of hepatitis as efficiently as possible inorder that a maximum of fitindividuals be returned to duty. However, absolute criteria for makingefficient dispositions are stillin the experimental stage and a final answer awaits the accumulation ofexperimental data. However,certain observations have been made which are helpful in determiningthe physical status of patientswho have been ill with hepatitis. These are:
a.Freedom from clinical jaundice with anicterus index which is within normal limits.
b.The absence of signs of anorexia,dyspepsia, or food intolerance when the patient is placed uponthe expeditionary force 'B' ration.
c.Lack of fatigue at the end of the day, andthe absence of any liver enlargement, pain, or tendernesslate in the afternoon after the patient has been up all day. Theenlargement must be determined withthe patient in the upright position, and the tenderness canbest be elicited by a light quick blow withthe doubled fist applied just below the costal margin in the rightanterior axillary line.
d. Work andexercise tolerance must beadequate and not produce jaundice, dyspepsia, liverenlargement, pain or tenderness. This is best determined by puttingpatients convalescing fromhepatitis through a graduated series of exercises followed immediatelyafter each exercise or workperiod by careful observation for the appearance of jaundice, anorexia,dyspepsia, undue fatigue,or enlarged, painful, or tender livers.
5. Patientssuffering from hepatitis with orwithout jaundice who show a persistence of jaundice,anorexia and dyspepsia, undue fatigue or enlarged, painful or tenderlivers should be evacuated fromfield, station, and convalescent hospitals to general hospitals forfurther observation, treatment anddisposition. All such cases and all recurrent or relapsing cases ofhepatitis should be carefullyobserved according to the suggested schedule as outlined above, and ifjaundice or dyspepsiapersists or work and exercise tolerance tests do not show a progressiveimprovement, and the livercontinues to become large, painful or tender, then such patients shouldhe carefully considered bythe medical disposition boards of general hospitals as candidates forevacuation to the Zone of theInterior.
6. In order tofacilitate the efficienthandling of patients suffering from hepatitis, the followingrecommendations are made to The Surgeon, Peninsular Base Section:
a.That a Surgeon's Circular upon the subjectof hepatitis, compiled by Lieutenant Colonel MarionBarker and the Consultant in Medicine NATOUSA, be issued immediately toall medical officersin PBS.
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FIGURE54.-23d General Hospital situatedbetween Bagnoli and Naples, Italy
b.That Major Richard Capps be placed ontemporary duty with the authority to visit all hospitalinstallations in PBS for the purpose of educating medical officers onmedical services of thehospitals in procedures which are of proven value in assisting medicalofficers to arrive at correctdecisions concerning the disposition of patients suffering fromhepatitis.???
c. That every facility be given Lieutenant Colonel Barker in the prosecution of his investigation upon accurate functional tests for the diagnosis, evaluation and disposition of patients suffering from hepatitis and in order to hasten his investigations, that fifty (50) beds be allotted for new cases of suspected or actual hepatitis in the 225th Station hospital, while all recurrences or relapses and protracted instances of jaundice, dyspepsia, or enlarged painful or tender livers (hepatitis) will be routed to the 21st, 23d (fig. 54), or 45th General Hospitals after Monday, the 6th of March, 1944. This last could be made effective by a memorandum to commanding officers of PBS hospitals at The Surgeon's conference on March 6th.
The recommendationscontained in this reportwere accepted by the Surgeon, Peninsular BaseSection, with minor modifications, such as the suggestion that theproposed circular letter be issuedby time Surgeon, NATOUSA, and that all investigative work be carriedout in the 182d StationHospital, in which 100 beds were allotted for the study. Thus, in March1944, a concentrated attackon the disease was initiated under the general supervision of ColonelBarker, who was assisted byLt. Col. Ross L. Gauld, MC, and Lt. Col. Harold H. Golz, MC, Maj.(later Lt. Col.) Richard B.Capps, MC, and, as the program developed, by many other medicalofficers in the theater. On 28March 1944, Circular Letter No. 19, subject: Infectious Hepatitis, wasissued by the Office of theSurgeon, Headquarters, NATOUSA.
Circular Letter No. 19 wasrescinded byCircular Letter No. 37, which was issued on 8 July 1944from the Office of the Surgeon, Headquarters,
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NATOUSA. This circular letter brought up todate the available information in respect to infectioushepatitis and stressed the therapeutic effects of a high-protein,low-fat, high-carbohydrate diet.Circular Letter No. 37 drew severe criticism from certain officers ofthe Medical ConsultantsDivision, Office of the Surgeon General, because of their disbelief inthe existence of certain of theclinical types of the disease that had been described, theirdisagreement with the diagnostic criteriathat had been established their dislike of the method of treatment thathad been prescribed, andfinally their fear that the regime employed in the treatment of thesepatients would producepsychoneurotics. That these criticisms were unjustified wasdemonstrated by the record of thetheater in respect to the diagnosis, treatment, and disposition ofpatients with infectious hepatitis.
In the fall and earlywinter of 1944,hepatitis again became epidemic in MTOUSA. This time, theair force and base section troops came off almost unscathed, and thebulk of the cases were reportedfrom the infantry units of the Fifth U.S. Army. This outbreak providedanother excellent opportunityfor time study of the disease. Important contributions were made bymedical officers in respect tothe value of the various tests of liver function in early diagnosis;the importance of using the high-protein, how-fat, high-carbohydratediet was confirmed; the necessity of using the exercise-tolerancetest for establishing cure was reaffirmed; and important pathologicalstudies were made by Maj.Thomas N. Horan, MC, Lt. Col. Tracy B. Mallory, MC, and Capt. Leslie S.Jolliffe, MC. Theseinvestigators utilized the peritoneoscope for obtaining biopsies of theliver in various stages of thedisease. It can be said without hesitation that the management of casesof hepatitis during the falland winter of 1944-45 was infinitely superior to that of the previouswinter. The total experience ofthe theater regarding the diagnosis, treatment, and disposition ofpatients ill with infectious hepatitiswas summed up in Circular Letter No. 21, issued on 20 June 1945, by theOffice of the Surgeon,Headquarters, MTOUSA, subject: Infectious Hepatitis.
Diphtheria
Although diphtheria neverbecame epidemic inthe theater, it always caused concern because of therelative unfamiliarity of most U.S. practitioners with the disease inyoung adults and because deathsfrom diphtheria were always tragic and avoidable. Circular Letter No.37, issued on 2 October 1943,by the Office of the Surgeon, Headquarters, NATOUSA, stressed theimportance of the earlydiagnosis and treatment of diphtheria. In this letter, the use of largedoses (from 50,000 to 250,000units) of antitoxin was recommended, and the necessity for keepingsoldiers ill with diphtheria inbed for considerable periods of time (from 2 to 4 weeks or more) wasindicated. These injunctionswere based upon realization that the definitive treatment of thedisease in soldiers would probablyoccur at a later period than in civilian patients. With the apparentdemonstration within the theaterthat therapy with penicillin
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FIGURE 55.-Winter in Italy, 1943
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FIGURE 56.- Trenchfoot, Fifth U.S. Army,1943.
was of some value in eliminating Cornebacteriumdiphtheriae from the throats of carriers, thetherapeutic use of this antibiotic in conjunction with large doses ofantitoxin was recommended insection II, Circular Letter No. 51, dated 19 October 1944, Office ofthe Surgeon, Headquarters,NATOUSA. Although attempts were made to assess the value of thecombined therapy, it wasimpossible to arrive at any definite conclusion.
Trenchfoot
In the late fall andwinter of 1943 (fig.55), conditions of climate and terrain were such in the areaopposite the Hitler Line, to the north of the Volturno River, thatabout 6,000 cases of trenchfootoccurred in the Fifth U.S. Army (fig. 56). For reasons unknown, thedisease was considered asurgical rather than a medical emergency, and the advice of theconsultant in medicine was notasked until February 1944. At that time, the Surgeon, Peninsular BaseSection, was confronted withthe problem of what to do with several thousand individuals who had hadtrenchfoot of varyingdegrees of severity. Unwisely, an attempt had been made to send some ofthese men back to combatduty, but, as the same conditions that had produced the injuryprevailed, relapses of trenchfootoccurred. In a report made to the Surgeon, Peninsular Base Section, on2 March 1944, the consultantin medicine gave the following advice, which was accepted:
The solution of theproblem is relativelysimple. With the return of the feet apparently to a normalcondition these men should be sent to personnel centers where theyshould be
4 A detailed discussion ofthe serious losseswhich occurred from cold injury among U.S. Armypersonnel in World War II appears in Medical Department,United States Army. Cold Injury,Ground Type. Washington: U.S. Government Printing Office. 1958.
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organized immediately into separatebattalions and then a gradual process of conditioning forcombat should be instituted. The only care which must be takenin this program is that it be gradual,that during the next six weeks these men must not be exposed tofreezing or near freezing weatherunder conditions in which their feet will be damp or wet, andtheir feet must be kept dry and warm.It might be advisable to have two medical officers, one experienced inthe treatment of 'TrenchFoot' and one in orthopedic surgery attached to these battalions duringthe training period. It wouldseem quite certain that if this program could be activated immediately,a considerable group ofexperienced veterans would be ready for combat by 15th of April, 1944.
During the late spring andearly summer of1944, certain incapacitating late sequelae of trenchfootwere noted, and, in Circular Letter No. 41, 29 July 1944, Office of theSurgeon, Headquarters,NATOUSA, it was recommended that patients showing the following signsshould either be placedon limited duties or be evacuated to the Zone of Interior:
* * * * * * *
(1) Pain and swelling of the feet afterwalking short distances.
(2) Loss of cornified epithelium on thesoles, resulting in tender 'tissue paper' skin which is veryprone to blister.
(3) Hyperhidrosis with vasomotor changes.
(4) High rate of epidermophyton infection.
(5) Atrophy of the subcutaneous [tissues] andmuscles of the feet which results in an acutebreakdown of the transverse and longitudinal arches and which at timesis so marked that shoes ofsmaller size may be required.
Early in the fall of 1944,a conference washeld with the Surgeon, Peninsular Base Section, thetheater consultant in surgery, and certain interested medical officersupon the subject of trenchfoot.The recommendations made by this group, after being coordinated withthe Surgeon, Fifth U.S.Army, were incorporated in Circular Letter No. 2, issued on 2 January1945, by the Office of theSurgeon, Headquarters, MTOUSA. They read as follows:
* * * ** * *
4. The managementof 'trench foot' in thefirst echelon:
a. Unless actual gangrene or a superimposedclinical infection requiring immediate surgical care isfound, all patients suffering from 'trench foot' should be sent to themedical services of first echelonhospital units. [Evacuation and Field Hospitals].
* * ** * * *
5.The managementof 'trench foot' in thesecond echelon:
a. Patients sufferingfrom 'trench foot'sufficiently severe to require evacuation to the secondechelon usually should be treated in general hospitals. Patients willbe admitted to the surgicalservice in the second echelon hospitals upon presence of gangrene orinfection for which surgicaltreatment is necessary. Otherwise, they will be sent to the medicalservice of these hospitals.
* * * * * * *
6.The properdisposition of patientssuffering from 'trench foot' should be a matter of primaryconcern to the disposition boards in station and general hospitals ofthe second echelon. It must beremembered that while it is the primary duty of the Medical Departmentto maintain [conserve]manpower, patients sent back to general or limited assignments must beable to perform the dutiesrecommended by the Medical Corps. It is of little value to send back aman who will promptlybecome a physical liability to a service or combat unit. Hence,the case
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of each patient must be strictly individualized by disposition boards, and the type of duty recommended be based upon the known fact that a patient who has suffered from 'trench foot' is very susceptible to cold and wet and may be unable to march or stand for periods of time without producing a return of symptoms. Therefore, the following broad criteria are suggested for the disposition of these patients:
a. General Duty. The patient must he able to pass an exercise tolerance test similar to that outlined for hepatitis in Circular Letter Number 37, Office of the Surgeon, Headquarters NATOUSA, dated 8 July 1944. The skin of the feet should be normal, free from lesions or loss of subcutaneous tissue, and anesthesia, paresthesia or marked hyperhidrosis should not be present.
b. Limited Assignment. The patient should be able to stand a two mile walk or two hours on guard duty. The skin of the feet should be normal, free from infections or loss of subcutaneous tissue, and anesthesia, paresthesia or hyperhidrosis should not be present. In recommending the patient for limited assignment it should be stressed that he should be kept away from the cold and wet.??????
c. Patients not falling into the two categories mentioned above, should be considered individually as possible candidates for evacuation to the Zone of the Interior.
Fortunately, owing to theprovision of moresuitable footwear and to the static nature of the tacticalsituation in the northern Apennines during the winter of 1944-45,trenchfoot was not the problemthat it had been the previous winter.
Sandfly Fever
A minor, though realproblem encountered byColonel Long during 1943-44 was the hesitancy ofmedical officers in making the diagnosis of sandfly fever. In thesummer of 1943, this disease wasprevalent in Tunisia and Sicily and, later, on the Salerno beachhead.Despite the fact that the clinicalpicture was clear cut, the diagnosis of sandfly fever was made in onlya small fraction of a percentof the total cases, with the result that FUO (fever of undeterminedorigin) was reported to a degreeentirely out of proportion to its actual occurrence. This situationresulted from an unfamiliarity withthe disease, from lack of a diagnostic test for it, and fromintellectual laziness on the part of medicalofficers. Despite an intensive education campaign carried out in1943-44, it may be said that it wasnot until the summer of 1945 that the reporting of sandfly fever becamesatisfactory.
Tuberculosis
Late in 1943, the 46thGeneral Hospital,Mediterranean Base Section, the 6th General Hospital,Atlantic Base Section, the 24th General Hospital, Eastern Base Section,and later, early in 1944, thel7th General Hospital, Peninsular Base Section and the 26th GeneralHospital, Adriatic BaseSection, were designated as centers for the diagnosis, reception,treatment, and disposition ofpatients suffering from tuberculosis. This plan of hospitalization wasoriginally recommendedbecause Colonel Long believed, on the basis of his observations instation and general hospitals, thatthe diagnosis, treatment, and disposition of tuberculosis patients wasnot being very well managedbecause of a lack of knowledge of the disease and lack of interest,once the
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diagnosis had been made, on the part of mostmedical officers. During the latter part of 1943, thesecenters, especially the one in the Mediterranean Base Section,functioned well, but owing to a lackof understanding on the part of medical officers in other hospitals ofthe fundamental purposes ofthese centers, they did not reach high standards of efficiency untilthe following memorandumdealing with their function was published, at first locally in thePeninsular Base Section, June 1944,and later in Circular Letter No. 41, Office of the Surgeon, NATOUSA, 29July 1944:
* * * * * * *
a.All patients suffering from activetuberculosis will be sent from other hospitals to the generalhospitals which have been designated as 'tuberculosis receptioncenters' as soon as the diagnosisof active tuberculosis is made. The 'tuberculosis reception centers'will manage and dispose of allpatients suffering from active tuberculosis.??????????
b. All patients in whom the activity of a recent or old tuberculosis is a matter of doubt will be sent to a 'tuberculosis reception center' for an evaluation of their status, and if follow-up checks are desirable, patients with doubtful lesions will be returned to a 'tuberculosis reception center' after the advised interval, for the necessary diagnostic tests. The 'tuberculosis reception centers' will maintain in their patient record file, adequate records of patients in whom the diagnosis of tuberculosis is doubtful, and will preserve all X-ray films of such patients until the case is closed. These records will be made available to other 'tuberculosis reception centers' upon request.
c.It will be the responsibility of thecommanding officers of the 'tuberculosis reception centers' tonotify the medical officer of any organization, in which an 'open case'of tuberculosis is discovered,of the existence of such a case, and it will then be the responsibilityof the unit medical officer toinitiate promptly such studies as are considered necessary for thedetection of pulmonarytuberculosis in intimate contacts of the patient.??????
d. Patients suffering from active tuberculosis or in whom there is a question of activity which will necessitate follow-up studies, will he evacuated promptly from all medical installations to the nearest 'tuberculosis reception centers.' In order to facilitate the routing of such patients, the hospital destination of the patient will be prominently noted upon MD Form 52d.
Following the publicationof this circularletter, the triage of patients suffering from tuberculosis tothe 'tuberculosis centers' became excellent, and with it the care anddisposition of the patientsmarkedly improved.
Dermatological Conditions
By the fall of 1943, it became evident to the consultant in medicine that an improvement could be made in the methods used for the management of patients with diseases of the skin. After considering various measures to accomplish this end, he communicated his views to the Surgeon, NATOUSA, in the following letter dated 13 November 1943:
1. Dermatologicalconditions (excludingsyphilis) are not being properly treated in NATOUSA. Thisis especially true of eczema and fungus infections of the hands andfeet.
2. There are fewqualified dermatologists inNATOUSA.
3. Two excellently trained dermatologistsareupon the staff of the 46th General Hospital while onewell trained and one fairly well trained dermatologist are upon thestaff of the 64th General Hospital.
4. When the opportunity offers itselfshortly, an appraisal will be made of the dermatologists in theGeneral Hospital PBS.
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FIGURE57.-64th General Hospital, Leghorn,Italy, 1945.
5. It is recommended that the 46th General Hospital MBS and the 64th General Hospital (fig. 57) EBS he designated as dermatological centers and that the facilities of these hospitals he made available for consultation, diagnosis and treatment of skin diseases within their respective Base Sections.
These recommendations wereaccepted. Early in1944, a third dermatologic center was opened inthe 45th General Hospital in Naples. It can be said without hesitationthat the establishment of thesecenters created a renewed interest in dermatologic problems and that adefinite improvement waseffected throughout the theater in the treatment of diseases of theskin.
PENICILLIN
The medical use ofpenicillin in the NorthAfrican theater began in the late summer of 1943. At thattime, because the supply of the agent was limited, its use wasrestricted to cases in whichsulfonamide therapy fell short of expectations. During the fall of1943, the supply became moreabundant, and, upon the recommendation of Colonel Long, most of thepenicillin that was availablefor medical purposes was devoted to the treatment of gonorrhea whichhad proved resistant totherapy with the sulfonamides. By the end of the winter of 1944, enoughpenicillin was availablein the theater to permit a more general use of this antibiotic. Thefull treatment of all cases ofgonorrhea
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and syphilis with penicillin was initiated on1 August 1944. It was the policy in the North Africantheater to follow the instructions received from the Office of theSurgeon General concerning themedical uses of penicillin. As a result, there was littleexperimentation with the product, and it is feltthat penicillin was both effectively and economically used in thetheater.
DISPOSITION OF PATIENTS TO ZONE OF INTERIOR
The opening of the Italiancampaign and thesubsequent activation of the Peninsular Base Sectionwith its numerous general hospitals created a problem in thedisposition of patients to the Zone ofInterior, which had not existed to any degree when the generalhospitals were situated in NorthAfrica. During the late fall and winter of 1943-44, many patients hadto be evacuated to NorthAfrica from Italy in order that a reasonable status of vacant bedsmight be maintained for armycontingency that might arise. This meant that many patients,recommended by the medicaldisposition boards of general hospitals in Italy, were sent tohospitals in North Africa (fig. 58) toawait evacuation to the Zone of Interior. In December 1943, complaintswere heard from the generalhospitals in Italy that many such patients, being reviewed by themedical boards of the generalhospitals in North Africa, were being returned to a general servicecategory. As a result, these menwere then returned to their units in Italy, where, within short periodsof time, they frequently hada return to their original disease and were rehospitalized, therebynecessitating a complete clinicalreview of the case with the attendant paperwork and other necessaryprocessing. By the first of 1944,the situation reached a point where the medical services of the generalhospitals in Italy and in NorthAfrica began to question each other's professional qualifications.
At the direction of theSurgeon, theconsultant in medicine made a thorough study of this problemand came to the conclusion that the root of the evil lay in amisunderstanding on the part of thegeneral hospitals in North Africa of the environmental conditionsexisting in forward army, air force,and base areas. Upon the recommendation of the consultant in medicine,the Surgeon, NATOUSA,issued instructions in Circular Letter No. 21, dated 3 April 1944,concerning the disposition ofpatients from medical services. These instructions were based upon thenatural history of certaindiseases as observed in the theater and upon an appraisal ofenvironmental factors that mightinfluence the course of certain diseases. In formulating this policy,special consideration was givento establishing stringent criteria for the medical disposition of keycommissioned personnel andMedical Corps officers. The important points of policy established wereas follows:
1. The followingmemorandum is based uponexperience gained in this Theater and is to be used asa guide by medical officers in formulating the disposition of certainpatients from field, evacuationand station hospitals to general hospitals and from the latter to theZone of the Interior. Thismemorandum is to be used as a guide and not as a directiveand should be so interpreted by medicaldisposition boards of general hospitals, especially when such boardsare dealing with the dispositionof medical officers or other key commissioned
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personnel. It is of paramountimportance thatthe manpower needs of the theater be safeguarded, butat the same time it is incumbent upon medical disposition boards tomake a careful estimate of eachpatient's potential effectiveness, in order that effective manpower maybe maintained at the highestlevel, and multiple admissions to hospital, resulting from recurrent orchronic disease be reducedto a minimum.
2. A study of thenatural history of diseasein NATOUSA has demonstrated that under the conditionswhich exist in this theater, the occurrence of the following diseaseentities in patients may beconstrued as relative indications that such individuals should beconsidered as candidates for limitedservice assignments (if medical officers or key commissionedpersonnel), or for evacuation to theZone of the Interior. When the indications for evacuation out of thetheater are considered absolute,such a statement will be made
a.The existence of the following diseaseentities may be considered as an indication that the patientshould be evacuated to the United States.
(1) Virus diseases.
(a) Anteriorpoliomyelitis with persistentparalysis. (b) Encephalitis lethargica (von Economo'sdisease). (c) Equine encephalomyelitis.
(2) Bacterial diseases.
(a) Diphtheria with a complicatingpersistent(6 weeks) paralysis, or any definite cardiacinvolvement. Care should be exercised to see that patients in thelatter group are not evacuated untilthey are entirely free from clinical signs of cardiac involvement andessentially free fromelectrocardiographic changes. (h) Typhoid fever complicated by multiplerelapses or by perforationof the ileum, generally requires a prolonged period of convalescenceand such patients should beevacuated as soon as their conditions permits. (c) Recurrent undulantfever. (dl) Active pulmonaryor other types of active tuberculosis. (e) Mycoticinfections such asactinomycosis, blastomycosis,streptothricosis or sporothricosis,
(3)Protozoan infections.
(a) Malaria withchronic cachexia, resistantanemia, blackwater fever, repeated attacks of thecerebral type, or with repeated attacks of the disease and apermanently enlarged spleen. (b)Recurrent amoebic infection which is resistant to therapy or which hasproduced a chronic colitis.
(4)Diseases of doubtful origin.
(a) Acute or chronic rheumatic fever.(b)Disseminated lupus erythematosus. (c) Sarcoid.??????
(5) Diseases due to allergy.
(a) Asthma which is persistent, resistant to therapy, or to changes of environment, or which due to frequency of attack renders the diseased individual ineffective.
(b) Recurrent, treatment-resistant,disablingangioneurotic edema.
(6) Diseases due to chemical agents.
(a) Chronic lead poisoning withencephalopathy or hypertension and vascular changes. (b) Proven,persistent damage to the hematopoietic system produced by chemicalagents.
(7) Diseases due to physical agents.
(a) True sunstroke (not heatexhaustion).(h) Frost bite with gangrene resulting in incapacitatingamputations.
(8)Diseases of metabolism.
(a) Diabetes in enlisted personnel. (h)Proven gout. (c) Diabetes insipidus.
(9)Diseases of the digestive system.
(a) Proven peptic ulcer in enlistedpersonnel. (b) Proven cases of mucus or spastic colitis. (c)Regional ileitis. (d) Recurrent intestinal diverticulitis. (e) Provenchronic pancreatitis. (f) Cirrhosisof the liver. (g) Chronic persistent, infectious hepatitis. (h)Relapsing or recurrent infectioushepatitis, with or without jaundice, which relapses or recurs despiteadequate periods ofconvalescence and reconditioning.
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FIGURE 58.-Air evacuation from Italy to North Africa.
189
190
(10) Diseases of the respiratory system.
(a) Chronic, persistent bronchitis associatedwith physical signs and X-ray changes. (b) Clinical,radiographically proven, moderate or severe bronchiectasis. (c)Subacute or chronic lungabscess.??????
(11) Diseases of the kidney.
(a) Paroxysmal hemoglobinuria. (b) Acute orchronic glomerular or interstitial nephritis. (c)Nephrosis. (d) Proven pyelonephritis. (e) Pyo- or hydronephrosis withdecreased function in theother kidney.
(12)Diseases of blood-forming organs.
(a) Treatment resistant secondary anemias.(b) Pernicious anemia in enlisted personnel. (c)Leukemia or lymphosarcoma. (d) Hodgkin's disease. (e) Idiopathicthrombocytopenic purpurawith enlarged spleen. (f) Hemolytic icterus. (g) Hemophilia. (h)Banti's disease.
(13)Diseases of the circulatory system.
(a) Chronic valvular heart disease exceptthose instances in which the lesions are minimal andthere is no history of recent rheumatic attacks. (b) Syphiliticvalvular disease or aneurysm. (c)Subacute bacterial endocarditis. (d) Proven, chronic, myocardialdisease with signs of functionalfailure. (e) Proven essential hypertension in enlisted personnel. (f)Thrombo-angiitis obliterans.(g) Proven coronary occlusion or insufficiency. (h) Angina pectoris inenlisted personnel.
(14) Diseases of the ductless glands.
(a) Exophthalmic goitre. (b) Addison'sdisease. (c) Proven hypo- or hyper-parathyroidism.
(15)Diseases of the joints.
(a) Recurrent persistent or cripplingrheumatoid arthritis. (b) Still's disease. (c) Ankylosingspondylitis. (d) Degenerative arthritis in which symptoms and signspersist or in which repeatedclinical attacks occur.
(16)Neoplastic disease.
(a) Malignant neoplastic disease with theexception of minor superficial lesions for whichtreatment is available in the Theater.
(17) Neuropsychiatric disease.
(a) All instances of progressiveincapacitating neurological disease. (b) Epilepsy with grand malattacks. (c) Psychoses. (d) Severe or frequently recurringpsychoneuroses.
(18)Dermatologicaldisease.
(a) Chronic incapacitating treatment-resistant or frequently recurrent dermatological diseases which are productive of prolonged hospitalization.
b. The existence of the following disease entities in medical officers or in key commissioned personnel may be considered as an indication that officer patients can be reclassified to a limited service status and retained within the theater.
(1) Disease of metabolism.
(a) Diabetes mellitus which is mild and forwhich adequate dietary and treatment facilities areavailable.
(2)Diseases of the digestive system.
(a) Uncomplicated peptic ulcer for which anadequate dietary regime can be provided.
(3)Diseases of the blood-forming organs.
(a) Pernicious anemia inmedical officers.
(4)Diseases of the circulatory system.
(a) Proven essential hypertensionwithout symptoms or signs of renal or cardiac failure inmedical officers. (b) Mild angina pectoris.
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Following the publicationof this circular letter, the problems concerning the disposition ofpatients were markedly reduced and were rarely the cause of disputesbetween hospitals.
LABORATORY SERVICES
Duringthe first 7 months of his service in the North African theater, ColonelLong supervisedthe activities of hospital laboratories (figs. 59 and 60) byvirtue of the fact that he was also actingas time preventive medicine officer. Following the establishment of thePreventive MedicineService in the Office of the Surgeon, Headquarters, NATOUSA, thecontrol of the laboratoriespassed to this service. This separation made for immediate difficultiesbecause endlesscoordination at all levels was needed in order to have the laboratoriesfunction in their properrelation to the clinics, it must be remembered that clinical laboratorywork, like roentgenology, isprimarily an adjunct to diagnosis and therapy and hence should besubordinated to the variousclinics in the hospital. This is the policy in effect in all universityclinics and in the better class ofcivilian hospitals. When such a system is used intelligently, it tendsto decrease the amount oflaboratory work required for patient care, which, on the other hand,increases when the directionof laboratories is in hands other than those responsible for the careof the patient. It was theconsidered opinion of Colonel Long that the system of organizationwhich placed thesupervision of laboratories under preventive medicine was archaic andthat the supervision oflaboratories belonged to the Medical Consultants Division.
PROBLEMS OF EVACUATION AND HOSPITALIZATION
Principles of evacuationand hospitalization in the Mediterranean theater were finallycrystallized, but only after a long process of evolution. Part of thedifficulty arose from the factthat both evacuation and hospitalization had dual aspects. Theseaspects were largelyadministrative or operational problems, it is true; but it is equallytrue that both had basic clinicalcomponents which could not be ignored. At times, some officers incharge of evacuation incertain base sections did not understand this fact. This wasparticularly true during the first 18months of the life of the theater when some sick and wounded were movedabout in frantic haste.
In spite of hisrealization of the importance of logistic and other considerations, theconsultant inmedicine could not lose sight of the fact that, when casualties passedthrough a number ofhospitals, breaks in the even tenor of medical care occurred, andtherapy was interrupted. From asound professional viewpoint, the best interests of neither the Armynor patient would have beenserved if the consultant in medicine had not continuously interestedhimself in such matters andstruggled to keep medical care at respectable levels. Continuity oftreatment was of primeimportance in the care of the sick or wounded patient.
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FIGURE 59.-Hospital laboratory activities.A. Bacteriology. B. Histopathology.
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FIGURE 60.- Mobile laboratory, Florencearea, Italy, 1945.
MEDICAL CARE OF PRISONERS OF WAR
Before the battle fornorthern Tunisia in May 1943, Colonel Long was requested to submit totheSurgeon, NATOUSA, his views upon the provision of medical care forprisoners of war (fig.61). This request was answered in two memorandums; the first, dated 18March 1943, coveredthe prevention of disease in prisoners of war, while the second, dated19 March 1943, detailed inbroad outline professional services for prisoners of war.
The text of the 18 Marchmemorandum follows:
Subject: Prevention of Disease in Prisonersof War
1.The comingbattle of Tunisia will throw a heavy strain upon existing medical andsanitaryfacilities in the AUS [Army of the United States], NATOUSA, because inaddition to themedical cases of enemy sick and wounded, the AUS will be charged withthe prevention ofdisease among captured enemy troops. This burden willfall mainly upon the AUS becausepresent plans call for the evacuation of prisoners of war alongAmerican lines ofcommunications.
2. Every effortmust be made to prevent the outbreak of epidemic disease among theanticipatedprisoners of war not only because of the humane aspects of the problem,but also because of thedangers to our own forces which would be created by such outbreaks.
3. At the presenttime G-2 [intelligence] has very little information concerning the
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FIGURE 61.-German and Italian prisoners ofwar, North Africa, 1943.
status of immunization procedures carried out in enemy troops. Current information from nonmilitary sources would lead one to believe that the following procedures are in effect:
German Italian
Typhoid Inoculations + +
Tetanus ' 0 +
Typhus ' + ?
Smallpox ' + +
Accurateinformation upon this point should be obtained at once through theinterrogation ofprisoners and by asking for information upon this point from Cairo.
4.There are three main health problems which will concern prisoners ofwar: typhus, malariaand dysentery.
a. Typhus.According to available nonmilitary information at least a portion ofthe German armyis inoculated with Weigl's vaccine (typhus). The exact protectiveaction of this vaccine isunknown under field conditions but it is likely that the German vaccineis at least as protective asthe Cox vaccine used by the American Army. The status of the Italianarmy in respect to typhusvaccination is unknown. Excerpts from diaries of captured Italiansoldiers as published in theweekly G-2 reports speak of the lousiness of the Italian troops. It isto be assumed that there willalso be a considerable degree of lousiness in German prisoners. Everyeffort must be made tocombat this situation by delousing procedures (fig. 62), because iftyphus breaks out in prisonersof war, it will not only throw an added and unwanted burden upon ourhospitals, but due toquarantine regulations, the movement of the prisoners toward base campsin the L.O.C. lines of communication) and the Z.I. (Zone of Interior)will be greatly hampered. To prevent such an occurrence, delousing andbath units, both British and American, should be mobilized in theforward units and prisoners of war should be deloused before they areconcentrated in large prisons
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FIGURE 62.- Delousingof prisoners of war.
pens. Toaccomplish this, immediate plans should be made in consultation withthe EngineerCorps, Quartermaster Corps and the Provost Marshal, to cope with thelousiness of prisoners ofwar. In addition to delousing, adequate stocks of licepowder should be available in the forwardarea.
b. Malaria. Theconcentrations of prisoners in exposed areas, without the benefits ofmosquitonets amid other physical methods of malarial control will result inmany cases of malaria if rigidprophylaxis of the disease is not carried out in prisoners of war. Thisshould be done by theadministration of Atabrine 0.2 gram, on Monday and Thursday nightsafter the evening mealsfrom the 22nd of April until the 30th of November. The responsibilityfor the enforcement of thisscheme should be placed on the shoulders of the various enemynoncommissioned officers whowill have certain responsibilities for the enforcement of discipline intheir respective prison pens.Inasmuch as there is no knowledge concerning the enemy stocks ofAtabrine in Tunisia andbecause of the possibility that existing stocks might be destroyed as aresult of action on our ownpart,or that of theenemy, plans for the prophylaxis of malaria among prisoners of warshouldenvisage that the AUS will supply the Atabrine needed to carry out thisprocedure.
c. Dysentery. Due to the necessarily exposed conditions of prisoncamps, the lack of sanitaryfacilities, and the impossibility of screening cook shacks and messhalls, it is likely thatdysentery will be a problem among prisoners of war. To offset thisthreat, a most rigid andsevere sanitary discipline must be enforced in all prison camps inrespect to the disposal ofhuman excreta and every effort must be made to remove fly breedingsources from the environsof all prison camps to a distance of at least one and one-half miles.Even if such measures areenforced it is likely that a considerable amount of dysentery willoccur and that sulfaguanidine inlarge quantities will be needed for the treatment of this disease.
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Provisions shouldbe made immediately for increasing the supplies of sulfaguanidine inNATOUSA and for maintaining such supplies at a high level. As far as itis known, very little ifany sulfaguanidine is produced in Germany or Italy, hencecaptured supplies will probably benegligible.
The text of the19 March memorandum follows:
Subject: Professional Services for Prisonersof War
1.The anticipated number of prisoners of war as laid down in recent G-3[operations] reportswill throw a heavy strain upon the medical personnel and facilities ofthe AUS in NATOUSA. Inorder to lighten this burden every effort should be made to initiatepreventive measures and tocoordinate medical services for prisoners of war.
2. A primary consideration must be that of personnel, and to this end,it is suggested that medicalofficers be detailed to each secondary forward concentration area toinitiate and supervisesanitary and preventive procedures and to look after the health ofprisoners. As this will be adispensary type of medical practice, such supplies as are needed shouldbe made up and allottedto each concentration area in advance. In order to relieve the strainupon AUS medical personnelthe services of captured medical officers should be utilized at theearliest possible moment in themedical care of prisoners of war. To facilitate this, plans should hemade with the ProvostMarshal to the end that enemy medical officers andmedical corps men should be routed as soonas possible to concentration areas and that this should be done with aminimum of delay and redtape. In the Middle East, the British have utilized the services ofenemy medical officers within24 hours after their capture.
3.The aim of the medical service should he to cut down the average periodof hospitalizationrequired for the treatment of a given disease to a minimum which isconsistent with goodmedical practice. In the instance of infectious diseases which requirehospitalization and forwhich there exist specific therapies, it is well known that the soonerthe patient comes underadequate treatment, the more promptly is a cure accomplished and hencethe shorter is the periodrequired for hospilization. It is likely that acute infections willaccount for the majority ofrequests for the hospitalization of prisoners and in order that theirstay in the hospital will not heprolonged, arrangements must be made for the prompt and rapidevacuation of prisoners of warto medical installations for the definitive treatment of infectiousdiseases. This will require aplan which will cover the evacuation of enemy patients from forwardareas, through the L.O.C.and in the MBS [Mediterranean Base Section] and ABS [Atlantic BaseSection] along the routesand in the base section hospitals, where prison ward facilities shouldbe designated for thereception of these patients.
Uponreceipt of the memorandums, the Surgeon, NATOUSA, had them circulatedto theinterested staff sections. By some accident of fate, instead of theirbeing returned to thesurgeon's office, they were buried in the records section of theAdjutant General's Office,AFHQ, and no action was taken upon the recommendations made in them. ByMay 1943, thebattle for northern Tunisia was well under way, and prisoners of war(fig. 63) began to stream inby the thousands. At that time, it was found that, through agreementsmade at a general stafflevel, the care of prisoners of war taken in northern Tunisia wouldbecome the initialresponsibility of the British. After being processed, the majority ofGerman and Italian prisonerswould then be turned over to the U.S. troops at points near Constantinefor transportation tocompounds in the Mediterranean and Atlantic Base Sections. The Britishwere thereforeresponsible for the initial steps to be taken in the prevention ofdisease in prisoners of war andfor the segregation and division of protected personnel.
In the course of a tourof inspection made by the consultant in medicine
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FIGURE 63.- Prisonersof war, Tunisia, 1943.
during the closing daysof the campaign in northern Tunisia, it was noted that the recommendedmeasures for the prevention of disease among prisoners of war werebeing disregarded by bothof the capturing powers and that little use was being made of enemymedical officers for the careof their own nationals. The following memorandum was prepared for theSurgeon's signatureand was sent to the Provost Marshal General, NATOUSA, on 17 May 1943:
1.Insofar as it is possible prisoner of war medical officers and corpsmenshould he used to assistin the prevention of disease and the care of the sick and wounded inprison compounds.
a. In order to assure an adequate supply ofsuch medical personnel it is therefore recommendedthat enough of such protected personnel he retained in this theateruntil the prisoners of war areall evacuated.
2.Prisoners of war should immediately receive a stimulating dose of 0.5cc. of T.A.B. typhoidvaccine upon entering American prison compounds.
3.Prisoners of war should be placed upon suppressive Atabrine therapy asoutlined in paragraph2, NATOUSA Circular No. 38, dated 20 March 1943, and it is stronglyrecommended that thissuppressive therapy be continued for one month after they reach theirfinal destination in USA.
4.Additional medical supplies required should be requisitioned from theBase concerned.
Bythe first week in June 1943, prisoners of war were arriving by thethousands (fig. 64) in theMediterranean and Atlantic Base Sections, and, although the bareoutlines of compounds hadbeen erected, little else had been prepared for their arrival. None ofthe recommendations as toimmunization had been effected, suppressive therapy with Atabrine wasbeing carried out by fitsand
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starts, and thesanitation within the compounds was generally poor. As a result,malaria anddysentery were rife, and, because of the slowness with which enemymedical personnel wasbeing obtained from the British, American hospitals had to look afterthe prisoner-of-war sick.The following report upon these conditions was made early in June totime Surgeon,NATOUSA:
Diarrhea and Dysentery in Prisoners of War
A considerable amount of dysentery is occurring in prisoners of war in the forward areas.
Prisoners of war are being sent to American areas in very unsanitary convoys.
This results in dysentery developing among prisoners on their way to, and after they arrive in American controlled prison camps.
Because of the unsanitary conditions which prevail, a line of potentially infected material is being created along the railroad line from Constantine to Casablanca. This is evidenced by the following statement taken from Lt. Paul Goetze, ASN 53, 1/44 Flak regiment, German Army:
'On May 31 this officer and 39 other officer prisoners were placed in a barrel car at Constantine. The food provided for them for their trip was adequate, but no water was furnished them and they got none until the second day of their trip. On the first day out 4 officer prisoners developed dysentery and on the next day two more came down with the same disease. Because there were no latrine facilities (not even a flimsy can) in the car they had to defecate in their bread bags, which they then threw out of the railway car. On the second day of the trip, the train stopped and all were allowed to go to the latrine.' This prisoner was taken off the train at St. Barbe at 11:30 A.M. on June 3, 1943, because he was suffering from acute dysentery and was placed in the 16th Evacuation Hospital.
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The fact that prisoners are corning down the line with dysenteryconstitutes a grave healthmenace to American troops because the infected feces will constitutesources of infection allalong the way. Immediate steps should he taken to eliminate unsanitaryconditions along theconvoy line. Latrines should be built at proper intervals and should bepoliced daily. It is saidthat latrines have been contemplated but that little has been doneabout them, because no servicewill take the responsibility for looking after them.
Theconsultant in medicine conferred with the British consulting physician,and the agreed thatthe consulting physician would do all in his power to bring about animprovement in the care ofprisoners of war before they were turned over to the Americans andwould try to expedite themovement of prisoner-of-war hospitals and the needed medical personnelfrom the British to theAmerican areas. After a further conference by these two officers withthe officer in charge ofprisoners of war in the office of the Provost Marshal General, NATOUSA,the followinginformal memorandum was sent to the Provost Marshal General, on 11 June1943:
1.Enemy medical personnel should be segregated until classified andrecommendations aremade as to their disposal by The Surgeon, NATOUSA. This scheme willprovide adequatemedical personnel for the POW camps and will permit us to keep theneeded specialists in thetheater. This has been agreed to informally.
2. The P.M.G. plans for medical care of POW on ships returning to US orUK is consideredadequate from a professional point of view.
3.Those cadres of prisoners of war which will remain in the theater forany length of timeshould receive the various immunizations prescribed in Army Regulationsand modified as tosubsequent doses in NATOUSA.
4.Every effort should be made to maintain camp sanitation. Flies must bekept down to avertoutbreaks of dysentery. Fly-swatting squads should be on duty daily inall compounds in thekitchens and around latrines. Kitchens should be screened.
5.Every effort should he made to expedite the shipment of the capturedhospitals, theirequipment and personnel, to the POW camps in order to relieve Americanmedical personnel.
6. The Consulting Physician (Br) and the Consultant in Medicine (A)will he glad to render anyaid within their province on the professional service aspects.
Unfortunately for all concerned, a sweeping reorganization of theoffice of the Provost MarshalGeneral took place at about the time this memorandum was submitted,causing further delays incarrying out the suggested changes.
Atthe opening of the campaign in Sicily, the preparations for thereception and processing ofprisoners of war in the Eastern Base Section were still primitive, aswas indicated by thefollowing report made by the consultant in medicine to the Surgeon,NATOUSA, on 25 August1943:
* * * * * * *
6.POW Medical Service and Sanitation. One would have imaginedthat the P.M. [ProvostMarshal], EBS [Eastern Base Section] had never been previously informedthat an offensiveoperation was contemplated and that prisoners would he taken. (TheP.M., EBS, complained thathe had had little help from NATOUSA.) When the first prisoners arrived,the stockades werehalf completed, latrine pits not dug, latrine boxes not flyproofed,kitchen facilities and wastedisposal were primitive, water and rations were short, delousingfacilities were lacking, medicalsupplies were short, one medical officer was in the area, and abattalion of the 135th Infantry hadto be used to guard prisoners because but a handful of the P.M.representatives were available.The POW (especially the Italians) arrived ex-
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hausted and ill with dysentery and malaria. Scabies was frequent and venereal diseases were not uncommon. They were herded off the LST's (on which water was frequently short), lined up in the hot sun, and then marched along the main roads to the POW compound. (The result was always an important traffic block.) En route many fell out from heat exhaustion or from other causes. On one occasion a large group of POW burst through their road guards like a bunch of wild animals and practically threw themselves into a badly contaminated well, so great was their thirst. Such conditions were undoubtedly responsible for the lighting up of chronic malarial infections in the prisoners, with the result that they took up hospital beds in the Bizerte-Mateur area which otherwise would have been available for use by American patients. The one medical officer in the compound did a sterling job without much assistance. He selected POW medical officers and corpsmen as his aides, and soon had a smooth running dispensary which took care of many of the medical needs of the prisoners.
As the organization and planning in respect to time care of prisoners of war became more mature, an improvement was noted in the manner in which they were handled, as is evidenced by the following paragraph taken from a report made to the Surgeon, NATOUSA, on 29 September 1943:
1. The following report is based upon data available in the WD MD Forms 86ab for prisoners of war. To obtain information upon the morbidity resulting from certain diseases, the records of the 56th Station Hospital, 16th Evacuation Hospital, 21st General Hospital, 78th Station Hospital, and the 80th Station Hospital were studied. These hospitals were selected because the bulk of the sick prisoners of war who were hospitalized between June 15th and September 15th, entered these hospitals.
a. Morbidity. In the discussion of morbidity the hospitals will be grouped as follows: (1) 56th Station Hospital, 16th Evacuation Hospital, and 21st General Hospital. (2) 78th Station Hospital and 80th Station Hospital. This grouping has been adopted because the prisoners entering the hospitals listed in the first group were Germans and Italians taken primarily in the Tunisian campaign, while those in the second group were primarily Italian prisoners taken during the first phase of the Sicilian campaign.?????????
b. Deaths. All deaths recorded upon the MD Form 86ab for prisoners have been grouped as to cause.
2. Morbidity.
a. 56th Station Hospital. In theperiod from June 11 to August 13, 1943, the total admissions intothis hospital for certain infectious diseases were as follows: (1)Diphtheria-15 cases. (2)Primary atypical pneumonia-11 cases. (3) Tuberculosis-9 cases. (4)Dysentery-532 cases. (5)Typhoid fever-1 case. (6) Malaria-432 cases. (7) Jaundice-28 cases. (8)Smallpox-2 cases.(9) Typhus-1 case.
b. 16th Evacuation Hospital. From June 18th until August 8th, 1943, thefollowing prisoner-of-war patients were received: (1) Diphtheria-5cases. (2) Primary atypical pneumonia-5 cases.(3) Tuberculosis-3 cases. (4) Dysentery-194 cases. (5) Typhoid-1case.(6) Malaria-310cases. (7) F.U.O.-28 cases. (8) Jaundice-8 cases.????
c. 21st General Hospital. From June 18th until September 11th, 1943, the following prisoner-of-war patients were received: (1) Tuberculosis-8 cases. (2) Dysentery-48 cases. (3) Typhoid fever-8 cases. (4) Malaria-157 cases. (5) Jaundice-8 cases. (6) F.U.O.-8 cases.
d. 78th Station Hospital. From July 17 until September 2S, 1943, the following prisoner-of-war patients were received: (1) Primary atypical pneumonia -12 cases. (2) Tuberculosis-16 cases. (3) Dysentery-43 cases. (4) Typhoid-4 cases. (5) Malaria-587 cases. (6) F.U.O.-225 cases. (7) Jaundice-12 cases.
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e. 80th Station Hospital. From July 24 until September 25, 1943, the following prisoner-of-war patients were received: (1) Primary atypical pneumonia -10-cases. (2) Tuberculosis-6 cases. (3) Dysentery-20 cases. (4) Typhoid fever-7 cases. (5) Malaria-609 cases. (6) F.U.O-150 cases. (7) Jaundice-16 cases.??????
f. Total number of patients in each disease category received by the above mentioned hospitals during the stated periods.
(1)Diphtheria-12 cases
(2)Primary atypical pneumonia-38 cases
(3) Tuberculosis-42 cases
(4) Dysentery-827 cases
(5) Typhoid fever-21 cases
(6) Malaria-2095 cases????????
(7) F.U.O.-411 cases
` (8) Jaundice-115 cases<>
(9) Smalpox-2 cases
(10) Typhus-1 case (Another case was reported in an Italian prisoner of war by the 23d Hospital)???????
g. Discussion of observed disease morbidity in prisoners of war. The high initial occurrence of dysentery in patients on admission to the 56th Station Hospital and 16th Evacuation Hospital (ABS [Atlantic Base Section] and MBS [Mediterranean Base Section]), reflects the unsanitary conditions which prevailed along the route and in POV compounds which were not ready to receive the influx of over 200,000 prisoners which were taken at the end of the Tunisian campaign. It is to be noted that as sanitation improved, admissions for dysentery fell. It is interesting to observe that on the contrary in the 78th Station Hospital and 80th Station Hospital (EBS) [Eastern Base Section], the admissions for dysentery were low. This was probably due to a short evacuation route and a relatively well sanitated POW compound in EBS. The admissions for malaria follow a trend which is quite comparable to those noted for American troops so it can be assumed that the patients entering the 56th Station Hospital and 16th Evacuation Hospital at least in part, contracted their disease either in POW compounds or en route to them across North Africa. The patients ill with malaria entering the 78th Station Hospital and 80th Station Hospital during July and the first week in August obviously contracted their disease in Sicily. However, it seems quite probable (and this thesis is supported by a shift from 10 vivax infections to 1 falciparum infection, to 3 vivax infections to 1 falciparum infection in prisoners of war in EBS) that many of the cases of malaria developing after the first week of August were the result of infections incurred in North Africa. The high percentage of F.U.O. noted in the EBS resulted from the non-recognition of sandfly fever, the treatment of true malaria before blood films could be taken, and from inadequate laboratory work due in turn to the influx of febrile patients. On some days as high as 150 or 200 blood films were examined in a single station hospital laboratory. Jaundice has been increasing in the prisoners of war, but not out of proportion to the increase of this disease noted in our own troops. There have been 42 instances of tuberculosis recognized. There are probably more unrecognized cases among the prisoners. It is interesting that 38 instances of primary atypical pneumonia have been noted. The occurrence of 21 cases of typhoid fever is indicative of crowding, imperfect sanitation and incomplete vaccination. As steps have been taken through command channels to re-vaccinate fully all prisoners of war against typhoid fever, a lessened incidence of this disease should be observed in the future. Twenty-one cases of diphtheria occurring in a period of the year in which the incidence of diphtheria is minimal probably reflects crowding, the non-recognition of early cases of the disease and a normal or slightly high carrier rate. It is interesting to note that 15 of these cases were received in the 56th Station Hospital in ABS and occurred in prisoners taken in the Tunisian Campaign. Two cases of smallpox and two of typhus have been recorded in prisoners.
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3.Deaths. The following causes of death have been recorded. These dataare fairly but notcompletely accurate because deaths among prisoners of war occurring inother than the statedhospitals are not listed. Those occurring in POW camps are included.
Cause - Deaths
Malaria - 24
W.I.A - 12
Hypertension - 1
Brain Abscess - 2
Dermatitis exfoliativa (arsenical) - 1
Acute Nephritis - 1
Typhoid Fever -3
Acute Amoebic Colitis - 1
Acute Ulcerative Colitis - 1
Acute Infectious Hepatitis - 1
Carcinoma - 1
Dehydration and Exhaustion - 2
CoronaryThrombosis - 4
Deadon arrival (?) - 1
Respiratoryparalysis - 1
Tuberculosis - 2
Suicide - 1
Killedby guards - 8
Diphtheria - 2
Pneumonia - 3
Accidental - 1
RupturedAppendix - 1
Asurvey of these deathsshows one striking thing; namely, that the case fatality rate frommalaria in prisoners of war far outstrips that observed in Americantroops. An example of this isthat of 2095 admissions to prisoner-of-war hospitals for malaria, 16 or0.77 percent died. Whenone considers the conditions of concentration, surveillance,supervision, etc., under which theprisoners were kept, this is a high case fatality rate. The two deathslisted as 'dehydration andexhaustion' were undoubtedly due to imperfect handling of POW personnelwhile in transit. Thedeaths from diphtheria are tragic.
4.Summary. The recordof the prevention and treatment of disease among prisoners is fair. Twogreat causes of morbidity (malaria and dysentery) could have beenmarkedly reduced if adequatepreparations for the reception and care of prisoners of war had beenmade. The following figures(which are based upon average periods of hospitalization noted forAmerican patients) show thenumber of hospital-bed days taken up by prisoners of war who weresuffering from diseases forwhich preventive measures are well established.
a. Malaria - 31, 425 days
b.Dysentery - 4, 135 days
c. Typhoid fever - 745days
Total 36,305 days
5.Consolidated figuresreceived from the Surgeon MBS, show that 77 cases of typhoid fever inPOW have been admitted to POW hospitals #129 and #130 since July 4th.
Inthe winter of1943-44, the German prisoner-of-war hospital was moved from its formerlocation to Prisoner of War Camp No. 131, and following this move thepersonnel of the hospitallost their 'protected' status and were treated by the local compoundcommander as ordinaryprisoners of war. This violation of the Geneva Convention was noted bythe consultant in
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medicine, in the courseof an inspection of the hospital, and was made the subject of thefollowing report to the Surgeon, NATOUSA, dated 17 May 1944:
1. When the originalGerman POW Hospital was set up near Ste. Barbe, the German medicalofficers and corpsmen were given the full status of 'ProtectedPersonnel' and were allowedrecreational facilities outside of the prison compound afterworking hours. There was at least oneviolation of this status and the offending German medical officerreverted to a POW status.
2.In December 1943,this POV Hospital was moved from Ste. Barbe to its present locationwithin a compound in PW Camp #131, and since that the German medicalofficers and corpsmenhave not been permitted to leave the stockade which in part is guardedby Italian Carbinieri.
3.In the course of aninspection of the professional services of this hospital made upon May10,1944, Dr. Meyer, the German Surgeon of the hospital, stated that therestrictions placed upon hismedical officers and corpsmen represented a violation of the 'ProtectedPersonnel'' clause of theGeneva Convention of 1929, and that as a result of this violation, hedoes not feel that he can askhis officers and corpsmen to behave as 'protected personnel' whenactually in one respect, theyare being treated as ordinary prisoners of war.
4.From time to time,the repatriation of wounded and sick German POV takes place from thishospital and it can he assumed that when such prisoners come underenemy authority, they arequestioned regarding the 'Protected Personnel' status of medical corpspersonnel in the POWHospital, and that retaliatory measures will he taken against AmericanMedical Corps[Department] personnel, now held by the enemy, if the ''ProtectedPersonnel'' status of theGerman medical officers and corpsmen is questionable.
5.It is thereforerecommended that the necessary steps be taken to insure to the fullestextent the'Protected Personnel'' status of German medical corps personnel now inour hands.
Action was immediatelytaken by the Surgeon, MTOUSA, with the result that the ProvostMarshal, Mediterranean Base Section, restored in part the ''protected'status of the medicaldepartment personnel of the German hospital.
Fromthe summer of 1944until the capitulation in Italy, German medical department personnelreceived privileges that were pretty much in accord with the Genevaconventions, and the sickand wounded prisoners of war received adequate treatment. At the timeof the capitulation inItaly, many thousands of sick and wounded Germans and hundreds ofGerman medicaldepartment personnel (fig. 65) fell into the hands of the U.S. Army.The decision wasimmediately taken to utilize all captured German medical installationsto their fullest extent.Two large German hospital centers at Bolzano and Cortina had been takenover, and the capacityof these centers was increased by the addition of isolated hospitalsthat had been captured.Colonel Long made an extensive study of these hospitals in May and June1945 and reported tothe Surgeon, MTOUSA, on 11 June 1945, as follows:
1.This study is basedupon practices observed in German General and Camp Hospitals in theMerano and Cortina and Chide areas and upon interviews and discussionswhich were held withCol. Matisse, the chief consultant in medicine of the German Army Groupin Italy, Lt. Col.Professor Horster. (Wurzburg) Chefarzt of the German hospital in thePalace Hotel, Merano, Lt.Col. Professor Schopper, (Leipsic) Consultant in Pathology to the ArmyGroup, Major AssistantArtz Veith, (Freiburg) Pathologist in the Pathological Laboratory,Merano group of hospitals, Lt.Col. Professor Marks, (Munster) Consultant in Medicine to the 10thGerman Army, Lt. Col.Professor Bock. (Wurzburg) Consultant in Medicine
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to the 14thGerman Army,Lt. Col. Schreiber, Chefartz of the German General Hospital in theSavoia in Cortina, Col. General Menardus, Surgeon of the German ArmyGroup in Italy, MajorPeters, Chief Malariologist, German Army Group in Italy, and numerousStabsartzen in theGerman hospitals which were visited. It is believed that they representa true cross section ofmedical practices in German General Hospitals in Italy. In everyinstance, the German medicalofficers who were interviewed or with whom the Consultant in Medicinewent ward-rounds,were entirely cooperative, were polite, gave out information freely,and were not arrogant. Thisexperience is to be contrasted with that reported by the Consultant inSurgery, who found theGerman surgeons arrogant. Perhaps this observation means that in theGerman army, as in otherarmies which the Consultant in Medicine has had the opportunity toobserve, the physicians ofnecessity are meek and lowly.
2. The medicalpracticesin these German general hospitals were, by and large, very good. Therecords of all patients who were observed were well kept, neat andcomplete. The Germansystem of charting the complete course of the patient upon temperaturecharts from his time ofentry into a hospital installation, made it very easy to follow thecourse of disease in any givenpatient. The laboratory work in general was adequate and while certainof the laboratory testswhich are commonly used in American hospitals were not in evidence, dueeither to a lack ofmaterials or to unfamiliarity with the tests, those which were beingutilized were being usedintelligently. Therapeutic practices were somewhat similar to those inthe American Army, withthe exceptions that more nonspecific protein fever therapy was beingused and there was atendency to employ parenteral products frequently, when from theAmerican point of view,peroral therapy would have sufficed. The medical ward officers in thesegeneral hospitalsseemed to be adequately trained in the art of history taking, physicalexamination and the properutilization of the laboratory tests which were available. TheConsultant in Medicine was struckby the fact that the average period of hospitalization andconvalescence for practically everydisease observed in these German hospitals was considerably longer thanthat in Americanmilitary hospitals in
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MTOUSA. This means that the average noneffective days' rate per patient was higher in the German army. It also appeared that the criteria used for the discharge of medical patients to a civilian status from the German army were less severe than those in force in the U.S. Army.
3. In general, the bulk of the patients seen, except at Chide, were true general hospital types of patients, and in American hospitals would have been classified as 'C' for evacuation to the Zone of the Interior. This same classification would have been given these patients by the German medical officers, had not their 'Zone of the Interior' disappeared during April and May. Hence the eventual disposition of many of the patients will be a problem unless some arrangement can be made for their return to Germany and their discharge from the German army.
4. The following diseases were especially observed:
a. Field or War Nephritis. This disease was quite a problem in the German army in Italy during the winter of 1944-45 and a great problem every winter in Russia. Lt. Col. Professor Marks states that at one time, when he was medical consultant in a hospital center in Germany, he had 3000 cases of Field Nephritis under his supervision. At the time this visit was made it was estimated that there were about 500 patients ill with Field Nephritis in the two hospital centers. The following are points of interest concerning this disease.
(1) Etiology. There is one school of thought in Germany which believes that field nephritis is a virus disease; however, Lt. Col. Professor Marks states that Volhard and others in Germany consider the disease to have the same etiological basis as does the type of hemorrhagic glomerular nephritis seen in civilian life. In surveying the histories of and talking to about 40 patients with this disease, a story of a recently antecedent nasopharyngitis (hemolytic streptococcal infection) was rare and the onset of the disease was ordinarily insidious in nature. The German medical officers considered that sudden chilling or wetting played an important role as a precipitating etiological factor in field nephritis. The average time from the appearance of symptoms and signs to first hospital entry was 10 days.?????????
(2) Facial and ankle edema were the most common presenting signs. headache was uncommon. In a few instances a grossly bloody urine was noted as the first sign.
(3) On entry into the hospital, the common signs were facial and ankle edema, hypertension and a urine which showed from 1 to 2 plus albumin with many hyaline and granular casts and red blood cells. Clinical evidence of cardiac enlargement and uremia were rare. In many instances the NPN was normal and rarely was it highly elevated. Lt. Cols. Professor Marks and Horster both stated that abnormalities of the fundi were rare.?????????
(4) The clinical course of the disease in the patients whose records were examined was quite constant. In most instances the edema disappeared quite promptly and the blood pressure returned to normal within a few days. If the NPN was elevated it also returned to within normal limits within a few days. From this point on, the course of the disease had to be judged primarily from laboratory tests. The albumin slowly disappeared but there was a persistence of microscopic hematuria for weeks and months, and the dilution-concentration tests showed definite abnormalities over long periods of time. These two examinations were the ones which were depended upon most and a normal urinary sediment from repeated fresh morning specimens and normal dilution-concentration tests were used as criteria in determining the cure.
(5) The prognosis for recovery in the great mass of patients was said by the German medical officers to be good. However, it was their practice to recommend for discharge from the army all patients whose urinary sediments and dilution-concentration tests were abnormal at the end of six months' observation. None of the medical officers had had an opportunity to observe the eventual course of patients returned to civilian life. Relatively few patients had died in the acute or subacute stage of this disease while in army hospitals.?????????
(6) The treatment consisted of absolute bed rest, a modified Karrel diet for the first three days, this then followed by fruit and fruit juices for 5 days, and then the patient was placed on a low protein (20 to 40 grams of protein) salt-free diet. Bed rest was
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absolute for about one month and quite well maintained for three months. Lt. Col. Professor Marks also used the 'Hunger and Durst' regime for three-day intervals about once [a month] in all of his patients. Lt. Col. Professor Horster did not use the 'Hunger and Durst' regime. Both observers added salt in gradually increasing amounts to the diets of these patients before they were permitted to be up freely, and it was generally 3 or 4 months before the patients were placed on the normal hospital diet.?????????
(7) Comment. It can be said with certainty that the type of kidney disturbance which has just been described did not occur in any appreciable amount in the American troops who were in contact with time Germans in the northern Apennines during the winter of 1944-45. No explanation for this difference can be offered.
b. Infectious Hepatitis. This disease was first noted in epidemic form in the Afrika Corps in the winter of 1941-42. Later it became epidemic German units in Russia and there was a high incidence of the disease in the German forces in Italy during time fall of i943. In the fall of 1944, while the incidence of the disease was increased, it did not reach epidemic proportions. This, the Germans attributed to the development of a herd immunity throughout their army. The Germans were certain that the disease was caused by a virus, but believed that it was spread by droplet infection. They had no idea that the virus was present in the stool of hepatitis patients.
(1) Diagnosis was made generally after jaundice appeared. The only liver function test employed was the Taka-Arata test.?????????
(2) The sheet anchor employed by time Germans in the treatment of hepatitis was absolute bed rest for 4 or more weeks. The diet used was of the conventional, old fashioned, high-carbohydrate, low-fat type. The average period of hospitalization was eight weeks. Relapses have been uncommon since the prolonged hospitalization program has been in effect, but were very common initially in the Afrika Corps when patients with hepatitis were either kept on duty or were released from hospital when their jaundice had disappeared. The intensive hospitalization program began about the middle of 1942 and has been strictly adhered to since.
(3) The Germans have conducted fairly thorough studies of the pathology of hepatitis by means of 'liver-punch' biopsies. Their findings are in line with those made in this theater.??????
c. 'Trench Fever,' Volhynia Fever. There were hundreds of cases of this louse-borne disease among troops in the Mediterranean area in the winters of 1943-44, 1944-45. It reached epidemic proportions in German troops in Russia.
d. Atypical Primary Pneumonia. The German medical officers insisted that this disease was unknown (unrecognized?) in Germany prior to 1939. The first appearance of this disease in the German army occurred in Greece in 1941, at which time it was considered a 'new' disease. Following the publication of abstracts of American papers upon this disease in German, the true nature of the 'Grecian' disease was recognized. Since that time it has appeared sporadically in the German army. It is the opinion of the consultant in medicine that there has been much more atypical pneumonia in the German army, but because routine roentgenograms of the chest were not made (only sparingly so) the disease was frequently missed. At one hospital in which X-ray films of the chest were made frequently, an approximately normal admissions rate for this disease was noted.??????
e. 'Trench Foot.' As the Germans said, a word for this condition does not exist in the German language. Plenty of true frostbite was seen in the Russian Campaign but all German medical officers stated that they had not seen 'Trench Foot' in German soldiers in MTOUSA during the winters of 1943-44 and 1944-45. In fact some of them said that they had traveled many miles to observe American prisoners of war who were suffering from 'Trench Foot.' They attributed this absence of 'Trench Foot' to:
(1) Excellent foot hygiene and discipline.
(2) The easily removable high leather German field boot.
(3) The four pairs of thick but loosely woven all-wool high stockings provided to German forward troops in winter.
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f. Peptic Ulcer. Many patients suffering from peptic ulcer were seen. All had been confirmed by roentgenograms and all were being treated by low residue diet without alkalies. The average period of treatment was 4 weeks. Patients with initial severe symptoms, with gastroenterostomies or with partial resections of the stomach were discharged to the particular 'Magen' battalion which represented their part of Germany. There they were given light duties and low residue diets based upon the accustomed diet of their part of Germany.??????
g. Diphtheria. The Germans have been experiencing an increased incidence of diphtheria during the past year. A fair amount of diphtheritic paralysis has followed this disease. It is the opinion of the medical consultant that low initial doses of antitoxin (10-20,000 units) were responsible for this increased incidence of paralysis.
h. Amoebic Disease. Stool-carrier studies conducted in German troops in Italy during the fall of 1944 showed an incidence of 14 percent cyst carriers. Amoebic dysentery is not uncommon and has been treated with emetine and Yatrin with good results. Amoebic hepatitis and amoebic abscess have not been very common.??????
i. Streptococcal and typhoid-paratyphoid infections occurred in the German Army in Italy somewhat more frequently than in the American army. The treatment of these diseases was similar to that used in the American army.
5. General Comments??????
a. German rations for the staff and patients in hospitals in the Cortina area were available for about ten days more at the time of this inspection The Consultant in Medicine was informed by the commanding officer of the 379th Collecting Company that at the end of that period, the patients in German hospitals would receive the American hospital ration, while the Medical Department staff will receive type 'C' rations. If this is correct, then title III, chapter 2, article II, Treaty Series No. 846 which was proclaimed by the President of the United States, 4 August 1932, is being violated, because it is distinctly stated 'The food ration of prisoners of war shall be equal in quantity and quality to that of troops in base camps.' It is being argued that inasmuch as Germany did not observe time Geneva Convention, we do not have to treat their prisoners of war in accordance with the Convention. Such reasoning is specious and it should always be remembered that 'two wrongs do not make a right.'
b. It is the opinion of the Consultant in Medicine that our aim should be to utilize every method to get the German sick well, or if they are suffering from known chronic disease to give then a certificate of discharge for disability as soon as such a course is feasible. To this end it is therefore recommended:?????????
(1) That our treatment directives be sent to all German hospital installations with instructions that they be translated into German and be used as the basis for treatment.
(2) That penicillin be made immediately available for the treatment of acute and chronic gonorrhea, acute syphilis and such other diseases in which the use of this antibiotic has been shown to be timesaving in the cure of disease. The present methods used by the German Medical Corps for treating gonorrhea have produced resistance to sulfonamide therapy with the result that time-consuming methods (intermittent fever therapy, prostatic massage, irrigation, etc.) are being used in the treatment of chronic infections and patients are being discharged before a bacteriological cure has been affected. It would seem important to use penicillin in these patients because eventually a certain number of them will return to the area being occupied by the American Army in Austria or Germany, and there will become foci of infection in the civilian population.
c. It is recommendedthat Colonel General Menardus be sent to Germany and be discharged fromthe German army at the earliest possible moment. His presence in theCortina-Merano area isunnecessary and somewhat confusing.
Insummary, it may besaid that during 1943 and early 1944, the consultant in medicinefrequently encountered serious problems in carrying out the
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FIGURE 66.-Germanprisoners of war, Italy, 1945
duties specificallygiven to him by a verbal order of Maj. Gen. Everett Hughes, DeputyTheaterCommander, NATOUSA.
General Hughes hadstated unequivocally, 'I want prison camps, both disciplinary and POW,runin a strict but humane fashion.' At tunes, the level of care inprisoner-of-war camps wasexcellent and in full accord with these orders (fig. 66). At othertimes, it was considerably lessgood, chiefly because of thoughtless administrative practices in lowerechelons. The solution ofthe problem was strict adherence to the Geneva Convention dealing withthe treatment ofprisoners of war, and the consultant in medicine, wheneverinefficiencies were detected, made ithis business to see that those in charge of these men fully understoodtheir responsibilitiestoward them.
NUTRITION
Inthe course of a tourof inspection of British military hospitals made 13 to 20 January 1943,theconsultant in medicine heard his first complaints concerning themonotony and unpalatability ofthe C ration. At the same time, complaints from American units attachedto British units wereheard in respect to the monotony and lack of bulk of the compoteration. However, during thistour, clinical evidence of vitamin deficiencies was not noted in
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American soldiers, andthe January 1943 sanitary reports did not mention vitamin deficienciesand contained few complaints about rations. The sanitary reportsarriving in February andthereafter however, increasingly mentioned various inadequacies notedin the rations. Thesecomplaints were especially frequent from the Army Air Force units,which, operating in forwardareas where conditions were often difficult logistically, werecompelled to exist for considerableperiods of time upon emergency or unbalanced rations.
Itwas not until the IICorps was visited in northern Tunisia, in April and May 1943, thattherewere bitter reports about the rations, and vitamin deficiencies werenoted. Battalion surgeonsreported that their men had been fed C rations for such long periods oftime that they had ceasedto eat them and that the continued use of these rations producednausea, vomiting, and diarrhea.These surgeons stated also that their men were undernourished. Theconsultant in medicinechecked upon these reports by observing and interviewing men of the 3dBattalion, 39thInfantry, and patients in the evacuation hospitals. He found himself inagreement with thebattalion surgeons. During this same period, he also observed patientssuffering fromdeficiencies of vitamin A, thiamine, riboflavin, nicotinic acid, andascorbic acid in theevacuation hospitals of the II Corps.
Theextent ofundernutrition observed in the II Corps prompted the consultant inmedicine, on 1May 1943, to recommend to the Surgeon, NATOUSA, that a board ofofficers be appointed toascertain the facts and make recommendations concerning the diet ofcombat troops in thistheater. The consultant's recommendation for the appointment of a boardwas accepted by theSurgeon and was forwarded in the form of a memorandum to the deputytheater commander on15 May 1943. After being circulated by the Chief of Staff to G-4(logistics (supply)) and thequartermaster sections, where it was received favorably, the memorandumwas submitted to theDeputy Theater Commander who returned it to the Surgeon, with thesuggestion that thedifficulty lay in the misuse of the C ration rather than the rationitself. The Surgeon then againrecommended that a board of officers be appointed, but the DeputyTheater Commander negatedthis suggestion.
The2-month period thatelapsed between the end of the campaign in northern Tunisia and theopening of the Sicilian campaign was one of great activity along thewhole North African coastand especially in the Eastern Base Section. Troops were being trained(fig. 67) for amphibiousoperations in this period, and their diet varied from C to fullybalanced B rations. Supplies of alltypes were being poured into the Eastern Base Section, and there,inevitably, the B rationbecame unbalanced. Caloric estimates, prepared by the 56th EvacuationHospital, demonstratedthat during June, July, August, and September 1943, the average caloricvalue of the B ration, asissued in the Eastern Base Section, was in the neighborhood of 2,500calories per day.
Fourof the sixdivisions entering the Sicilian campaign had been, relatively orcompletely,inactive as far as combat was concerned, but the other two divisionshad seen extensive serviceduring the Tunisian campaign, during which, toward
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FIGURE 67.-Amphibioustraining.
the end, patients withclinical nutritive deficiencies had been received in hospitals of theII Corpsfrom both divisions.
During the initialstages of the Sicilian invasions, the majority of the troops subsistedupon C andK rations (fig. 68), but, as the campaign progressed, 5-in-1
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FIGURE 68.-U.S. ArmyField Ration K and British Ration.
and modified B rationsmade their appearance. This was especially true of those divisions thattook the western half of the island because, in addition to rationsissued to them, variety andnutritive value were increased by the capture of a certain amount offrozen beef and Germanfield rations (fig. 69), as well as by local purchase. The troops inthe II Corps which wereprogressing towards the northeast were not so well off, becausetactical conditions were suchthat C and K rations frequently had to be issued, especially to combatinfantry units. However,owing to the shortness of the campaign and to the fact that troopreliefs were made, localforaging was permitted, and the 5-in-1 and modified B rations wereprovided early, it seemslikely that the nutritive status of the combat many during the Siciliancampaign was better thanin any previous, or any subsequent campaign in 1943. However, at thispoint, that part of WDCircular No. 208, 1943 that dealt with percentage reduction of theauthorized allowances forfield rations based upon unit strength, was activated by section III ofNATOUSA Circular No.164, dated 29 August 1943. This move resulted in penalizing members oflarge units at theexpense of small units and did not fulfill its anticipated purpose ofsaving food. In fact, theevidence at hand showed that it contributed further to the generalstate of undernutrition thenexisting in NATOUSA.
Again, following theSicilian campaign, a period of intensive training took place, but, as Brations were used largely during this period and many of the troopunits were well rested andwell fed, one can conclude that the opening of the Italian campaign wasmade with troops in afairly good state of nutrition. The term 'fairly' is used advisedly, inview of the fact that theexpeditionary-force B ration was a deficient ration, as was shown bythe quartermaster board
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project. However, as theItalian campaign evolved, the nutritive status of divisional troops,especially the infantry progressively deteriorated. This was because of(1) the longtimeemployment of troops in combat, (2) tactical situations that made C orK rations the sole rationsfeasible for use, (3) the unbalancing of the B ration as evidenced by50 percent substitutions oreliminations on certain days, and (4) the use of a summer type Bration, which had not beenchanged to meet the energy requirements of continuous hard fighting andcold weather.
Thus,by the end ofNovember 1943, while the nutritive status of Peninsular Base Sectiontroopsand service troops in armies, corps, and divisions was constantlyimproving, that of the combatinfantry troops was progressively deteriorating. During the end ofNovember and in December, asurvey of nutrition in NATOUSA was made by Col. Paul E. Howe, SnC,Chief, NutritionSection, Office of the Surgeon General, and Colonel Long. Grossevidence of nutritionaldeficiencies was observed in the course of this tour and the followingrecommendations weremade: (1) That the percentage reduction in rations as provided forsection III, NATOUSACircular No. 164, dated 29 August 1943, be eliminated; (2) that thatpart of section I, par. 3,NATOUSA Circular No. 122, dated 27 June 1943, forbidding the drawing ofexcess rations, beeliminated; (3) that the pertinent parts of WD Circular No. 208,paragraphs 16b and c dealingwith increased issues, be made effective immediately in
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FIGURE 70.-Fresh breadfrom 110th Quartermaster Bakery Company, Italy, January 1945.
NATOUSA; (4) that combat and other troops, who, owing to the prolonged use (3 or more days) of C, K or other nutritionally deficient rations be subjected to nutritional rehabilitation until the estimated caloric loss has been restored; (5) that monthly reports be rendered by army and base section commanders on elimination and improper substitutions within the B ration; (6) that menus be provided and that issue sheets, indicating the proper amounts of food to be drawn, be issued to all organizations drawing rations; and (7) that multivitamin capsules or tablets be issued automatically to all troops subsisting for 3 or more days upon C or K rations. These recommendations were under consideration at the end of the year. Recommendations (1) and (2) were accepted officially, and (4) was being carried out unofficially in the Fifth U.S. Army and in the hospitals of NATOUSA. Time B ration was improved markedly during the last 2 weeks of December by the addition of frozen meat, poultry, bread (fig. 70), and fresh butter.
Latein May 1943, aconference group was appointed, under the chairmanship of Brigadier R.M.Hinde, O.B.E., to consider establishing an interallied common rationscale. The possibility ofevolving a common ration had been contemplated for some time, and,following approval of thedeputy theater commander, the chief administrative officer (British),AFHQ, had nominated thiscommittee with the consultant in medicine as one of the two Americanmembers. The functionof the committee was to consider the matter from all angles and tosurmount any difficulties thatmight prevent the proposed scale from being put into operation.
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Several sessions wereheld beginning 13 June 1943. At the first meeting, it was pointed outthat acommon ration scale would save duplication of depots as well asshipping tonnage and foodsupplies, both in the United States and in the United Kingdom. Furtherdiscussions made clearthat the existing British scale lacked variety and many issues were toolow in quantity. BrigadierHinde called upon the medical member of the committee to submitschedules of the calories,vitamins, minerals, variety of foodstuffs, and similar items that wouldconstitute an adequatecommon ration scale. This was done after a series of joint conferencesand was accepted with afew minor modifications by the committee at a meeting on 8 July 1943.The proposed scale wasreferred to the Quartermaster Section and by it to Headquarters,Service of Supply. The latteroffice added a few minor changes, and in addition, suggested that a10-day cycle and issue chartbe prepared and that the ration be fed to test groups of individualsfrom both armies before beingformally adopted. These suggestions were agreed upon by the committeeon 29 July 1943.Nothing has been heard of the interallied common ration scale sincethat date.
Although the rations forcombat troops became temporarily unbalanced during periods of intensefighting in 1944-45, situations such as existed in 1943 were rarelyencountered. The nutrition ofall in the theater was at a relatively high level, especially duringthe stabilization of combat inthe high Apennines during the winter of 1944-45. The breakout into thePo Valley, with thesubsequent drive towards the Alps, was so rapid and through country sorelatively well suppliedwith food that the nutrition of the force was never a serious problem.
RECONDITIONING
Theproblems associatedwith the physical rehabilitation of sick and wounded soldiers becameapparent in the late spring of 1943, when patients convalescent fromvarious diseases and fromwounds were being discharged directly to the replacement depots. It wasfound that many ofthem, although convalescent and in need of no further medicalattention, were in such a poorphysical state that they could not undertake the training programs thenin force in thereplacement depots. Accordingly, the Surgeon, NATOUSA, requested theadvice of theconsultants in surgery and medicine in respect to the physicalrehabilitation of convalescentpatients. At the direction of the consultants, Maj. (later Lt. Col.)James H. Townsend, MC, 6thGeneral Hospital, and Capt. Lewis T Stoneburner, III, MC, 45th GeneralHospital, were detailedto make a study of all convalescent and rehabilitation facilitiesexisting in the theater. After astudy of the problem in the 2d Convalescent Hospital, the Palm BeachConvalescent Camp, the1st Replacement Depot, in numerous station and general hospitals, andin the 8th and 10thBritish Convalescent Depots, these officers made the followingrecommendations on 30 August1943, which were favorably endorsed by the consultants in surgery andmedicine and approvedby the Surgeon, NATOUSA.
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* * * * * * *
3. Conclusions.??????
a. It is believed that theme is a clearly demonstrated need for some type of installation in this theater for the rehabilitation of men who have completed their treatment in general hospitals and station hospitals acting as general hospitals, who by virtue of their long periods of hospitalization and absence from their units, are in need of physical reconditioning and mental reorientation before undertaking the training program of replacement centers.
b. It is believed that this can be most effectively accomplished with an organization under the administration of line officers with the assistance of a suitable medical detachment and continuous liaison with the medical department.??????
c. An installation organized as a separate training battalion with a slightly augmented medical detachment is believed to be well suited to this purpose. It could be an independent installation, or attached to a replacement center.
d. The outline of the organization and operational program of such an installation are appended. They do not differ materially from what is already in operation at the Combat Conditioning Battalion of the 2d Convalescent Hospital, and at Palm Beach.
4.Recommendations.??????
a. That in each geographical center of hospitalization in this theater a rehabilitation center be established to recondition men discharged from hospitals who are to be returned to combat duty.
b. That such installations should be organized under line administration with a suitable medical detachment.
c. That professionalliaison be established between hospitals, rehabilitation centers andreplacement centers to insure optimum results in the functioning of thewhole program.
Thepolicy laid down inthese recommendations, namely, that it was not the mission of theMedical Department to train men for combat or other army duties, wasaccepted by the Surgeon,NATOUSA, who, however, took no specific action upon the report of MajorTownsend andCaptain Stoneburner. Early in 1944, reconditioning units, whose solepurpose was to rehabilitatepatients to the point where they could undergo the type of trainingrequired in the combat.reconditioning companies and in the training sections of thereplacement depots, wereestablished in most station and general hospitals (figs. 71 and 72) inthe theater. The efficiencyof these units varied with the enthusiasm and interest of thenoncommissioned andcommissioned officers who were in charge of them. However, with thedevelopment of exercisetolerance as a test for cure in patients convalescent from hepatitis in1944, the physicalreconditioning program was given a boost, and it functioned in asatisfactory manner during theremainder of the life of the theater.
PROFESSIONAL EDUCATION
Fromthe beginning ofhis duties as consultant in medicine in the North African theater,ColonelLong attempted to stimulate and plan the graduate education of medicalofficers, believing that aprogram of graduate education would materially assist in themaintenance of reasonablestandards of medical practice within the theater. It has been notedearlier in this chapter thatmedical officers of service and tactical units were isolated frommedical thought. In a reportmade to the Surgeon, NATOUSA (Deputy Surgeon, AFHQ) on 25 January 1943,the consultantin medicine made two recommendations.
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FIGURE 71.-Occupationaltherapy, 21st General Hospital, Italy, 1944.
First, every effortshould be made to improve the professional standards of unit medicalofficers by conferences, short courses, lectures, meetings (fig. 73),and similar methods. Suchprograms could be carried out when divisions and units were in restareas. The consultant staff,Medical Section, NATOUSA (AFHQ), and the staff of general, stations,and evacuationhospitals could be used as instructors. Second, all circulars,directives, and other mediumsdealing with the professional aspects of patient care that mightoriginate from the MedicalSection, NATOUSA (AFHQ), should be prepared insuch quantities that a copy of each mightbe placed in the hands of each unit medical officer.
Hospital Programs
During his first tour ofall American hospitals in NATOUSA, completed in March 1943, theconsultant in medicine had noted that, although the general caliber ofprofessional work upon themedical services was excellent, the libraries in certain hospitals werenot very accessible orcomplete, and, in some hospitals the holding of medical conferences orstaff meetings had beenabandoned. Upon his recommendation, Circular Letter No. 2, dated 18March 1943, Office ofthe Surgeon, Headquarters, NATOUSA, was distributed to the commandingofficers of all field,evacuation, station, convalescent, and general hospitals. It read asfollows:
1.The Surgeon, NATOUSA,has been impressed with the high standards of professional servicewhich exists in the army hospitals in NATOUSA, and he desires thatevery effort
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FIGURE 72.-Reconditioning, 21st General Hospital, Italy, 1944.
be made to maintain or even increase the levels of professional practice. To this end it is suggested:??????
a. That hospital libraries be placed in a position where they are easily available to all members of the hospital staff and that the Office of the Surgeon, NATOUSA, be notified immediately of any deficiencies noted in medical books and journals.
b. That medical officers be encouraged to study the clinical course of interesting groups of patients with the viewpoint of collecting adequate data upon which medical and surgical reports may be based. It is suggested that completed papers be submitted to the Surgeon's Office, NATOUSA, for editing and forwarding to The Surgeon General.????????
c. That weekly clinical or clinical pathological conferences be held by the staffs of all hospitals in NATOUSA.
d. That when theopportunity arises members of one hospital staff will visit neighboringhospitals for the purpose of observing professional practices.
As aresult of thisletter, deficiencies in time libraries of hospitals were corrected,weeklymedical meetings were instituted as a regular procedure in allhospitals, and papers dealing withdisease in the North African theater began to be sent in forpublication. Thus was initiated acontinuous program of practical medical education, which lastedthroughout the life of thetheater.
Meetings and Societies
Withthe grouping andconcentration of hospitals in certain areas such as Oran, Bizerte,Naples,Leghorn, and in time Fifth U.S. Army area, it was
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only natural to expectmedical officers to organize medical societies. As a result of suchactivities the Mediterranean, Eastern and Peninsular base medicalsocieties were organized, andthese flourished as long as the base sections existed. A particularlyinteresting organization wasthe Fifth U.S. Army medical society, which held its weekly meetings inthe opera house of thepalace of Caserta in the winter of 1943-44. The success of these parentorganizations led to theformation of specialist groups such as the Peninsular Base Sectionneuropsychiatric association,which was active through 1944.
Hospital sponsoredmeetings and societies. - The large general medical societiesserved averyuseful purpose because the topics presented were of a practical andtimely nature, and thesessions of these societies provided a common meeting ground formedical officers in thevarious areas. The success of these meetings led individual hospitalsto sponsor medicalmeetings; those of the 26th General Hospital at Bari, Italy, and the8th Evacuation Hospital whenit was located near Raticosa, are worthy of comment. The 26th GeneralHospital functioned asthe general hospital for the Fifteenth Air Force from January 1944until June 1945, and, becauseof its central location within that air force, was accessible tosquadron surgeons. Hence, itsmedical meetings were well attended and served a very useful purpose inkeeping the medicalofficers of the Fifteenth Air Force au courant with the latestdevelopments in medicine. The 8thEvacuation Hospital (fig. 74) conducted a series of afternoon andevening meetings for medicalofficers of field units that were near the Florence-Bologna road duringthe first 4 months
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FIGURE 74.-8thEvacuation hospital, Italy, January 1945.
of 1945. At times, theprogram was presented by the personnel of the 8th Evacuation Hospital;atother times, guest speakers were present. The meetings were soorganized that an afternoonprogram of 2 hours' duration was followed by the opportunity to take ahot shower, followed bycocktails and dinner, and in the evening another scientific program waspresented. Thus, theneeds of both mind and body were met. The attendance at these meetingswas always large.
Interallied meetings. -During the life of the North African and Mediterranean theaters therewere several large meetings that were interallied in scope. The firstof these, organized under theaegis of the Surgeon, Mediterranean Base Section, was held in Oran,Algeria, on 6 November1943. Owing to the geographical location of Oran, the meeting waslargely attended byAmerican and French medical officers, and papers were presented byofficers of bothnationalities upon subjects of current interest. An attractive featureof this meeting (fig. 75) wasa series of exhibits dealing with the work of optical units, malariasurvey and control units,certain aspects of medical supplies, the treatment of fractures, andother interesting subjects.
Thesecond large medicalmeeting was the Interallied Medical Congress, which was held inAlgiers, Algeria, 21-24 February 1944. Membership in this congress wasopen to medicalofficers of the Allied nations and to French civilian physicians inNorth Africa. Unfortunately,owing to the transpor-
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tation situation and theproblem of billeting, American and British participation in thiscongresshad to be limited to medical officers who were then resident in NorthAfrica. Despite thislimitation, the congress was well attended - over a thousand membersregistered - and thesubjects of typhus, venereal diseases, malaria, dysentery,neuropsychiatric conditions, andmilitary surgery received special attention.
Thethird large medicalmeeting was sponsored by the 26th General Hospital and was held inBari, Italy, on 4 November 1944. The program was designed to be ofcurrent interest, and amongthe speakers were both British and American medical officers.Transportation to and from thismeeting was mainly aerial, made possible through the cooperation of theFifteenth Air Force andthe Air Transport Command. Several hundred medical officers attendedthis meeting.
Thefourth large meetingwas organized by the 300th General Hospital in Naples and was heldon 26 and 27 January 1945. The program was presented largely by thestaff of the hospital,although certain papers were presented by British and other Americanmedical officers. Afeature of this meeting was the fact that most of the more than sixhundred American and Britishmedical
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officers who attendedwere billeted in the hosptal. They were transported to and from Naplesbyair.
Thefifth and last largemeeting was the conference of Army physicians, which met in Romefrom 29 January to 3 February 1945. It was organized by BrigadierBoland, the Britishconsulting physician of AFHQ. The membership was made up primarily ofthe officers in chargeof medical divisions and time medical specialists of British, Canadian,South African, NewZealand, Indian, and Polish general hospitals and casualty clearingstations, but more than fiftychiefs of the medical services of American hospitals in the theaterwere invited to attend. Inaddition, the consulting physicians from the Middle East Force, EastAfrican Command, Persiaand Iraq Force, South Africa, New Zealand Corps, Canadian Corps, andthe consultant inmedicine and the Surgeon, MTOUSA, were in attendance. Thus, a widevariety of opinion wasrepresented, and the sessions in which malaria, diphtheria, infectioushepatitis, trenchfoot,amebiasis, penetrating wounds of the chest, neuropsychiatric problems,and the medical uses ofpenicillin were covered, were well attended, and the subjects werefreely discussed. Ample timewas taken out during the conference to permit visits to places ofinterest in Rome, an audiencewas granted the members of the conference by the Pope, and thedelegates were invited to a widevariety of social functions. It was considered one of the mostsuccessful meetings held in theNorth African and Mediterranean theaters.
Rotation of MedicalOfficers
Theproblem ofcontinuing the graduate education of field service medical officersattracted theattention of the consultant in medicine within the month after hearrived in North Africa, whenhe noted the paucity of opportunity for these officers to do anythingresembling the practice ofmedicine as they had known it. It was almost impossible, because of thevarying tacticalsituations, to place these officers in hospitals for periods oftemporary duty. In May 1943, at thesuggestion of the consultant in chemical warfare medicine, a flexibleplan for rotating medicalofficers from service and combat units to hospitals was devised. Theplan envisaged thereplacement of all medical officers, after varying periods of combatduty, by general dutymedical officers from army hospitals within the theater. This plan,which was never enumeratedas official policy, had as its purpose the professional rehabilitationof medical officers who hadlong been removed from the practice of medicine. Initially, minoropposition was presented bycommanders of the field units and the hospitals concerned, because bothgroups of commandersdisliked giving up trained and known medical officers for unknown ones,but, when the planbegan to function and its merits were understood, this oppositionquickly disappeared. As aresult of this program, more than three hundred service and combat unitmedical officers wererotated from the field to hospital services during the existence of theNorth African andMediterranean theaters.
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Plans for Postarmistice Training
On 30 August 1944, the consultant in medicine initiated an action by sending to the theater surgeon a memorandum, subject: Proposed Staff Memorandum of a Plan for the Postarmistice Professional Rehabilitation in North African Theater of Operations, United States Army of Field Service and Administrative Medical Officers in Internal Medicine, which read as follows:
1. There are many medical officers in NATOUSA who have not had adequate contact with the practice of medicine for extended periods of time. This is especially true of field and administrative service medical officers, many of whom have been out of the practice of medicine, as it is commonly understood, for from 2 to 3 years. The experience of this theater indicates that medical officers who have been in the field or administrative services for a year or more require from 3 to 6 months training before they can be fully trusted with the care of patients upon the wards of station or general hospitals. To date no plan for training which will rehabilitate these medical officers in the art of taking care of patients, has been put forth either by the War Department or civilian agencies at home. It is believed that if the following plan could be made effective in NATOUSA immediately in the postarmistice period, that the morale of medical officers would be maintained and that this theater would be performing a definite service, not only to the civilian population bitt also to the Army as well.
2. Plan for the professional rehabilitation of medical officers in NATOUSA.??????
a. Post graduate training must be carried out upon a temporary duty basis, with the student medical officers assuming definite ward responsibilities in the hospitals to which they may be attached.
b. The period of training should be 6 weeks in duration and the program can be carried out in all General and the 7th, 23d, 182d, and 225th Station hospitals.????????
c. The primary aim of the rehabilitation program should be to refresh medical officers in the techniques of history taking, physical examination, the value of laboratory diagnostic procedures and the advances which have been made in medicine since 1940. This can best be accomplished by giving the student medical officers direct responsibility (under competent supervision) for the management of ward patients, by formal teaching ward rounds, lectures upon special subjects, X-ray conferences, clinical pathological conferences and journal clubs. The training program should concern itself primarily with general internal medicine, but special emphasis should he placed upon the newer aspects of the diagnosis and treatment of venereal diseases, modern concepts of dietary regimes, and a thorough review of indication for use and the practical application of penicillin, etc.
d. The modus operandi could be as follows: There are approximately 100 ward medical officers in the general and station hospitals which have been listed, and there are roughly 675 field service medical officers in NATOUSA. Obviously, it is impossible to estimate how many of these officers will desire training in internal medicine. It is suggested, therefore, that upon the signing of the armistice a paragraph outlining the scope of the program be published in a NATOUSA Circular and that application for training he filed through command channels. Priority on training would be given to those officers who have been longest in field or administrative medical positions, irrespective of whether such service was in the United States or overseas. It is the consensus of opinion that from 45 to 50 medical ward officers (and as the surgical service will be light, surgical ward officers would also be available) could be placed on 6 weeks temporary duty with field units as replacements for the trainees. Additional candidates for the program, for whom replacements would not he necessary could be obtained from the administrative services. Is it estimated that from 75 to 100 medical officers could be rehabilitated at a time under such a system.??????
e. In order to assure the smooth functioning of this program it would be necessary to have a 'school director' attached to the Office of the Surgeon, NATOUSA. His duties
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would be toselectcandidates and to supervise and coordinate the proposed program. Thisofficershould be attached to the Office of the Surgeon, NATOUSA, whenthearmistice seemsimminent, in order that the program may be started as soon as thetactical situation in the theaterbecomes stabilized.
This memorandum was thoroughly discussed with the Surgeon, MTOUSA, and upon his recommendation, it was decided to suspend action upon this plan until it appeared that the enemy was about to surrender.
Early in March 1945, the end of hostilities in the Mediterranean theater seemed imminent, and a committee, under the chairmanship of Col. Edward
D. Churchill, MC, was formed to make plans for graduate education in the postsurrender period. This group held its first meeting on 15 April 1945, and the following recommendations were made to the Surgeon, NATOUSA.
a. A director of Professional School Service should be appointed to the staff of the Surgeon, MTOUSA, and implemented with clerical aid.
b Authorization of courses as official War Department school courses should be sucured.????
c. When the program has been formulated, a circular letter or bulletin describing the program should be distributed to every medical officer in the theater.
d. General hospitals and the 7th Station Hospital should be requested to submit plans for a basic course in accord with the following general policies:?????????
(1) Medical officers attached to a general hospital for a basic course are to be regarded as students and will not he used for army other function except in an emergency.
(2) A basic course of 6 weeks duration will he designed so that a student may enter at any time and, when essential, depart at any time.?????????
(3) General hospitals will plan for 20-25 students each at a time; the 7th Station Hospital will plan for 7 students.
(4) Supplemental professional teaching personnel will be supplied, when available, by the director of Professional School Service. The mobile hospitals will be a source of personnel for this purpose.?????????
(5) The course will include: clinical pathology, general medicine, general surgery, preventive medicine, and neuropsychiatry.
(6) Ward rounds in general medicine or general surgery will he conducted by a senior officer. In addition, there will be clinics, clinicopathologic conferences, X-ray conferences, didactic lectures, round-table discussions and journal club meetings.??????
e. The director of Professional School Service shall also arrange elective courses, usually of 2 weeks' duration, in the following: Field course in preventive medicine, (malaria control, typhus, enteric diseases, venereal disease). In general, these should follow completion of the basic course.
The Surgeon, MTO1IJSA,accepted the recommendations of the committee, and shortlyafterwards, Lt. Col. Joseph O. Weilbaecher, Jr., MC, of the 64thGeneral Hospital was placed ontemporary duty in the Office of the Surgeon, MTOUSA, as director ofprofessional schoolservice. Colonel Weilbaecher immediately made a detailed study of theproblem of setting up thedesired courses in the general hospitals of the theater, and, at thecompletion of his study, Hesubmitted a comprehensive plan for instruction over a 6-week period.This plan was accepted bythe Surgeon, MTOUSA, shortly after the surrender of the enemy in Italy,but it could not be putinto effect immediately because of the redeployment program. After thecompletion of theredeployment program early in July, it was found that the staffs ofcertain hospitals had been so
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disrupted as to makethem unavailable for teaching purposes, and in the end, it was foundnecessary to shift from the rather formal course that had been planned,to on-the-job training inthe 33d General Hospital, Leghorn, Italy, 64th General Hospital,Ardenza, Italy, and the 300thGeneral Hospital. Undoubtedly, some benefit was derived by the medicalofficers who receivedtraining in these hospitals, but the experience of the Mediterraneantheater definitely showed thedifficulty of organizing and carrying out postgraduate training at sucha time, and it appearedthat completely satisfactory programs for medical education could notbe devised during periodsof redeployment.
RESEARCH PROBLEMS
Itbecame evident to theconsultant in medicine early in 1943 that practical and, possibly, somefundamental contributions to medical knowledge might be made in anoversea theater ofoperations, if the investigative spirit that lay dormant in manymedical officers was stimulated.In the course of his first tour of inspection of hospitals, interestingproblems were noted inrespect to the etiology of diarrhea, the significance of chronicdyspepsia in the Army, thetreatment of gonorrhea, the treatment of anxiety states, and thedescription of exotic diseases,and medical officers were asked to send papers on these subjects to TheSurgeon General.
Malaria. - Theinitiation of the policy of universal Atabrine therapy for thesuppression ofmalaria in the Allied Forces offered excellent opportunities for thestudy of the toxicology andpharmacology of the drug, and in a report to the Surgeon, NATOUSA,dated 17 May 1943,recommendations were made regarding the possibility of making suchstudies.
1.The next six monthsare going to offer unrivaled opportunities for the study of the effectsofAtabrine therapy in respect to its actual effect in suppressingmalaria, the conditions under which'breakthroughs' occur, the value of the drug in respect to the varioustypes of malarial parasitesand the effect of terminal concentrations of the drug on the subsequentdevelopment of malaria.In addition, the use of quinine could be studied from the same point ofview.
2.This same period willoffer the same opportunity for studying new methods of malarialtherapeusis.
3. To date all of our ideas in respect to the suppressive and therapeutic aspects of Atabrine or quinine therapy have been based upon empirical observations and there is good reason to believe that with the techniques for determining the concentrations of Atabrine and quinine in the tissues and body fluids which have been developed within the last year, notable contributions might be made from NATOUSA upon the suppression and therapy of malaria. This will also benefit our troops.
4. Physical equipment such as laboratory space, benches, etc., are readily available and unused in French civilian institutions in Algiers.
5. It has been the policy of the Surgeon General's Office to investigate special disease situations within and without the United States by civilians who are designated as consultants to the Secretary of War.??????
a. The investigations of the Board for the Control of Influenza and other epidemic diseases.
(1) Under army auspices but with civilian personnel a large laboratory has been set up at Fort Bragg.
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(2) The civilian members of the various commissions have conducted extensive investigations under army auspices in the field in the United States.??????
b. Two members of the Virus Commission have been dispatched to Cairo to study sand fly fever and jaundice from the point of view of the causative organisms.
c. The army has sent special investigators outside the continental United States to study certain special problems since December 7, 1941. An example of this is the inspection of wounded made by Drs. I. S. Ravdin and P. H. Long at Pearl Harbor in 1941.
6. Therefore, inasmuch as the problem is pressing and of great importance and the following recommendation involves no question of War Department policy or precedent, it is strongly recommended:??????
a. That the theater commander urgently request that the services of Dr. James Shannon, Professor of Pharmacology, New York University, one junior assistant and four technical assistants, be made available immediately in this theater of operations and that permission be given to permit them to bring those laboratory instruments and reagents, necessary for them to accomplish their mission. Dr. Shannon is the individual who developed the methods for the quantitative determination of both quinine and Atabrine in body tissues and fluids.
b. If thisrecommendation meets with your approval the following radio to the WarDepartment,attention Surgeon General, is suggested: 'Unrivaled opportunities willexist in NATOUSAduring the next seven months for the scientific study of suppressiveand therapeutic activities ofquinine and Atabrine from the pharmacological and toxicological pointsof view. Specialexperimental studies upon this problem can he arranged easily withFrench civilian medicalauthorities. Laboratory space is available. Information gained fromthese studies will be mostvaluable in its application to the personnel of this theater. It isurgently requested that Dr. JamesShannon of New York University, one designated associate, and fourtechnicians be sentimmediately under a civilian status to NATOUSA to study these problems.Such technicallaboratory instruments and reagents needed for their mission should bebrought with them.Because of the urgency of these problems priority of transportation isrequested.'
TheSurgeon acceptedthese recommendations and communicated informally with the Chief,Preventive Medicine Service, Office of the Surgeon General, concerningthe possibility ofcarrying out such studies in the North African theater. Unfortunately,the reply to thiscommunication was misaddressed and did not arrive until September, whenit was too late to doanything about such studies.
Dysentery. - In latespring of 1943, a major outbreak of flyborne bacillary dysenteryoccurred inthe North African theater. Careful studies upon the types ofmicro-organism responsible for thisoutbreak were made in the Second Medical Laboratory in Casablanca,French Morocco, the151st and 69th Station Hospitals in Oran, Algeria, and the 73d StationHospital at Constantine,Algeria, with the result that not only was the etiology of the diarrheain North Africa clarifiedbut also hitherto unrecognized species of the Shigella familywere described. These studies wereespecially helpful in counteracting the French point of view thatbacillary dysentery wasuncommon in North Africa.
Thearrival of the l5thMedical General Laboratory (fig.76) in the fall of 1943 acceleratedthetempo of investigation in the theater because such a unit couldfunction as the clearinghouse forresearch activities and specifically because the stimulating presenceof Major Mallory was feltby all. The
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FIGURE 76.-15thMedical General Laboratory, Italy, 1945.
laboratory wasestablished in Naples early in 1944 and from that time on served veryusefully asthe center of research activities within the theater.
Earlyin 1944, theSurgeon, NATOUSA, created a board of officers to evaluate proposals fortheinvestigation of various problems and to stimulate research in thetheater. The members of thisboard were the medical inspector, the consultant in surgery, thecommanding officer of the 15thMedical General Laboratory, the consultant in medicine, and thepreventive medicine officer. Itwas the opinion of the consultant in medicine that although the MedicalResearch AdvisoryBoard served a useful purpose in screening certain suggestions forresearch and in bringing theweight of its authority to bear when necessary to accomplish certainthings, it rarely fulfilled itsmission of stimulating research. Certain of the individual members did,but certainly not theboard as such
During 1944-45, certainexamples of investigation involving laboratory studies were as follows:
Hepatitis. - Studies oninfectious hepatitis were instituted on a large scale under thedirection ofColonel Barker, early in 1944, and were continued until July 1945.These investigations includedcomprehensive investigations on the etiology, epidemiology, pathology,clinical course,prognosis, and treatment of this disease.
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Atabrine. - In thesummer of 1944, an extensive study was made by Capt. (later Maj.) JohnC.Ransmeier, MC, of the 300th General Hospital, on the relation of theconcentration of Atabrinein the blood to alleged breakthroughs in the course of the use ofAtabrine for the suppression ofmalaria.
Liver function. - During1944-45, numerous medical officers studied the value of various testsofliver function, not only in patients ill with infectious hepatitis, butalso in those with malaria,syphilis, tonsillitis, primary atypical pneumonia, bacillary dysentery,and in normal individuals.
Trenchfoot. - Studieswere carried out in the winter of 1944-45 upon the capillary beds andupontemperature variations in the skin of individuals suffering fromtrenchfoot.
Other studies. -Inaddition to these investigations, many excellent clinical papers werewrittendealing with malaria, dysentery, boutonneuse fever, sandfly fever,arthritis, rheumatic fever,primary atypical pneumonia, leishmaniasis, and other diseases, and thetreatment of gonorrheaand syphilis with penicillin, in the North African and Mediterraneantheaters.
EDITORIAL DUTIES
Everyeffort was made bythe consultant in medicine to provide the physicians in MTOUSA with thelatest information concerning advances being made in medicine. In thisattempt, it was foundthat the reports received from the National Research Council and theCommittee on MedicalResearch, Office of Scientific Research and Development, wereespecially useful because theywere valuable sources of restricted information upon such subjects asmalaria, dysentery,insecticides, and penicillin. These reports were frequently reprintedin circular letters within thetheater and were greatly appreciated by all medical officers. The WDtechnical bulletins,medical, were also valuable sources of information, but, unfortunately,in the Mediterraneantheater, these bulletins frequently did not arrive until after the needfor the advice contained inthem had passed.
In1943, it becameevident that a means other than circular letters for disseminatinginformationof current value to medical officers was greatly needed in the NorthAfrican Theater ofOperations. After considerable thought and discussion, in which Col.Earle G. Standlee, MC,Deputy Surgeon, NATOUSA, was the leader, it was decided to produce amonthly medicaljournal, the Medical Bulletin of The North African Theater ofOperations. An editorial boardconsisting of the chiefs of the various divisions and sections in thesurgeon's office, and underthe chairmanship of the Surgeon, NATOUSA, was established. Capt. CarlD. Clarke, SnC, wasappointed managing editor. The success of this publication (the titleof which was changed on 1December 1944 to the Medical Bulletin of the Mediterranean Theaterof Operations wasinstantaneous, and there can be but little doubt. that it was a leadingeducational stimulus, ascopies reached every medical officer in the theater.
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InJuly 1944, followingconferences with various chiefs of medical services, the consultant inmedicine decided to recommend to the Surgeon, NATOUSA, thatcomprehensive monographscovering diseases of importance in the theater be prepared byindividual medical officers, orboards of medical officers, in order that the collected opinion ofmedical officers concerningthese diseases might be recorded. In a memorandum to the Surgeon,NATOUSA, dated 9September 1944, subject: Clinical Description of Disease in Respect toManagement,Disposition and Prognosis in NATOUSA, the following recommendation wasmade:
Itis recommended thatcomprehensive reports on the problems concerned with the management,disposition and prognosis of the following diseases in NATOUSA beprepared by the followingmedical officers. It is furthermore recommended that immediately afterthe armistice is signed orbefore that occurrence if necessary, these medical officers be placedon D.S. [detached service]in order that they may collect the necessary data on various diseaseentities and assemble itwithout being disturbed by administrative or clinical duty.
Thisrecommendationreceived favorable consideration from the Surgeon, NATOUSA, and, athis suggestion it was decided that two reports would be made in eachinstance. A preliminaryreport, which would be prepared in the fall of 1944, and a finalreport, which would be writtenafter the war ended in Italy. This decision was activated by thefollowing letter, signed by theDeputy Surgeon, NATOUSA, dated 16 October 1944.
Subject: TheDetailing of Medical Officers to Assist in the Preparation of ClinicalMonographson disease Problems in NATOUSA.
To: Surgeon,Peninsular Base Section, APO 782 (Thru: Surgeon, COMZONE, NATOUSA,APO750)
1. It is desired thatclinical monographs be prepared on the major disease problems withwhichthis theater has been concerned. The objective is to have considered,authoritative statements inrespect to these various problems available before the termination ofmedical activities inNATOUSA.
2.The purpose of thesemonographs is to describe accurately the diagnostic methods employed,clinical course, treatment and the results thereof, and the dispositionof patients ill with certaindiseases in NATOUSA. Special attention should be paid to the problemsfaced in dealing withthese diseases under the military conditions which have existed in theTheater since one aim ofthese reports is to differentiate clearly those factors influencing themanagement of disease in anactive theater from those operative under garrison or civilianconditions.
3.To facilitate thisundertaking, it is requested that the designated medical officerscompile andedit time available data upon specified diseases. These medicalofficers will receive the fullestcooperation in their endeavors, and furnished facilities such assecretarial aid, etc., necessary inthe preparation of reports.
4.In the instance ofcertain diseases, two or more officers from different hospitals, willconstitute a board to collaborate upon the reports in order that abroad critical analysis may beobtained. They will confer whenever necessary with each other or withmedical officers in theTheater upon their particular problems. The senior officer will act aschairman of the board.Direct communication between members of the group or any other medicalofficer whopossesses pertinent data is authorized.
5.As far as ispossible, the reports should be based upon factual data and not uponimpressions.To this end, all necessary records will be made available to theauthors of
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the variousmonographs.Use should be made of the pertinent laboratory data accumulated by the15th Medical General Laboratory and 2d Medical Laboratory. Duecreditwill be given for thecontributions of these laboratories.
6. When more than one officer is concerned in the preparation of a report, the individual experiences of each officer will be recorded first, and the final report will represent the consensus of opinion of the board. This will naturally require a certain amount of professional give-and-take
7. Travel orders will be issued for such inspection of records, conferences, etc., as is necessary in the opinion of the authors, for the completion of their assigned missions.
8. It is desired that these monographs be completed within 60 days after designation of the responsible officers, and one original and four carbon copies forwarded through technical channels to the Surgeon, NATOUSA. These reports will be classified 'Restricted.'
9. Diseases and authors,
a. Common respiratory diseases.
Primary atypical pneumonia.
Streptococcal sore throats.
Lt. Col. D. W. Myers, 0-437966, 7th Station Hospital
Major E. D. Matthews, 0-436735, 24th General Hospital??????
b. Common diarrheas.
Bacillary dysentery.
Major H. W. Hurewitz, 0-1700449, 73d Station Hospital?????????
c. Malaria.
Major P. B. Bleecker, 0-355049, 225th Station Hospital
Major F. S. Perkin, 0-470551, 17th General Hospital
Major H. H. Golz, 0-318515, 182d Station Hospital??????
d. Infectious hepatitis.
Lt. Col. M. H. Barker, 0-409083, l2th General Hospital
Major R. B. Capps, 0-386360, 12th General Hospital
Major F. W. Allen, 0-257301, 15th Medical General Laboratory?????????
e. Tuberculosis.
Lt. Col. D. S. King, 0-413283, 6th General Hospital
Capt. G. T. McKean, 0-428031, l7th General Hospital?????????
f. Dermatological conditions.
Major C. B. Kennedy, 0-40377 1, 64th General Hospital
Major R. N. J. Buchanan, 0-404505, 300th General Hospital
Major R. C. Manson, 0-330183, 45th General Hospital
Major R.. E. Imhoff, 0-479552, 61st Station Hospital?????????
g. Arthritis and rheumatic fever.
Major C. L. Short, 0-178366, 6th General Hospital
Major E. F. F. Bland, 0-397996, 6th General Hospital?????????
h. Peptic ulcer.
Major N. F. Fradkin, 0-430698, 33d General Hospital
Major D. P. Head, 0-230608, 26th General Hospital
Major C. J. W. Wilson, 0-445327, 24th General Hospital?????????
i. Infections polyneuritis.
Major J. W. Johnson, Jr., 0-468994, 300th General Hospital?????????
j. Allergic diseases.
Major H. H. Golz, 0-318515, 182d Station Hospital
Capt. A. C. Kahisch, 0-1695328, 182d Station Hospital?????????
k. Sandfly fever.
Lt. Col. William A.Reilly, 59th Evacuation Hospital
Major Roberto F.Escamilla, 59th Evacuation Hospital
Col. Perrin H. Long,Medical Section, A.F.H.Q.
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l. Venerealdisease.
Capt. R. L. Gettman,0-1693729, 23d General Hospital?????????
m. Leishmaniasis.
Major Alfred Kranes, 6thGeneral Hospital.
For the Surgeon:
E.Standlee
Colonel,M. C.,
DeputySurgeon
The initial monographs were forwarded to the Chief Consultant in Medicine, Medical Consultants Division, Office of the Surgeon General, in February 1945, for suggestion and criticism and were then rewritten and brought up to date after the surrender of the enemy in Italy. This was done in compliance with the directive contained in the letter of the Surgeon, MTOUSA, dated 7 February 1945, subject: Clinical Monographs on Disease Problems in
MTOUSA.
MEDICAL INTELLIGENCE
Earlyin 1943, whenfaced with the problem of the medical care of prisoners of war, ColonelLong realized that there was practically no source of medicalintelligence in the theater. Withthis in mind, he made the following report to the Surgeon, NATOUSA
1. There is available in NATOUSA very little information regarding enemy immunization programs, medical field service, medical practices and medical supplies. The possession of such information would be of value in the planning of future operations and in the medical care of prisoners of war. It is also conceivable that information or drugs might be picked which would aid the AUS in improving certain aspects of medical practice.
2. It is thereforesuggested that an intelligent trained young medical officer be attachedimmediately to the G-2 Section, II Corps, and that he be instructed:
a. To interviewprisoners of war in order to obtain medical information from them.
b. To inspect,photograph and describe captured enemy medical installations.
c. To inspect, describeand photograph enemy medical equipment and supplies.
d. To report theexistence, general type of, and location of captured enemy medicalsupplies.
e. To send samples ofnew instruments, drugs. etc., promptly to The Surgeon, NATOUSA.
f. To file reports ofhis findings with G-2, NATOUSA.
TheSurgeon, NATOUSA,did not take these recommendations very seriously and did nothingabout them. When this became evident, the consultant in medicine madearrangements with theDocuments Branch, G-2 Section, AFHQ, to have sent to him all thecaptured enemy documentsthat related to any field of medicine. This arrangement worked outfairly successfully, and someuseful information concerning the incidence of typhus and tetanus, theprophylaxis of malariaand immunization against disease was obtained. However, it was alwaysfelt that much morevaluable material could have been obtained if a properly trainedmedical service officer had beenplaced in charge of medical intelligence.
