Activities of Medical Consultants
CHAPTER IV
EuropeanTheater of Operations
William S. Middleton, M.D.
Part I. Chief Consultant in Medicine
HISTORICAL NOTE
In 1942, the organizational pattern of the ProfessionalServices Division, Office of the Chief Surgeon, Headquarters, ETOUSA (EuropeanTheater of Operations, U.S. Army), took its basic design from the organizationset up for the American Expeditionary Forces of World War I in France. CircularNo. 2, dated 9 November 1917, Office of the Chief Surgeon, AmericanExpeditionary Forces, had listed eight directors of the Professional Servicesto serve as an element under the Division of Hospitalization. Four monthslater, it was disclosed that The Surgeon General of the U.S. Army had, on 11November 1917, proposed a Consultants Service of three divisions. However, heexpressed his willingness to support the plan of the American ExpeditionaryForces, and, eventually, 7 of the 8 directorships of Professional Services wereestablished in the Departments of Medicine and Surgery.2
Unusually happy was the selection of the two leaders of thismovement: Brig. Gen. John M. T Finney in surgery, and Brig. Gen. William S.Thayer in medicine. From the outset, however, the geographic dissociation ofthe directors, located at Neufchateau, from the General Headquarters located atChaumont, 45 miles away, bespoke difficulties that were exaggerated whenGeneral Headquarters moved to Tours. On 18 April 1918, Col. William L. Keller,MC, was made director of Professional Services. Although his appointmentafforded leadership and a measure of cohesion, his assignment to the generalheadquarters accentuated the physical detachment of the officers whose work hesupervised. The unfortunate term "director" was changed by definitionto "consultant" by Circular No. 25, dated 5 May 1918, Office of theChief Surgeon, American Expeditionary Forces. The pattern of organization wasmost ambitious and was designed to be carried through at all echelons of command;namely, army, corps, and division.
In the Medical Division, under General Thayer atheadquarters, there were two senior consultants in general medicine, Col.Thomas R. Boggs, MC, and Maj. Franklin C. McLean, MC; a senior consultant ininfectious diseases, Col. Warfield T. Longcope, MC; a senior consultant inneuropsychiatry, Col. Thomas W. Salmon, MC; a senior consultant in generalmedicine, poisoning
1 Dr.Middleton, who is the author of part I, served as editor and reviewer for theremainder of the chapter.
2 The MedicalDepartment of the United States Army in the World War. Administration, AmericanExpeditionary Forces. Washington: U.S. Government Printing Office, 1927, vol.II, p.351.
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by deleterious gas, Lt. Col. Richard Dexter, MC; a senior consultant incardiovascular diseases, Lt. Col. Alfred E. Cohn, MC; and a senior consultantin tuberculosis, Lt. Col. Gerald B. Webb, MC.
As might be anticipated, this comprehensive plan, idealisticin its conception, failed at many points through patent sources of weakness.Communication was difficult and mobility limited. As late as 2 September 1918,in a communication to the Chief Surgeon, American Expeditionary Forces, GeneralFinney and General Thayer indicated their inability to control the distributionof skilled personnel. This fundamental defect sharply curtailed the usefulnessof the consultants and led to an almost overwhelming sense of frustration.Without sympathetic cooperation at the highest levels, both within the MedicalDepartment of the Regular Army and within the command, the potential of theconsultants in fulfilling their mission was not well exploited.
As an observer of the activities of the ProfessionalServices at close range in World War I, the following inherent faults becameapparent to the author:
(1) Overorganization; (2) concentration of highly skilled personnel atconsultant levels; (3) detached leadership; (4) lack of cohesive attack; (5)difficulties in transportation, leading to immobilization; (6) inadequateprofessional and military rapport; and (7) insufficient time to correct theseerrors of organization and operation.
EVOLUTION OF MEDICAL CONSULTATION SERVICE
With the World War I experience as background, theopportunities and the responsibilities of the Medical Consultation Service,Office of the Chief Surgeon, Headquarters, ETOUSA, in World War II, stood insharp relief. In London, as the Army Medical Directorate Consultants Committeeto the Director General of the Royal Army Medical Corps, were gathered some ofthe outstanding men in British medicine. As advisers to the Royal Canadian ArmyMedical Corps, there were four leaders in the Canadian profession. The combinedexperience of these Allies was available at all phases of planning and activityin ETOUSA. Their advice and assistance were invaluable, and many pitfalls wereavoided through their sustaining counsel.
Organization
On 13 July 1942, Lt. Col. (later Col.) William S. Middleton,MC (fig.77), reported as Chief Consultant in Medicine, Office of the ChiefSurgeon, Headquarters, ETOUSA, then located at Cheltenham, England. On 21 July1942, Col. James C. Kimbrough, MC (fig.78), Director, Professional ServicesDivision, Office of the Chief Surgeon, Headquarters, ETOUSA, proposed to set upthe following four separate divisions of consultants: Medicine, surgery,neuropsychiatry, and venereal disease control. Colonel Middleton indicatedcertain practical and functional objections to the separation ofneuropsychiatry and venereal disease control from medicine. On 25 July 1942,Colonel Middleton conferred with Col. (later Maj. Gen.) Paul R. Hawley, MC,Chief Surgeon,
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FIGURE 77.- Col. William S. Middleton, MC,Chief Consultant in Medicine, Office of the Chief Surgeon, ETOUSA.
ETOUSA, and urged surveys of the British and Canadian medical situations, withparticular reference to the physical, tactical, medical, and educationalprograms in these respective services. At this conference, an adaptation of theBritish and the Canadian experiences to the medical needs of the U.S. Army inthe European theater was urged to avoid duplication on one hand and the loss ofidentity on the other. In discussing the educational program for the theater,the improvement of medical services for the troops was the objective. Pastefforts had fallen short of the mark, owing to a failure to reach the medicalofficers most in need of instruction. The interchange of medical officers ofcompany grade on the staff of general hospitals with those in line duty wasproposed at this conference.
In the eventual plan of organization, Colonel Kimbroughincluded, under the chief consultant in medicine, senior consultants in timefollowing subspecialties: General medicine, gas defense, acute infectiousdiseases, cardiology, tuberculosis, gastroenterology, dermatology, nutrition,neurology, and psychiatry. With the concurrence of Colonel Kimbrough, nutritionwas later made the responsibility of the Preventive Medicine Division, Officeof the Chief Surgeon, Headquarters, ETOUSA. In London, on 11 August 1942,Colonel Middleton met with Col. (later Brig. Gen.) Elliott C. Cutler, MC, ChiefConsultant in Surgery, Office of the Chief Surgeon, Headquarters, ETOUSA, andCol. (later Brig. Gen.) Charles B. Spruit, MC (fig.79), Deputy Chief Surgeon,ETOUSA. In this conference, Colonel Cutler expressed a desire to have hissenior consult-
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FIGURE 78.- Col. James C. Kimbrough, MC (left)and Col. William S. Middleton, MC.
ants as a cabinet to advise him at all times within the subspecialties ofsurgery, including X-ray and anesthesiology. In light of the World War Iexperience and from a personal evaluation of the requirements of ETOUSA,Colonel Middleton outlined a plan that would maintain at headquarters a minimumof senior consultants in the medical subspecialties and a majority in a dualrelationship with primary responsibilities as chiefs of immedical services ingeneral hospitals and a subsidiary function as advisers to the theater at largein their respective fields. Upon conferring with Colonel Hawley, both chiefconsultants were advised that they would be held responsible for theirrespective functions, regardless of the manner of implementation. Asanticipated, with the evolution of the medical picture in the theater,neuropsychiatry and dermatology (when venereal diseases were included in thelatter) constituted areas that required the full time of the senior consultantsfor direction and advice. Accordingly, the senior consultants for neuropsychiatryand dermatology were attached to headquarters.
With the approval of Colonel Hawley, a list of specialistsin the United States to serve as senior consultants in the respectivesubdivisions of medicine in the European theater was submitted to the SurgeonGeneral's Office on 16 August 1942. The Surgeon General's response, received on22 October 1942, left no doubt as to further procedure, stating: "It issuggested that Consultants be obtained from men already assigned to theEuropean Theater. Many of the
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FIGURE 79.-Col. Charles B. Spruit, MC.
men listed in the basic communication hold key positions in civilian life, andcannot be obtained for the Army. Many others, if they can be declarednonessential, are required for consultant positions in the United States."
On 25 August 1942, Lt. Col. (later Col.) Lloyd J. Thompson,MC, assigned as Senior Consultant in Neuropsychiatry, ETOUSA, reported to thetheater. The Surgeon General likewise named Lt. Col. (later Col.) Donald M.Pillsbury, MC, as Senior Consultant in Dermatology, ETOUSA, and he reported forduty on 5 December 1942. On 25 December 1942, Lt. Col. (later Col.) Theodore L.Badger, MC, Chief, Medical Services, 5th General Hospital, located nearSalisbury, England, was recommended as Senior Consultant in Tuberculosis,ETOUSA. Colonel Badger was the first medical officer to have the distinction ofserving in the dual capacity anticipated for all senior consultants.
Plans for Gas Defense
To Colonel Middleton, as one who had served with troops inWorld War I and to whom the ravages of gas warfare were familiar, the necessityfor sound organization to meet such a threat weighed heavily. Opportunities tostudy the situation in the British Army were afforded through the courtesy ofthe Royal Army Medical Corps, through the good offices of Colonel Walker andCaptain Hill, RAMC. On 10 August 1942, Colonel Middleton was granted everyfacility of the Royal Army Medical Corps School of Instruction at Boyce
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Barracks, Aldershot, England. Tables of organization and plans of instructionfor gas defense were carefully reviewed. The realistic attitude of the schoolofficials indicated a sharp appreciation of the limitations in therapy. Forexample, oxygen therapy was to be given to the "blue" subjects ofphosgene poisoning but not to the "gray."
Colonel Walker proposed to take from 10 to 15 U.S. Armymedical officers in each class, rather than the existing quota of three, as thepressure of the military situation increased. On 4 November 1942, ColonelMiddleton attended the course at the M. S. Factory, Randalestown, NorthernIreland, where the program included a demonstration of the manufacture of toxicagents. The preventive measures among workers and detailed data as to thetreatment of the several forms of toxic gases, including bromobenzylcyanide andbenzylcyanide, phosgene, lewisite, and other arsenic-containing toxic agents,were discussed. Doctors Chiesman, Ferrie, Wilkinson, and Stopford-Taylor andMr. Phillips afforded a most instructive day.
Meanwhile, the key position of gas defense officer in theOffice of the Chief Surgeon, Headquarters, ETOUSA, remained vacant in spite ofColonel Middleton's importunities. When Lt. Col. (later Col.) Perrin H. Long,MC, was transferred to General Hawley's office on 20 November 1942, he wasassigned to duties of Acting Senior Consultant in Chemical Warfare Medicine,ETOUSA. With characteristic energy, he lent every effort to the orientation andorganization of the available information in an unfamiliar field, until histransfer to the North African theater on 18 December 1942. At this time, thepresence of Comdr. (later Capt.) George M. Lyon, MC, USN, in the naval officeof the U.S. Embassy in London, was fortuitous. A student of gas warfare and gasdefense for many years, Commander Lyon brought recognized authority to thisfield. His cooperation with the Army and assistance during this periodillustrates one of the strongest justifications for the unification of theArmed Forces. Finally, Col. William D. Fleming, MC, the long-awaited gasdefense officer, reported for duty on 23 February 1943. Three days later, indeference to Army protocol, Col. Oramel H. Stanley, MC, Deputy Surgeon,Headquarters, Service of Supply, ETOUSA, indicated that Colonel Fleming hadbeen assigned directly to General Hawley as assistant surgeon in charge of gasdefense. This function was thereupon removed from the organizational pattern ofthe Medical Consultation Service. The gas casualty kit assembled by ColonelFleming is shown in figure 80.
Dual Functions
With these minor readjustments, the ultimate plan oforganization of the Medical Consultation Service, ETOUSA, was completed by theaddition of Lt. Col. (later Col.) Gordon E. Hein, MC, Chief, Medical Service,30th General Hospital, located near Mansfield, England, as Senior Consultant inCardiology, ETOUSA; Lt. Col. (later Col.) Yale Kneeland, Jr., MC, Chief,Medical Service, 2d General Hospital, Headington, Oxford, England, as SeniorConsultant in
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FIGURE 80.-ETO gas casualty treatment kit.
Infectious Diseases, ETOUSA; and Maj. (later Col.) Ralph S. Muckenfuss, MC(fig.81), Commanding Officer, General Medical Laboratory A, as Director, MedicalResearch, ETOUSA. Colonel Badger continued to function in the dual capacity ofChief, Medical Service, 5th General Hospital, and Senior Consultant inTuberculosis. With the growth of the theater, the basic pattern was maintained,always with the thought of utilizing the senior consultants in dual capacities,where possible. As the need developed, whether in hospital centers, basesections, or a major area such as the United Kingdom, the senior consultants ininfectious diseases, cardiology, and tuberculosis continued to serve in twodistinct roles. The primary responsibilities of these senior consultants to ahospital or a larger administrative unit hospital center, base section, ormajor area) in no way interfered with their important function of directing thetheater policy within their respective specialties.
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FIGURE 81.-Col. Ralph S. Muckenfuss, MC,Director of Medical Research, ETOUSA.
The effectiveness of any plan can be established only by thetrial of experience. As stated, the administrative load in neuropsychiatry anddermatology (including venereal disease) was anticipated. Colonels Thompson andPillsbury, operating from headquarters, discharged their onerous duties withdistinction by dint of painstaking planning and assiduous effort. The earlyoccurrence of a serious problem in the incidence of primary atypical pneumonialed the Chief Surgeon to establish a committee, composed of Colonels Kneelandand Muckenfuss and Lt. Col. (later Col.) John E. Gordon, MC, Chief, PreventiveMedicine Division, Office of the Chief Surgeon, Headquarters, ETOUSA, to studythis problem. This group was continued as the Advisory Committee on InfectiousDiseases to coordinate the mutual effort in this area. In the interest ofprofessional coverage for consultation in isolated units, the temporaryexpedient of regional consultants was invoked on 21 May 1943.3Seventeen such consultants in medicine were named from the chiefs of fixedhospitals. The plan of base section consultants was first established in NorthIreland Base Section by the appointment of Colonel Badger. With the evolutionof the military program in the United Kingdom, the next phase of the MedicalConsultation Service, ETOUSA, involved the movement of the following seniorconsultants: Colonel Kneeland to the Southern Base Section, Colonel Hein to theWestern Base Section, and Colonel Badger to the Eastern Base Section.4Eventually, base section consultants were assigned to the United Kingdom (fig.82), Brittany, Normandy, Oise, and Delta Base Section. The Brittany BaseSection had a very short life, and its medical consultant, Col. O. C. McEwen,MC, was given command of a hospital. As time passed, hospital center consultantswere named in 15 centers-7 in the United Kingdom, 8 on the Continent. Medicalconsultants in each army afforded the direct channel of communication with thefield. The names and assignments of the medical consultants who served inETOUSA are listed in appendix A (p. 829).
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3 CircularLetter No. 89, Office of Chief Surgeon, Headquarters, ETOUSA, 21 May 1943,subject: Regional Consultants.
4NOTE.- The hospital center development soon made a single medical consultantfor the United Kingdom a more effective agent for coordination of these groups.J. B.C., Jr.
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Channels of Communication
The use of official channels was requiredin all matters pertaining to military or tactical procedure. With the supportof General Hawley, direct communication in purely professional matters wasencouraged. By the expedient of direct professional communication, thesimplified system of decentralized control afforded prompt informationregarding disease trends, therapeutic innovations, and pertinent medical data,which might have been long delayed had use of regular military channels beenrequired. In the European theater, the chief consultant in medicine and hissenior consultants had direct communication with the base section, hospitalcenter, and army consultants. This arrangement reduced the obstructive factorsin dissemination to a minimum and assured prompt and adequate rapport in allmatters medical. Not infrequently, the advantage was centripetal rather than
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centrifugal since General Hawley's office, through this medium, was constantlyin touch with all medical echelons of the theater.
The scheme of organization did not extend beyond the levelof the field army into the corps and divisions as had been planned in World WarI. Although there had been early designs in this direction, it was foundinexpedient and ineffective to carry the plan beyond the army level. However,through the army medical consultants, an effective medium of exchange existedon a reciprocal plane. Through 5 army consultants, 15 hospital centerconsultants, and ultimately 5 base section consultants, the senior consultantsin medicine and the chief consultant in medicine found ready and cooperativeprofessional communication.
The necessity for this decentralization becomes apparent inview of the existence of over 200 fixed-hospital units in the theater.Furthermore, with the OVERLORD movement, Colonel Middleton and theheadquarters-based senior consultants, Colonel Thompson and Colonel Pillsbury,were transferred to France, when the Office of the Chief Surgeon, Headquarters,ETOUSA, moved to Valognes, and later to Paris (fig. 83) and Versailles. At thistime, the direct responsibility for the direction of the Medical ConsultationService in the United Kingdom devolved upon Colonel Kneeland. Under hisimmediate supervision came the organization and operation of the medicalservices within the total of 140,000 beds, represented by the fixed hospitalsin the United Kingdom after D-day.
GENERAL MORGAN'S VISIT TO EUROPEAN THEATER
The support of the Medical Consultation Service, ETOUSA, extendedthrough the Chief Surgeon to the staff of The Surgeon General of the Army. Inaddition to the official interchanges of the Medical Department, informalprofessional communication was encouraged between the members of the staff inWashington, D.C., and their respective associates in the Zone of Interior andin the oversea theater. Brig. Gen. Hugh J. Morgan, Chief Consultant in Medicineto The Surgeon General, utilized continuously this expedient of informalcommunication as a medium for reciprocal advice. This ready exchange ofprofessional information redounded to the improvement of medical service in theEuropean theater. General Morgan's leadership gave intimate direction to themany major developments.
General Morgan visited the European theater for a tour ofinspection from 7 February to 21 March 1945 (fig.84). A summary of the tour wasmade on 28 March 1945 by Colonel Middleton to General Hawley, as follows:
General Morgan was afforded the opportunity to observemilitary medicine in four armies, under field conditions. In three of thesearmies he followed the line of evacuation from the battalion aid post [station]to the evacuation hospital. Typical fixed installations of the CommunicationZone were visited on the Continent and in Great Britain. Particular pains weretaken to cover the entire range of facilities from tented units to units housedin buildings of every degree of adequacy. The medical organization of theseveral echelons was covered in detail by qualified members of the staff.Clinical subjects of special interest to General Morgan, such as cold injury,hepatitis, malaria and "field" nephritis, were
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FIGURE 83.-Avenue Kleber, Paris, France,showing section of buildings occupied by Office of the Chief Surgeon, ETOUSA.
demonstratedin adequate numbers to meet his requirements. Through the cooperation of theSenior Consultants in Psychiatry and Dermatology, special facilities in thesefields were demonstrated to General Morgan. Through Colonel Diveley and ColonelStinchfield, similar opportunities were afforded for the study of the programin physical rehabilitation (fig.85). The complete cooperation of theadministrative and clinical divisions of all echelons of the Medical Departmentmade this tour possible.
The Medical Consultation Service profited immeasurably fromthe firsthand counsel of General Morgan on his European tour of duty.
CONFERENCES OF CHIEFS OF MEDICAL SERVICES
Colonel Middleton initiated periodic conferences of thechiefs of medical services, in the interest of the coordination andconsolidation of medical practice within the fixed hospitals of theCommunications Zone. The first of these conferences was held on 25 March 1943at Cheltenham. Fourteen of the sixteen chiefs of medicine in fixed hospitals inthe theater at that time were in attendance. Representatives from the Office ofthe Chief Surgeon, Headquarters, ETOUSA, included Colonel Fleming, Medical GasDefense Officer; Colonel Kimbrough, Director, Professional Services Division;Lt. Col. (later Col.) James B. Mason, MC, Chief, Operations and TrainingDivision; Col. Joseph
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FIGURE 84.-General Morgan (second from right)on visit to ETO. Others (left to right): Colonel Kimbrough, General Hawley, andColonel Middleton, Hotel George V, Paris, France.
H. McNinch, MC, Chief, Medical Records Division; Colonel Pillsbury, SeniorConsultant in Dermatology; Colonel Thompson, Senior Consultant inNeuropsychiatry; and Major Muckenfuss, Commanding Officer, General MedicalLaboratory A. There were detailed discussions on the following subjects Gasdefense; records; laboratory service; functions of the chiefs of medicalservices; distribution and utilization of medical personnel; current clinicalproblems in the theater; clinical procedures in communicable diseases;syphilis; shock; supply problems, including drugs, special diets, andequipment; disposition of patients; convalescent hospital facilities;evacuation and transportation of patients; educational programs; professionalrelations; and military responsibilities. Mimeographed transcripts of theproceedings were circularized to the hospitals of the theater and to theheadquarters staff.
The second conference of the chiefs of medical services washeld at Headquarters, ETOUSA, on 30 July 1943. The chiefs of medical servicesof 22 fixed installations and the following representatives of General Hawley'soffice were present: Colonel Spruit, Deputy Chief Surgeon; Col. Edward M.Curley, VC (fig.86), Chief, Veterinary Service; Colonel Fleming, Gas DefenseOfficer, Colonel Gordon, Chief, Preventive Medicine Division; ColonelKimbrough, Director, Professional Services; Col. David E. Liston, MC, Chief,Personnel
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FIGURE 85.-Convalescent patient undergoingobstacle course training at 203d Station Hospital, Stoneleigh Park, England.
Division; Colonel McNinch, Executive Officer; Col. Walter L. Perry, MC, Chief,Finance and Supply Division; Colonel Thompson, Senior Consultant in Psychiatry;Lt. Col. John K. Davis, MC, Hospitalization Division; Colonel Mason, Chief,Operations and Training Division; Colonel Pillsbury, Senior Consultant inDermatology; and Colonel Muckenfuss, Director, Medical Research. The subjectsconsidered were milk supply; fever therapy; intensive arsenical therapy ofsyphilis; anesthesia; laboratory services; current clinical problems of thetheater, including respiratory infections, infectious mononucleosis, primaryatypical pneumonia, poliomyelitis, mumps, encephalitis, and allergy;administrative problems, particularly involving the cooperation amonghospitals; special training of nurses and enlisted men; and dispositionproblems. Colonel Curley presented an analysis of the problem of bovinetuberculosis in Great Britain which was timely and revealing. The presence ofrepresentatives from the several divisions of General Hawley's office led to anopen forum, with most profitable discussions of such subjects as plans forspecial hospitals, availability of special equipment, supply and procurement ofnonstandard drugs, nomination for special schools, proposed medical bulletins,and records.
By 1944, the theater had grown to such an extent that it wasnecessary to divide the third conference of the chiefs of medical services intotwo sections. The first, held on 26 January 1944, included the chiefs of themedical services
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FIGURE 86.-Col. Edward M. Curley, VC (left),and Col. William S. Middleton, MC.
of the hospitals in the Eastern, Western, Central, and North Ireland BaseSections. The second, held on 2 February 1944, was attended by the chiefs ofthe medical services from the hospitals of the Southern Base Section. At thetwo meetings, 70 chiefs of the medical services of the respective hospitals ortheir representatives were in attendance. The following representatives ofGeneral Hawley's office took active part in the proceedings of these sessions:Col. J. C. Darnell, MC, Chief, Hospitalization Section; Col. Rex L. Diveley,MC, Senior Consultant in Orthopedic Surgery; Colonel Fleming, Medical GasDefense Officer; Colonel Gordon, Chief, Preventive Medicine Division; ColonelKimbrough, Director, Professional Services Division; Colonel McNinch, ExecutiveOfficer; Col. W. L. Perry, Chief, Supply Division; Colonel Thompson, SeniorConsultant in Psychiatry; Col. W. D. White, DC, Chief, Dental Service; Lt. Col.Kenneth D. A. Allen, MC, Chief Consultant in Radiology; Lt. Col. G. D. McCarthy,MC, Hospitalization Division; Colonel Muckenfuss, Director of Medical Research;Colonel Pillsbury, Senior Consultant in Dermatology; Lt. Col. J. C. Rucker, MC,Chief, Personnel Division; Lt. Col. A. Vickoren, MC, Chief, Operation Division;Capt. William G. Craig, MAC, Personnel Division; Capt. Claude M. Eberhart, MC,Preventive Medicine Division; Capt. H. E. Gannon, MC, Supply Division; andCapt. M. D. Switzer, MC, Medical Records Division.
In opening these sessions, Colonel Middleton outlined theorganization of the medical service on a functional basis. The subjectsconsidered were delegation of duties, training, clinical duties, consultation;clinical problems,
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with the report of progress in the experimentation on the prophylaxis of acuteupper respiratory infection, pneumococcal infection, typhus fever, sulfonamide-resistantgonorrhea (penicillin therapy, fever therapy); intensive arsenical therapy ofsyphilis; neuropsychiatric problems, including alcoholism; disposition oftuberculous patients; certain laboratory problems; outpatient department;rehabilitation; and the conduct of professional meetings. In the open forum,Vincent's stomatitis, disposition, detachment of patients, and evacuationreceived due consideration. The Records Division, Office of the Chief Surgeon,Headquarters, ETOUSA, made a special appeal for the accuracy of diagnosticnomenclature and stressed the importance of maintaining forms and of carefulpaperwork in support of statistical analyses, as well as in the soldiers'interest to establish the service connection of disabilities. X-ray suppliesand equipment received full attention. Air transportation and evacuationbetween Northern Ireland and the United Kingdom and between the United Kingdomand the Zone of Interior were discussed. The deliberations of the earliermeetings led to the promulgation of a memorandum concerning policies ofprocedure for chiefs of medical services, which proved both opportune andeffective.
The conferences of the chiefs of the medical services hadclearly established their extreme usefulness. By the same token, it had alsobecome evident that further similar conferences would prove unwieldy; hence,subsequent meetings of this nature were set up on a base section level. Thefirst of these was held on 5 May 1944, in the Southern Base Section under the leadershipof Colonel Kneeland. With the further development of the theater and theattendant restrictions on transportation, these conferences were eventuallylimited to the hospital center level. All senior consultants, base sectionconsultants, and any consultants were invited to these meetings, and anopportunity for the free discussion of plans and problems was afforded tomembers of General Hawley's office in attendance.
INTER-ALLIED RELATIONSHIPS
The rapport of the medical officers of the U.S. Army, ingeneral, and the staff of the Chief Surgeon, ETOUSA, in particular, with themedical profession of Great Britain was conspicuous. General Hawley and ColonelKimbrough cultivated this relationship by every attention to social andprofessional amenities. Every courtesy was shown to Colonel Middleton and hissenior consultants. Early in the evolution of the basic plan for the MedicalConsultation Service, ETOUSA, Maj. Gen. Sir Alexander H. Biggam, RAMC, and Col.Lorne C. Montgomery, RCAMC, Chief Consultants in Medicine for the British andCanadian Armies, respectively, in every way helped to expedite theorganizational plans of the U.S. Army in the European theater. ColonelMiddleton regularly attended the monthly meetings of the Medical Subcommittee ofthe Army Medical Directorate Consultants Committee to the Director General ofthe Royal Army Medical Corps, under the chairmanship of General
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Biggam. The following distinguished clinicians constituted the MedicalSubcommittee: General Biggam, Consultant Physician; Brigadier D. B. McGrigor,Consultant Radiologist; Brigadier J. R. Rees, Consultant Psychiatrist;Brigadier G. W. B. James, Consultant Psychiatrist; Brigadier F. D. Howitt,Consultant in Physical Medicine; Brigadier George Riddoch, ConsultantNeurologist; Brigadier T. E. Osmond, Consultant Venereologist; Brigadier R. M.B. MacKenna, Consultant Dermatologist; Brigadier J. A. Sinton, ConsultantMalariologist; and Brigadier Sir Lionel Whitby, Consultant in Transfusion andResuscitation (fig.87).
In the deliberations of this group of British clinicians,free and uninhibited discussion of mutual problems was encouraged. The regularmeetings of the Army Medical Directorate Consultants Committee were held theday after the meetings of the Medical Subcommittee, under the leadership of Lt.Gen. Sir Alexander Hood. Although these sessions were important, theproceedings represented a duplication of the activities of the medical andsurgical sub- committees. Hence, regular attendance, while invited, was deemedredundant.
Under the chairmanship of Prof. John A. Ryle, theInterservices Medical Consultants Committee was organized. Representatives ofthe Royal Army Medical Corps, Royal Navy, Royal Air Force, Royal Canadian ArmyMedical Corps, Emergency Medical Service, the U.S. Army, and the U.S. Navy metin Kelvin House, London, at regular intervals to discuss mutual problems. AirCommodore Alan Rook served as its secretary. Upon the resignation of ProfessorRyle, Surgeon Rear Admiral R. A. Rowlands, R.N., occupied the chair.
FUNCTION OF MEDICAL CONSULTANT
From the standpoint of the Army, the fundamental aims of theMedical Department are (1) to establish and maintain high standards, bothphysical and mental; (2) to prevent disease and disability from trauma; and (3)to limit morbidity and mortality in disease and trauma, both battle andnonbattle. Within military circles, there can be no question as to the supremeimportance of preventive medicine in reaching such objectives. In the Europeantheater, in General Hawley's office, there was a complete meeting of the mindsbetween the Professional Services Division and the Preventive MedicineDivision. Few days passed without an interchange of information betweenColonels Gordon and Middleton. As a rule, the propinquity of offices made suchcontacts very simple. For a short period, the detachment of the PreventiveMedicine Division to London while the Professional Services Division remainedin Cheltenham was immediately felt as a distinct dislocation between twodivisions with a common objective. The interlocking interests of thesedivisions should always be borne in mind in future planning in the interest ofthe health of a command. Their missions are inseparable, and they can operateeffectively only when interdependent.
The medical care of the patient is secondary only to theprevention of disease and disability. The former responsibility fell clearlywithin the pur-
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FIGURE 87.-British guests at regular series ofbanquets held by General Hawley and consultants for distinguished members ofBritish medical profession. Thirelstaine Hall, Cheltenham, England, 2 April1943. Left to right: Colonel Middleton, Brigadier Sir Lionel Whitby, Sir EdwardMelanby, General Hawley, Brigadier McGrigor, and Colonel Cutler.
view of the Medical Consultation Service, ETOUSA. In the interest of the bestpossible medical care, the primary function of the medical consultants mustperforce be clinical. At an early stage in the evolution of the theater,Colonel Middleton made clinical rounds of each hospital in the United Kingdomat least once a month. During this early period, calls for personalprofessional consultations multiplied these clinical exposures many times. Wheneverpossible, Colonel Middleton used such contacts as a teaching outlet. Aside fromthe obvious professional aspect, these recurring consultations with youngclinicians ultimately paid dividends in the assessment of their capabilitiesfor growth and, in turn, aided Colonel Middleton in making recommendations forpersonnel assignment when new and understaffed units flooded the theater. Withthe mounting trooplift and accelerated hospitalization program (ultimately atotal of 259,725 beds, of which 183,550 were in fixed hospitals), the routineof monthly clinical rounds, which had been so profitable, was necessarilymodified by decentralization. In place of a single consultant for the theater,a base section or a hospital center consultant made periodic and requestedprofessional visits in the area of his responsibility, with distinct advantageto the service to the individual soldier.
In General Hawley's office,the Medical Records Division sent regular reports to the Professional ServicesDivision, which had an obvious interest in
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the current incidence and trends of disease. The weeklystatistical reports of deaths presented an unusual challenge. These weeklylists were checked for preventable diseases by Colonel Middleton. By directcorrespondence with the chief of the medical service in the hospital reportingsuch deaths, a copy of the complete clinical record was obtained. GeneralMedical Laboratory A submitted a duplicate set of the histologic sections ofthe pathologic materials from such subjects to Colonel Middleton, so that allpoints of discrepancy might be reconciled. The situation having beenreconstructed from the available evidence, arm analysis with appropriateobservations was forwarded to the responsible medical chief. As a rule, thisconstructive procedure was well received. Although its value is impossible ofestimation, undoubtedly, the result was intangible dividends in the improvedcare of the sick in this theater.
PERSONNEL MANAGEMENT
The confidence of the Chief Surgeon, ETOUSA, in the missionof the consultants was evident in his mandate to them to offer direct advice tohis Personnel Division on the movement of highly trained medical personnel. Inturn, the Personnel Division depended implicitly upon the consultants of theProfessional Services Division for such counsel. In the interest of the bestmedical service under existing conditions, there must be an optimal utilizationof the available personnel. Obviously, extreme inequalities existed in many ofthe hospitals assigned to the Communications Zone. In the early phases ofdevelopment, disproportionate professional strength was evident, particularlyin the affiliated units. With the increasing demand upon the decreasing pool ofmedical officers in the Zone of Interior, this situation was eventually reversed.As already intimated, the existing professional assets of the theater had beencarefully cataloged by Colonel Middleton on the basis of personal andprofessional observations in the wards of the existing units. Upon the arrivalof new hospitals in the theater, personal interviews and staff conferences werearranged to assess the professional qualifications and capabilities of allmedical officers on the medical services. Alarming discrepancies, bothquantitative and qualitative, were disclosed as the reserve of medical officersin the United States was depleted. Some idea of the magnitude of the problemmay be gathered from the fact that, in 1944, Colonel Middleton visited andinterviewed the officers of the medical sections of 108 general and 11 stationhospitals from the Zone of Interior and 4 general and 2 station hospitals fromMTOUSA (Mediterranean Theater of Operations, U.S. Army). Colonel Kneelandlikewise surveyed a group of these new units. To meet obvious deficiencies ofskilled personnel in these hospitals in 1944, 58 new chiefs of medical serviceswere assigned from the reservoir of qualified and tried internists of theaffiliated units of the European theater and those which had been transferredfrom MTOUSA.
The place of the affiliated hospital (fig. 88) in thereserve pattern of the Medical Department has been subjected to sharp criticismin certain quarters. Clearly, superior professional qualifications may beanticipated in these units.
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At times, the loyalty to the mother institution may overshadow the greater needof the military situation. A natural pride in organization may bias thejudgment of responsible officers, but, upon a clear presentation of theproblem, cooperation in the release of highly qualified internists seriouslyrequired in other units was willingly made in the European theater. Withoutthis source of support, the medical services of the fixed hospitals of thistheater would have presented a strange mosaic of professional adequacy, rangingfrom superb to impossible, and the standards of medical care would havefluctuated immeasurably from one hospital to another. In this relation, thePersonnel Division of General Hawley' office can not be too highly commendedfor their cooperation. Never was a recommendation for the movement of a medicalofficer in the interest of better care for the soldier made by the medicalconsultants without prompt compliance.
The professional interchange of the consultants of GeneralHawley's office with medical officers of the armies was intimate. Frequently,advices in medical matters from the field initiated inquiry or appropriateaction at Headquarters, ETOUSA, to the ultimate advantage of the U.S. soldier,while, conversely, medical information flowed freely from Headquarters, ETOUSA,to the field. In the movement of personnel, the prerogatives of the army wereassiduously respected. Usually, in General Hawley's office the ProfessionalServices Division, upon the request of an army consultant in medicine forpersonnel to meet certain medical needs of army units, would advise the armysurgeon of its willingness to arrange, through the Personnel Division, forreplacements from fixed hospitals of the Communications Zone. As mutualconfidence was established, at times the army surgeon, through theintermediation of the Professional Services Division, sought the transfer ofmedical officers from his echelon to fixed hospitals for the better utilizationof their special skills.
In his first conference with General Hawley on 25 July 1942,Colonel Middleton emphasized the importance of the continuity of medical carethroughout all echelons of the medical service. In the interest of sustainedprofessional efficiency and, in turn, improved medical service to the troops,an exchange of officers of company grades from the field units with officers ofsimilar rank in fixed-hospital units was proposed. With General Hawley's support,conferences were held in early August 1942 with Col. Max G. Keeler, MC,Commanding Officer, 5th General Hospital, Lt. Col. (later Col.) Mack M. Green,MC, Surgeon, North Ireland Base Section, and Col. Charles E. Brenn, MC,Surgeon, V Corps (Reinforced), relative to the implementation of such exchangeson a temporary basis. Colonel Brenn expressed his categorical objection to sucha movement on the basis of the inevitable loss of medical officers from thefield to the hospitals. Opposed to this viewpoint was the obvious bilateraladvantage in the professional improvement of the medical officer from the fieldand the cultivation of an understanding of the medical problems of the field onthe part of officers on exchange from the fixed hospitals. A pilot plan wasinitiated in the North Ireland Base Section between the 5th General Hospitaland tactical units in training in Northern Ireland. These temporary
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exchanges were well received and presented proof of the predicted bilateraladvantage. As a result, this basic plan was given general application in thetheater in the interest of the professional advancement of the medical officersand the medical care of the soldier.5
A situation similar to the medical drought experienced byofficers with field units was encountered in the medical officers of the EighthAir Force. Indeed, medical officers attached to the dispensaries and scatteredunits of the Eighth Air Force became extremely dissatisfied with theirprofessional detachment. As a result of conferences with Col. (later Maj. Gen.)Malcolm C. Grow, MC, and Col. (later Maj. Gen.) Harry G. Armstrong, MC, aprogram of rotation of medical officers from the Eighth Air Force, not toexceed 10 per month, to fixed hospitals in the United Kingdom was arranged tobegin 20 April 1943. In time judgment of Colonel Armstrong, after certain earlyunfortunate experiences, the exchange of similar numbers of officers of companygrade from the general hospitals to the Eighth Air Force without indoctrinationwas deemed unwise. The assignment of Eighth Air Force representatives was,therefore, unilateral. Although the plans were sound and although theProfessional Services Division in General Hawley's office made continuousefforts to maintain the flow of medical officers, operation difficulties andpassive resistance limited the success of the program.
In a similar vein, an entirely different approach to themaintenance of clinical interest of medical officers in the field wasattempted. Perhaps one of the most stultifying experiences for medical officerswith field medical units is the necessity for the transfer of all seriously illpatients from tactical units to fixed hospitals for definitive medical care.Immediately upon such a movement, an interruption of the primary professionalinterest of the medical officer with the tactical unit occurs. Also, theopportunity for clinical contact commonly afforded through visits to thehospital of transfer is not available in the Army because either the tacticalsituation, transportation, or command policy may make such sporadic effortsimpractical. To meet this situation, the postcard Form 306, Follow-up Card(Medical) was devised.
The medical officer of a line or detached unit merely wrotehis address on the front of this medical followup card and the name of thepatient in whom he was interested on the reverse side. Pinned to the emergencymedical tag or placed in the jacket of the field medical record, this medicalfollowup card was filled out by the first medical officer rendering definitivecare and mailed to the interested medical officer in the forward unit. Theinformation on the card included the diagnosis, necessary clinical andlaboratory findings, treatment rendered, disposition made, and anyrecommendations. General Hawley and Colonel Middleton conducted educationalprograms indicating the importance of maintaining this centrifugal influence ofthe hospital units of the theater. The utilization of this very significantexpedient extended to mobile hospitals evacuating to fixed hospitals and tostation hospitals evacuating to general
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5AnnualReport, Professional Services Division, Office of the chief Surgeon,Headquarters, ETOUSA, 1943
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hospitals. In short, this expedient established a channel of medical orprofessional communication that afforded information as to the care anddisposition of evacuated patients and that could not otherwise have been obtained.
EDUCATIONAL PROGRAMS
Air Force Field Service School
The educational programs were the function of the Operationsand Training Division of General Hawley's office. The Professional ServicesDivision was called upon to assist in planning and implementing such programs.Under the leadership of Colonel Armstrong, the Eighth Air Force developed theEighth Air Force Provisional Field Service School at High Wycombe, England. Atthe request of Colonel Grow, on 6 and 13 October 1942, Colonel Middletonpresented 3-hour lectures on tropical medicine. Thereafter, the topics usuallycovered were the common cold, influenza, pneumococcal and atypical pneumonia,and the sulfonamides. With appropriate changes in subject matter and atintervals lengthening to semimonthly and monthly, Colonel Middleton continuedto participate in this program until the discontinuance of the school in thefirst week of May 1944. Not only did this teaching opportunity provideexcellent rapport with the headquarters staff and medical officers of theEighth Air Force but it also served to emphasize the vital requirement of theAir Force group for a broader clinical outlet.
Medical Field Service School
On 8 September 1942, with Colonel Cutler, Colonel Middletonstudied the prospects of medical teaching in the Army Medical Field ServiceSchool at Shrivenham (fig.89). The program for clinical instruction as outlinedby Lt. Col. George D. Newton, MC, was deemed inadequate for the needs of thetheater. Actual participation in this area was delayed, and it was not until 22March 1943 that Colonel Middleton gave his first lectures. The initial 4 hoursof lectures for medical officers were reduced to 2 hours. One hour was allottedfor lectures to nurses. Topics of current medical interest in the theater, suchas respiratory infections, meningococcal infections, infectious hepatitis, andrickettsial diseases, were discussed at these monthly sessions. Particularattention was given to the dignity of the sick call. In the lecture to the ArmyNurse Corps representatives at the school, particular attention was given theservice, functions, and responsibilities of the Army nurse. The psychology ofthe sick and wounded was discussed, and due emphasis was given to the role ofthe Army nurse as the medical intermediary for the tending medical staff.
The Army Medical Field Service School continued its classesat Shrivenham until 13 October 1944. In the spring of 1945, it resumedoperation near Etampes, France (fig.90). With the altered tactical situation,the schedule
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FIGURE 89.-Formation of student medicalofficers, Army Medical Field Service School, Shrivenham Barracks, England.
of instruction was accelerated. This educational effort, primarily conceived byColonel Mason (fig. 91), was directed toward the improvement of theprofessional opportunities for medical officers of tactical and detached units.Its successful implementation depended in a large measure upon administrativeefforts of Maj. (later Lt. Col.) Bernard J. Pisani, MC (fig.92), and Capt.(later Lt. Col.) Kenneth Smith, MC, who were charged with the immediatedirection of the school. From time to time, the exigencies of service led to adiversion from the primary function of these courses; namely, the instructionof medical officers of tactical and detached units. In spite of these minordefections, this overall plan may well be counted a major contribution of thetheater to the improvement of medical care of the soldiers through theeducation of medical officers.
Professional Rehabilitation Following Cessation of Hostilities
As early as 18 December 1943, in a memorandum to GeneralHawley, Colonel Middleton had proposed a plan for professional rehabilitation.This plan envisioned the reciprocal advantages of the transfer of medicalofficers from tactical units to fixed Army hospitals and to civilianinstitutions and practice in Great Britain and on the Continent after the war.Upon the cessation of hostilities, the Operations and Training Division inGeneral Hawley's office evolved an extensive program of medical education. Inaddition to the decentralized plan for independent courses at the several
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FIGURE 90.-Medical Field Service School on theContinent, Etampes, France, spring 1945.
hospital centers, an intensive educational program was planned for theMourmelon area near Rheims, under the leadership of Col. Sam Seeley, MC.Colonel Middleton proposed a preceptorial plan under leaders in internalmedicine in Great Britain. This program received the support of General Hawleyand his Operations and Training Division. Upon personal solicitation, a numberof the representative internists of Great Britain and Northern Ireland agreedto cooperate in this important enterprise. Indeed, a few medical officers inthe U.S. Army were so assigned, but all of these thoughtfully conceived plans
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FIGURE 91.- Lt. Col. James B. Mason, MC.
fell short of their goal or were actually abandoned in the turmoil ofredeployment in the summer of 1945. In retrospect, all of these educationalplans were sound and worthy of support.
Specialty Board Certification
At first glance, the certification of the medical officersin the specialty boards might appear beyond the interest or purview of theMedical Consultation Service. However, qualified medical officers who weredenied the right of examination and certification by reason of militaryservice, particularly in an oversea theater of operations, had a reasonablebasis for a sense of discrimination. As secretary of the American Board ofInternal Medicine, Colonel Middleton felt a serious responsibility inattempting to remove this potential source of irritation. On 19 April 1942, theAmerican Board of Internal Medicine authorized regional oral examinations underthe supervision of a member of the board "to meet the convenience of menin the Armed Forces," and, on 10 June 1944, the board took the officialaction that "while on active duty, Colonel William S. Middleton, MC, USA,and Captain William S. McCann, MC, USN, be authorized to conduct special oralexaminations for eligible candidates wherever they are." This specialauthorization was unusual, particularly in view of the termination of the legaltenure of office of Colonel Middleton as of 30 June 1944. Under the authorityso vested, the oral ex-
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FIGURE 92.- Maj. Bernard J. Pisani, MC.
amination of candidates for certification by the American Board of internalMedicine was arranged at the mutual convenience of the examinees and guestexaminers. The following guest examiners cooperated willingly in thisenterprise:
Lt. Col. Benjamin I. Ashe, MC, 1st General Hospital.
Lt. Col. Wardner D. Ayer, MC, 52d General Hospital.
Lt. Col. Theodore L. Badger, MC, 5th General Hospital.
Lt. Col. Elton R. Blaisdell, MC, 67th General Hospital.
Maj. Donald J. Bucholz, MC, 93d General Hospital.
Lt. Col. E. Murray Burns, MC, 46th General Hospital.
Lt. Col. Augustus H. Clagett, Jr., MC, 90th General Hospital.
Col. Cyrus J. Clark, MC, 32d General Hospital.
Lt. Col. Sander Cohen, MC, 40th General Hospital.
Lt. Col. Stanley C. W. Fahlstrom, MC, l08th General Hospital.
Lt. Col. Frederick W. Fitz, MC, 70th Station Hospital.
Lt. Col. Carl H. Fortune, MC, 49th Station Hospital.
Lt. Col. Gordon E. Hein, MC, 12th Hospital Center.
Maj. Henry B. Kirkland, MC, 110th General Hospital.
Maj. George L. Leslie, MC, 95th General Hospital.
Maj. Arthur S. Mann, MC, 91st General Hospital.
Lt. Col. Richard M. McKean, MC, 36th General Hospital.
Maj. Norman L. Murray, MC, 186th General Hospital.
Maj. Arthur D. Nichol, MC, 93d General Hospital.
Maj. Christopher Parnall, Jr., MC, l9th General Hospital.
Maj. Frank Perlman, MC, 124th General Hospital
Maj. Herbert W. Rathe, MC, 347th Station Hospital.
Capt. Bernard D. Rosenak, MC, 49th Station Hospital.
Lt. Col. Donald C. Wakeman, MC, 2l7th General Hospital.
Lt. Col. Bernard A. Watson, MC, 36th General Hospital.
Maj. Herbert B. Wilcox, MC, 2d General Hospital.
Maj. Carl R. Wise, MC, 2d General Hospital.
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A total of 113 candidates were examined, and 4 candidateswere examined twice, to make a total of 117 examinations. The results of these117 examinations are interesting: Internal medicine, 73 (65 percent) passes, 41(35 percent) failures; cardiovascular, 1 pass and 1 failure; and tuberculosis,1 pass.
It is impossible to assay the contribution of theseexaminations to the morale of the theater. The dependence of the PersonnelDivision upon such tangible data as certification by the several specialtyboards in deriving the MOS (military occupational specialty) of medicalofficers gave this formula unusual weight in the minds of many individuals. Tothe cooperation of the American Board of Internal Medicine, especially theassistant secretary-treasurer, Dr. William A. Werrell, and to the guestexaminers in the European theater, due credit is given for the successfuldischarge of this mission.
PROFESSIONAL MEETINGS
American Medical Society, ETOUSA
Medical society meetings constitute an important element inmaintaining an alert profession in civilian life. Medical Departmentregulations insure a continuance of this activity in the Army hospitals. Wherethe spirit prevails, the meetings help maintain high standards. Such was thecase in the European theater. In certain hospitals, X-ray and clinicopathologicconferences added to the superb tone of professional alertness. These routinehospital meetings were supplemented by the American Medical Society, ETOUSA.The seed for this theater activity was sowed in a meeting for the discussion ofhepatitis at the General Medical Laboratory A, Salisbury, England, in which,1st Lt. (later Maj.) William L. Hawley, MC, Maj. (later Col.) Paul Padget, MC,and Colonel Gordon, of the U.S. Army; Dr. William H. Bradley, of the BritishMinistry of Health; and Dr. James K. McCollum of the Wellcome Laboratoryparticipated.
The occasion of the first anniversary of the 5th GeneralHospital in the European theater led to a medical and surgical conference inwhich Colonel Badger discussed postinoculation hepatitis; Dr. John McMichael,traumatic shock; and Dr. Eric G. L. Bywaters, crush syndrome.
The first meeting of the American Medical Society, ETOUSA,was held on 23 June 1943, at the 298th General Hospital, Frenchay Park,Bristol, England. The commanding officer, Col. Oscar C. Kirksey, MC, and hisstaff were hosts. A committee on organization, composed of Colonels Knee-landand Hein, and Col. Robert M. Zollinger, MC, was named. This committee drafted abrief constitution which was adopted. The following officers were elected: President,Colonel Zollinger; vice president, Lt. Col. (later Col.) William F. MacFee, MC;secretary-treasurer, Maj. (later Lt. Col.) Clifford L. Graves, MC; councilors,Major Muckenfuss and Maj. (later Col.) Edward J. Tracy, MC. The second meetingof the society convened on 28 July 1943 at the 30th General Hospital. Thecommanding officer, Col. Charles B.
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Kendall, MC, and his staff presented a very instructive program. On 18 August1943, the third meeting of the society convened at the 2d General Hospital.Under the commanding officer, Col. Paul M. Crawford, MC, and his staff, a veryprofitable session was held. The last meeting of the American Medical Society,ETOUSA, was held on 26 April 1944, at the l27th General Hospital, Sandhills(near Taunton), England, with the commanding officer, Col. James L. Murchison,MC, and his staff as hosts. Colonel Middleton spoke on the care of the medicalcasualties from the far shore. Thereafter, the tactical situation and thenumber and dispersion of medical units made further meetings of the societyimpractical. This function, in turn, devolved upon the base sections and thehospital centers. Indeed, the Western Base Section had anticipated thiseventuality and had arranged for a medical meeting to be held at the 52dGeneral Hospital, Kidderminster, on 29 December 1943. This meeting was attendedby 200 medical officers.
Inter-Allied Conferences
More far reaching in their influence were the Inter-AlliedConferences on War Medicine. In April 1942, Col. Victor Gallemaerts, Director,Belgian Army Medical Service, suggested to the British War Office theestablishment of conferences on War Medicine. At that time, the difficulties inorganization seemed insuperable, but the early and rapidly increasing numbersof medical representatives in the Armed Forces of the United States paved theway for a reconsideration of the subject. Colonel Cutler stimulated thismovement through the offices of Mr. L. R. Broster, then surgical secretary ofthe Royal Society of Medicine. In the preliminary discussions, the RoyalSociety of Medicine offered its facilities as a meeting place and clericalassistance for the organization of the meetings. The meetings were designed"for the interchange and communication of medical experiences in the fieldand of the practical application of medicine to the needs of warfare, and forthe exposition of the general principles of administration and organization ofthe medical services."6 The first of these meetings,attended by approximately 120 medical officers of the U.S. Army, was held atthe Royal Society of Medicine on 7 December 1942. Maj. Gen. Sir Henry Tidypresided (fig.93). The meetings were continued until 8 July 1945. A total of 24conferences was attended by over 6,500 officers of the Allied medical services.These sessions served as a clearinghouse for the war experiences of the Alliedforces. The topics covered the entire gamut of medicine and surgery as encounteredunder the war conditions of the period. Stirring stories of firsthandexperiences at Dunkirk, Dieppe, Lake Chad, Arnhem, Bastogne, Buchenwald, and inthe Arctic convoy held the interest of large audiences derived from allservices. Two hundred and twenty speakers appeared before the conferences.Among these were the Chief Surgeon and a number of representatives of theProfes-
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6Inter-Allied Conferences on War Medicine, 1942-1945, edited by H.L. Tidy and J.M. B. Kutschbach. London: Staples Press, 1947.
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FIGURE 93.- Maj. Gen. Sir Henry Letheby Tidy,President, Royal Society of Medicine (center) conferring informally withColonel Kneeland (left) and Colonel Pillsbury.
sional Services Division. General Hawley, Colonel Kimbrough, Colonel Cutler,Colonel Kneeland, Lt. Col. (later Col.) Paul C. Morton, MC, and ColonelMiddleton served on the organizing committee. To the success of this effort,none contributed more effectively than the secretary of the Royal Society ofMedicine, Mr. Jeffrey R. Edwards, upon whom fell much of the detailed work oforganization. One hundred and twenty of the papers presented at these meetingswere bound and published in 1947 as Inter-Allied Conferences on War Medicine,1942-1945, and constitute an essential element of the official medical historyof World War II.
Allied Consultants Club
With the close rapport between the medical officers of theU.S. Army and their fellows in the Allied armed services came not onlyprofessional but also social interchange, cementing internationalrelationships. Continued over the years of association with the British andCanadian consultants, particularly, came the natural design for the formationof the Allied Consultants Club. Broad though the term appeared, its membershipwas limited to the consultants in the English-speaking Allied armies. The firstmeeting of this group convened on 15 October 1944 at the l08th General Hospital(fig.94) in Paris, with Colonel Kimbrough presiding (fig.95). Generaldiscussions of battle trauma occupied the morning session. After luncheon, theconsultants divided into two sections:
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FIGURE 94.-Rear view of 108th General Hospital,Paris, France
(1) Surgical conference under Colonel Cutler, and (2) medical conference underColonel Middleton (fig.96). The medical conference concerned itself with thefollowing topics: Neuropsychiatric casualties in the Army, treatment ofvenereal diseases, special medical problems, and the proposed sulfonamideprophylaxis of infectious diseases. Participating in this conference were:General Biggam, Consulting Physician of the British Army; Brig. E. Bulmer,RAMC, Consulting Physician, British 21st Army Group; Brigadier Riddoch,Consulting Neurologist of the British Army; Col. J. S. K. Boyd, RAMC,Consulting Pathologist, British 21st Army Group; Colonel Pillsbury, SeniorConsultant in Dermatology and Syphilology; Colonel Thompson, Senior Consultantin Psychiatry; Colonel Badger, Senior Consultant in Tuberculosis; ColonelKneeland, Medical Consultant, United Kingdom Base, and Senior Consultant inInfectious Diseases; Colonel Hein, Senior Consultant in Cardiology, Lt. Col.Nathan Weil, Jr., MC, Consultant in Medicine, Third U.S. Army; Lt. Col. Guy H.Gowen, MC, Consultant in Medicine, Seventh U.S. Army; Lt. Col. John B. McKee,MC, Consultant in Medicine, Ninth U.S. Army; Colonel McEwen, Consultant inMedicine, Brittany Base Section; Colonel Muckenfuss, Director of MedicalResearch, and Commanding Officer, General Medical Laboratory A; and Maj. Alfred0. Ludwig, MC, Consultant in Neurology, Seventh U.S. Army.
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FIGURE 96.- Col. William S. Middleton, MC(seated at table, rear), presiding at medical conference held as part ofInter-Allied Consultants Conference, 108th General Hospital, 15 October 1944.Col. Neil Crone, MC (standing), is the speaker.
The session was continued on the morning of 16 October 1944,with a clinical program by the staff of 108th General Hospital, Lt. Col. (laterCol.) Louis M. Rousselot, MC, presiding.
The next conference of the consultants club, which in allpropriety should be termed "Anglo-American Consultants Club," washeld in Brussels, 11 December 1944. Conspicuous among the papers presentedbefore the medical section was Brigadier Riddoch's stirring appeal forsustained attention to the spastic paraplegic patients.
The third allied consultants conference (Anglo-AmericanConsultants Club) was held in Paris, on 25 and 26 May 1945, at the l08thGeneral Hospital. Among the topics of interest in the general session of thefirst day was shock. On the second day, the medical section discussed syphilis,hepatitis, malnutrition, tuberculosis, and typhus fever.
The registrants and participants in the discussion of themedical topics insured a most profitable session. They included: BrigadierBulmer, RAMC, Consulting Physician, 21st Army Group; Brigadier MacKenna, RAMC,Consultant in Dermatology; Brigadier Osmond, RAMC, Consultant in Venereology;Brig. J. H. Palmer, RCAMC, Consulting Physician; Brig. Robert C. Priest, RAMC,Consulting Physician, Western Command; Brigadier Withby, RAMC, Director of ArmyBlood Transfusion Service; Colonel
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Kneeland, Consultant in Medicine, United Kingdom Base, and Senior Consultant inInfectious Diseases; Colonel Pillsbury, Senior Consultant in Dermatology andSyphilology; Colonel Fitz, Consultant in Medicine, Delta Base Section; ColonelGowen, Consultant in Medicine, Seventh U.S. Army; Colonel McKee, Consultant inMedicine, Ninth U.S. Army; Lt. Col. Carter Smith, MC, Consultant in Medicine,Fifteenth U.S. Army; Colonel Weil, Consultant in Medicine, Third U.S. Army;Surgeon Vice Admiral Sir Sheldon Dudley, RN, Director General of MedicalServices; Surgeon Rear Admiral Gordon Gordon Taylor, RN., Consulting Surgeon;Surgeon Rear Admiral Rowlands, Consulting Physician; Maj. Gen. Morrison C.Stayer, Chief Surgeon, MTO; General Tidy, President, Royal Society of Medicine;Brig. E. Boland, RAMC, Consulting Physician, British Army in Italy; Sir ClaudeFrankau, Deputy Director, EMS; Dean Charles Newman, British PostgraduateMedical School; Col. E. N. Alling, Commanding Officer, 814th Hospital Center;Colonel Gordon, Chief, Preventive Medicine Division; Lt. Col. (later Col.)Wendell H. Griffith, SnC, Chief, Nutrition Section, Preventive MedicineDivision; Col. Esmond R. Long, MC, Consultant in Tuberculosis for The SurgeonGeneral; Lt. Col. Hamilton Southworth, MC, Office of Scientific Research andDevelopment; Colonel Cohen, Chief of Medical Service, 40th General Hospital;Lt. Col. Alva V. Daughton, MC, Chief of Medical Service, 48th General Hospital;Colonel Fahlstrom, Chief of Medical Service, 108th General Hospital; ColonelFortune, Chief of Medical Service, 191st General Hospital; Lt. Col. (laterCol.) Rudolph A. Kocher, MC, Chief of the Medical Service, 203d GeneralHospital; Lt. Col. Carl S. Lytle, MC, Chief of Medical Service, 62d GeneralHospital; Lt. Col. (later Col.) Herbert B. Pollack, MC, Chief of Medicine, l5thGeneral Hospital; Lt. Col. Leonard G. Steuer, MC, Chief of the Medical Service,198th General Hospital; Maj. Sarah H. Bowditch, MC, Assistant Military Attache,American Embassy, London; Maj. Marion Loiseaux, Consultant of the Women's ArmyCorps; Maj. Moses D. Deren, MC, Chief of the Medical Service, l94th GeneralHospital; Maj. (later Lt. Col.) Charles P. Emerson, Jr., MC, Chief of theMedical Service, 231st General Hospital; Maj. David Greeley, MC, AmericanTyphus Commission; Maj. Richard Reeser, MC, Chief of the Medical Service, 202dGeneral Hospital; and Capt. T. E. Caulfield, MC, Chief of the Medical Service,230th General Hospital.
Upon the release of Buchenwald, Dachau, and other horrorcenters from German control, Colonel Pollack, of the 15th General Hospital,Liege, Belgium, and Capt. Leonard Horn, MC, of the 19th General Hospital,Rennes, France, had been ordered on detached duty for service with ColonelGriffith to study and collaborate in the control of malnutrition among thereleased military and civilian prisoners. Colonel Pollack's analytic discussionof the subject was a highlight of this conference. The opportune presence inthe theater of Colonel Long had added greatly to Colonel Badger's master planfor the management of the recovered Allied military personnel coming into U.S.fixed hospitals upon release. Some idea of the magnitude of the problem may begained from the fact that of 1,700 of these patients received at the 46thGeneral Hospital,
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FIGURE 97.- One of recovered Allied personnelcared for at 46th General Hospital showing debility and malnutritioncharacteristic of many.
975 had tuberculosis (fig.97). Of this group, 650 were in a moderate tofar-advanced stage of the disease. A system of aseptic technique was combinedwith clean areas for the protection of the nursing and medical personnel.Although only three meetings of the Anglo-American Consultants Club were held,its very existence should be recorded as a measure of the spirit of mutual goodwill and confidence engendered among the English-speaking consultants throughthe years of their effort in a common cause. Truly, this organization serves asan object lesson in international amenities.
SUPPLY AND USE OF DRUGS
The consultants of the Professional Services Division inGeneral Hawley's office were regularly consulted by the Finance and SupplyDivision about problems of mutual interest. On 31 August 1942, ColonelMiddleton conferred with Lt. Col. George Perkins, MC, in charge of supplies forthe U.S. Army Medical Department, and with Major Gallagher, RAMC, at 39 HydePark Gate, London, in a survey of the availability of British drugs andchemicals for use in the U.S. Army. By all standards-- atomic weight, meltingpoint, freezing point, solubility, measures of purity, and othercriteria--drugs of
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British origin were checked against the U.S. pharmacopoeial standards. Wherecomplete concurrence existed, no change was recommended, and the assignednumber in the Standard Supply Table of the Medical Department could be usedinterchangeably. Where differences in strength were found in articles ofuncommon usage, a change in the label was recommended. In only one importantarea did the U.S. consultants differ with their British confreres; namely, thenecessity for broadening the base of sulfonamides. The British were limited byavailable manufacture and supply to sulfapyridine. The American officersinsisted upon the inclusion of sulfadiazine at least. On 11 September 1942,Colonel Perkins and Colonel Middleton recommended a reconciliation of thenomenclature by a listing of 14 preparations of different strengths accordingto their values in the British Pharmacopoeia. Apparently, these carefullyconsidered recommendations were not completely implemented, but, on 9 February1944, at the request of the Finance and Supply Division, Colonel Middletonreported to Depot G-30 in London to review certain available drugs from Britishsources with Lieutenant Smith, SnC. The drugs without a useful prospect wererejected. On 5 October 1942, Colonel Middle ton reviewed the first aid kit ofan M-4 tank in the 372d Tank Battalion with Captain Moore, near Tidworth. Theposition of the first aid kit behind time left shoulder of the driver on thelateral wall of the forward compartment of the tank made it inaccessible toanyone except the driver. Furthermore, the kit contained no sulfonamide ormorphine, and the burn therapy was limited to tannoid. A correction of thesedeficiencies was recommended to the Supply Division.
The necessity for the conservation of quinine led to thepreparation of Circular Letter No. 55, dated 23 October 1942, Office of theChief Surgeon, Headquarters, ETOUSA. This circular letter recommended use ofsalicylates and coal-tar derivatives rather than the empirical use of quinine.The directive also stated that quinine would not be used for the treatment ofconditions other than malaria. Furthermore, it stated: "Since all malarialpatients will be evacuated to hospital units, no quinine will be issued to divisionalmedical installations. Atabrine will be used for time suppressive therapy ofmalaria."
On 2 October 1942, the faculty of Oxford University gave areception for the staff of the 2d General Hospital. Colonel Middletonrepresented General Hawley at this function. On this occasion, Prof. Howard W.Florey extended to Colonel Middleton an invitation to visit the William DunnLaboratory of Pathology. With General Hawley's approval, Colonel Middietonarranged an appointment with Professor Florey for 24 October 1942. At thistime, Professor Florey acceded to a plan to supervise penicillin treatment andto train teams for each of the U.S. general hospitals. The plan was to becarried out at the 2d General Hospital. The teams to be trained were to includea clinician and a bacteriologist, and a week was decided as adequate time forthe necessary instruction. Lt. Col. (later Col.) Rudolph N. Schullinger, MC,Chief, Surgical Service, 2d General Hospital, had attended the reception andhad anticipated the official visit by making personal observations of theclinical application of
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penicillin in several institutions in the environs of Oxford. (On 18 May 1944,he submitted a report, entitled "Penicillin in the treatment of SurgicalInfections," based on these early observations.) When the 2d GeneralHospital was agreed upon as the training center, Colonel Schullinger was namedas the logical medical officer of the unit to serve as the Chief Surgeon'srepresentative with Professor Florey. The plan was submitted to General Hawley,who approved. Complete acquiescence to the plan came from Professor Florey byreturn mail. He suggested that he would use his influence to have Prof. A. N.Richards send the American penicillin to Oxford.
Medicine came naturally to its own in the application ofpenicillin to the treatment of infectious diseases. In one area of itsapplication, the European theater broke new trails. Penicillin was recommendedin the treatment of diphtheria carriers and of severe clinical diphtheria as anadjuvant to, not a substitute for, diphtheria antitoxin.7 Somemeasure of success attended this procedure.
The table of basic allowance is the bible of the supplyofficers. Its periodic review and correction is required under conditions ofactive warfare in a foreign theater. In ETOUSA, this lot fell to theProfessional Services Division in General Hawley's office. It was not an easyone, when viewed in the light of the accretion of the years and the traditionalbibles of therapeutics. Interestingly, one of the most questionable of alltherapeutic agents and one whose accounting gives commanding officers of Armyhospitals the greatest concern, namely, spiritus frumenti, proved to have thestrongest defenders at the highest levels. The tables for basicallowance--class I items--for the North African campaign were completed in somemeasure by the Professional Services Division. In this instance, arbitraryfigures for the incidence of tropical diseases were applied to the requirementof special or specific drugs. This problem did not prove as pressing in theplanning for OVERLORD, since tropical diseases are not a problem in northernEurope. However, certain secret advices indicated an unusual incidence ofserious diphtheria in northern France and the Low Countries. Accordingly, a disproportionatelylarge supply of diphtheria antitoxin was stocked for the invasion.
HOSPITAL FACILITIES
The Chief Surgeon, ETOUSA, encouraged a close liaisonbetween the Professional Services and the Hospitalization Divisions of hisoffice. In an early survey, 4 to 6 August 1942, Colonel Middleton was requestedto report to the Hospitalization Division his observations of the hospitalsituation in the North Ireland Base Section. This area was unusual in itsprimary utilization as a training center for ground troops. With the completecooperation of the base surgeon, Colonel Green, the hospital facilities atMusgrave Park, Waringfield, Irvinetown, and Londonderry were surveyed from aphysical as
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7Administrative Memorandum No. 151, Office of the Chief Surgeon, Headquarters,ETOUSA, 27 Nov. 1944, subject: Tentative Program for the Observation of theEfficacy of Penicillin in the Treatment of Diphtheria.
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FIGURE 98.- Lt. Col. John Douglas, RAMC
well as a professional standpoint. In this relation, one detail is worthy ofrecord. At Londonderry, the l0th Station Hospital was established in one oldbarracks-type building and a series of detached structures in which there was aserious fire hazard. Furthermore, Londonderry was at the end of a narrow gagerailroad, and evacuation by rail depended upon a shuttle pattern. Evacuation bysea required shallow draft craft. Directly across the street from the 10thStation Hospital was a superbly constructed and equipped naval hospital.Colonel Middleton recommended the abandonment of the Army installation by theconsolidation with the naval unit, as an economical and sound solution to theproblem. This consolidation was particularly feasible by reason of therelatively light patient load of both hospitals. General Hawley indicated hiswillingness to accept the validity of the recommendation but stated that, underexisting conditions, such a pooling of medical interests in the Londonderryarea was impractical.
With the invaluable assistance of Lt. Col. John Douglas,RAMC (fig.98), the Hospitalization Division, under Col. Eli E. Brown, MC,secured 90,000 beds in British installations before August 1943. The Britishfacilities ranged from temporary conversion camps to permanent construction andfrom the Royal Victoria (Netley) Hospital at Southampton Water to a series ofpavilion hospitals newly constructed under the Emergency Medical Service forthe postwar implementation of the white paper (later the National Health Act)(fig.99). Under a mandate of General Hawley, the consultants reported upon thephysical details of strength and deficiency in these hospitals. The absence ofshower baths and the limitation of toilet facilities were among the commonestcomplaints. In many of the newer hospitals and in all of the temporary unitshoused in Nissen huts, the source of heat was two stoves placed at either endof the center of the ward. These stoves were stoked by lifting a lid from thetop and pouring in bituminous coal from a scuttle (fig.100). The resultantsmudge was inevitable, but this source of heating obtained in the UnitedKingdom for the duration. The open corridors without provision
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FIGURE 99.- Continued. C and D. Temporary buildings converted for use as U.S.Army hospitals.
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FIGURE 100.- Provision of heat in Nissen-hutwards by two coal stoves.
for wind or storm break were eventually closed in some areas (fig.101). TheProfessional Services Division cooperated with the Hospitalization Division inimprovising isolation facilities which, under the British plans, wereinadequate in a majority of instances. In the adaptation of existing buildingsto hospital purposes, fire hazards were occasionally overlooked, as at the 5thGeneral Hospital and the 10th Station Hospital, Musgrave Park, Ireland, and atthe 38th Station Hospital, Winchester, England (fig.102). In these instances,the consultants recommended appropriate protective devices. The elementsoccasionally confirmed the advice. On 20 October 1943, with Colonel Kimbroughand Colonel Zollinger, Colonel Middleton visited the 12th Evacuation Hospitalat Carmarthen, Wales, to find it located in a pocketed valley. A recent rainhad made a quagmire of the tent area, and the enlisted personnel and officersin mess line were knee-deep in mud and water. Needless to say, thoseresponsible for selection at this site erred seriously in planning.
A real challenge arose in the establishment of fixedhospitals in tented units in the field. On 22 February 1944, in a survey of the280th Station Hospital at Shortgrove Park, commanded by Col. Howard W. K.Zellhoefer, MC, an unusually efficient expedient was observed. To combat mudand confusion, all roads and paths were laid out before any construction wasbegun. No one was permitted to walk on the grass or earth. The concretefoundations were laid and tents pitched as soon as the concrete dried (fig.103). Interestingly, a similar plan employed at the 298th General Hospital,near Liege, Belgium, under Col. Walter G. Maddock, MC, commanding officer, madethis installation the model of field perfection on the Continent.
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FIGURE 101.- Long, open corridors at hospitalof temporary Nissen-hut construction.
EVACUATION POLICIES
General Hawley charged his Professional Services Divisionwith the responsibility of advising in the formulation of evacuation policy forthe theater. On 10 December 1944, evidently concerned by an apparent lag intime evacuation of patients from fixed hospitals, General Hawley issued thefollowing instructions to his chief consultant in medicine in a letter,subject: Survey of Clearance of Hospital Beds.
* * * * * *
4: You are to observe particularly the following:
a. Are patients held in hospital toassist in the work of the hospital?
b.Are patients being held in hospital purely for subjective complaints that cannot be confirmed by objective findings?
c. Are patients for the Z/I being ordered and reportedpromptly? In the great majority of instances, the decision as to the ultimatedisposition of a patient can and should be made within 48 hours of hisadmission.
d. Are directives of this office being followed as to thelimitations upon definitive treatment that will be done in this Theater?
5: I desire that you make periodic reports to me in personwith information covering specific wards and hospitals and proportion of casesfound that should have been cleared before.
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FIGURE 102.-38th Station Hospital, Winchester,England, formerly the St. Swithin's School.
If this order be related to the tactical situation, itsexplanation becomes obvious. A similar communication to the ProfessionalServices Division from the Chief Surgeon, ETOUSA, dated 21 January 1945,carried the same implication. It read:
1. We are getting constant complaints which even though eachinvolves only small numbers in the aggregate show that there is still need formuch training of medical officers both in sorting of cases, and in dispositionof such cases as are returnable to duty. I realize that there has beenconsiderable improvement in this situation in the past six months, but there isstill room for improvement.
2. I desire, therefore, that without delay, you have athorough survey made of every Reinforcement Depot on the Continent by competentobservers. This survey:
a. Will be sufficientlycomprehensive to give a true picture of conditions. Without imposing any rules,I feel that each observer should remain at a depot for several days, evaluatingthe fitness for duty of every man returned from hospital during this period.
b. Will present facts, notgeneralities.
c. Will evaluate the professionalcompetence of medical officers and the system of reexamination at ReinforcementDepots.
d. Will at the same time educateand train medical officers on duty at Reinforcement Depots.
3. Necessary coordinationwill be made with GFRS.
4. Action indicated byresult of survey will be presented to me in form of plan and directive.
5. Please expedite.
With Maj. (later Col.) John N. Robinson, MC, SeniorConsultant iii Urology, ETOUSA, Colonel Middleton visited the 11thReinforcement Depot at Givet, France, and the 16th Reinforcement Depot atCompiègne, France, on 26 January 1945, and the 9th Reinforcement Depotat Fontainebleau, France, on 29 January 1945. After a careful survey and spotcheck upon the
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situation in these units, these officers reported a remarkably good dispositionrecord to General Hawley. Indeed, the quoted figure of 0.5 percent improperdisposition proved excessive.
The problem of disposition to the Zone of Interior formedical reasons had interested the medical consultants from the beginning ofoperations. The year's experience to 1 June 1943 was deemed a reasonable basisfor judgment. In this period, 3,248 transfers for physical causes had been madefrom the European theater to the Zone of Interior. Of this group, medicalreasons accounted for 1,015 transfers (31.2 percent). The important diagnosesinvolved were hepatitis, peptic ulcer, chronic arthritis, and bronchial asthma.Hepatitis accounted for 352 (34.6 percent); peptic ulcer (20.1 percent) wasnext in order of frequency. Chronic arthritis (10.9 percent) and bronchialasthma (9.5 percent) were appreciable factors in the attrition of manpower.Pulmonary tuberculosis (3.6 percent), bronchitis (2.4 percent), and rheumaticheart disease (2.2 percent), although lesser contributors to the loss of man-power,reflected the improved screening before induction and represented the occasionfor continued vigilance. Arterial hypertension (1.9 percent) and bronchiectasis(1.2 percent) were the only remaining conditions accounting for more than 1percent of the disabilities. An analysis of the records, with particularreference to the occurrence of symptoms prior to induction, led to therecommendation that chronic or recurring conditions, such as peptic ulcer,chronic arthritis, and bronchial asthma, preclude oversea assignment to anactive theater of operations.
CLINICAL STUDIES
Peptic ulcers.- In this relation, the furtherexperience with peptic ulcer in the European theater should be a matter ofrecord. At the urgent behest of Lt. Col. (later Col.) John M. Sheldon, MC,Chief, Medical Service, 298th General Hospital, a pilot plan for the managementof peptic ulcers was instituted in that unit. This plan proposed the salvage ofa group of soldiers with peptic ulcer by their assignment to limited duty undercareful control and restrictions within the hospital unit. The difficultiesinherent in such a clinical experiment became evident early, and the trialfailed despite the cooperation of the commanding officer and the sincereefforts of the medical staff. The similar experiences of several lesswell-controlled attempts to retrieve patients with peptic ulcer for activeservice in the theater confirmed the conviction that no soldier with a historyof this condition should be assigned to an oversea theater of operations. Theaverage contribution of soldiers with this condition to the war effort was 3months of more or less interrupted service. With transportation at a premiumand hospitalization doubly expensive in personnel and materiel in overseatheaters, further trials of the utilization of these patients in the ArmedForces on limited duty should be restricted to the Zone of Interior.
Hepatitis. - This was the first disease encounteredin epidemic proportions in the European theater. Its early incidence wasexplained by its mologous
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serum source in the yellow-fever vaccine, but its persistence depended upon thenaturally occurring virus. A survey of its epidemiology and clinical course arebeyond the purview of this section. The interest from a historical standpointlies in two directions. On 7 August 1942, Colonel Middleton proposed to ColonelHawley a plan to label the record of all patients with hepatitis, with athought to their later study. Furthermore, it was proposed that theidentification tag of all soldiers suffering from hepatitis be given adistinctive mark and that instructions be promulgated to insure the section ofthe liver of such soldiers at subsequent laparotomy or necropsy. Such materialswere to be forwarded to the Army Medical Museum to insure a careful registry andcontribute to expanding knowledge of the evolution of the pathologic changes ofthis condition. The Surgeon General rejected this suggestion, and a personalletter, dated 27 January 1943, from Col. James E. Ash, MC, Curator, ArmyMedical Museum, maintained that complete histologic restoration of hepatitismight be expected. Although this position proved to be true in the overwhelmingmajority of instances in which microscopic studies of the liver were affordedsubsequent to attacks of viral hepatitis, Lt. Col. D. Murray Angevine, MC, inGeneral Medical Laboratory A, collected several instances of the progression ofviral hepatitis to portal cirrhosis (Laennec's).
In conference on 26 February 1943 with Col. John Beattie,Director, Bernhard Baron Research Laboratories, Royal College of Surgeons ofEngland, at Finchingfield, arrangements were made to afford clinical facilitiesin an Army hospital for the study of the influence of sulfhydryls(sulfur-containing amino acids) on the course of hepatitis. By analogy with theaction of these amino acids in protecting the liver against toxic agents,Colonel Beattie predicted distinct advantages in the management of hepatitis.On 27 February 1943, Colonel Griffith of the Preventive Medicine Division ofGeneral Hawley's office supported this position on the basis of his personalexperimentation, which indicated that methionine and cystine protected theliver against cobalt and nickel poisoning. General Hawley designated the 12thEvacuation Hospital at Braintree, England, as the proper location for thisstudy. Upon conferring with Lt. Col. (later Col.) Marshall S. Brown, MC, Capt.Austin P. Boleman, Jr., MC, was designated as the medical officer of thishospital to head the unit.
On 6 July 1943, after thetransfer of the 12th Evacuation Hospital from this location, Colonel Middletondiscussed the problem with Colonel Beattie and with the staff of the 121stStation Hospital. Miss Smith, of the 5th General Hospital, was transferred tothis unit for laboratory duties, and Colonel Hatcher, commanding officer, andColonel Teitelbaum, Chief, Medical Service, afforded the supporting leadership.Maj. Charles Steele, MC, and Lieut. David L. Fingerman, MC, were in clinicalcontrol, and Captain Johnstone, in the laboratory.
In a conference on jaundice at the RoyalCollege of Surgeons on 23 November 1943, Colonel Beattie postulated theprobable existence of two etiologic factors; namely, X in arsphenaminehepatitis, and Y in the naturally occurring
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hepatitis. This is probably the first public reference to such a distinction.The clinical experiment on the value of the sulfur-containing amino acids inthe treatment of hepatitis was extended to carbon tetrachloride poisoning andinfectious mononucleosis. Certain brilliant results attended the intravenoususe of methionine in carbon tetrachloride poisoning. The results in themanagement of infectious mononucleosis and infectious hepatitis may betranslated in the simple terms of improved nutrition. In this relation, thereappeared no advantage over time high-protein diet in use in the theater. However,the relapse rate among patients receiving sulfhydryls was appreciably lowerthan the prevailing rule.
Motion sickness. - In all amphibious andairborne operations, particularly those involving small seacraft and gliders,motion sickness must be given serious consideration. Although the professionalresponsibility for this study resided in the Medical Consultants Division ofGeneral Hawley's office, the Division's role primarily was advisory. On 10November 1943, Colonel Montgomery, Medical Consultant to the Canadian Army, andthe Chief Consultant in Medicine, ETOUSA, conferred with a Canadian surgeon,Lt. William S. Fields, RCNVR, who had been engaged in research in motionsickness at the Neurological Institute, Montreal. In the judgment of thisgroup, 30 percent of individuals had a psychic basis for this experience. TheCanadian seasick remedy consisted of hyoscin hydrobromide, 0.6 mg.;hyoscyamine, 0.3 mg.; and nicotinic acid, 100 mg. The Canadian resultsindicated 50 percent protection from this agent. Capt. James C. Williams, MC,had been assigned by the Army Ground Forces for studies of motion-sicknesspreventive, U.S. Army development type, under simulated invasion conditions.His results were limited and inconclusive. In studies of troops airborne ingliders (fig.104), Lt. Col. (later Col.) David Gold, MC, with the cooperationof a regimental surgeon, 4Oth Infantry, concluded that there was someprotection in the motion-sickness preventive (Sodium Amytal (amobarbitalsodium) 60 mg., scopolamine hydrobromide 0.2 mg., atropine sulfate 0.15 mg.).On 17 November 1944, in a status report to General Hawley on themotion-sickness preventive, U.S. Army development type, Colonel Middletonreported on two groups of soldiers returned from the Continent to fixedhospitals in the United Kingdom after D-day. Of the soldiers analyzed, 613 hadtaken motion-sickness preventive, and, as control, 306 soldiers had taken nopreventive. A statistical analysis of the results by Lt. Col. John H. Watkins,SnC, of the Medical Records Division in General Hawley's office indicated nosignificant difference in the two groups. The adverse effects, namely, blurringof vision and unusual sleepiness, obtained in only 38 soldiers (0.6 percent).From the available evidence, the following deductions were drawn:
A. The grounds for the adoption of Motion SicknessPreventive, U.S. Army Development Type, were not sound from pharmacologic andclinical standpoints. Combined potent drugs need not show an additive effect intheir composite action.
B. The wide range of dosage and interval of administrationmilitate against an accurate statistical analysis of the results of thisparticular operation; but from the available evidence,
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FIGURE 104.- Troops of First Allied AirborneArmy in glider during Arnhem operation
itmay be stated that the agent showed no material advantage over a largecontrolled group. Admittedly, the latter individuals represent a groupresistant rather than susceptible to motion sickness.
C. An interesting by-effect of Motion Sickness Preventive,U.S. Army Development Type, among a limited number of airborne troops was asingular sense of relaxation. Certain of the glider troops mentioned thiseffect in striking contrast to their usual feeling of tension. The mildhypnotic effect of amytal and scopolamine in all probability accounts for thisdesirable reaction.
More caution in the delegating of medical functions such asthe administration of potent drugs by untrained lay personnel was cited.
PHYSICAL STANDARDS
The establishment of physical standards was a responsibilityof the Professional Services Division in General Hawley's office; hence, greatinterest was attached to the British and Canadian experience in this area. In aconference on 28 June 1942 with Air Commodore Conybeare and Air Commodore Rook,medical consultants to the Royal Air Force, Colonel Middleton was astonished tolearn of the policy of the early rehabilitation of pilots with pulmonarytuberculosis. So pressing were the British demands for manpower that pilotsunder artificial pneumothorax therapy for limited pulmonary tuberculosis werebeing utilized as trainers. Apart from this drastic departure from the veryconservative position of the U.S. Army, many other instances of
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compromises in the interest of the more complete utilization of British andCanadian manpower were encountered.
On 7 July 1943, at the monthly meeting of the MedicalSubcommittee of the Royal Army Medical Consultants Committee, Brig. Frank D.Howitt, RAMC, consultant in physical medicine, reported on his study of thePULHEMS system, a plan of physical categorization which had been devised by theCanadians and which afforded a profile of the examined soldier by systems sothat a composite picture of an individual could be gathered at a glance.Subsequent discussions of this subject, particularly with Colonel Montgomery ofthe Canadian Army, left no doubt as to its general applicability. The carefulstudies of Lt. Col. (later Col.) George G. Durst, MC, led to its adoption bytime U.S. Army as the PULHES (Physical capacity or stamina, Upper extremities,Lower extremities, Hearing, Eyes, Neuropsychiatric status) physical profileserial. With the pressure of redeployment, Maj. Charles D. May was called toHeadquarters for the interpretation of this system.
REDEPLOYMENT
The program of redeployment placed an overwhelming burdenupon the Personnel Division in General Hawley's office, which required thecontinuous support and advice from the Professional Services Division. Withintheir respective divisions, the consultants were required to act upon thequalifications of all medical officers in the theater. The point systemtogether with the MOS designation became determining factors in decisions as tothe ultimate disposition of the medical officers. Fortunately, the mutualinterests of the service and the concerned medical officer could, in a majorityof instances, be protected by the consultants' personal knowledge of theofficer's qualifications. Notwithstanding thus modifying circumstance, theexigencies of the situation were such as to resolve much of the actualredeployment to the cold figures of supply and demand.
On 10 February 1945, Colonel Kimbrough returned to the Zoneof Interior (fig.105). Colonel Cutler was named as time new director ofProfessional Services Division in the Chief Surgeon's Office, and ColonelPisani became Colonel Cutler's executive officer. The Medical ConsultationService, ETOUSA, had remained remarkably stable throughout the period ofactivity of the theater. Among the senior consultants, only Colonel Hein hadbeen lost by reason of a physical disability. His position of senior consultantin cardiology was not refilled. The total picture of the Medical ConsultationService as of 30 June 1945 may be resolved by reference to the listing ofconsultants shown in appendix A, p.829. In the interest of a comprehensivepicture of the operation, the names of all medical consultants are included, astheir inclusion gives some idea of the fluidity of the tactical situation and,by the same token, of the changing requirement for consultation service.
With a slight lag after V-E Day, 8 May 1945, the medicalsituation in the European theater underwent rapid changes upon troop movementand redeployment. The Medical Consultation Service experienced even more rapidaltera-
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FIGURE 105.- Col. James C. Kimbrough's farewellparty on the eve of his departure. Left to right, Colonel Middleton, ColonelKimbrough, General Hawley, and Colonel Cutler, Paris, France, February 1945.
tions. Late in June 1945, Colonel Kneeland was recalled to the Zone ofInterior. No successor for him was named in the capacity of senior consultantin infectious diseases. The onerous duties that he had ably discharged asconsultant in medicine to the United Kingdom Base were taken over by Lt. Col.(later Col.) Laurence B. Ellis, M C.
As of 30 June 1945, the Medical Consultation Service,ETOUSA, had the composition listed in appendix A (p.829) with the exception ofa senior consultant in cardiology; a senior consultant in infectious diseases;a base section consultant to the Brittany Base Section, which, as has beenpointed out, was dissolved early in the war; and hospital center consultants tothe 15th, 801st, 802d, 803d, 804th, 814th, and 819th Hospital Centers. The factthat no consultants were serving in these capacities as of 30 June 1945reflects the tactical situation (end of hostilities in Europe) at the time. Thefield army consultants who served armies active in the theater remainedunchanged.
In the first week of July 1945, Colonels Pillsbury andThompson were ordered to the United States. Both of these consultants had donesuperb jobs of organization and leadership in their respective fields ofdermatology and neuropsychiatry and left enviable records of accomplishment inthe interest of welfare of the U.S. soldier. With the rapidly evolving medicalsituation and particularly with the urgent demand for continuing advice to thePersonnel Division in the redeployment program, Colonel Middleton requested theassignment of Colonel McEwen to the Professional Services Division as Senior
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Consultant in Medicine. On 27 July 1945, Colonel Middleton was ordered toWashington by The Surgeon General to attend the Pacific conference, whereuponhis duties devolved upon Colonel McEwen.
SUMMARY
In reviewing the record of the Medical Consultants Section,Professional Services Division, Office of the Chief Surgeon, Headquarters,ETOUSA, certain significant details come into sharper focus. The organizationalpattern was based upon the organizational setup used in World War I,supplemented by sound advice from the medical consultants of the British andCanadian Armies. For the duration of active military operations, the rapportwith the British and Canadian medical consultants was intimate and profitable.Through the limitations imposed by The Surgeon General, medical officers in thetheater were employed in a consulting capacity, utilizing their specializedskills, rather than drawing further upon the depleted professional resources inthe United States. In accordance with the principle of the most completeutilization of talent wherever possible, consultants were used in a dualcapacity. Their primary responsibility remained in their assignments as chiefsof the medical services of fixed hospitals, and at the same time their specialtalents were used in consultative relationships to the theater. With t he growthof the theater, these keymen were assigned larger responsibilities in hospitalcenters and base sections while continuing to function as senior consultants intheir respective sub-specialties of medicine for the theater, a plan which paidheavy dividends in its cohesiveness. Only two of the senior consultants whoseadministrative duties were deemed full time, namely, Colonels Pillsbury andThompson, were stationed at headquarters.
Before D-day, the pattern of organization had undergone afair trial under relatively quiet conditions in the United Kingdom, where bythis time almost 140,000 beds had been prepared. The Chief Surgeon, ETOUSA, wascommitted to the thesis that the only reason for the existence of the MedicalDepartment in the Army is the prevention and care of the sick and injured. Hiscomplete confidence in the mission of his Professional Services Divisioninsured the highest possible level of coordination among the several divisionsof his office. From an operational standpoint, unquestionably the ability tocontrol the distribution of trained professional personnel to the greatestadvantage of the sick and wounded was the most important dividend from thisfarsighted policy. With the support of the Chief Surgeon, invaluable channelsof direct communication for the dissemination of professional information wereencouraged, to the distinct improvement of medical service. Lastly, butcertainly not least in the final analysis, the medical consultants in theProfessional Services Division, to whom had been assigned the task ofdelivering the best possible medical care to the soldiers of the U.S. Army inthe European theater, were afforded every reasonable support to attain thisobjective. Within the personal capabilities and limitations of the individualsconcerned, the measure of their success in fulfilling this mandate must rest onthe record.
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Part II. Senior Consultant in Dermatology and Syphilology 8
EVALUATION OF THE SITUATION
Figure 106 -Col. Donald M. Pillsbury, MC, Senior Consultant in Dermatology, Office of the Chief Surgeon, ETOUSA.
Colonel Pillsbury (fig.106) arrived in the United Kingdom during December 1942 and was assigned as one of two full-time consultants in the Medical Consultation Service, Professional Services Division, Office of the Chief Surgeon, Headquarters, ETOUSA. Colonel Pillsbury filled the position of Senior Consultant in Dermatology and Syphilology, ETOUSA; the other full-time position was that of the Senior Consultant in Neuropsychiatry, ETOUSA.
Making immediate contact with his counterparts in the forces of the British Commonwealth of Nations, Colonel Pillsbury found a valuable source of information in Lt. Col. (later Brigadier) R. M. B. MacKenna, Consultant in Dermatology for the Royal Army Medical Corps. Colonel MacKenna was able to recount the skin diseases most frequently found in England, the measures undertaken by the British Army to prevent and control them, and the availability of dermatologic supplies in the United Kingdom. Lt. Col. Milton H. Brown of the Royal Canadian Army Medical Corps was particularly helpful because of the experiments the Canadian Army was conducting in massive arsenotherapy of early syphilis, a subject of great immediacy in view of the marked military advantage some shortened method of treatment would have. Contact with the British Emergency Medical Service was maintained in
8 The narrative for part II was compiled by Maj. James K. Arima, MSC, The Historical Unit, U.S. Army Medical Service, in collaboration with Donald M. Pillsbury, M.D., former Senior Consultant in Dermatology and Syphilology, ETOUSA. Dr. Pillsbury contributed the summary in retrospect in May 1956.
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connection with treatment of such U. S. personnel as were admitted to EmergencyMedical Service hospitals.
Dermatology
On his arrival in England, Colonel Pillsbury found scabies,superficial pyogenic infections of the skin, contact dermatitis, and chroniceczematous eruptions increasing in incidence. Pediculosis and various types ofringworm infections also appeared to be a problem. Inspections of hospitals anddispensaries showed that earlier diagnosis with appropriate treatment in fieldunits and hospitals was needed in many cases to prevent disability. In thechronic dermatoses, such as atopic dermatitis and severe psoriasis, earlyclassification and determination of prognosis would identify patients who, withno reasonable prospect of early permanent improvement, should be returnedpromptly to the Zone of Interior in order to prevent their becoming a heavyload on medical and nursing personnel. Many soldiers who had marked sensitivityto such items as wool, dye, and leather were incapable of full duty. Many hadhad these disabilities prior to induction and should not have been sent to thetheater.
The providing of dermatologic supplies in adequate amountsand the development of new drugs and emulsions were concomitant problems. Forexample, benzyl benzoate treatment of scabies was thought to be suitable foruse in field units, but there were problems as to supply, preparation, and thebest vehicle. A standard emulsion ointment as a vehicle for sulfonamides andother medicinal agents in the treatment of superficial pyogenic skin infectionswas also needed (p.285 and p.312).
Syphilology
The field of syphilology was rife with problems of immediateconcern. A schedule of treatment for venereal diseases was prescribed in adirective from The Surgeon General.9 This schedule, however, was notbeing followed in all units because of difficulty in obtaining Mapharsen(oxophenarsinc hydrochloride). In some instances, there had even been acomplete failure in the distribution of this drug. Consequently, AmericanMapharsen, British Mapharside, and neoarsphenamine were all being used. Becauseof the conflicting evidence regarding the toxicity of these antisyphiliticdrugs, considerable confusion had arisen in the minds of many medical officers.The subject had to be investigated fully and a trial of British Mapharsideinitiated. Such matters required the closest coordination with the MedicalSupply Division of General Hawley's office, and Lt. Col. Howard Hogan, MC, wasmost helpful in relieving the critical supply situation.
Colonel Pillsbury found that the standard of syphilistreatment in some hospitals could be improved and that he would have toinvestigate the standards
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9 Circular Letter No. 74, Office of the Surgeon General, U.S. Army,25 July 1942, subject: Diagnosis and Treatment of the Venereal Diseases.
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in field units. In the U.S. Army, as in the Canadian Army, it would benecessary to hold occasional conferences of medical officers treating venerealdisease because adequate direction or stimulation of interest in syphilotherapycould not be carried out by letters and directives alone. Various laboratoryprocedures, particularly facilities for dark-field and serologic diagnosis ofsyphilis, also needed improvement.
As the new year, 1943, came, "The above wouldindicate," wrote Colonel Pillsbury, "* * * that this Consultant hasplenty to do. It is believed that work along these lines can produce asignificant decrease in disability in ETO due to diseases included in the fieldof dermatology and syphilology." 10
FORMULATIONOF POLICIES AND PROCEDURES
During 1943 the problems of dermatology and syphilologybecame more clearly defined, permitting relatively clear lines of action toovercome them. The greatest room for improvement in the field of dermatologylay in the basic processes of diagnosis and treatment in the more easilycurable, most prevalent conditions. To Colonel Pillsbury, these two questionswere paramount: (1) What is necessary to keep the soldier, particularly thecombat soldier, from man-days lost as a result of preventable or easily curabledermatologic conditions, and (2) what types of good treatment are mostapplicable in forward units? The theater senior consultant in dermatology andsyphilology had to avoid scrupulously the temptation to investigate rare andinteresting conditions or to conquer time conditions with a reputation forchronicity. The year also saw the engagement of the enemy in the North Africanand the Mediterranean areas. The campaigns in North Africa provided anopportunity to outline clearly the problems--particularly in the venerealdiseases--that would be met under combat conditions.
Dermatology
Owing to an unfamiliarity among many medical officers of thevarious dermatologic conditions, the importance of skin diseases as a source ofman-days lost was often overlooked. Of 2,093 admissions to the 10th StationHospital during the later months of 1942, 10 percent were for a primarydiagnosis of skin disease. The 5th General Hospital found that 6.8 percent of7,049 admissions were for a primary diagnosis of skin disease. There were14,408 admissions to all hospitals in the European theater during November andDecember of 1943. Of these, 1,035 cases were admitted with a primary diagnosisof skin disease. This was about 7.2 percent of total hospital admissions. Buthospital admissions alone did not tell the whole story. Colonel Pillsburyinterviewed many medical officers in both the European and North Africantheaters and found that the incidence of skin diseases at sick call in serviceand combat units ranged from 15 to 40 percent of all patients seen.11
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10 Annual Report, Professional Services Division, Office of theChief Surgeon, Headquarters, ETOUSA, 1942.
11 Annual Report, Professional Services Division, Office of theChief Surgeon, Headquarters, ETOUSA, 1943.
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Scabies and its complications, superficial pyogenicinfections, fungus infections, seborrheic dermatitis, psoriasis, and varioustypes of dermatitis and eczema constituted over 95 percent of the cases. It wasnot too much to expect of all unit and hospital medical officers to diagnoseproperly this 95 percent of dermatologic cases, but many could not. Medicalofficers in ETOUSA were, in general, less well trained in the diagnosis andtreatment of skin diseases than in any other specialty, with the possibleexception of ophthalmology. It was the exception, rather than the rule, forgeneral hospitals, supposedly equipped to render the ultimate standard ofmedical care to the soldier, to have a trained dermatologist on theprofessional staff. There were only five medical officers in the theater whopossessed a certificate from the American Board of Dermatology and Syphilology.
Colonel Pillsbury made particular efforts to train competentyoung medical officers in dermatology. This training had to be continuous, withregular supervision by the senior consultant or regional consultants indermatology, in order to insure that the training efforts were being reflectedin better standards of care.
One means of reaching the officer in the field was throughmeetings and talks. Colonel Pillsbury gave lectures on the diagnosis andtreatment of skin diseases in the field at both the Medical Field ServiceSchool, Shrivenham, and the Field Service School of the Eighth Air Force, usinga series of personally owned colored lantern slides. The British Ministry ofHealth film on scabies was also shown at the Medical Field Service School.During the year, Colonel Pillsbury led discussions, by invitation, at staffmeetings of 10 hospitals in the theater.
On 12 November 1943, a meeting, sponsored by the ChiefSurgeon's Office, ETOUSA, was held at the Royal Society of Medicine attended by25 U.S. Army medical officers and certain guests of the United Kingdom andCanadian forces. Colonel Pillsbury believed that this was the first meetingdevoted to dermatology ever meld under auspices of the U.S. Army. Variousaspects of the diagnosis, treatment, and management of scabies, pyoderma,psoriasis, eczema, and cutaneous lesions associated with meningococcemia wereconsidered in individual sessions. There were discussions on (1) the superficialX-ray treatment of skin diseases, (2) the types of skin diseases requiring"boarding" or producing recurring disability or both, (3) the factorsdelaying involution of common dermatoses, and (4) the dermatologic disabilityin combat units. In addition, Brigadier MacKenna gave a talk on theorganization of a dermatologic service. Maj. J. H. Twiston Davies, RAMC,dermatologist for the Southern Command, discussed recent experiences inmilitary dermatology. A subject of considerable importance at the time, and onein which the average dermatologist could not be expected to have had muchexperience, was the dermatologic conditions that would occur should the enemychoose to use chemical agents on a large scale. This subject was expoundedadmirably by Col. William D. Fleming, MC, Chief, Gas Casualties Division,Office of the Chief Surgeon, Headquarters, ETOUSA. Material emerging from thisex-
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change of views and information was later published in the Medical Bulletin,ETOUSA.
In the European theater, the vehicles for communicationdirected to the bulk of medical officers were circular letters of the Office ofthe Chief Surgeon, Headquarters, ETOUSA, and the Medical Bulletin.Circular Letter No. 77, 8 May 1943, was entitled "Diagnosis and Treatmentof Scabies." In it, Colonel Pillsbury stressed the point that "onlyby prompt recognition of the disease before complications have developed andbefore other members of the unit have become infested, can scabies becontrolled satisfactorily." It was pointed out that: "Unwarranted numbersof patients with scabies are being admitted to hospital in E.T.O. It isessential that medical officers should be familiar with the clinical featuresof this disease, so that an early diagnosis may be made, and prompt effectivetreatment carried out in units."
Four articles on the recognition and care of dermatologicconditions were published during the year in the Medical Bulletin.
Colonel Pillsbury continued to maintain the closest liaisonwith Canadian and British medical officers in dermatology. His relations withthe Army Air Forces were extremely cordial, and ready agreement on improvementsin the treatment of skin diseases was always obtained. On 2 July 1943, thechief address at time British Association of Dermatology and Syphilology wasgiven by Colonel Pillsbury, on invitation. In his annual report for 1943,Colonel Pillsbury commented, as follows:
This consultant has attended all meetings of CommandDermatologists, British. Participation in the discussions at this meeting hasbeen active, on request. Brig. R. M. B. MacKenna has been extremely cooperativein making available time collected data of the RAMC and his own wide experiencein military dermatology. It is felt that our relations with British in thisfield of medicine have been particularly happy, and future complete cooperationis assured. This is particularly valuable, in view of the absence of anydirection in the field of dermatology from the Office of the Surgeon General.
Special problems. - In any foreign theater, newmedical problems arise that require special treatment methods. In the UnitedKingdom, the U.S. Army depended on British sources of supply for drugs andspecial equipment for dermatologic treatment. For example, Colonel Pillsburyrealized upon his arrival in England that benzyl benzoate would be the idealdrug of choice for the field treatment of scabies. The British had shown thatit was greatly superior to sulfur. The vehicle used by the British, a liquidLanette wax emulsion, had certain disadvantages for use of troops in the field.In collaboration with British industrial chemists, an indefinitely stable andhighly effective therapeutic preparation was devised for U.S. Army use (fig.107). The developmental work with sulfonamide emulsion ointments proceeded asplanned in conjunction with the Consultant in Plastic Surgery, ETOUSA, althoughsuch ointments were later discontinued because of their sensitizing properties.A very useful preparation, benzoyl peroxide ointment, was added to the nonstandardlist and proved its value immediately (p. 312).
Superficial X-ray therapy became desirable for the treatmentof certain skin lesions. In conjunction with time Senior Consultant inRadiology,
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FIGURE 107.- Medical officers viewing displayof benzyl benzoate preparations for treatment of scabies, 5th General Hospital,Salisbury, Wiltshire, England, 1 May 1943.
arrangements were made for such therapy to be administered in selected civilianclinics, but the system did not prove to be entirely satisfactory. Thefacilities were limited in number and overworked, there was lack of control ofthe treatment given, and the possibility existed that the records of dosagewould be lost. Approximately six such units were needed, but they were notavailable. It may be concluded that superficial X-ray therapy is not a methodof treatment adaptable for use in an active theater of operations. The Financeand Supply Division of General Hawley's office was able to provide additionalultraviolet-therapy equipment, which was needed in England because of the lackof sunshine. Electrodesiccating units for the removal of partially disablingwarts and papillomas were also provided and proved useful in the hands ofcompetent medical officers. Such units were subject to misuse, however, in thehands of inexperienced physicians.
Among other collaborations required of Colonel Pillsburywere two special studies. The first of these had to do with the determinationof toxicity of certain camouflage ointments being developed by the EngineersCorps. The test involved a sample of 200 men on whom such ointments were triedfor irritant effect and sensitizing capacity. It was found that the ointmentswere satisfactory provided the formalin contained in them was replaced by a
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nonsensitizing ingredient. The other was a study conducted in conjunction withthe Preventive Medicine Division of General Hawley's office to ascertain causesand incidence rates of disabling fungus infections, which were markedly on theincrease. In addition to certain deficiencies in preventive measures, it wasfound that the wearing of heavy British-issue socks during mild or warm weatherwas deleterious, and proper recommendations were made to the ChiefQuartermaster, ETOUSA, to remedy this situation,
Syphilology
The problems that existed in the treatment of syphilis werebrought to a sharp focus in March 1943, at the first general meeting ofhospital medical officers in the theater for the purpose of discussing thetreatment of venereal disease. This conference was called by Colonel Pillsburyin order (1) to provide an interchange of ideas and discussion of mutualproblems in the field of venereal diseases, (2) to arrive at a mutualunderstanding and interpretation of various letters and directives from TheSurgeon General and the Chief Surgeon, ETOUSA, and (3) to collect informationfor the Office of the Chief Surgeon, Headquarters, ETOUSA. The majority ofconferees consisted of medical officers, laboratory officers, and nurses whowere concerned with the control, diagnosis, and treatment of the venerealdiseases. Whereas in the highest echelons, treatment and controlresponsibilities were clearly divided between professional and preventivemedicine divisions and treatment responsibilities were further delimited withrespect to gonorrhea and syphilis between the surgical and medical services,respectively, this was not necessarily the case in the field. In the smallerhospital units and commands, all of these responsibilities were, often as not,entrusted to one individual medical officer. This attendance at this conferencecould not be confined to those officers whose treatment responsibilities werelimited to syphilis alone. Accordingly, representatives from Headquarters,ETOUSA, also included Colonel Kimbrough, Chief, Professional Services Division;Major Padget, Venereal Disease Control Officer, ETOUSA; Capt. John R. Poppen,MC, USN, from the U.S. Embassy; amid Colonels Montgomery and Brown fromCanadian Military Headquarters.
The primary problems discussed at this meeting wereconcerned with (1) deviation by medical officers in the field from treatmentschedules specified in the 1942 Circular Letter No. 74 from the Office of theSurgeon General, (2) treatment of sulfonamide-resistant cases of gonorrhea, (3)interpretation and use of dark-field and serologic tests for syphilis, and (4)maintenance of proper records of treatment for syphilis. In addition, papers onthe following subjects were read and discussed: (1) The diagnosis of earlysyphilis, (2) the treatment of sulfonamide-resistant gonorrhea, (3) thetreatment of syphilis at a replacement depot, and (4) the difficulties intreating syphilis in a general hospital in the European theater. There was alsoa discussion of plans for the trial of intensive arsenotherapy of earlysyphilis.
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It was fortunate for Colonel Pillsbury that so much of thediscussion centered on the treatment of gonorrhea, which, at a later date, wasto come into his field of responsibility.
As a result of this meeting and from experience gainedthrough other sources, Colonel Pillsbury listed the primary problems in thediagnosis and treatment of syphilis to be (1) failure of continuity oftreatment in units, (2) inadequacy of any method of prolonged treatment in menor units subject to repeated movement, (3) probable complete breakdown ofantisyphilitic treatment in troops in combat conditions, (4) difficulties inmaintaining adequate records and in insuring followup studies on completion oftreatment, (5) inaccuracies in dark-field and serologic diagnosis of syphilis,and (6) difficulty in coordinating the efforts of all agencies concerned withthe control and treatment of venereal disease.
The syphilis register and the supplementary record.-In order to assure continuity of treatment in patients on the standard 26-weekschedule of therapy, a form called the Supplementary Record of Treatment,ETOUSA MD Form 313, was devised to be carried by the patient. This form was notintended to replace the syphilis register but to supplement it. It wasdeveloped after much consideration and after similar forms had proved theirworth when used by the Royal Army Medical Corps and the Royal Canadian ArmyMedical Corps. Colonel Pillsbury believed that the newly devised form would beuseful to the individual patient after his discharge from the service as wellas provide essential information should his syphilis register become misplaced.Circular Letter No. 93, 24 May 1943, Office of the Chief Surgeon, Headquarters,ETOUSA, was published to govern the use of the new form. After a 6-month trial,Colonel Pillsbury was able to report that this supplemental record had demonstratedits value beyond doubt.
Circular Letter No. 74 from the Office of the SurgeonGemmeral provided that, on completion of treatment for syphilis, the patientwould have a final physical examination, a spinal fluid test, and a bloodserology (Kahn) test. Following this, if the results were satisfactory, thepatient was placed On probation from treatment with serology (Kahn) tests madeat intervals of from 3 to 6 months. The regimen was theoretically sound, but inpractice it broke down. The key to the breakdown lay in the handling of thesyphilis register of the individual patient. The registers were filed and notconsulted or, worse still, misplaced. Colonel Pillsbury found the answer tothis problem in the central inspection and control of the syphilis register.Circular Letter No. 106, 25 June 1943, Office of the Chief Surgeon,Headquarters, ETOUSA, directed that the syphilis register be forwarded to theMedical Records Division, Office of the Chief Surgeon, Headquarters, ETOUSA,upon completion of treatment. Colonel Pillsbury then inspected registers thatcontained discrepancies. If there were serious deficiencies in the treatment orin the tests of cure, the register was returned to the forwarding unit withappropriate instructions. Otherwise, the records were filed in the MedicalRecords Division, and requests for followup tests were sent out to theindividual's unit at the proper time. After a 6-month
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interval, Colonel Pillsbury assessed the advantages of this method to be: (1)It furnished a valuable means of determining that the soldier's treatment hadbeen adequate and of correcting deficiencies early; (2) it gave reasonable,although not absolute, assurance that followup Kahn tests would be done; and(3) it offered protection against loss of the syphilis register. It wasexpected, of course, that certain difficulties would arise in the system onceactive combat operations commenced or when the theater was dissolved at the endof the war. Moreover, it was recognized that such a system might not beapplicable to a less compact theater.
Success in establishing this system of central examinationof the syphilis register was in large measure due to the wholeheartedcooperation that was given by the Medical Recordis Division.
Laboratory problems. - Early 1943 foundthe situation in regard to serologic tests for syphilis unsatisfactory inseveral respects. Although British laboratories were very cooperative andhelpful in making up for the lack of U.S. Army laboratory facilities thenavailable, their standards varied considerably; there was no way to control themethods employed; reporting of results took many different forms; and nocentral reference laboratory existed fom cross-checking their work.Furthermore, the inexperience of many medical officers in the field compoundedthese difficulties. Samples were being collected improperly. Both ColonelPillsbury and Major Padget were highly concerned because patients were beingsubmitted to unnecessary antisyphilitic treatment on the basis of falliblelaboratory tests, when the case history or proper interpretation of tests wouldindicate that the diagnosis of syphilis was highly unlikely.
At Colonel Pillsbury's instigation, a conference was held inJanuary 1943 between Major Padget and Lt. Col. Ralph S. Muckenfuss, MC, CommandingOfficer, 1st General Medical Laboratory. As a result of this conference,Circular Letter No. 22, 4 February 1943, was issued by the Office of the ChiefSurgeon, Headquarters, ETOUSA. In October 1943, it was revised and reissued bythat office as Circular Letter No. 148. This directive specified controlprocedures, methods, and policies by limiting the performance of serologictests for syphilis to those laboratories (fig.108) specifically designated bythe Chief Surgeon, ETOUSA, setting up the means for rapid transmission ofsamples and reports, specifying in detail when and under what circumstances thevarious laboratory tests should be performed, and establishing a system ofinterlaboratory checks.
When the meeting of hospital personnel concerned with thecontrol and treatment of venereal disease was convened in March 1943, ColonelPillsbury was able to report continuous improvement in regard to serologictests for syphilis. With the cooperation of Colonel Muckenfuss, the laboratorysituation was reaching a point where it was possible to lighten the load theBritish laboratories had been asked to carry. In addition, facilities andapparatus for dark-field studies had also been considerably increased.
The closest rapport was maintained by Colonel Pillsbury withthe Preventive Medicine Division and the Director of Laboratories throughoutthe year
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FIGURE 108.- Serology Section, 1st MedicalGeneral Laboratory, Salisbury, Wiltshire, England.
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in maintaining better performance of diagnostic procedures for syphilis. Theneed was demonstrated time and again by instances of gross errors in theperformance of dark-field examinations and serologic tests. Neither was asimple procedure to be performed by amateurs.
Intensive arsenotherapy. - It would notbe proper here to discuss details concerning the intensive arsenotherapy ofsyphilis. The subject is adequately covered elsewhere in this series of volumeson internal medicine in World War II. It would be most appropriate, however, torecord here the part that the Senior Consultant in Dermatology and Syphilologyof the European theater played in pioneering the application of this method inmilitary medicine.
In a letter dated 16 March 1943 to Colonel Kimbrough,Colonel Pillsbury recommended the adoption of a 20-day schedule of intensivetherapy using Mapharsen or Mapharside. At that time, this was a grave andmomentous decision on a subject that had engaged Colonel Pillsbury's attentionfrom the first days of his arrival in the theater. For his guidance in makingthis decision there was very little of the data on the subject, althougheventually data became voluminous. He had, however, a source of information inhis close association with the Royal Canadian Army Medical Corps, which hadalready embarked on the plan experimentally. He had access to information fromthe Subcommittee on Venereal Disease of the National Research Council. He hadpersonal correspondence with Dr. John H. Stokes and Dr. Joseph Earle Moore, andMajor Padget also provided information and correspondence with authorities onthe subject.
The opinions of those closest to the studies connected withthe intensive arsenotherapy of syphilis varied considerably with respect totoxicity and schedules of optimum treatment. The National Research Council hadnot approved any plan for the Armed Forces. In fact, as late as October 1942,the Committee on Medicine of the National Research Council had recommendedthat:
* * * intensive arsenotherapy of early syphilis (including the five-dayintravenous drip method) be considered as still in the experimental stage; thatthe optimum time-dose relationship still requires to be established by furtheranimal and subsequent clinical experimentation; and that at present the methodcannot be recommended for routine use by the Armed Forces. 12
The committee, following a full discussion at the meetingand later study of data circularized to the committee, somewhat modified itsprevious stand by recommending a reconciliation between certain experimentaldata and the different types of suggested methods of therapy. Pending theacquisition of these data, the committee thought that:
* * * it seems undesirable for the committee to recommend the adoption of anyvery short and intensive method of treatment as a general procedure in theArmed Forces. However, the Armed Forces may well investigate the applicabilityof these methods to their own problems under certain conditions.
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12 Minutes, Thirteenth Meeting of the Committee on Medicine,National Research Council, 16 Oct. 1942.
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Dr. Stokes, a member of the Subcommittee on Venereal Disease, had written inNovember 1942, as follows:
It is easily conceivable that there will be situations inwhich * * * the methods must and should be employed. The decision to employthem in this fashion does not lie within the recommendatory power of anyadvisory body, as the National Research Council Venereal Disease Sub-Committeehas indicated, unless that power feels it can assume responsibility for an asyet unevaluated and not intrinsically uncriticizable experiment.13
On the other hand, the military situation facing the commandin Europe indicated clearly that any prolonged method of treatment of syphiliswas likely to be interrupted for various reasons, as it frequently was amongoperational aircraft crews. It appeared doubtful that adequate continuoustreatment of syphilis could be maintained in all syphilitic patients by eventhe most competent and conscientious medical officers under conditionsrequiring extensive movement, maneuvers, or combat. Furthermore, earlysyphilis, which had to be treated to the point of noninfectiousness andadequate protection against infectious relapse, was the only real problem.There was nowhere near the number of cases of latent syphilis found in civilianpractice in the United States. Altimough it was desirable that any method oftreatment furnish reasonable protection against the development of latevisceral syphilis, it could be considered unjustifiable to employ atime-consuming and difficult therapy in an active theater because of someslight reduction in the incidence of late syphilis 10 or 15 years later. Inthis respect, the treatment schedule outlined in Circular Letter No. 74 of theOffice of the Surgeon General was, in itself, experimental. It was a 26-weekcompromise with the standard 12-to 18-month regimen, and there was insufficientclinical evidence to prove conclusively that it was adequate.
The chief disadvantage of the intensive treatment ofsyphilis was its inherent toxicity. Another disadvantage was the fact thatintensive treatment methods would require more hospital beds. Based on theprevailing incidence, in certain units, of the number of patients given initialtreatment in quarters compared to the number treated in hospital, the MedicalRecords Division of General Hawley's office estimated that, under the existingschedule, 1.7 beds per 1,000 troops were required, while 2.6 beds per 1,000troops would be required under methods of intensive therapy.14 Thisconsideration was far outweighed, however, by the savings in time of medicalofficers and the solving of problems incidental to treatment in units.
The out-and-out advantages of intensive methods of treatmentwere significant. It was estimated that infectious relapse, if it occurred,would reveal itself within 1-year after completion of treatment, therebynecessitating just a 1-year followup instead of the prevailing 2 years.Treatment could be completed in 95 percent or more cases, while being completedin not more than half
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13 Stokes, J. H.: The Wartime Control of Venereal Disease. J.A.M.A.120: 1093-1099, 5 Dec. 1942.
14 Letter, Lt. Col. D. M. Pillsbury, Senior Consultant in Dermatology,ETOUSA, to Col. J. C. Kimbrough, Director, Professional Services Division,Office of the Chief Surgeon, Headquarters, ETOUSA, 16 Mar. 1943, subject:Intensive Treatment for Early Syphilis as a Substitute for the PresentSix-Month Schedule.
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the patients treated otherwise. The centralization required by intensivetherapy would afford better control, place responsibility for treatment in thehands of few, insure proper completion of the syphilis register, and easeproblems in medical supply.
The decision to embark on intensive treatment methodshaving been made, there yet remained the question of determining total dosage,dosage per injection, frequency of injection, and the total time over whichintensive therapy should be given. Experimentation in animals and human beingshad shown that slight modifications in the last three of these variablesproduced considerable differences in results, particularly with respect to themaximum tolerable dose. There were positive indications in the experimentaldata that the longer the time over which the total required dose of arsenicalwas given, the less mortality there would be from treatment. Dr. Moore hadsuggested in a personal communication to Major Padget that a 10-week treatmentschedule be used. Thus, obviously, was too long a period for hospitaltreatment, and such a schedule would nullify the advantages of intensivetreatment. Colonel Pillsbury finally decided on a 20-day period of treatmentwith a total dose of approximately 1,200 mg. for a 150-pound patient. The totaldose would be given at the rate of 40 mg. for the first day and 60 mg. for thesucceeding 19 days.
The program as recommended by Colonel Pillsbury was approved by General Hawleyand put into effect on an experimental basis in the 2d and 298th GeneralHospitals. It was subsequently extended to the 5th and 30th General Hospitals.The closest supervision was required on the part of the theater seniorconsultant in dermatology and syphilology, necessitating from 2 to 3 visitsweekly. Following the successful trial in these hospitals, General Hawleyapproved further extension of this treatment to all general hospitals andcertain other selected hospitals by Circular Letter No. 138, entitled"Intensive Treatment of Early Syphilis," issued from the Office ofthe Chief Surgeon, Headquarters, ETOUSA, on 10 Septemnber 1943.
By the end of 1943, approximately 1,200 patients with earlysyphilis had received intensive therapy without mortality. The average periodof hospitalization for each patient had been only 25 days. Although no finalstatements could be made at that time, it appeared that the incidence ofrelapse would be no higher than, if as high as, with the standard 26-weekschedule, and the serologic reversal rate was apparently satisfactory.15The Canadian Army, which had suffered 4 deaths in 681 cases treated under its6- to 10-day regimen, also adopted the 20-day treatment provided U.S. troops.In September 1943, Dr. Moore visited the theater and was apprised of theresults of intensive therapy at a meeting attended by both U.S. and Canadianmedical officers engaged in supervising and operating the program. Dr. Mooreconsidered the results highly satisfactory, advised extension of the type oftreatment being given to all troops in the European theater, and wholeheartedlyrecommended that the 26-week schedule be abandoned entirely within the theater.
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15 See footnote 11, p.283.
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RecommendationsBased on North African Experience
In late 1943, Colonel Pillsbury toured representativemedical installations in North Africa for the purpose of observing methods ofprevention and control of venereal and skin diseases. Between 15 November 1943and 7 December 1943, he visited all base sections of the North African theater,with the exception of the Atlantic Base Section, and inspected 10 generalhospitals, 6 station hospitals, 3 evacuation hospitals, 1 division clearingstation, and 3 general dispensaries. The results of his tour were reported in aletter, dated 10 December 1943, to the Chief Surgeon, ETOUSA, through theSurgeon, NATOUSA (North African Theater of Operations, U.S. Army).
In addition to reporting conditions as he found them,Colonel Pillsbury made the following recommendations with respect to thecontrol and treatment of dermatologic conditions and venereal disease inETOUSA.
Withrespect to dermatology: 1. Continued attempts to inform and train field and hospitalmedical officers concerning the proper methods of initial treatment ofpyoderma, fungous infections, and acute eczematous infections of the skinshould be made. The early initial treatment is a crucial period in preventingundue disability therefrom. If only harm from treatment can be prevented,considerable will have been accomplished.
2. Bathing facilities for combat troops in ETO should bechecked with a view to increasing their availability. It is believed that aconsiderable proportion of fungous and pyogenic infections can be entirelyprevented by more frequent bathing.
3. Continued emphasis must be placed on the importance ofgood foot hygiene, and this must be appreciated as an essential commandfunction. Arrangements have been made for distribution of four pairs of freshsocks weekly to combat troops in NATOUSA and it is recommended that plans forthis be made in ETO.
4. Adequate consultative service in dermatology should beavailable to evacuation and station hospitals which have no officer trained inthis specialty. Severe and chronic cases should be referred to generalhospitals for special treatment or other disposition as rapidly as possible.
Withrespect to venereal disease control:
1. It is recommended that resolute and determined oppositionbe offered to any policy that condones the operation of houses of prostitutionunder Army supervision or cooperation, direct or indirect.
2. The paramount importance of immediate venereal diseasecontrol measures in occupied territories should be appreciated. A venerealdisease control officer is an essential member of the initial medicalorganization.
3. It is recommended that active measures for venerealdisease control be taken by whatever organization will be responsible forcivilian administration. This is vital to an adequate program.
Withrespect to venereal disease treatment:
1. It is recommended that intensive therapy for earlysyphilis be continued in combat troops as long as the supply of hospital bedsso justifies.
2. It is recommended that resistance be offered to anyattempts to combine disciplinary measures and the treatment of venerealdisease. It is believed that venereal disease stockades and rehabilitationtraining battalions as applied to every patient with venereal disease areunjust, and frequently interfere with adequate medical care.
3. The supply of penicillin available for treatment ofsulfonamide-resistant gonorrhea should be increased as rapidly as possibleconsistently with the saving of lives in other infections. The saving of mandays lost made possible by this method of treatment is very considerable.
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In addition, Colonel Pillsbury realized the seriousnessof the problem of immersion (trenchfoot) and the fact that treatment had been unsatisfactory.He recommended that every clinical and laboratory facility of the Office of theChief Surgeon, Headquarters, ETOUSA, be made available for a thorough study ofthis condition with prompt transmission of results to the Surgeon, NATOUSA.
FULL-SCALE OPERATIONS
The period 1944 through the early months of 1945 was mostcharacteristic of the activities of a consultant in an active theater ofoperations and, of course, the busiest. First, there was the planning for theinvasion, then the invasion itself, and, following that, the mushroomingexpansion of the theater in both troops and area. The initiation of activecombat meant a preponderance of surgical casualties and a relative shortage ofhospital beds for the treatment of nondisabling skin or venereal diseases.There was frequent movement of units and hospitals with continuous changes inmissions and functions of the supporting medical elements. Evacuation policieshad to be changed frequently in accord with tactical and other considerations.The main portion of theater headquarters moved from the United Kingdom to theContinent.
During this period, there was a complete revolution in thetreatment of venereal diseases. In addition, the Medical Division of GeneralHawley's office was given responsibility for the diagnosis and treatment ofgonorrhea, a responsibility that previously had been vested in urologists underthe Surgical Division. Also, all the practices and procedures that had beencarefully established during the early days of the theater now required thegreatest effort and closest attention by the theater senior consultant indermatology and syphilology to keep them operating as originally planned.
In late 1944, Colonel Pillsbury was ordered to the Office ofthe Surgeon General for a period of temporary duty in the United States.
Treatmentof Venereal Diseases
Intensive arsenotherapy.- A total ofapproximately 4,000 patients with early syphilis received intensivearsenotherapy between April 1943 and July 1944 without any deaths fromtreatment. In mid-1944, however, this type of treatment was replaced bypenicillin therapy. There were some indications that intensive arsenotherapymight still be required for penicillin-resistant, cases and those sufferingrelapses. While intensive therapy was in progress, careful and constantsupervision was required by the theater senior consultant and regionalconsultants in syphilologv. The resulting absence of deaths proved the value ofthis supervision. Incidental to this mode of treatment were the careful keepingof followup records and the preparation of papers and species in response tomany requests for summaries of the U.S. Army's
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experience with the method. Although Colonel Pillsbury believed that the finalcure rate would be somewhere between 85 and 90 percent,16 he doubtedthat intensive therapy could have been administered successfully under theconditions of later 1944 because of the shortage of hospital beds and thesteady decline in the level of professional attainment of officers in hospitalsarriving in the theater after July l944.17
Penicillin therapy of gonorrhea. - Theinitial experience with penicillin therapy of gonorrhea in the European theaterresulted in the cure of 94.7 percent of the first 1,000 patients treated. Thistherapy called for an injection of a total of 100,000 units of penicillin infrom 5 to 10 divided doses. Its use was restricted to persons whose serviceswere urgently needed and who could not carry out their duties efficiently whilereceiving sulfonamides. Later experience showed that penicillin therapy waseffective in all but an almost negligible number of cases, in contrast to only65 percent of cases successfully treated in field units with sulfonamides. Evenafter treatment in a hospital, there had previously been a residuum of from 10to 20 percent of patients whose cure was very slowly effected, withcomplications of various sorts.18
The availability of penicillin had almost solved thisdifficult problem of military medicine. There remained for the consultant andothers in subordinate positions the constant effort to have this treatmentperformed as far forward as possible. Eventually, Circular Letter No. 107,Office of the Chief Surgeon, Headquarters, ETOUSA, was published on 25 August1944 prescribing the penicillin therapy of gonorrhea on an outpatient status asthe method of choice, except that female personnel continued to be treated inhospitals. Colonel Pillsbury, realizing the great savings in manpower andhospital facilities with the use of penicillin, paid constant attention to thepenicillin supply situation and, when the opportune moment arose, recommendedthat penicillin be used in the treatment of all cases of gonorrhea occurring inthe theater.19
Penicillin therapy of syphilis. - Inearly January 1944, it became apparent that penicillin was also destined tooccupy a preeminent role in the treatment of early syphilis. Keeping closewatch over all the research that was being conducted, Colonel Pillsbury wasconvinced that penicillin therapy would offer a method of treatment for combattroops superior to that being used. His observations in the North Africantheater had shown conclusively that treatment of early syphilis within combatunits was interrupted and unsatisfactory. Although no one could foretell whatthe final longterm effects of penicillin therapy would be, it was also knownthat inadequate treatment early in the disease was often worse than notreatment at all. On the other hand, there
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16 Later surveys of such patients, though incomplete, indicated thatintensive arsenotherapy had an effectiveness at or near that of penicillin interms of absence of relapse and the percentage of negative spinal fluidexaminations. However, it was obviously much more toxic.
17 Annual Report, Professional Services Division, Office of theChief Surgeon, Headquarters, ETOUSA, 1944.
I8 Ibid.
19 Memorandum, Professional Services Division for Chief Surgeon,ETOUSA, 20 July 1944 subject: Penicillin Therapy of Gonorrhea and Syphilis.
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could be no trial of penicillin therapy for early syphilis within the theaterif there was any danger of jeopardizing the supply available for conditionsthreatening to life or for sulfonamide-resistant gonorrhea in which penicillinwas practically always curative. Colonel Pillsbury discovered that supplies forsuch purposes were adequate and that possibly some of the supply might not evenbe used before it became outmoded. Accordingly, he did not hesitate torecommend a trial, in the European theater, of penicilin in the early treatmentof syphilis.20 The plan was approved and the experiment entrusted toCapt. (later Lt. Col.) C. R. Wise, MC, a regional consultant stationed at the2d General Hospital (fig.109). When Colonel Pillsbury visited the 2d GeneralHospital on 3 February 1944, five cases had already received or were undergoingtreatment. Three of the patients had marked Herxheimer's reaction--fever andincrease in the cutaneous lesions after the first injection--but, thereafter,the early lesions disappeared with a rapidity surpassing anything he had seenafter arsenical therapy.
At the time of Colonel Pillsbury's visit to the hospital on19 March 1944, a total of 15 cases had been treated, 8 with a total of 500,000units and 7 with 1 million units. The method of treatment, as far astherapeutic response and absence of reactions was concerned, appeared farsuperior to either intensive or standard therapy.
On the basis of these 15 cases, the 7 March 1944 minutes ofthe Penicillin Panel, National Research Council, and personal letters from Lt.Col. Thomas H. Sternberg, Director, Venereal Disease Control Division, Officeof the Surgeon General, Colonel Pillsbury recommended, on 26 April 1944, that acombined penicillin-bismuth-Mapharsen treatment be adopted for use in thetreatment of combat troops and in the small number of patients in other unitsin whom arsenical therapy was not possible because of sensitivity to Mapharsen.21At about the same time, he personally recommended to the Surgeon, EighthAir Force, that penicillin treatment for syphilis be made available for operationalcrews. The Eighth Air Force surgeon requested such permission from the AirSurgeon, but it was denied.
Before his recommendations could be implemented, ColonelPillsbury received from Dr. Stokes a personal letter dated 28 April 1944. Dr.Stokes stated that the Subcommittee on Venereal Diseases, National ResearchCouncil, had recently recommended the use of penicillin in the treatment ofearly syphilis, by the Army, wider conditions in which continuity of standardtreatment could not be maintained. In his letter, Dr. Stokes also indicatedthat modification of the previously recommended plan of treatment wasnecessary. While these modifications were being considered, The SurgeonGeneral, in a letter which arrived at General Hawley's office on 1 June 1944,
20 Memorandum, Senior Consultant in Dermatology for Col. J. C.Kimbrough, Chief, Professional Services Division, Office of the Chief Surgeon,Headquarters, ETOUSA, 9 Jan. 1944, subject: Penicillin Therapy of Syphilis.
21 Memorandum, Professional Services Division for Chief Surgeon,ETOUSA, 26 Apr. 1944, subject: Penicillin Therapy in Syphilis.
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authorized the use of penicillin in the treatment of early syphilis, withcertain limitations and suggestions, as follows: 22
Because of the recognized difficulties in carrying out themapharsen-bismuth therapy of early syphilis in active Theaters of Operation,the following recommendations concerning the immediate use of penicillin as ananti-syphilitic agent are made. It is intended that this recommendation shallapply only to previously untreated cases, and that those cases in whichmapharsen-bismuth therapy has already been initiated shall continue on suchtreatment.
a. That all new cases of primary and secondary syphilis betreated with pericillin in those areas or theaters where, because of theexigencies of the military situation, it may be expected that routinearsenical-bismuth therapy will not be carried out regularly.
b. That the schedule of treatmesit be 40,000 units intramuscularlyevery three hours for a total of 60 doses or 2,400,000 units per case.Preliminary experience with this dosage schedule indicates that better resultsthan those obtained with 1,200,000 units may be expected .
c. That followup examinations should be obtained at monthlyintervals for a minimum period of one year, in order that relapses may bedetected early and mapharsen-bismuth therapy initiated without delay. Thespinal fluid should be examined between the third and sixth month following treatment.
d. The syphilis registers should be properly maintained andtransmitted with each move of the patient to assure adequate followup.Additional methods of earmarking these patients, such as central registries,may be considered desirable.
Following this, Circular Letter No. 86, Office of the ChiefSurgeon, Headquarters, ETOUSA, subject: Penicillin Therapy for Early Syphilis,was published on 22 June 1944, citing penicillin as the drug of choice in thetreatment of early syphilis in field and air forces. The prescribed treatmentfollowed closely the recommendations of The Surgeon General, but followupprocedures, particularly with respect to serologic and spinal fluidexaminations, were modified to fit the needs of the theater.
Thus it is seen that an essential part of a consultant'sfunctions is to keep abreast of new developments, difficult as this is in anoversea theater. Although, eventually, specific recommendations reached thetheater from The Surgeon General, the preliminary investigations that had beenconducted within the theater proved extremely valuable. Before The SurgeonGeneral's letter ever arrived, Colonel Pillsbury was able to coordinate inadvance the implementation of penicillin therapy with the Surgeon, Third U.S. Army;the Consultant in Medicine and Venereal Disease Control Officer, First U.S.Army; and the Surgeon, U.S. Strategic Air Forces in Europe. When The SurgeonGeneral's letter arrived, Colonel Pillsbury was able to evaluate itsrecommendations in the light of firsthand experience and with due considerationfor the desires of those in the field. Had there been no preliminary experiencewith this type of therapy, a similar trial period would undoubtedly have beennecessary. A few months can be very important during wartime. In this case, thesignificance of the few months' headstart which the European theater had inplanning for penicillin therapy of syphihis is most evident. The Surgeon ________
22 Letter, The Surgeon General, to Commanding General, ETOUSA, Attn:Chief Surgeon, 24 May 1944, subject: Penicillin Treatment of Primary andSecondary Syphilis.
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General's letter was received on 1 June 1944, less than a week before D-day, 6June. Subsequent experience showed, too, that there was no reason to change thebasic principles of treatment, followup, and recordkeeping that were initiallyestablished.
When the supply of penicillin became sufficient, its use inthe treatment of early syphilis was extended by theater Circular Letter No.107, August 1944, to all cases occurring in the theater.
Laboratory procedures. - With extensivedeployment of troops on the Continent in 1944, specimens for laboratoryexamination had to be shipped greater distances while, at the same time,courier service became more unreliable. Tubes for the collection of specimenswere not kept in proper sanitary condition, and the drawing of specimens wasmore likely to be performed carelessly. Disruption in the supply of stains andantigens also interfered with the essential laboratory tests.
Again, close liaison was necessary with the PreventiveMedicine Division, Office of the Chief Surgeon, Headquarters, ETOUSA, whichsupervised the laboratories. In the latter months of 1944, Lt. Col. (laterCol.) Arthur P. Long, MC, Chief, Epidemiology Branch of the division,investigated and, together with Colonel Pillsbury, arrived at some remedialmeasures. On the Continent, prepared tubes containing a requisite amount ofMerthiolate (thimerosal) were put into use, and, in the United Kingdom, thepractice of placing 4 mug, of sulfanilamide in spinal fluid specimens wasadopted to prevent contamination. Problems in courier service eventually werealleviated to some extent by performing all spinal fluid tests on theContinent.
Other problems. - During this period,Colonel Pillsbury was also concerned with the management of cases of latentsyphilis and neurosyphilis, the few cases of penicillin-resistant gonorrhea,and with experimentation in the use of BAL for the treatment of agranulocyticreactions to intensive arsenotherapy (p.313). TB MED (War Department TechnicalBulletin) 48, in early 1944, established policies and procedures on an Armywidebasis for the management and treatment of neurosyphilis. Many provisions ofthis technical bulletin were obviously inappropriate as applied to the Europeantheater, and a suitably abridged and condensed version was prepared forpromulgation within the theater. Satisfactory provisions were made for thetreatment of penicillin resistant cases of gonorrhea by transferring them tothe Royal Victoria Hospital for fever therapy under the expert supervision ofLt. Col. Ambrose King, RAMC.
The syphilis registers. - The practiceof holding syphilis registers centrally at the theater headquarters andreviewing them there required the frequent attention of the theater seniorconsultant in dermatology and syphilology. The problem of finding the necessarytime to review registers became more acute when the theater headquarters wasdivided into two portions, one on the Continent and one remaining in the UnitedKingdom Base. Colonel Pillsbury was on the Continent, and the registers werekept at the Medical Records Division, United Kingdom Base. As time passed, itbecame more necessary
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for Colonel Pillsbury to scan these registers personally since they were usedto assess and collect data on the results of intensive therapy and penicillintherapy. Colonel Pillsbury eventually found himself spending 2 or 3 days atregular 2- to 3-week intervals to review the syphilis registers on which therewere questions as to the adequacy of treatment provided.
Colonel Pillsbury was able to report, in August 1944, that,through 20 August, 8,471 had been received in the Medical Records Division foradvice, closure, and holding for followup checks. The medical decisions on allthese were rendered by the Professional Services Division. An analysis of 1,920registers received between 15 June and 22 July 1944 showed that 536 (28percent) had been returned to units for information essential to closure orfurther treatment, 925 (48 percent) had been closed and sent to the Office ofthe Surgeon General, and 459 (24 percent) were lucid for followup tests.Colonel Pillsbury considered this analysis representative of the usualworkload.
In a letter to Colonel Pillsbury, dated 18 September 1944,Colonel Sternberg in the Surgeon General's Office wrote of this system inwarmly laudatory terms:
We get in fifteen hundred registers a week and we have tocheck them all over to see that they are satisfactory and return those whichare not. It is a real pleasure to get in a box from ETO and it saves us atremendous amount of work. I would like to adopt your system for our method ofhandling in the ZI but it is absolutely out of the question because of severalthousand new cases of syphilis a month in addition to eight to ten thousandinducted syphilitics per month, which would require a tremendous office staffjust to handle them.
Treatmentof Skin Diseases
The treatment of skin diseases saw no such dramatic changesas those that occurred in the treatment of the venereal diseases. The onlyadvances that approached these in significance were the local penicillintherapy of certain dermatologic conditions and the use of DDT in combatingpediculosis. Improvements were made by the strenuous application of moresuperficial measures, such as emphasizing standard methods of treatment,shifting skilled personnel to where they could do the most good, insuringadequate supplies of drugs, and centralizing hospitalization facilities for thetreatment of skin conditions, it was still just as essential during this period,as it was during the earliest days of the theater, to emphasize to the point ofmonotony the dangers of overtreatment.
To a considerable extent, the difficulty lay in theinadequate professional training of many medical officers in the diagnosis and treatmentof skin diseases, a deficiency of medical school training that the Army couldovercome only in part. On 26 June 1944, in a letter to Brig. Gen. Hugh J.Morgan, Chief Consultant in Medicine to The Surgeon General, Colonel Pillsburywrote:
I have been very much impressed with the extreme variationin training in dermatology which is offered by various medical methods. Theteaching in this specialty in some schools is very inadequate, either becauseof lack of time on the curriculum or because of poor pedagogic methods. I feeldeeply on this score, and intend to do something about it after the war.
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There is no reason in the world why every medical student should not becomeperfectly familiar with the characteristic picture and the chief variations ofthe eight or ten diseases which will comprise over 90% of all skin cases. Heshould also be well ingrained in the standard methods of treatment, at least tothe point where he will not do harm by treatment. Competent internists areoften surprisingly inept in dermatologic diagnosis I think this is largelyattributable to poor teaching methods in the past, to a failure to arouse theirinterest, and to the abominably complex terminology of dermatology.
On the other hand, the difficulty also lay in the fact thatthere were some basic disturbances in skin physiology for which availablemethods of treatment were, at best, unsatisfactory. The only solution to theseproblems lay in extensive scientific investigations on a much broaderphysiologic base than in the past. In the letter to General Morgan justmentioned, Colonel Pillsbury stated that the following conditions falling inthis category were of particular significance in the European theater: (1)Inflammatory eruptions of the hands and feet, including especially thedisturbed vasomotor states that regularly accompanied them; (2) itch; (3)psoriasis; (4) seborrheic dermatitis; (5) fungus infections of all types bothin their preventive and therapeutic aspects: (6) allergic conditions of varioustypes, including atopic dermatitis, in which methods of treatment were highlyunsatisfactory and too cumbersome for military medicine; (7) pyodermas, with agreat need for more rapidly acting, nonsensitizing methods of reducingbacterial flora of the skin; and (8) warts, particularly plantar.
In spite of the difficulties encountered, there were,nonetheless, indications that the efforts made to improve care and treatment ofskin diseases were paying dividends. Scabies, although posing a constant threat,never approached the staggering rates of World War I, when it was responsiblefor some 30 percent of all evacuations from the British Expeditionary Force.The number of patients evacuated to the Zone of Interior for skin diseasesremained constantly low, approximately from 30 to 40 cases per month.23
Planningfor Invasion of the Continent
Venereal diseases, - After visiting theNorth African theater, Colonel Pillsbury was impressed with the absolutenecessity of coordinated plans for the prevention and control of venerealdisease on the Continent after D-day. There were also intelligence reportswhich indicated that venereal disease among the civilian population of Franceand the Low Countries was increasing. This factor, plus the shortage of drugsand physicians in those countries, indicated that exposure of U.S. soldiers topersons with infections venereal disease would be greatly increased and that arise in the venereal disease rate could be expected. It was obvious, owing toseveral factors, that venereal disease in combat soldiers would be badlyhandled within the army areas unless special provisions were made. There wouldbe a shortage of facilities in field and evacuation hospitals for adequatediagnosis, and the large number of surgical casualties would have priority overpatients with venereal disease.
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23 Sec footnote 17, p. 196.
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In North Africa, these factors had led to erroneousdiagnoses and unwarranted evacuation of patients to fixed hospitals with theresultant loss in manpower. It was now fully realized that a patient withactive venereal disease would prove to be just as much a casualty from thestandpoint of combat usefulness as a man with a crippling wound and presented,moreover, a great opportunity to reduce noneffectiveness within the armies. Improvedmethods of treatment had made it possible to care adequately for such diseasesentirely within an army area and, in almost all instances, to return thepatient to his unit entirely cured. Obviously, the closest correlation ofduties and responsibilities of various medical officer's concerned withvenereal disease control and treatment activities was indicated.
On 4 January 1944, in a memorandum to Colonel Kimbrough,Colonel Pillsbury recommended that a meeting be held to consider all aspects ofthe venereal disease problem and to formulate plans that would betteranticipate and provide for the complex problems that could be expected toarise. In addition to himself, he suggested that the following attend: Chief,Preventive Medicine Division, and Chief, Professional Services Division, Officeof the Chief Surgeon, Headquarters, ETOUSA; Venereal Disease Control Officer,ETOUSA; Consultant in Urology, ETOUSA; and representatives from the Eighth AirForce and First U.S. Army.
The meeting was held on 29 January 1944, Colonel Pillsburyand Major Padget were directed to formalize the recommendations of this ad hoccommittee. The memorandum prepared by these two officers on 15 February 1944and presented to General Hawley discussed general considerations on which therecommendations were based and made specific recommendations with respect toprevention, prophylaxis, punitive measures, diagnosis, and treatment ofvenereal diseases.
The recommendations with respect to diagnosis were (1) thatfacilities for the differential diagnosis of ulcerative penile lesions be madeavailable as far forward as possible--it was believed that evacuation hospitalswere the most advanced hospitals in which the necessary procedures could becarried out satisfactorily--and (2) that Kahn tests for syphilis be performedonly as far forward as station hospitals.
The recommendations concerning treatment were fourfold, as follows:
1. That the policy of treatment of gonorrhea in units becontinued.
2. That treatment for acute urethritis be given promptly,whether or not laboratory facilities for the examination of smears wereavailable.
3. That intensive treatment of early syphilis becontinued and that it be administered as far forward as facilities would permit.The policy of giving such treatment only in fixed hospitals designated by theChief Surgeon, ETOUSA, should be continued.
4. That a strong policy beadopted against the establishment of venereal disease stockades or othersimilar treatment centers in which disciplinary and punitive measures mightinterfere with the adequate medical care of patients with venereal disease.
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Following this conference, Colonel Pillsbury was busycoordinating activities with other divisions in theater headquarters andparticularly in working with representatives of the First U.S. Army and, whenit arrived in Europe in March of 1944, with the Third U.S. Army. In addition,it was necessary for him to confer with the many subordinate consultants in thevarious supporting commands and fixed hospitals that were designated to receivethe evacuees.
As D-day approached, Colonel Pillsbury was able to report onthe problems that had been given first consideration and the plans that theFirst and Third U.S. Armies had completed.24 At this stage, itappeared that the following were problems that would have to be overcome:
1. Misdiagnosis of penile ulcers because of a lack ofdark-field equipment or unfamiliarity of medical and laboratory officers withdark-field diagnosis, unwarranted dependence on spirochetal stains or on grossmorphologic characteristics of ulcers for diagnosis, and misdirected attemptsto do diagnostic serologic tests for syphilis in evacuation hospitals.
2. Evacuation of venereal patients too far back in thecombat or communications zone because of a lack of facilities for properdiagnosis, the pressure of more crucial medical or surgical problems inevacuation hospitals, and the lack of interest on the part of medical officersin forward units in properly caring for the venereal diseases.
3. Regarding all venereal disease as an offense requiringdisciplinary measures.
4. Serious and dangerous interruption of continuity oftreatment for syphilis.
5. Persistence in sulfonamide therapy for gonorrhea forunjustified lengths of time.
The medical personnel of the two armieshad fully accepted the general principle that early diagnosis and treatment ofvenereal diseases had to be accomplished within the armies and that theadministrative and technical means were at hand to achieve this end. Acceptingalso the fact that very few medical officers were really competent in thediagnosis of ulcerative penile lesions, they were in agreement that somecentralization of facilities was necessary. Accordingly, the First U.S. Armyplanned to set up a center for the diagnosis and treatment of such patients ina convalescent hospital. The professional service of this center was placed incharge of an expert venereologist, Capt. (later Maj.) James M. Howell, MC,transferred thereto from the 10th Station Hospital. A unit of the armylaboratory, with an expert dark-field technician and serologist, was alsoattached.
The Surgeon, Third U.S. Army, however, favoredcentralization to a less degree. He planned to attach a platoon of a clearingcompany to each of three evacuation hospitals to care for venereal diseasepatients in tented expansions to these hospitals. A medical officer trained invenereal diseases was to be
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24 Memorandum, Colonel Pillsbury, for Chief, Professional ServicesDivision, Office of the Chief Surgeon, headquarters, ETOUSA, 14 May 1944,subject: Diagnosis and Treatment of Venereal Diseases in the Combat Zone.
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assigned to each of these hospitals and dark-field and serologic facilitiesprovided from the army laboratory.
All concerned generally agreed that penicillin should beused for the primary treatment of gonorrhea occurring in combat troops andthat, under any circumstances, persistence in sulfonamide treatment for periodslonger than 10 days was inadvisable. The surgeons of both armies wanted tointroduce time penicillin treatment of early syphilis as soon as possible.
As D-day became imminent and it was realized that, of thetwo armies, only the First would make the initial assault on the mainland ofFortress Europe, a meeting was held in the Office of the Surgeon, Headquarters,First U.S. Army, to make final plans for the diagnosis and treatment ofvenereal disease in the First U.S. Army. It was attended by Lt. Col. (laterCol.) John W. Claiborne, Jr., MC, Commanding Officer, 4th ConvalescentHospital; Lt. Col. Cornelius A. Hospers, MC, Commanding Officer, 10th MedicalLaboratory, First U.S. Army; Lt. Col. (later Col.) Tom F. Whayne, MC, FirstU.S. Army Group; Maj. Samuel L. Stephenson, Jr., MC, Venereal Disease ControlOfficer, First U.S. Army; and Captain Howell, 4th Convalescent Hospital. Thefinal plans adhered closely to the original plans just described for the FirstU.S. Army. In addition, the decision was made that penicillin would be used fortime treatment of early syphilis. Personnel from First U.S. Army agreed to providenecessary information on cases so treated so that there could be properfollowup of these patients. It was also agreed that the number of spinal fluidexaminations at the venereal disease center of the 4th Convalescent Hospitalwould, initially, be kept to an absolute minimum. It was further agreed thatroutine tests for closure of syphilis registers were out of the question forsome time. In addition, Colonel Claiborne and Major Stephenson earnestlyrequested that Colonel Pillsbury participate on the spot in helping to set umpand initiate operations of the venereal disease center. The Surgeon, First U.S.Army, concurred in this request, and it was approved by the Chief Surgeon,ETOUSA.25
As the Third U.S. Army made final preparations to cross theChannel in July 1944, the Surgeon, Third U.S. Army, voiced a desire to modifythe preliminary plans. He wanted permission either to conduct intensivearsenotherapy in hospitals within the army or to use the standard 26-weekschedule of therapy.26 He was assured there was every reason tobelieve that the supply of penicillin would permit its use in all cases ofearly syphilis arising in the army and that provision would be made fortransfer of patients to general hospitals for intensive arsenotherapy shouldpenicillin be unavailable. The Third U.S. Army surgeon, nevertheless, stoodfast in his demands. Accordingly, permission was granted Third U.S. Army toconduct intensive arsenotherapy in specifically designated hospitals, when andif necessary, in place of penicillin
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25 Memorandum, it. Col. D. M. Pillsbury, for Col. J. C. Kimbrough,Office of the Chief Surgeon, headquarters, ETOUSA, 21 May 1944, subject:Venereal Disease Diagnosis and Treatment in First Army.
26 Memorandum, Professional Services Division, for Chief Surgeon,ETOUSA, 3 July 1944, subject: Management of Syphilis in Third Army.
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therapy. The stipulation was added that a medical officer trained in intensivearsenotherapy must be transferred to the hospital so designated.
When put to test in combat, the plans formulated by FirstU.S. Army proved outstandingly successful. During the first 4 months ofoperation, 947 patients were admitted to the venereal disease center of the 4thConvalescent Hospital. Of these, 88 had to be transferred, either to anothersection of the convalescent hospital or to a general hospital. Thus over 90percent of those admitted were returned directly to duty. Moreover, thediagnosis of a venereal disease was confirmed in only 9 of the 88 patients notreturned directly to duty. The practice of treating venereal disease at onecentral place conserved beds in more active installations and permitted theconcentration of trained personnel so that more effective treatment could beadministered.27
The plan worked best, however, when the army was confined toa relatively small front The army laboratory (fig.110) was located with theconvalescent hospital, and it was not necessary to detach a unit to perform thedark-field and Kahn examinations. As the army expanded and the situation becamemobile, the hospital and laboratory separated, and patients had to be movedfrom 5 to 100 miles for laboratory examinations at a time when transportationwas scarce and the vehicular routes congested. Eventually, a portion of thelaboratory had to be assigned to the hospital as called for in the originalplans. Contrary to the advance planning, the laboratory performed extensivespinal punctures, not only for diagnosis but for the closing of syphilisregisters. The fluids were transported to the United Kingdom by aircraft, butduring the first month of operation over 50 percent of the specimens reachedthe central laboratory in an unsatisfactory condition. Again, the wisdom of theadvance plans was supported. Spinal punctures for the closing of syphilisregisters had to be deferred. Above all, the greatest problem was theimmobility of the venereal disease center as a part of a convalescent hospital.The front at one time so outdistanced the center that another unit had to takeover its functions temporarily. There was not enough transportation to move thecenter and not nearly enough personnel or equipment to establish two centersthat could continue to advance by leapfrogging.
When the use of penicillin had proved itself in theduty-status treatment of gonorrhea and in the treatment of early syphilis, thevenereal disease treatment plan for the Third U.S. Army was eventuallymodified, in practice, to parallel that of the First U.S. Army.
Dermatology. - The planning for care ofdermatologic patients was based on the fact that the dermatologic load in ahospital was directly proportional to its station hospital functions and thenumber of troops in its immediate area of responsibility. This meant that themajority of these patients would eventually be seen on the Continent. Furthermore,any need to evacuate patients from the Continent to the United Kingdom or theZone of Interior would represent a serious failure in professional servicesince in most derma-
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27 Annual Report, Professional Services Division, Office of theChief Surgeon, Headquarters, ETOUSA, 1944, with Exhibit D, thereto.
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tologic conditions cure and return to duty was feasible within the limits ofany reasonable evacuation policy, such as 30 days. On these premises, thedecision was made to supply hospitals being transferred to the Continent withspecially trained medical officers insofar as the number of officers permitted.The remaining officers who would have to care for the severe and disablingdermatologic cases evacuated to hospitals in the United Kingdom werecentralized in hospital groups to permit the optimum care and management ofsuch patients.
Hospitalizationand Evacuation
At frequent intervals, Colonel Pillsbury was required totake an active part in solving hospitalization and evacuation problems insofaras they concerned patients with diseases of the skin or venereal diseases. Inmost cases, the problems were local; that is, their solution rested in thehands of surgeons on the staffs of subordinate commands. Problems in this areawere usually discovered during field trips. In other cases, reports of improperor unsatisfactory treatment revealed that the cause and the cure lay in theestablishment and enforcement of evacuation procedures or hospitalizationplans.
For example, in late 1944, after the theater had growntremendously, there occurred sporadic cases of patients being evacuated duringthe course of penicillin treatment for syphilis. This interruption of treatmentnecessitated the initiation of another complete series of treatments and waswasteful of medical facilities, personnel, and supplies, and, in addition,jeopardized the ultimate cure of the patient. Colonel Pillsbury had to conferwith the surgeons and representatives of commands in which such discrepancieswere occurring in order to fix stringent requirements for the completion oftreatment mice it was started.
In another instance, the French had requested help in thetreatment of early or sulfonamide-resistant cases of gonorrhea, which wereaccumulating in the French Military Hospital at Val de Grace. Colonel Pillsburyinspected the hospital and discovered that 30 or 40 patients a month wereadmitted who required penicillin therapy. Arrangements were made to care forthese cases in the 217th General Hospital with the approval of the Surgeon,Seine Base Section, in whose area the hospital was located, under conditionssatisfactory to the French and the hospital authorities.
Previously, centralized treatment centers for dermatologiccare in the United Kingdom were mentioned. These had to be established becausehospitals arriving from the Zone of Interior were staffed by increasingly lessexperienced and less well trained medical officers. On the other hand, the numberof dermatologic patients in each general hospital was so small as to occupyonly a fraction of the time of a specialist.
Obviously, two solutions were possible--centralization ofpatients or the use of peripatetic consultants. Both were used, but the formerproved much the more effective. In September 1944, such a center was inoperation at the 192d General Hospital of the 15th Hospital Center. Here, therewas
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assurance of accurate diagnosis and disposition. Such centralization alsofacilitated the collection of information as to the incidence of variousconditions and effectiveness of treatment. Moreover, patients could be furthercentralized on one or two well-run wards with adequate facilities for specialexamination and sufficient supplies of the common ointments, solutions, andother necessary medicinals. Above all, specialized dermatologic wards helped toinsure the interest of wardmen and nurses in the care of these patients. Goodtreatment effected in this manner paid off in the saving of hospital-bed daysper patient. The difference in length of hospitalization between good diagnosisand treatment and bad was particularly marked in dermatologic conditions.
Classification,Training, and Assignment of Personnel
The adequacy in numbers and in training of dermatologistswas the primary personnel problem, owing to the fact that diagnosis andtreatment of diseases of the skin could not be standardized to the extent thatstandardization was possible in the venereal diseases. In addition, some olderofficers with special training in dermatology were so immersed in the specialtyand so narrowed in their outlook as to make them unadaptable to Army medicalpractice and to duty outside their particular specialty. On the other hand,medical officers trained in dermatology in the 10 to 15 years before the war incertain civilian graduate centers proved extremely valuable. It was this smallgroup that carried the load as regards the return to duty of really difficultcases. The number of medical officers in the theater with any training in dermatology,including A, B, C, and D classifications, was 47 as of the end of 1944. Thisnumber was so few that a trained dermatologist could not even be assigned toeach general hospital in the theater, although well-conceived hospitalizationpolicies alleviated this need. However, when the First U.S. Army indicated aneed for a dermatologist to be assigned to the army surgeon's staff, ColonelKimbrough flatly refused to consider such an assignment of dermatologists.28
The problem of providing adequate service with a limitednumber of officers was met by interviewing and assessing the professionalqualifications and experience of each dermatologist and assigning him where hecould be most fruitfully employed. Those who were not full-trained dermatologistsbut were filling positions as such were also interviewed to determine theirability to carry the load expected of them and to help them acquire anytraining or experience that would make them more capable. Some officers whoseprofessional qualifications justified their assignment as ward officers indermatology and syphilology in a general hospital nevertheless requiredtraining in methods particular to the theater and in military hospitaladministration procedures. In September 1944, all dermatologists assigned to _________
28 Memorandum Lt. Col. D. M. Pillsbury, for Chief, ProfessionalServices Division, Office of the Chief Surgeon, Headquarters, ETOUSA, 24 Oct.1944, subject: Report of Visit to First and Third Armies with Comment No. 2,Col. J. C. Kimbrough to Chief Surgeon, ETOIJSA, thereto.
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hospitals in the United Kingdom were classified as "medical officers oftop special ability, fully qualified to act as regional consultants indermatology and venereology," and "medical officers with specialtraining, but for various reasons not quite so well qualified to act as regionalconsultants." In December 1944, Colonel Pillsbury and Maj. (later Lt..Col.) Charles J. Courville, MC, who had functioned as the theater seniorconsultant in dermatology and syphilology during Colonel Pillsbury's temporaryduty in the United States, classified all dermatologists in the theater as totheir professional ability.
It was no small problem to keep track of dermatologistsduring the height of activities in the theater. Either the units to whichdermatologists were assigned would be moved or the hospitalizationresponsibilities of the units would be changed. A hospital center whoseconsultant in dermatology was assigned to one of its compomment generalhiospitals would suddenly find itself without a consultant when the particulargeneral hospital was transferred elsewhere. A dermatologist assigned to aparticular hospital would suddenly find himself treating no skin diseases andperforming sundry other duties upon change of the hospital's mission.Malassignments, once they had been permitted to occur, were difficult tocorrect, and exceedingly delicate readjustments were sometimes necessary. Toeffect transfers, Colonel Pillsbury had to obtain concurrences from theindividuals concerned, from the commanding officers of gaining and losing hospitals,and often from one or more area commands. Commanding officers of hospitals andsurgeons of commands, jealous of their prerogatives, often refused tocountenance transfers of personnel that were desired by the theater seniorconsultant in dermatology.
The direct instructional and training activities engaged inby Colonel Pillsbury, or carried on under his supervision, included thefollowing: (1) Instruction to medical officers in field medical and hospitalunits regarding the diagnosis and treatment of common skin diseases throughlectures at the Medical Field Service School and the Eighth Air Force FieldService School; (2) continued widespread showing of the Ministry of Health filmon scabies; (3) providing opportunities for medical officers to attendprofessional meetings and conferences, such as the monthly meetings of thesection of dermatology, Royal Society of Medicine; (4) frequent and timelyarticles in the Medical Bulletin of the European theater; and (5) on-the-jobtraining of interested young medical officers with some training in dermatologyor venereology.
The on-the-job training took two forms. One way was to placepotential specialists in charge of a ward and have their work frequentlysupervised and reviewed by visiting consultants. These visits were made atleast once weekly. Another method was to place the trainee on temporary duty atan installation where a qualified medical officer was operating a largeservice. A typical report of on-the-job training accomplished with four medicalofficers is as follows:
1. The following officers were on detached service at thishospital for training in the technique of 20 day intensive arsenotherapy from16 April 1944 to 29 April 1944 * * *
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2. In the training of these officers our facilities andcases were used to give them experience in clinical and laboratory diagnoses ofvarious venereal diseases and the technique of administrating arsenicals. Problemcases and treatment reactions were discussed in group meeting and ward rounds.They became familiar with the administrative details by preparing the recordsfor admission and discharge of patients. In addition a discussion on thissubject was given by the registrar of this hospital.
3. The group as a wholewas enthusiastic and cooperative and gave evidence that when placed in chargeof this type of patient would be able to give a good account of themselves. Itmight be mentioned that none of these men have had the opportunity ofpracticing clinical medicine for approximately two years.29
Visitsto Field Installations
Colonel Pillsbury found it essential to make frequentrecurrent visits to hospitals and installations in the field These visits enabledhim to have a grasp of the general situation as it really was at the operatinglevel. It also enabled him to check on the manner in which programs anddirectives were being carried out, to consult on difficult cases, to conductward rounds, and to advise the hospital, local command or, when necessary, thetheater headquarters on problems he had discovered (fig.111). Coming on top ofhis other duties, field trips took a considerable toll of his time and energy.Field trip duty was hard unremitting labor, but essential work, and the theatersenior consultant had to be durable.
Some visits to hospitals were conducted for limited,specific purposes; others were concerned with more general matters. During theperiod when many casualties from the North African and Mediterranean theaterswere being received in the United Kingdom, there occurred frequent cases of anirritating dermatitis variously referred to as ''Sicilian itch'' and ''desertsores.'' These had to be seen by the European theater senior consultant indermatology. During Colonel Pillsbury's period of temporary duty in the UnitedStates, Major Courville surveyed all hospitals in the Normandy and BrittanyBase Sections to evaluate services for the treatment of dermatologic andvenereal disease patients, particularly with respect to the qualification ofmedical officers assigned to these duties.30 When General Morganvisited the theater in March 1945, Colonel Pillsbury was one of those whoaccompanied General Morgan and Colonel Middleton through various medicalfacilities and installations on the Continent.
Research and Development
During the period of 1944-45, which was occupied primarilywith medical support of the Army in combat, time was nevertheless found foractivities in applied research, principally directed to the solution ofproblems as they arose in the theater, for which there was no immediateavailable answer.
29 Letter, 298th General Hospital, to ChiefSurgeon, Western Base Section, ETOUSA, 4 May 1944, subject: Training inIntensive Arsenotherapy.
30 (1) Letter, Maj. C. J. Courvillo to Surgeon,Normandy Base Section, ETOUSA, 20 Nov 1944, subject: Facilities for Treatmentof Dermatologic and Venereal Disease Cases in Normandy Base Section. (2)Letter, Maj. C. J. Courville to Surgeon, Brittany Base Section, ETOUSA, 1 Dec.1944, subject: Survey of Facilities for Treatment of Skin and Venereal Cases inBrittany Section.
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FIGURE 111.-Colonel Pillsbury (second fromright) putting across a point to (left to right) Col. David E. Liston, DeputyChief Surgeon, ETOUSA; Col. Angvald C Vickoren, Chief, Troop Movements andTraining Branch, Operations and Training Division, Office of the Chief Surgeon;and Col. Howard W. Doan, Executive Officer, Office of the Chief Surgeon.
Preparations for use in scabies. - Thepreliminary work done in the developing of benzyl benzoate for the treatment ofscabies has been described (p.285). During 1944 and 1945, benzyl benzoate wasused on an increasingly wide scale in spite of occasional supply problems. Itproved highly satisfactory, especially for treatment given in unitdispensaries. The rate of cure, provided the therapy was carried out withstrict adherence to a few simple details, was more than 95 percent. Thebenefits resulting from development of benzyl benzoate as a treatment forscabies was not to be limited to the European theater alone. In early 1944, TheSurgeon General requested information on the results of its use in Europe, and,in reply on 24 January 1944, General Hawley gave him detailed information onall aspects of the matter. Among other things, General Hawley was able to statethat the emulsion and method of treatment in use had proven satisfactory asregards clinical effectiveness, nonirritativeness, and stability in thetemperatures encountered in the European theater (except Iceland, where it wasnot used). He also stated that the formula was not necessarily the ideal oneand that some compromise with shortages of material had been necessary.
In the spring of 1944, a trial was conducted at the 7thGeneral Dispensary and the 49th Station Hospital on the use of a new louserepellent in the treatment of scabies. This preparation, made up of DDT andbenzocaine, turned out to be useless as a scabicide.
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BAL for arsenical intoxication. - Inlate 1943 and early 1944, when the intensive arsenotherapy of early syphiliswas reaching its height, some 1 percent of those being treated showed severereactions to the arsenicals used. Information was available indicating that BALwas highly effective in the treatment of arsphenamine dermatitis. ColonelPillsbury attempted to obtain a small supply of the preparation from the Officeof the Surgeon General without success. Successful arrangements were then madelocally in England to obtain ampules of BAL ointmnent (OX.217) from Prof. R. A.Peters, Department of Biochemistry, Oxford University. Although ColonelPillsbury thought that BAL was proving to be of value in treating severereactions to arsenotherapy, many factors, such as the limited supply of BAL,movements of hospitals, and treatment with penicillin instead of arsenotherapy,militated against the setting up of any conclusive test of its worth.31
Penicillin ointment for superficial skin infections.- Many medical units throughout the theater devised methods of using penicillinfor the external treatment of superficial infections of the skin. A Britishproprietary preparation, Lanette Wax SX, was favored initially as an emulsionbase. Later, standard U.S. Army emulsion bases proved satisfactory. Ordinarylubricating jelly and Mennen's Brushless Shave cream were also good. Theprimary problem was the keeping qualities of the penicillin incorporated intothese bases. Here again, the experiences in the European theater were asked forby The Surgeon General, and a report was submitted.32
Slow absorption of penicillin. - Ifthere had been some way of administering a large amount of penicillin so thatit could have been absorbed slowly, the benefit to combat troops in thetreatment of gonorrhea would have been tremendous (fig.112). Work was beingdone on the problem in the Zone of Interior. The Strategic Air Forces inEngland had attempted a single-injection treatment of gonorrhea with 100,000units of penicillin, but the rate of cure had not been satisfactory. ColonelPillsbury informed Colonel Middleton that the development of such an item wastoo great an undertaking for the theater at that time under combat conditions.His judgment was confirmed when considerable technical difficulties wereencountered in the United States in the development of penicillin in oil.33
After Colonel Pillsbury had an opportunity to observefirsthand the progress that was being made in the United States in developing aslowly absorbed penicillin preparation, attempts were made to produce some ofthe material locally in the theater using British sources of supply. WhenGeneral Morgan visited the theater in February 1945, he brought samples of asuccessful preparation with beeswax used as a base and made up in strength of500,000 units per cubic centimeter.
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31 (1) Memorandum, Professionsi Services Division, for ChiefSurgeon, ETOUSA, 28 Feb. 1944, subject: BAL Ointment (OX.217) for Arsenicalintoxication. (2) Memorandum, Professional Services Division, for Col C. P.Rhoads, Gas Casualties Division, Office of the Chief Surgeon, Headquarters,ETOUSA, 27 July 1944, subject: BAL (OX.217) in Treatment of Reactions toMapharsen.
32 Letter, Col. D. M. Pillsbury, to Brig Gen. Hugh J. Morgan, Officeof the Surgeon General, U.S. Army, 8 Aug. 1944.
33 Memorandum, Col. D. M. Pillsbury, for Col. W. S. Middleton, ChiefConsultant in Medicine, Office of the Chief Surgeon, Headquarters, ETOUSA, 21Oct.1944, subject: Technical Data Reports.
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FIGURE 112.- Standard preparation of penicillinfor use. Distilled water, 10 cc., is added to sealed vials containing 100,000Oxford units of sodium penicillin.
ProfessionalActivities
Meetings and conferences. - The yearsof active warfare saw no letdown in the number and variety of meetings andconferences. Colonel Pillsbury continued to attend the conferences of commanddermatologists held by the British Army and, at one of the conferences,presented a talk on the nomenclature of skin diseases used in the U.S. Army.The British had requested this presentation in conjunction with a contemplatedrevision of the nomenclature used by the British Army. Addresses were also madebefore the Society for the Study of Venereal Diseases; the Section of Medicine,Royal Society of Medicine; the British Association of Clinical Pathologists;and the Inter-Allied Conference on War Medicine. Maj. (later Lt. Col.) WinfredP. Killingsworth, MC, from the Office of the Surgeon, Headquarters, Third U.S.Army, through arrangements made by Colonel Pillsbury, also gave a talk onpenicillin therapy of venereal diseases before a gathering of the Inter-AlliedConference on War Medicine lucid in London during late 1944. ColonelPillsbury's most important address during this period was made before theInternational Conference on Venereal Diseases, sponsored by the U.S. PublicHealth Service and held at St. Louis, Mo., on 9 November 1944. While ontemporary duty in the United States, he also attended and spoke briefly at theconference of medical consultants held by The Surgeon General at AshfordGeneral Hospital, White Sulphur
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Springs, W. Va., and at the meeting of service command venereal disease controlofficers held at St. Louis on 8 November 1944.
Writing and editing. - ColonelPillsbury assumed editorship of the Medical Bulletin of the Chief Surgeon'sOffice, European Theater of Operations, in August 1944. It was felt that thegreat advances being made in many fields of military medicine in the Europeantheater, front the standpoint of both administration and professional care,were not being adequately circulated. As editor of the bulletin, ColonelPillsbury was specifically responsible for (1) stimulation of medical officersin all echelons in the writing of papers suitable for publication, (2)collecting and abstracting of material from various meetings, (3) editorialrevision of papers, (4) submission of papers to qualified experts for reviewand revision, and (5) recommendation of changes in format of the bulletin inconjunction with Col. Howard W. Doan, MC, General Hawley's executive officer.Much emphasis was placed upon the many new developments in the management ofbattle casualties in clearing stations and evacuation hospitals.
As a contributor to the bulletin, Colonel Pillsbury with hissubordinate consultant associates published papers on the proper handling andshipment of specimens for serologic examination, on a method for preventingcontamination of spinal fluid, on the indications for spinal fluid examinationin the management of syphilis, and on penicillin therapy in gonorrhea.
The following directives emanating from the Office of theChief Surgeon, Headquarters, ETOUSA, were drafted by Colonel Pillsbury duringthis period: Circular Letter No. 31, 10 March 1944, subject: The Diagnosis andReporting of the Venereal Diseases; Circular Letter No. 34, 6 March 1944,subject: Management of Simple Skin Diseases; Circular Letter No. 49, 30 March1944, subject: Amendment of Circular Letter No. 22; 34 CircularLetter No. 86, 22 June 1944, subject: Penicillin Therapy for Early Syphilis;Circular Letter No. 103, 9 August 1944, subject: Management of Neurosyphilis;and Circular Letter No. 107, 25 August 1944, subject: Treatment of Gonorrheaand Syphilis with Penicillin.
SUMMARYIN RETROSPECT
Donald M. Pillsbury, M.D.
As has been noted elsewhere in this volume, the consultantsystem instituted by the Chief Surgeon, ETOUSA, was unique in the Armed Forcesof the United States in 1942. The Office of the Surgeon General, U.S. Army,lacked adequate consultant representation of the various branches of clinicalmedicine at the beginning of the war and never achieved representationcompletely. In the field of dermatology, for instance, in which greatdisability was encountered, especially in the Southwest Pacific Area, there wasno consultant representation in the Office of the Surgeon General until the warwas almost over. The system
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34 This circular letter first authorized the use of penicillin forthe treatment of gonorrhea occurring in combat troops and air crews
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adopted in the European theater was based upon the "Advisor" schemeof the Office of the Director General, Royal Army Medical Corps, and the professionalrepresentation was essentially similar.
It is the firm belief of the writer that the availability ofcompetent consultant service in any large body of troops is essential to a highdegree of professional medical service. On the other hand, the number ofconsultants must not be inordinate, to avoid wasting high-grade professionalpersonnel. The representation among various branches of medicine, surgery,psychiatry, and the laboratories will vary somewhat depending upon theincidence of particular diseases and of combat casualties among the body oftroops concerned. Obviously, consultants are justified only in large bodies oftroops; for example, in a field army or a higher command.
Certain advantages of the consultant system may be put down,as follows:
1. Provided the consultants concerned are aware of theactual medical situation on a day-to-day basis, from adequate reports andcontinuous observation in the field, the origins and growth of importantmedical problems can be detected very promptly. An impending situation willfrequently be suspected by a competent consultant long before it appears inofficial reports through channels in the form of significant disability rates.
2. Provided the distances of travel do not make it impractical,regular consultant visits to medical installations of all types make possiblepersonal consultation on large numbers of patients in the light of the latestinformation and the broader experience that a competent consultant may bepresumed to have.
3. A consultant group furnishes a means for exchange oftechnical information through special channels on an informal basis, and thisis very useful. However, it must be done with the greatest care, in order notto infringe on the administrative functions and responsibilities of commanders.
4. The consultant is in a position to alert the surgeonof a command to the need for the preparation and distribution of technicalbulletins or, in some instances, a need for command directives, particularly inthe field of preventive medicine.
5. A respected and acceptable consultant can be ofconsiderable assistance in the maintenance of morale and effectiveness amongmedical officers, particularly those who have been long away from home or whoare working in isolated stations. The reverse effect may, however, result ifthe consultant is ill informed, brusque, or personally objectionable.
6. One of the most useful functions of a consultant isthe evaluation of the special and general professional competence of medicalofficer personnel. Specialty numbers are frequently an uncertain guide inrespect to a medical officers true effectiveness; to evaluate an officerproperly, personal contact with him and observation of his work are essential.In such evaluations, however, the consultant must exercise the utmostdiscretion and remain aware of the responsibilities of command and of personnelofficers in this regard.
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In an atmosphere of mutual respect, however, transfers andother changes essential to good professional care in any unit can ordinarily beeffected without difficulty or friction.
It should be pointed out that the relatively staticconditions obtaining in the European theater in the years 1942 to mid-1944(with the exception of the Army Air Forces) permitted the gradual absorptionand indoctrination of consultants. It seems doubtful that such a condition willexist in any future war, and planning for such an organization must be madebeforehand if it is ever to be effective.
Certain attributes that characterize an effective medicalofficer apply equally to consultants, but there are additional stresses andresponsibilities that require a broader professional background and a highdegree of diplomacy. These may be summarized as follows:
1. The professional competence of the consultant must beof a high order; he cannot depend too greatly upon rank and military customs togain the true professional respect of his fellow medical officers, howeverjunior. A consultant who too consistently gets beyond his depth professionallywill soon become ineffective.
2. In a large theater of operations, it is impossible,however, for a chief consultant to function effectively at too low a rank,particularly in dealing with commanding officers of hospitals and seniorofficers in other command and staff positions. The absence of any approvedtable of organization for consultants in ETOUSA was a source of some difficultyin this respect but was overcome to a great extent by the continuous staunchsupport and backing of the Chief Surgeon.
3. A consultant who is not well indoctrinated in Armyadministrative processes will have difficulty in attaining full effectiveness,regardless of his professional competence, and may encounter repeated officialor personal difficulty because of lack of knowledge of simple rules of procedure.The experienced medical officer develops an acute sense of when to proceedthrough channels and when to cut across, when to be official and when to bepersonal. This requires many years of experience to realize fully, but therudiments of the game may be learned in a few months of study.
4. The most useful consultant is one with a real breadthof professional vision and willingness. Complete restriction to a narrowspecialty is ordinarily impossible because the consultant is regarded as arepresentative of the surgeon and therefore reasonably cognizant of the matureand scope of the chief problems being encountered. He may find himself oflittle usefulness at times if he refuses to function outside of some verynarrow branch of medicine and surgery. Moreover, such an attitude may bedestructive to the total effort if it leads to competition among specialistsfor increasing recognition of their respective activities, without regard forthe relative contribution that each may make.
5. Under some circumstances,a medical officer in particuilar fields must serve both as a consultant and asan active practitioner in any or all types
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of medical installations, ranging from a general hospital to a battalion aidstation. Under such circumstances, it is of vital importance that this dualresponsibility be recognized by the commanding officer of the unit concerned.
Although the preceding comments are my considered opinions,they could, nonetheless, be illustrated by numerous incidents and personalitieswhich constitute the historical record.
Part III. Senior Consultantin Neuropsychiatry 35
ARRIVALAND EVALUATION
The Senior Consultant in Neuropsychiatry, ETOUSA, Col. LloydJ. Thompson, MC (fig.113), reported for duty on 25 August 1942 to the Office ofthe Chief Surgeon, Headquarters, ETOUSA, then located at Cheltenham, England.He was placed under the overall direction of Colonel Middleton, ChiefConsultant in Medicine, ETOUSA, in keeping with the organizational plan ofGeneral Hawley's office and the precedent established in World War I, ColonelThompson was the second consultant in neuropsychiatry to be appointed by TheSurgeon General during World War II.
Colonel Thompson soon realized that he would be engaged inmuch staff work and activities of an operational and planning nature. At thetime of his arrival, the functions of a consultant were as yet unspecified inWar Department doctrine or directives. It was the general understanding thatthe primary duty of a consultant was to coordinate and supervise effectivelythe strictly professional aspects of problems involved in providing hospitalcare to patients.36 Colonel Thompson had to initiate the necessarysteps to establish special facilities for the care of neuropsychiatricpatients, evacuation plans and policies with respect to them, and specializedtraining and educational activities for those entrusted with their care. Inconjunction with the supply service, he had to insure that adequate suppliesand equipment peculiar to treatment of neuropsychiatric cases were alwaysavailable. The problems in neuropsychiatry, insofar as Colonel Thompson wasconcerned, were obviously those concerned with the development and managementof a broad mental health program.
Colonel Thompson found that there was a definite need forcurrent, reliable data to serve as a basis for his plans and a need fortangible evidence to bolster his arguments for their support in discussionswith those persons in a position to approve or disapprove them.
The British, who by this time had had nearly 3 years ofexperience in the war, were very cooperative in providing useful data,information, and counsel.
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35 (1) The narrative for this section was compiled by Maj. James K.Arima, MSC, The Historical Unit, U.S. Army Medical Service, in collaborationwith Lloyd J. Thompson, M.D., formerly Senior Consultant in Neuropsychiatry,ETOUSA. Dr. Thompson contributed the summary in retrospect in May 1956. (2)Unless otherwise noted, this section is based on the following documentsprepared by Colonel Thompson: Annual Reports of Senior Consultant in Neuropsychiatry,ETOUSA, for 1942, 1943, 1944, and 1945 (first haif); the official diary ofColonel Thompson; and preliminary manuscripts submitted by Colonel Thompson toThe Surgeon General for the history of neuropsychiatry in World War II.
36 Letters, The Surgeon General, to Commanding General, Services ofSupply, 28 May 1942 and 23 June 1942, subject: Coordination and Supervision ofMedical Service in Station Hospitals.
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FIGURE 113.- Consultants in medicine, Europeantheater. (Right, top) Col. Lloyd J. Thompson, MC, Senior Consultant inNeuropsvchiatry, Office of the Chief Surgeon, ETOUSA; (left, bottom) Col.Ernest H. Parsons, MC, Acting Senior Consultant in Neuropsychiatry, Office ofthe Chief Surgeon, ETOUSA; (right, bottom) Lt. Col. Jackson M. Thomas, MC,Chief, School of Military Neuropsychiatrists, ETOUSA.
During the first month of his tenure, Colonel Thompson spentconsiderable the studying the neuropsychiatry organization and experiences ofthe Royal Army Medical Corps and the Royal Canadian Medical Corps. Brigadier J.R. Rees, Consultant in Psychiatry to the British Army at home, and Col. F. H.van Nostrand, Consultant in Psychiatry to the Canadian Army, were extremelyhelpful. In company with these officers, Colonel Thompson visited manygarrisons, training activities, and hospitals to observe first hand thepractice of psychiatry in the British forces. He also attended meetings andconferences of their psychiatric staffs and was later to become a regularparticipant in meetings of their command consultants. In order to share this
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newly found knowledge with those who could most profit by it, Colonel Thompsonsent special reports to The Surgeon General on the organization and operationsof the British psychiatric services. In particular, Colonel Thompson wasimpressed by the efforts of the British to venture beyond the limits ofhospital practice and to emphasize prevention rather than cure.
The British, on the other hand, revealed that they had foundmuch of value in the U.S. Army Medical Department history of neuropsychiatry inWorld War I,37 particularly in coping with their own early problemsconcerning neuropsychiatric activities in World War II. They referred to partsof the work as a "bible." Colonel Thompson also found it useful as areference and a guide in forming policies and organizing units and services.
Current analytical and statistical data for U.S. troops,however, were lacking. It was necessary to create, in conjunction with the MedicalRecords Division, Office of the Chief Surgeon, Headquarters, ETOUSA, specialforms for reporting neuropsychiatric cases. One form was devised for the use ofpsychiatrists in writing up diagnoses and dispositions for submission to theOffice of the Chief Surgeon. Another form was to be made out by both themedical officer and the individual's commanding officer on all patientsreferred for psychiatric consultation or treatment. It provided backgroundhistory on such matters as convulsive disorders and head injuries and providedspecial information desired on flying personnel.
The North Ireland Base Section was a closely knit,relatively independent command. It had an early start in the European theater.Here were marshaled the forces necessary for the invasion of Africa in late1942. Capt. (later Lt. Col.) Frederick R. Hanson, MC, working asneuropsychiatric consultant to U.S. Army forces in that command and part-timeconsultant to British forces, had coordinated the neuropsychiatric services inthat area, established outpatient and consultation services to care forneuropsychiatric problems outside of hospitals, and was maintaining closeliaison with ground forces in the screening, assignment, and classification ofpersonnel in combat units and replacement centers. Need for similar serviceswould doubtless arise in other parts of the theater. With the invasion ofAfrica on 8 November 1942, the exodus of troops from Northern Ireland put anend to most of these particular activities.
Hospitals and personnel in 1942. - At the time of ColonelThompson's arrival in the theater, there were 3 general hospitals--2 in Englandand 1 in Northern Ireland--and 2 station hospitals. All the psychiatric wardswere filled to capacity. Each hospital had one qualified neuropsychiatrist onthe staff, and some had one or two assistants with practically no previousexperience or training in the specialty. In addition, four partly qualifiedmedical officers were attending the British School of Neuropsychiatry. There wasalso one recently assigned neuropsychiatrist at Headquarters, Eighth Air Force,Capt.
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37 The Medical Department of the United States Army in the World War.Neuropsychiatry. Washington: U.S. Government Printing Office, 1929, vol. X.
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(later Lt.Col.) Donald W. Hastings, MC,38 and one at theheadquarter's of the North Ireland Base Section, Captain Hanson. Each hospitalhad one ward for psychiatry, but in only one was there a closed ward, a meremakeshift. It was necessary to send nearly all disturbed psychotic patients toBritish mental hospitals. There were a few nurses who had had some psychiatrictraining, but none of the wardsmen had had any previous experience. Plans hadalready been furnished British contractors who were building additionalhospitals for the U.S. Army; but for closed-ward neuropsychiatric patients,these plans provided for only two small cell-like rooms, designed with only onesmall, barred window near the ceiling. These rooms were inconveniently situatedwith respect to latrine and other ward facilities and the efficient use of wardattendants.
In September 1942, the U.S. Army negotiated for the use ofthe Exeter City Mental Hospital in England. The hospital was built in 1885,but, in spite of its age, it appeared that it would prove satisfactory. On 23December 1942, the 110th Station Hospital moved into the Exeter Hospital. Itwas planned to relieve the 110th Station Hospital with a neuropsychiatrichospital unit that was expected shortly from the United States.
Upon review of the situation, Colonel Thompson recommendedthat all general hospitals have at least two separate psychiatric wards, oneopen and the other closed. He supervised preparation of plans for theconversion of one general ward to a mental ward in each general hospital. Hewas assisted in this project by a hospital architect in the HospitalizationDivision, Office of the Chief Surgeon, Headquarters, ETOUSA. Colonel Thompsonalso submitted recommendations for the establishment of a neuroses center wheretreatment conducive to return of patients to duty could be rendered in anatmosphere removed from the influence of sick, wounded, or psychotic patients.
By the end of 1942, two other general hospitals had beenestablished, and the 5th General Hospital had been transferred from Ireland toEngland.
Division psychiatrists. - During avisit to the 1st Infantry Division in September 1942, Colonel Thompson foundthat a psychiatrist had been assigned to the division surgeon's office a yearand a half before but that the most recent tables of organization no longerprovided for a division psychiatrist. Yet there was evidence of the excellentwork done by this psychiatrist in the 1st Division; plans had even been workedout for his functions during combat. This situation brought about muchdiscussion by Colonel Thompson with other medical and line officers on the needfor a division psychiatrist. In World War I, a similar need had beendiscovered, and the assignment of one psychiatrist to each division wasauthorized in early 1918. Although the type of warfare had changed, there waseven indication that a division psychiatrist would be very valuable throughoutthe long training period and that his value in combat as well, especially inthe diagnosis and treatment of fatigue, concussion, and neurosis cases, seemedunquestionable. Accordingly, Colonel Thompson initiated a
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38 Captain Hastings was later replaced by Capt. (later Maj.) DouglasD. Bond, MC, who served until the end of the war.
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recommendation to The Surgeon General for reestablishment of the position ofdivision psychiatrist 39 It was not until considerably later,however, that it was authorized (p.344).
This was the first time that Colonel Thompson submittedrecommendations for a change in Army organization, but it was not the last. Hewas to find that one of his key functions would be the submitting ofrecommendations for the establishment of new tables of organization and changesin existing tables. Furthermore, the impetus for submitting suchrecommendations was, eventually, not only to originate from the consultanthimself but from other sources as well.
Summary. - As Colonel Thompson becamethoroughly familiar with the prevailing situation, it was clear that the firstand most logical step would be the establishment of special facilities for thehandling of seriously disturbed, psychotic patients. A more difficult butequally essential project was the setting up of special wards in all fixedhospitals for both open- and closed-ward care of neuropsychiatric patients. Themost important and apparently insurmountable task was that of providing theframework throughout all elements of the theater to prevent, recognize early,and alleviate the more commonly occurring neurotic and psychopathic states. Inspite of the fact that the experiences of World War I were fully documented,that the early British experience in World War II was readily available, andthat a working organization had been initiated in Northern Ireland, it was aninescapable conclusion that the European theater as a whole would be making acompletely fresh start,
FROMBUILDUP AND INVASION TO VICTORY
KeyPersonnel
As the theater expanded and his activities became morediversified, Colonel Thompson found that he could not give all projects theamount of personal attention they required, particularly special, long-termprojects of such a nature that they could not be established by directive aloneand then carried through solely on the initiative of medical officers insubordinate echelons. In some cases, the projects required close coordinationand supervision by one centralized authority. In others, one well-qualifiedindividual could carry on the project better than many others on a part-timebasis. Colonel Thompson found he had to rely on a few unusually well qualifiedand dependable neuropsychiatrists to take the onus of carrying through manysuch projects. As special requirements arose these few officers were calledupon time and again and were often shifted from one assignment to another asdictated by the situation.
With few exceptions, these officers conducted their specialproject while still assigned to a hospital unit. In some cases, it was theirprimary duty; in others, it was an additional duty; and, in a few cases, theofficers were placed
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39 Letter Col. P. R. Hawley, MC. Chief Surgeon, ETOUSA. to TheSurgeon General, U.S. Army, 3 Nov. 1942.
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on temporary duty with the particular activity they were supporting. In onlytwo instances were officers placed on duty with the theater headquarters toaugment the professional staff. Maj. (later Lt. Col.) Paul V. Lemkau, MC,filled in for Colonel Thompson during the latter's temporary duty to the UnitedStates in December 1944 and January 1945. Maj. (later Lt. Col.) Douglas M.Kelley, MC, in February 1945, was assigned for duty with Colonel Thompson asthe consultant in clinical psychology.
In 1942, Colonel Thompson, having in mind one who could be trained in both neurologyand psychiatry, had requested an additional officer to act as coordinator ofhospital neuropsychiatric activities. Some months later, an officer arrived inthe European theater who, although well trained in neurology, did not have theother necessary requisites for the position. Any further overtures to obtain anassistant were not favorably considered. Colonel Thompson also suggested theappointment of full-time neuropsychiatric consultants in base sections to servein a capacity similar to base section medical and surgical consultants. Thisrecommendation was also not accepted. 40
Hospitalizationand Evacuation
The policy of providing inpatient, outpatient,rehabilitation, and consultation neuropsychiatric services in all station andgeneral hospitals was adopted early. It was a policy designed to establishcloser rapport between psychiatrists in hospitals and the general duty medicalofficer in the unit, thus opening the door for emphasis on preventive aspectsof psychiatry. Since the combat elements did not have neuropsychiatrists as apart of their organization at that time, this policy served also to take thepractice of neuropsychiatry into the environs where neuropsychiatric problemsoriginated. For Colonel Thompson, the translation of this policy into practiceinvolved frequent visits to hospitals to make sure that qualified personnelwere assigned to neuropsychiatric positions and that everything was being done,within the means available, to provide adequate facilities, equipment, and service.The most fruitful results, however, could be obtained only through extensiveeducational and training activities.
Specializedhospitals
The creation of hospitals solely for neuropsychiatricpatients was a step taken with considerable reluctance. It was consideredextremely important to keep neuropsychiatry intimately related to and part ofgeneral medicine. However, the general hospitals and larger station hospitalsdid not have the facilities to hold and care for psychotic patients.
Moreover, as time went on, there was ever-increasingevidence that, in the care of neuropsychiatric patients who actually requiredhospitalization, specialized facilities would have certain distinct advantagesover nonspecialized hospitals. This was particularly true of nonpsychoticpatients for whom there
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40 Letter, Lloyd J Thompson, M.D., to Col. John Boyd Coates, Jr,MC., 1 May 1956.
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was a good prognosis for recovery and return to useful duty. It was apparentthat a total atmosphere capable of inducing a desire to return to duty had tobe created in order to salvage patients in this category. It was furtherapparent that, in order to create such an atmosphere, the patient capable ofrehabilitation had to be segregated from psychotic and from nonneuropsychiatricpatients as well. General Hawley, the theater Chief Surgeon, had acknowledgedearly the need for these facilities and maintained continuing interest in theirestablishment and operations.
36th Station Hospital. - This was thefirst neuropsychiatric hospital to be established in ETOUSA. When it arrived atLiverpool on 13 January 1943, the situation was unique in that this was theonly neuropsychiatric hospital in the theater until much later in the war whenunits from the Mediterranean theater were transferred to ETOUSA. The 36thStation Hospital was the special neuropsychiatric unit that had been expected(p.321). It was commanded by Lt. Col. (later Col.) Ernest H. Parsons, MC (fig.113), who was an experienced neuropsychiatrist and who had been a Regular Armyofficer for 12 years.
The hospital unit had been well trained in the Zone ofInterior and was ready to function efficiently upon arrival. With a minimum ofstaging, the hospital replaced the 1l0th Station Hospital at Exeter. Ten daysafter its arrival in the theater, on 23 January 1943, the 36th Station Hospital(fig.114), admitted its first patient, although the directive announcing itsopening and functions was not published until 6 days later.41 Theunit was designed as the hospital of choice for definitive treatment ofneuropsychiatric patients. It received patients only from other station andgeneral hospitals.
An obvious problem was presented, however, in that thisinstallation, with a rated 384-bed capacity, would not be able to meet theneeds of the theater. Colonel Thompson made a detailed study of prevailingpsychiatric rates and those of World War I. The solution appeared to lie in theestablishment of a separate center for neurotic patients. Colonel Thompsonreasoned that neurotics who did not respond to treatment in a short time shouldbe isolated from the physically ill before symptoms became too fixed. A centerfor neurotics required ordinary facilities for hospital care and treatment, butthe unique part and heart of the center would be a training camp where patientscould live a normal military life with drill, physical training, and the like.Colonel Thompson recommended that a station hospital at Moreton Hampstead beused for this purpose. He further recommended that, to save personnel, theneuroses center and the 36th Station Hospital be combined into one unit with asingle overhead.42
General Hawley studied the recommendations carefully but sawobjections to the hospital at Moreton Hampstead. There was some questionwhether it
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41CircularLetter No 20, Office of the Chief Surgeon, Headquarters, ETOUSA, 29 Jan. 3943,subject: Hospitalization of Neuropsychiatric Patients.
42 Letter, Lt. Col. L. J. Thompson to Col. J. C. Kimbrough,Director, Professional Services, Office of the Chief Surgeon, Headquarters,ETOUSA, 14 Feb. 1943, subject: Estimate of Needs for Hospitalization forNeuropsychiatric Disabilities in E.T.O.
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FIGURE 114.- 36th Station Hospital, Exeter,England.
had sufficient facilities for expansion, particularly sewers and powerlines.Also, this installation would be 18 miles away from the 36th Station Hospital,and General Hawley doubted that two hospitals that far apart could be operatedefficiently under a single administration. He concurred in the plan forcombined facilities but suggested that another 250-bed hospital be used for theneuroses section.
Colonel Thompson had no alternative butto go to the 36th Station Hospital and work out plans for the establishment ofa training adjunct to that hospital. By mid-March, a training company had beenactivated. An Air Corps captain, who was a convalescent patient, was designatedas its commanding officer. Quarters were arranged and operated as barracks. Arigid, daily schedule of military activities was initiated. The program alsoincluded work details, occupational therapy, group discussions, and fullinformation and education activities. Without too much difficulty, anatmosphere of return to duty was created (fig.115). The return-to-duty rate fornonpsychotic cases soon rose to over 50 percent.
In April 1943, Colonel Thompson submitted revised estimates,project ed to January 1944, of theater needs for neuropsychiatric beds. Theseestimates emphasized the need for a larger facility for more serious psychoticcases and the immediate need for a special rehabilitation hospital fornonpsychotic cases. 43 At the 30 June 1943 meeting of the MedicalConsultants Subcommittee,
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43 Letter, Lt. Col. L. J. Thompson to Col. J. C. Kimbrough, Directorof Professional Services, Office of the Chief Surgeon, Headquarters, ETOUSA, 30Apr. 1943, subject: Future Needs for Hospitalization of Neuropsychiatric Patients.
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327
FIGURE 116.- Closed ward at 36th StationHospital.
Colonel Thompson reported to Colonel Middleton that the census at the 36thStation Hospital had remained over 300 for the past few weeks. Owing to a greatvariety of patients, ranging from acutely disturbed psychotics to mildneurotics and passive homosexuals, there had to be several subdivisions withinthe hospital. As at any specialized facility, the dispersion factor was high,and at any given time one subdivision could be overcrowded while another hadseveral vacant beds. Colonel Thompson emphasized the point that it could neverbe hoped to equal by actual occupancy the estimated bed capacity of 384. Underthe circumstances, the training-company barracks were being encroached upon andthe work of the training company, which was so important in getting men back toduty, was being hampered. There was an increasing number of men being sent backto duty, but, since some were being sent out prematurely to make room for newpatients, there remained the possibility of relapse in some cases. ColonelThompson emphasized again the urgent need for a neuroses unit. For the time being,as the need arose, more closed wards could be provided at the 36th StationHospital (fig.116), for psychotic patients if such a separate neuroses unitcould be established elsewhere.
Colonel Middleton brought Colonel Thompson's statements tothe attention of General Hawley. Eventually, General Hawley and Col. Charles B.Spruit, MC, Deputy Chief Surgeon, ETOUSA, agreed on the hospital site atBarnstable to receive the overflow of neuropsychiatric patients. It was notuntil late September, however, that Colonel Spruit discussed with ColonelThompson the possibility of using the hospital at Barnstable as a neurosescenter. Colonel Spruit pointed out that, although it was intended in the futureto use this hospital for neurotic patients, at the moment it had to take alltypes of patients and be used to provide medical care for the Assault TrainingCenter. He
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directed that inquiries be made into the possibility of obtaining land in theenvirons of the hospital. It was found that ground space for outdoor militaryand athletic activities was entirely inadequate and additional ground could notbe obtained.
Neurosescenter for treatment and rehabilitation
General Hawley had always maintained an active personalinterest in the establishment of the neuroses center, and, on 2 October 1943,Colonel Thompson conferred with him on the matter. Shortly thereafter, it wassuggested to Colonel Thompson that a station hospital site at Shugborough Parkbe considered for his neuroses center. On 23 October 1943, Colonel Thompsoninspected the installation at Shugborough Park and found that there were almost100 acres of land that could be used for the purpose intended. On 27 October1943, he visited the Southern Base Section and conferred with the base medicalconsultant and the commanding officer of the 36th Station Hospital regarding personneland other details, and, on 8 November 1943, he conferred with chiefs of variousdivisions in General Hawley's office who would be concerned with the opening ofthe hospital.
The problems did not end with finding a site, however. The4th Convalescent Hospital, which was originally designated to be converted intoa neuropsychiatric unit and operate the center, was claimed for assignment tothe First U.S. Army.
312th Station Hospital - This stationhospital, a nonspecialized unit which had recently arrived from the Zone ofInterior, was then selected to operate the facility at Shugborough Park. Uponrecommendations initiated by Colonel Thompson, the Southern Base Sectiontransferred key individuals, including Colonel Parsons, from the 36th StationHospital to the 312th Station Hospital. There was an adjustment of otherpersonnel so that, eventually, two neuropsychiatric hospitals were manned inthe theater without bringing in additional personnel from the United States.The 3l2th Station Hospital was officially opened on 1 December 1943, and thefirst patient was admitted on 3 December 1943, nearly 10 months from the timethat the establishment of such an installation was first recommended.
The plan of function that had been evolved at the 36thStation Hospital was adopted. After initial workup of each case, with adecision as to type of treatment, the patient spent from 10 days to 2 weeks inthe treatment section. Following this, he was transferred to the training orrehabilitation wing, such transfer being the needed step between hospital careand duty. Officers of the training section were, initially, line officers whohad been wounded in action in the North African theater. The return-to-dutyrate averaged 80 percent, which was remarkable since the patients representedfailures received from other hospitals.44 The 3l2th Station Hospitalcontinued to maintain this record of performance throughout the subsequentmonths of its operations on the Continent.
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44 Thompson, L. J.: Neuropsychiatry in the European Theater ofOperations. New Eng. J. Med. 235: 7-1l, 1946.
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Holdingcenter for psychoses
96th General Hospital. - To fill theneed defined in April 1943 (p.325) for a larger facility for the care of moreserious psychotic patients, a site near Malvern was chosen in August 1943, andthe facility was opened by the 56th General Hospital in November 1943;subsequently, in January 1944, it was operated by the 96th General Hospital. Ofparticular significance was the fact that this hospital was organized accordingto T/0&E 8-550S (Table of Organization and Equipment) that was proposed bythe European theater for a neuropsychiatric general hospital and approved bythe War Department. As with the 312th Station Hospital, however, the 96thGeneral Hospital, a nonspecialized general hospital unit arriving from the Zoneof Interior, had to be transferred into a specialized neuropsychiatric unit byexchanging qualified neuropsychiatric personnel available in the theater fornonneuropsychiatric medical officers arriving with the unit.
The primary mission of this hospital was that of a holdingunit. It was ultimately responsible for the care and disposition of nearly allpsychotic patients in the theater. The 96th General Hospital was alsoresponsible for the disposition of neuropsychiatric patients determined byother hospitals to be incapable of rehabilitation for duty in the theater. Aneed for such a unit was well vindicated following the invasion of theContinent. For example, in October 1944, the census of the 96th General Hospitalwas 1,206 with over half of these patients awaiting evacuation to the Zone ofInterior.
Transithospitals
Forces that invaded the Continent on D-day were providedmedical support in the United Kingdom in two phases (fig. 117). First, boat-and air-evacuated casualties were received at transit hospitals located alongthe southern shores or at airfields. Then all casualties were transported byhospital train or other conveyance to general hospitals in the United Kingdom.In the early days of the invasion, all casualties, including neuropsychiatric,were completely intermingled upon arrival at transit hospitals, and the primaryconsiderations governing their transfer to other hospitals were convenience inmovement and availability of beds.
It was impossible, at this time, to sort patients on theContinent and evacuate them to designated transit hospitals for furtherevacuation to a specialized treatment center, as had been recommended. Triageof neuropsychiatric patients at transit hospitals for transportation tospecialized treatment centers also was recommended but could not be done.Neuropsychiatric patients were surprisingly low in number and their arrival attransit hospitals so haphazard and sporadic that they could not be groupedtogether for a single shipment. The heavy load upon limited transportationfacilities and the necessity of adhering to straightforward transportationschemes did not permit transfer of small groups of patients from one hospitalto another at crosscurrents to the general flow of traffic. This situationcontinued for neuropsychiatric casualties until well into August 1944.
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Troublesome consequences of this largely unavoidablesituation were soon to appear. The replacement depot reported that, betweenD-day and 2 July 1944, more than 100 neuropsychiatric patients had been sentback to duty too soon. About half of them had been on neuropsychiatric servicesin general hospitals, but apparently the psychiatrists had been tooenthusiastic in applying their indoctrination of sending patients back to dutyas soon as possible. The remaining half were patients who had been initiallyadmitted for a primary diagnosis other than neuropsychiatric but whoseneuropsychiatric symptoms appeared at the replacement center. Colonel Thompsonhad to visit as many general hospitals as quickly as possible in order toanalyze and correct the situation on the spot. Colonel Parsons was also calledupon to help.
The general situation grew worse as the tactical situationgrew more fluid on the Continent. By 1-15 August, the third U.S. Army hadjoined the offensive, and the first fixed hospitals had begun to establishthemselves in Normandy. Before most of these hospitals could begin operatingefficiently, they were far outdistanced by the rapidly expanding front.Psychiatric casualties evacuated from the field armies were being shunted fromhospital to hospital with no treatment except sedation. Evacuation policiesthat limited holding of patients to not more than 10 days prohibitedinstitution of any worthwhile psychotherapy. The First U.S. Army had counteredloss of personnel by establishing procedures, on 10 July 1944, wherebyneuropsychiatric casualties could be reassigned to limited duty within thearmy. Heretofore, a casualty either had to be returned to duty with his unit orevacuated out of the army. The Third U.S. Army established procedures forreassignment of casualties to limited duty within the army similar to thoseestablished by the First U.S. Army. This policy relieved the situation somewhatbut was by no means an answer to the greater problem of what to do with thosecasualties which the armies themselves could not handle.
Advancedneuropsychiatric units
In World War I, the American Expeditionary Forces hadfound it necessary to establish neuropsychiatric units immediately to the rearof the combat areas. Having foreseen the recurrence of such a situation,Colonel Thompson had recommended as early as January 1944 that a unit beequipped and trained to operate as an advanced unit for receivingneuropsychiatric casualties from a field army. At various times prior to theinvasion, he had recommended that personnel of the 36th Station Hospital, andlater the 312th Station Hospital, be trained and employed for such a mission.45
In July 1944, Colonel Thompson held aconference attended by the Commanding Officer, 312th Station Hospital, theDeputy Chief Surgeon, ETOUSA, the Chief, Planning Branch and the Chief,Training Branch,
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45(1) Letter,Lt. Col. L. J. Thompson to Col. J. C. Kimbrough, Director, ProfessionalServices Division, Office of the Chief Surgeon, Headquarters, ETOUSA, 26 Apr.1943, subject: Psychiatric Teams for Service During Combat. (2) Letter, SeniorConsultant in Neuropsychiatry, ETOUSA, to Chief Surgeon, ETOUSA, 31 Dec. 1943,subject: Psychiatric Services in the U.S. Army in NATOUSA. (3) Letter, Col. L.J. Thompson to Col. Wm. S. Middleton, Chief Consultant in Medicine, ETOUSA, 22Jan. 1944, subject: Psychiatric Report for Medical Subcommittee.
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Operations Division, Office of the Chief Surgeon, Headquarters, ETOUSA. ColonelThompson informed the conferees that, from D-day to D-plus-34, 2,012neuropsychiatric casualties, excluding those with secondary neuropsychiatricconditions, had been evacuated to the United Kingdom. He calculated that ahospital located just back of the First U.S. Army would receive some 400patients weekly. With a 3-week schedule of treatment, 1,200 beds would benecessary. But such a hospital could return to duty nearly 90 percent of thepatients admitted--half of them back to combat--thus saving considerable evacuationto the United Kingdom. In view of these considerations, Colonel Thompsonsuggested that a 1,000-bed general hospital would adequately cover personnelneeds for the establishment of such a hospital. The conferees evolved a plan toorganize this special neuropsychiatric unit.
This plan was dubbed Colonel Thompson's "triangularplan" by Colonel Middleton because it involved three hospitals. Itconsisted of taking a general hospital arriving from the Zone of Interior inAugust 1944 and designating it a neuropsychiatric hospital, filling it withtrained personnel from the 312th Station Hospital, bolstering the remnants ofthe 312th Station Hospital with trained personnel from the 36th StationHospital, and leaving a nonspecialized station hospital (the 36th) with theresidue of personnel. It was further planned that the general hospital unitwould start staging 1 September 1944, move to ADSEC (Advance Section),Communications Zone, on 21 September, and commence to function on 1 October1944. The location was to depend on the situation, but it was agreed that itshould be well forward and easily accessible from army evacuation points. Thescheme was duly presented to Colonel Kimbrough in a memorandum dated 19 July1944 and its approval announced by Colonel Middleton at the next meeting of theChief Surgeon's Consultant Committee. The 130th General Hospital was earmarkedfor this purpose.
130th General Hospital. - The planprogressed well up to the point where the 130th General Hospital arrived on theContinent on 4 September 1944 and a choice location had been designated for itat Ciney, Belgium (fig.118). A month later, 5 October 1944, Colonel Thompsonwas obliged to go to Operations Division of General Hawley's office and reportthat the hospital was not yet able to operate and that the situation wasbecoming urgent. The equipment for the hospital had not arrived.
On 30 October and 1 November 1944, Colonel Thompson againconferred with Operations Division. While discussing admission and dispositionpolicies pertaining to the l30th General Hospital with the chiefs of theEvacuation Division and Operations Division (chart 3), Colonel Thompson waschagrined to learn that there was still some question as to how this hospitalwould function. However, he did learn, on 2 November 1944 from the SupplyDivision of General Hawley's office, that the equipment had been located on 1November, was loaded on trucks, and was on the way to the hospital.
While Colonel Thompson was at the hospital on 6 November1944, the first truckload of supplies arrived. That very evening, a staffmeeting was
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FIGURE 118.- l30th General Hospital, Ciney,Belgium.
held, and problems incident to beginning operations were discussed. It waslearned that the commanding officer had already agreed with Headquarters,ADSEC, Communications Zone, to use the main hospital building for generalhospital and station hospital purposes (fig.119). The psychiatric service wasto be in tents, and in prefabricated buildings previously erected by theGermans (fig.120). The training company was to be located at a chateau about amile and a half from the hospital proper (fig.121).
On 7 November 1944, Colonel Thompson inspected thefacilities and then attended a meeting at Headquarters, ADSEC, when allcommanding officers of hospitals in the vicinity were in attendance. Problemsin the handling of neuropsychiatric casualties were discussed with them and itwas evident that many of these problems would be solved upon opening of thel30th General Hospital. Later the same day, plans for evacuation to and fromthe l30th General Hospital were completed with the Deputy Chief Surgeon,ETOUSA, and Chief, Evacuation Division, Office of the Chief Surgeon, Headquarters,ETOUSA. A draft of the directive announcing these plans was drawn up.
On 17 November, the hospital was opened and the firstpatients admitted. A week later, the hospital was receiving medical andsurgical patients but very few neuropsychiatric patients (fig.122). ColonelThompson brought this fact up at the Chief Surgeon's Consultant Committeemeeting of 24 November1944. Although realizing the necessity for the presentarrangement, he expressed the hope that Communications Zone neuropsychiatricpatients would soon be able to get suitable treatment at the l30th GeneralHospital.
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CHART 3.-Flow chart of patients at 130thGeneral Hospital from admission to disposition
The Deputy Chief Surgeon, Col. Liston, replied:
We certainly hope you can. I speak for all of us. These 14hospitals in UK are reasonably up to T/O strength. I might mention that thesehospitals are those supposed to have arrived here in September and operating.For reasons outside our control we don't have them. If we did have them,certainly the 130th could operate in the manner we intended it should operate fromits inception. The problem is finding enough beds for the patients we have. Assoon as possible, I hope that we will be able to isolate this hospital for whatyou want to use.46
Before the situation could be amended, the Germans struck intheir winter offensive of 1944, known as the Battle of the Bulge. The hospitalwas engulfed by advancing German forces. Most of the patients and personnelwere evacuated, but the commanding officer and a few volunteers remained behindto care for nontransportable cases.
According to an account given Colonel Thompson by ColonelParsons, some German officers had come to the door of the hospital in few daysbefore Christmas. They stated that the hospital was surrounded and that theGermans expected the commanding officer to take care of German casualties thatmight be sent there. No German officers were assigned to take over thehospital, and Colonel Parsons did the best he could and did receive severalGerman casualties. On or about 27 or 28 December 1944, while sitting in hisoffice, Colonel Parsons looked at his telephone and decided to see if it wasstill connected. To his surprise, he was able to get through to some head- _______
46 Minutes of meeting, Chief Surgeon's Consultant Committee, 24 Nov.1944.
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FIGURE 119 - Medical ward, main hospitalbuilding, 130th General Hospital.
quarters in Liége and was told to sit tight because Allied troops wouldsoon be coming back through that area.47
Shortly thereafter, U.S. troops regained the area, and the hospital acted as afield hospital and evacuation hospital for these troops mounting thecounteroffensive.
On 6 and 7 February 1945, Colonel Thompson again inspectedthis hospital and found that it was acting as a station hospital for the 11thReplacement Depot, Headquarters, ADSEC, and nearby Air Force installations. Thecensus was 1,242 patients, of which only 119 were neuropsychiatric. On theafternoon of 7 February, the commanding officer of the hospital and ColonelThompson held a conference with Colonel Liston and the Chief, EvacuationDivision, Office of the Chief Surgeon, Headquarters, ETOUSA. The desire toreturn the hospital to its primary function seemed to be well understood, andcooperation toward this end was promised. But two weeks later, other hospitalsin close proximity to the l30th General Hospital were receiving many moreneuropsychiatric patients than the 130th General Hospital. On 18 March, aconference was held with the chief of the Evacuation Division on this matter.Although he was not very optimistic about the use of this specializedneuropsychiatric hospital, owing to transportation difficulties, he agreed toissue
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47 See footnote 40, p. 323.
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FIGURE 120.- Psychiatric service in tentedsection, 130th General Hospital.
specific instructions to ADSEC, Communications Zone, that all neuropsychiatricpatients from First and Ninth U.S. Armies should be sent to the 130th GeneralHospital.
After receiving a report from Lt Col. (later Col.) WilliamG. Srodes, MC, neuropsychiatrist of the First U.S. Army, that he had beentagging neuropsychiatric patients for the 130th General Hospital but they werenot getting there, Colonel Thompson took another trip to the l30th GeneralHospital. He found that the commanding officer had conferred with Headquarters,ADSEC, Communications Zone, and the Commanding Officer, 8l8th Hospital Center,and had brought about an agreement that all neuropsychiatric patients cominginto the center would be transferred directly to the 130th General Hospital.Visiting Headquarters, ADSEC, Colonel Thompson found that the medical staffthere had a good understanding of the needs for early treatment ofneuropsychiatric cases and were in full agreement with plans for the evacuationof such patients to the l30th General Hospital. He learned, furthermore, thatall neuropsychiatric patients coming out of the First and Ninth U.S. Armieswent to the 8l8th Hospital Center at Liege (fig.123), and it was only a littleover an hour from there to the l30th General Hospital at Ciney. The medicalliaison officer from the Ninth U.S. Army was seen, and he confirmed the factthat all cases from that army came through the 77th Evacuation Hospital andwere tagged for the l30th General Hospital.
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FIGURE 121.- Headquarters. Rehabilitation(training) Section, 130th General Hospital.
Visiting the 818th Hospital Center, he found there, too,that the commanding officer, Col. Robert B. Hill, MC, and his evacuationofficer were in complete agreement with the necessity of transferring allneuropsychiatric patients to the 130th General Hospital, In fact, Colonel Hillwas anxious to get the training section of the l30th General Hospital firmlyestablished and operating so that the chateau which hat been designated for thetraining section of that hospital would not be lost to the Medical Departmentthrough lack of use. Colonel Hill stated that he had a large bus that could beused for transporting patients to the 130th General Hospital. He also remarkedthat the l30th General Hospital was using its own transportation to takepatients to the replacement depot near Liége daily, and there was noreason why this transportation could not be used to take neuropsychiatricpatients from the 818th Hospital Center to the 130th General Hospital.
Finally, Colonel Thompson visited the 28th and 56th GeneralHospitals, Liége, Belgium, and the 298th General Hospital. These werepart of the 818th Hospital Center and were receiving the bulk ofneuropsychiatric cases in the center. They did not have a very clear picture ofthe relationship of the 130th General Hospital to the center. When thesituation was explained, these hospitals promised their full cooperation. Duringthe course of these visits, it was learned that the 818th Hospital Center didnot hold patients over 10 days, which was an added argument for the use of thel30th General Hospital.
These efforts by Colonel Thompson brought results. For thefirst time since the hospital began operating, neuropsychiatric admission beganto ex-
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FIGURE 122.- Surgical ward, 130th GeneralHospital.
ceed all others. This continued through the last week in March and most ofApril 1945 (figs.124 and 125). By that time, however, the front had again sofar outdistanced the general hospitals that orderly evacuation to the 130thGeneral Hospital was not appropriate in many cases. At the same time, theemphasis in the theater changed from that of saving and rehabilitating manpowerto that of boarding and evacuating patients to the Zone of Interior as rapidlyas possible. Accordingly, patients were being flown to large centers in andabout Paris (fig.126), bypassing intervening installations (p.457).
51st Station Hospital. - The 51stStation Hospital was a special neuropsychiatric unit which had been organizedin North Africa and had worked its way up through Italy. It came into theEuropean theater in November 1944 as a fully equipped and efficiently workingunit with much experience. When Colonel Thompson visited the hospital on 29November 1944, it was located at Dijon and was receiving neuropsychiatricpatients from the Seventh U.S. Army and a limited number from the Third U.S.Army. Colonel Thompson thought it would be feasible for the 51st StationHospital to receive neuropsychiatric patients directly from both Third andSeventh U.S. Armies. In that way, the hospital could perform a missionidentical to that of the 130th General Hospital for the First and Ninth U.S.Armies. The hospital, however, was already quite far to the rear.
Colonel Lemkau, acting for Colonel Thompson during thelatter's temporary duty in the United States, attempted to implement this planon a firmer basis. The support of the Surgeon, Southern Lines of Communication,was
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FIGURE 123.- Buildings and grounds of 818thHospital Center, Liege. Belgium
obtained. On 29 December 1944, the 51st Station Hospital was moved up toLunéville. Nevertheless, it was never close enough to the armies it wassupporting for the efficient discharge of its mission. Neuropsychiatriccasualties could not be evacuated to it in the numbers planned. Furthermore, aswith the l30th General Hospital, the mission of the 51st Station Hospital wasdecidedly altered during the German winter offensive. Surgical teams wereattached, and the hospital's mission became surgical.
Summary
The establishing ofspecialized hospitals for the care of neuropsychiatric patients was atremendous project requiring great effort by all concerned. When establishedand operating as planned, the results were well worth the effort; however,owing to the tactical situation, they could not always be used as intended.Difficulties encountered in establishing these specialized facilities wereillustrative of the type of problems met in the general area of hospitalizationand evacuation. In addition to specialized facilities, Colonel Thompson wasinvolved in planning and establishing policies for evacuation andhospitalization of neuropsychiatric patients within field units, to and fromother fixed hospitals, and from the theater to the Zone of Interior. The latterwas, at times, a particularly difficult problem. Certain aspects of thehandling of neuropsychiatric patients in field units during combat arediscussed under the heading that immediately follows.
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NeuropsychiatricServices With the Field Armies
It was necessary for Colonel Thompson to have at all timesaccurate knowledge of the state of mental health of all troops in the theaterand of what was being done to maintain mental health, for as an adviser in hisspecialty to General Hawley he had to provide dependable information and tosubmit appropriate and timely recommendations, either on his own initiative orin response to specific direction by his superior officers. As a staff officerin the headquarters of the theater commander, it was also his duty to superviseactivities within his special field in all subordinate echelons to insure thatestablished theater policies, procedures, and doctrine were being adhered toand successfully carried out.
In accordance with the general responsibilities and dutiesof a staff officer, a consultant did not exercise command. He could notlawfully give direct orders in his own right to commanders of subordinateunits. However, as an officer on the theater Chief Surgeon's staff--and inexercising staff supervision-- he was bound only to stay within limits of thepolicies and directives of the theater commander and the technical (medical)doctrine established by General Hawley. Inspections and visits enabled him toobserve activities in the field and offer on-time-spot suggestions forcorrection of any deficiencies observed. When changes in technical doctrine orestablishment of new doctrine were necessary, he could make appropriaterecommendations for their adoption to General Hawley (through Colonel Middletonand Colonel Kimbrough). When it was found necessary to issue orders tocommanders of subordinate echelons, he could again submit specificrecommendations through his immediate superior officers and General Hawley.Upon approval of his recommendation, Colonel Thompson was usually called uponto prepare for General Hawley or the theater commander, as appropriate to thecase, proper directives implementing their decisions.
Field Army psychiatrists. - In hisday-to-day dealings with the Armies, Colonel Thompson found it expedient to usetechnical channels. His technical channel of communication with Armies wasthrough the consultant in neuropsychiatry to the Army surgeon. Inneuropsychiatric circles, this officer was commonly referred to as the Armypsychiatrist. In a letter, 8 July 1944, to Col. (later Brig. Gen.) William C.Menninger, MC, Consultant in Neuropsychiatry to The Surgeon General, ColonelThompson described his relationship with the Army psychiatrist as follows:
In one of your recent letters you asked about the Army psychiatrist. I presumedthat you knew about this since they arrived over here already appointed in thatposition. However, Lt. Col. Srodes did replace the psychiatrist who originallycame with that Army. The Army psychiatrist is the only position between mine inthe Office of the Chief Surgeon and the division psychiatrist. He acts asConsultant in the Office of the Army Surgeon, and supervises the work of thedivision psychiatrists, as well as the psychiatric services in the evacuationhospitals, and the special N.P. unit. I can report that we have excellent menin the positions.
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During the major portion of the fighting in Europe, the Armypsychiatrists were: Colonel Srodes, First U.S. Army; Maj. (later Lt. Col.)Perry C. Talkington, MC, Third U.S. Army; Maj. Alfred O Ludwig, MC, SeventhU.S. Army; Lt. Col. (later Col.) Roscoe W. Cavell, MC, Ninth U.S. Army; and Lt.Col. (later Col.) Joseph S. Skobba, MC, Fifteenth U.S. Army.
In the early days of the theater, a vigorous program wasembarked upon to carry the principles of preserving mental health to men andofficers of the line. With the concurrence of the First U.S. Army, ColonelParsons spent considerable time and effort to carry out this program He livedwith the units, held daily instructional periods, and joined informalconferences among the officers in the evenings. The work was carried on laterby Colonel Srodcs. When division psychiatrists were appointed in late 1943,much of this activity was passed on to them (p.321). Guidance of divisionpsychiatrists and of general-duty medical officers, as well, was effected throughthe Army psychiatrist and formal instruction at the school of neuropsychiatryestablished at the 3l2th Station Hospital in the United Kingdom.
Tactical organizations and units in North Africa.- The inadequacy of plans and preparations for neuropsychiatric services,particularly in tactical organizations and units, was suddenly placed in sharpfocus when final preparations were being made in October 1942 for the NorthAfrican invasion. Except for the unofficial and opportune presence of a psychiatristin the 1st Infantry Division, it was evident that psychiatry would berepresented no further forward than general hospitals. The 400-bed evacuationhospitals had a table of organization position for a neuropsychiatrist, but nosuch units were in the theater at that time.
At the suggestion of General Hawley, Colonel Thompsonvisited Col. John F. Corby, MC, who had been designated surgeon for U.S. forcesinvolved in the operation. Colonel Thompson advised him to consider moreseriously the problem of handling neuropsychiatric casualties and urged that hetake along a consultant in neuropsychiatry. Colonel Corby did not seem inclinedto accept Colonel Thompson's advice but did say that, if the need for apsychiatrist developed, he hoped that one could be provided the force. ColonelThompson assured him this would be done, and he discussed this eventuality withCaptain Hanson, Colonel Parsons, and some other psychiatrists, as well as withColonel Middleton. There was general agreement that Captain Hanson, because ofhis previous experience, would be the logical one to go.48 Theinvasion of North Africa took place on 8 November 1942. Not long thereafter, on21 January 1943, a cablegram was received in the European theater from theNorth African theater, reading: "Select competent psychiatrist forassignment to ABS." It was brought to Colonel Thompson's attention a fewdays later. Conferring with General Hawley, Colonel Thompson proposed his ownname along with that of Captain Hanson. General Hawley selected Captain Hansonfor the assignment. Prior to departing for North
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48See footnote 40, p. 323.
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FIGURE 125.-Continued. C. and D. Physicalconditioning.
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FIGURE 125.-Continued. E. Group psychotherapy.F. Military training utilizing sandtable.
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FIGURE 125.-Continued. G. Information andeducation activities. H. Retraining shop in radio repair.
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FIGURE 125.-Continued. I. Retraining shopin auto mechanics. J. Retraining in draftsmanship.
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Africa, Captain Hanson met in conference with Colonel Thompson, ColonelParsons, and other neuropsychiatrists. Out of these conferences came atentative plan for the organization and operation of neuropsychiatry in thecombat zone, the soundness of which later developments confirmed in manyrespects. The plan also contained a proviso that detailed recommendations ofdiagnosis, treatment, and disposition would be forwarded to Colonel Thompson afterfurther study under combat conditions.
In November 1943, Colonel Thompson was given permissionto visit the North African theater. He departed on 13 November 1943 andremained in North Africa until 15 December 1943. There he studied U.S. Armyrecords and statistics, observed neuropsychiatric cases within a few hoursafter evacuation, interviewed medical officers, and visited clearing stations,evacuation hospitals, general hospitals, and a convalescent hospital. He studiedCanadian reports and statistics, interviewed several division psychiatrists,and observed the Canadian 15th General Hospital. He conferred with the Britishadviser in psychiatry, interviewed British corps psychiatrists and observedtheir corps exhaustion centers, and observed advanced psychiatric wings ofgeneral hospitals, general hospitals, and casualty clearing stations.
Upon his return, Colonel Thompson submitted detailedreports on his observations of United States, Canadian, and British forces inNorth Africa and Italy.49 He also made recommendations dealing withthe function and training of medical officers in line organizations;indoctrination of line officers; selection, appointment, and training ofdivision psychiatrists; organization, functions, and training ofneuropsychiatric personnel in evacuation hospitals; establishment and trainingof a cadre for forward neuropsychiatric hospitals; hospitalization inspecialized facilities in the United Kingdom; and the rehabilitation and returnto duty of psychoneurotic casualties. In these recommendations, he stated thatsuch matters as methods of treatment, evacuation procedures, and diagnosticterminology should be explicitly set forth in directives, but theindoctrination of all personnel in basic tenets had to be accomplished throughformal courses and personal informal contacts.
Colonel Thompson’s recommendations were publishedon 6 January 1944 as Circular Letter No. 2, Office of the Chief Surgeon,Headquarters, ETOUSA, subject: Early Recognition and Treatment ofNeuropsychiatric Conditions in the Combat Zone. At this stage in thedevelopment of the European theater, the document was most succinct, yetcomprehensive, and remarkably prescient. No need was found to change it duringthe period of combat operations in the theater, and much of the material ondiagnosis and treatment was later incorporated in the Manual of Therapy,European Theater of Operations.
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49 (1) Letter, Senior Consultant in Neuropsychiatry, to Chief Surgeon, ETOUSA,23 Dec. 1943, subject: Canadian Psychiatric Services in North Africa and Italy.(2) Letter, Senior Consultant in Neuropsychiatry, to Chief Surgeon, ETOUSA, 31Dec. 1943, subject: Psychiatric Services in the U.S. Army in NATOUSA. (3)I.etter, Senior Consultant in Neuropsychiatry, to Chief Surgeon, ETOUSA, 31Dec. 1943, subject: British Psychiatric Services in Middle East, North Africa,and Italy.
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Exhaustion centers. - However, the most pressing problemat this time was the provision for neuropsychiatric services behind thedivisions. In North Africa, two small station hospitals were used, which heldpatients for not over 14 days. These hospitals, which received patientsdirectly from evacuation hospitals, had returned over 60 percent of them tononcombat duty in base sections, whereas other fixed hospitals had returnedover 60 percent of their neuropsychiatric patients to the Zone of Interior.When Major Hanson visited the European theater in mid-January 1944, aconference was held with Colonel Spruit. In attendance were Major Hanson,Colonel Srodes and Colonel Thompson. Major Hanson was very influential inshowing the need for special neuropsychiatric facilities between evacuationhospitals and general hospitals in the rear. Colonel Thompson suggested thatpersonnel could be trained and made available at the three neuropsychiatrichospitals in England and such a special hospital could be brought intoexistence when the need arose. Colonel Spruit was convinced that a specialforward neuropsychiatric hospital was needed, but he was of the opinion that itshould be a field hospital under army control. At any rate, there wasconcurrence in the general principle, and the way was opened for furtherplanning.
At this stage, Colonel Thompson felt that the evacuationhospital with its organic neuropsychiatric facilities and personnel should doall in its power to treat and return neuropsychiatric casualties to duty. Theadditional hospital that he was proposing was to take care of patients theevacuation hospitals could not send back to duty and for whom there was goodprognosis for quick recovery. Apparently, the First U.S. Army did not want to changeits prevailing practices in the employment of its hospitals, and there were nofield hospitals available for establishing holding facilities for exhaustioncases as contemplated by Colonel Spruit.
At the Medical Consultants Subcommittee meeting of 2March 1944, Colonel Thompson was able to report that the basic principles hadnow received full support of General Hawley and that an apparently suitablecompromise measure had been reached. While continuing to entertain thepossibility of using a field hospital, thie First U.S. Army had decided to makea 250-bed neuropsychiatric hospital based on a separate clearing companyreinforced by neuropsychiatric personnel from evacuation hospitals. This meantthat early treatment would be carried out in this special hospital atapproximately the same level of evacuation as the evacuation hospital. The onlyobjection that Colonel Thompson saw to this plan was the fact that theneuropsychiatric casualty would have to go through the evacuation hospitalbefore getting to the special neuropsychiatric unit, and lengthening, by thatmuch, the chain of evacuation and delaying early treatment.
The First U.S. Army made the invasion on 6 June 1944 andtwo weeks later had established two exhaustion centers based on ColonelSrodes’ plan of reinforced clearing companies. Colonel Thompson wrote toColonel Menninger on 8 July 1944, as follows:
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I note that the special N.P. unit, which was made up from aclearing company, and called an “Exhaustion Hospital” isfunctioning very well with the army. Patients returning to this area have comeback well treated through sedation, and approximately 90 percent had the term Exhaustionon the E.M.T.
On 3 August 1944, Colonel Thompson wrote:
Bill Srodes, the ArmyPsychiatrist, is keeping a cool head and is extremely helpful to the DivisionPsychiatrist. His arrangement of filling the two exhaustion centers instead ofpsychiatric services in Evacuation Hospitals seems to be working well. I shouldlike to see another good try at the use of Evacuation Hospitals before I wouldsay that Srodes set-up is better.
When Colonel Menninger visited the theater in Septemberand October of 1944, it was generally agreed that the centralized exhaustioncenter provided the best service. Before Colonel Menninger departed, Colonel Thompsonpromised to submit detailed recommendations on the organization and equipmentof an exhaustion center. On 11 November 1944, Colonel Thompson wrote to ColonelHanson, as follows:
` On the last day ofMenninger’s visit in this theater, we spent most of the time discussingthe question of the best Army NP. unit. * * * we came to the conclusion thatthe Field Hospital, with its three platoons, seemed to be the very bestarrangement that could be set up. Colonel Menninger was going to recommend thisthrough his office and I have already put it in writing for this theater.However, we have not gone into great detail about T/O and T/E, and yourinformation along this line will be greatly appreciated. Eventually, it ishoped that a definite and separate N. P. unit based on these plans may become apermanent fixture. But, as we all know, this will take a great deal of time.
Since Colonel Srodes had been concerned with the planningof these exhaustion centers from the time of their inception in the Europeantheater, Colonel Thompson visited him on 8 February 1945 and discussed thematter further with him. Colonel Srodes agreed to submit a detailed table oforganization and equipment which the theater believed should be considered apermanent War Department organization.
In other armies that eventually fought in the Europeantheater, psychiatric services behind divisions were variously handled in theabsence of theater or War Department specifications. The Third U.S. Army keptits psychiatrists in evacuation hospitals, as originally suggested by ColonelThompson, but had, in addition, a convalescent hospital to take the overflowfrom the evacuation hospitals. Colonel Thompson thought that this system workedwell for the type of combat engaged in by this army. The Seventh U.S. Army usedclearing companies to set up two exhaustion centers in the same manner as theFirst U.S. Army and had indeed used this system in the North African theatereven before its use in the First U.S. Army. The Ninth U.S. Army set up oneexhaustion center using a medical gas treatment battalion augmented bypsychiatrists from evacuation hospitals. When field hospitals became available,this army immediately put them into use for the holding and treatment ofneuropsychiatric patients in the army area.
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Rest periods for the combat so1dier. - Another matter ofgreat moment to all combat forces in the theater was the concept of using restperiods for individual soldiers and units as a motivating factor in preventingloss of manpower from psychiatric disorders. The impetus for this idea arose ina report from The Surgeon General. 50 In sober, matter-of-factlanguage, the report pressed home the point that, unless an infantryman ismotivated to look forward to a ‘‘break,’’ he hasnothing to look forward to but “death, mutilation, or psychiatricbreakdown.” Citing data from experiences of the Fifth U.S. Army in Italy,the report showed how a soldier in combat wore out “just as an averagetruck wears out after a certain number of miles.’’ Obviously, theproblem was how to get this information translated into appropriate action.Most psychiatrists or other medical personnel realized these facts and had beentrying with varying degrees of success to apply them in their units. Theapproach now chosen was most direct and pointed. The Surgeon General’sreport was appropriately edited to include only those facts that were ofimmediate concern to a commander of a unit or organization. A terse, forwardingcommand letter, dated 4 October 1944, emanating from the theater headquartersread simply: “It is desired that copies of the inclosed extract from areport of the Office of the Surgeon General be furnished to the commanders ofall organizations down to, and including, regiments and similarunits.’’
As the staff officer of the theater most directlyconcerned, it remained for the theater senior consultant in neuropsychiatry toobserve how the stated principles were being carried out, supervise theirimplementation where applicable, and recommend corrective action where indicated.Colonel Thompson visited the recreation center of the XIX Corps in November1944. The center used five small hotels located in Valkenburg, Netherlands.Together, they accommodated 300 enlisted men and 34 officers. Men came for 48hours of rest during which they were more or less on their own. Ampleopportunity for recreation as well as bathing and getting new clothes wereprovided. Nembutal (pentobarbital sodium) was administered the first night, ifimplicated, but, otherwise, no medical treatment was carried out. The centerwas under the control of line officers, but a medical officer was inattendance.
During this same visit to units of the Ninth U.S. Army,Colonel Thompson inspected the recreation center of the 30th Infantry Division,which was located in a large monastery in Kohlscheid, Germany, and could house1,000 to 1,200 men at one time. Soldiers came for 48-hour periods. At thisrate, it was estimated that combat troops could be rotated to this center every3 weeks. In fact, at the time of Colonel Thompson’s visit, the firstgroup to have visited the center had returned for its second visit. There werenot enough beds for all of them, and some men had to sleep on blankets on thefloor. In addition to a medical officer, there was a dentist, and the men hadan opportunity to talk to a chaplain, a finance officer, and a representativeof the judge advocate. The soldiers had a chance to bathe and get dry clothes.
50 Monthly Progress Report, Army Service Forces, War Department, 31 Aug. 1944, Section 7: Health. (Colonel Thompson was also aware of the benefits gained in World War I where divisions were relieved in turn from trench warfare.)
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A dance band played at each meal. The plan was similar tothose employed by other divisions in the XIX Corps.
These and similar visits, plus information from othersources, indicated a need for more common understanding of the principlesinvolved and a standardized program of rest for infantry divisions throughoutthe theater (fig.127). Accordingly, on 14 November 1944, Colonel Thompsonrecommended that command action be taken to implement such a standardizedprogram. Colonel Kimbrough recommended approval of the plan to General Hawley.But on this and numerous other occasions, any plan suggested, collidedimmediately with the objection that there was a serious shortage of manpower inthe combat areas. In his capacity as the preventive medicine officer of the12th Army Group, Col. Toni F. Whayne, MC, did everything possible, at hislevel, to arrange for units in that command to have some relief from the ardorsof constant combat. It was an uphill fight 51
Special Projects for Nonmedical Agencies
Behavior varies from “normal,”well-integrated adjustment at one pole to the disintegration of the psychoticat the other. It is a continuum which cannot be cut up into tight nosologicalgroups. Accordingly, it was impossible to draw a line which absolutelyseparated neuropsychiatric cases from the rest. A broad line of distinction hadto be arbitrarily drawn. The more obvious neuropsychiatric cases were funneledinto medical channels and came within the purview of the Medical Department,while agencies other than medical often invited the concern of the theatersenior consultant in neuropsychiatry in the more borderline cases. The types ofcases involved were in the nature of mental deficiency, inaptitude,instability, minor psychoneuroses, and pathologic personality types. Many ofthe patients manifested no noticeable organic or functional disorders butrequired medical consultation to eliminate this possiblity. Later, certaincombat-exhaustion cases were to fall into this borderline category also.
Replacement depots. - Replacement depots (latercalled reinforcement depots) in the European theater came under an organizationinitially known as the Ground Forces Replacement System. The surgeon of thiscommand was Lt. Col. (later Col.) George G. Durst, MC. In addition to receivingand assigning individuals as replacements, depots received and assigned allpersonnel who had been discharged from hospitals after assignment to adetachment of patients. It was this latter function that originally resulted inconferences between Colonel Thompson and Colonel Durst. Proper assignment ofneuropsychiatric patients following rehabilitation was a crucial factor intheir complete recovery. As time went on, there were needs for psychiatricservices at replacement depots arising from other sources, such as largenumbers of casuals who offered physical complaints in absence of demonstrableorganic disease, numerous dischargees arriving from disciplinary training
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51 See footnote 40, p.323.
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centers in the United States and from within the theater, and occasional problems of maladjustment in cadre personnel.
There was no authorization for a neuropsychiatrist in the table of organization of a replacement depot. When the 33d Station Hospital was brought in to serve the 10th Replacement Depot in April 1943, an opportunity was presented to provide psychiatric service to that depot, and, although there was no specific position for a neuropsychiatrist on the staff of the station hospital, a neuropsychiatrist was assigned. Once assigned, he was placed on detached duty with the depot. Except for a short period when Capt. (later Maj.) Benjamin Cohen, MC, was actually assigned to the 10th Replacement Depot, this system of placing officers on detached and/or temporary
duty with the depot had to be resorted to. By August 1944, it was necessaryto have two full-time neuropsychiatrists attached to this depot from the 3l2thStation Hospital. Thus reduced the effective medical strength of the hospital,but there was no other satisfactory expedient.
When the Ground Forces Reinforcement Command wasestablished on the Continent, the 19th Reinforcement Depot was activated atEtampes, France, with functions similar to the 10th Reinforcement Depot in theUnited Kingdom. Other depots were also established, but the 19th ReinforcementDepot was the key installation in receiving rehabilitated patients forreassignment to noncombat duties. Here again, an officer had to be provided ontemporary duty from the 130th General Hospital. On 19 November 1944, wholediscussing with Colonel Durst the reassignment of patients who were being sentback to duty by the 130th General Hospital, Colonel Thompson promised thatCaptain Cohen--then assigned to that hospital--would be placed on detachedservice at the l9th Reinforcement Depot to initiate and superviseneuropsychiatric consultation services, but it was not until March 1945 that hecould be released and reassigned to this duty.
With a small number of neuropsychiatrists borrowed fromhospitals, a great deal was done in the replacement depots toward insuring thesupply of only mentally and emotionally qualified soldiers to combat duties,making the maximum use for noncombat duties of soldiers who were unstable,rehabilitating soldiers who were still capable of improvement, and eliminatingfrom military service soldiers who were grossly unfit. The relationshipsestablished in this way with the replacement system also helped solve problemsof primary concern to the theater senior consultant in neuropsychiatry, as willbe noted in what follows.
While Colonel Thompson was on temporary duty in theUnited States, he attended the first conference of psychiatrists in charge ofconsultation services at replacement training centers in the Zone of Interior.He learned that there were 33 such centers with consultation services,including, in addition to the psychiatrist, clinical psychologists andpsychiatric social workers. At the time Colonel Thompson returned to theEuropean theater, manpower shortages in combat units were becoming acute. A planwas under way to take thousands of soldiers from Communications Zone units andtrain them in
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four replacement depots for assignment to combat duties. In addition,another depot was to be designated as an officer candidate school. In manyrespects, the situation was similar to that of replacement training centers inthe United States. Colonel Thompson reasoned that an organized consultationservice would be most appropriate and recommended that a service modeled afterthose in the United States be established. The Ground Forces ReinforcementCommand also requested similar services. General Hawley did not concur in therecommendations and request. He interpreted such work to be concerned withbasic training and stated that a theater of operations was no plate to embarkon basic training.
Disciplinary centers. - Information had come toColonel Thompson from the British, from the experiences of Captain Hanson inNorthern Ireland, and other sources neuropsychiatric services might be requiredin detention centers. On 5 February 1943, at a conference of the ChiefSurgeon’s Consultant Committee, Colonel Thompson expressed the need forstudy of this subject, which aroused the immediate concern of General Hawley.General Hawley quoted statistics indicating that less than 1 percent of offenderswere restored to full duty from disciplinary barracks and that only a very lowpercent age of these ever made good afterwards. He said the staff should keepin mind the possibility of detailing a man permanently on the staff of thedisciplinary center for the purpose of studying offenders, should the work growin sufficient proportions to warrant it. In reply to a question by GeneralHawley, Colonel Thompson said there was an officer available in the theater whohad knowledge and experience in the field of criminal behavior.
Again the problem lay in the lack of a mechanism by whicha psychiatrist could be assigned and again it was solved by placingneuropsychiatrists on temporary duty with disciplinary centers from a medicalinstallation to which they had been assigned for this purpose. The firstincumbent was obtained from the 36th Station Hospital and placed on duty withDisciplinary Training Center Number 1 at Shepton Mallet, England. Theseofficers had to be selected with great care because General Hawley insistedthat the neuropsychiatrists assigned had to be of the highest order.“Those people [the neuropsychiatrists] have got to be prettysolid,” he maintained. “or they [disciplinary center personnel]won’t car whether they have any psychiatrist or not.” 52
By the end of 1944, stockades of various base sectionshad grown in number as well as in census, and stockades at replacement depotswere equally well populated. Neuropsychiatric service had been well accepted bydisciplinary training centers. The increase in malefactors also resulted inrequests for additional neuropsychiatrists to help in disciplinary,rehabilitation training. It was no longer feasible, however, to continue deprivinghospitals of trained neuyropsychiatrists for this duty. In January 1945, it wasnecessary to confer with the Office of the Provost Marshal, Headquarters,ETOUSA, and submit
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52 Minutes, Chief Surgeon’s Consultant Committee meeting, 30April 1943.
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recommendations for permanent modifications of time table of organization ofa disciplinary training center to provide for neuropsychiatry personnel. Therecommended changes were approved. Qualified psychiatrists were found to fillthe newly created positions.
Although results at these centers were not gratifying interms of men returned to useful duty, the work of the neuropsychiatricpersonnel was of considerable value to the theater and the Army as a whole inmany ways. Case records were worked up on all individuals, and expert opinionwas provided in medicolegal aspects of disciplinary procedures, thus assuringjustice to the individual prisoner and broadening the scope of militarycorrective measures. Special studies developed techniques in dealing with the militaryoffender and uncovered personality factors that could help identify his type inthe unit or at an induction center.
Special training units. - In early 1944, it wasrealized in the ETO that special training units would be needed so that maximumuse could be made of marginal soldiers who couldn’t adapt to nominalmilitary assignments and yet were not sufficiently mentally ill to be admittedto medical treatment facilities. It was hoped that considerable numbers ofphysically fit men could be put to gainful use who were otherwise seriousliabilities to the military effort. Thus, the project for recouping this lostmanpower involved the establishment of a recovery center. On 20 February 1944,Colonel Thompson explained the project to Colonel Menninger, as follows:
We are just about to openanother activity called the recovery center. This will be under line officers,and the trainees will be those in whom no definite mental disorder exists, butwho manifest poor adjustment through incorrigibility, repeated physicalcomplaints without demonstrable basis, and unwillingness to work, or inaptitudefor any special work. The object is to fit these men, through special militarytraining, for assignment to labor units or similar organizations in this theater.All soldiers going to the recovery center will be screened through the 312thStation Hospital (N.P.).
On 6 February 1944, Colonel Thompson was summoned toGeneral Hawley’s office and conferred with his executive officer, ColonelDoan, on correspondence proposing the establishment cut of the recovery center.On 9 February, Colonel Thompson accompanied Colonel Spruit to Headquarters,Western Base Section, ETOUSA, where they conferred with the Surgeon, WesternBase Section and inspected the proposed site at Havdock Camp, approximately 20miles from Liverpool. This camp had a capacity for 250 to 300 men withsufficient room for expansion by tentage. The Western Base Section surgeonexpressed a strong desire to have a full-time medical officer and some enlistedpersonnel on the table of organization of the center because a dispensary wasobviously needed. It had been previously agreed that no psychiatric personnelwould be required. Conferring later in the day with G-1 (personnel andadministration) of Western Base Section, it was discovered that no cadrepersonnel had been selected pending receipt of definite word from Headquarters,ETOUSA, to go ahead with the project. The conferees agreed that it would bedesirable to have on the staff of the recovery center
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one or more line officers who had been incapacitated from frontline service in the North African theater.
The question of whether trainees should be screened by psychiatric personimel before assignment to the recovery center was raised. Plans called for all trainees to be screened by the neuroses center at the 312th Station Hospital before assignment to the recovery center. At the Chief Surgeon’s Consultant Committee meeting of 25 February 1944, Colonel Kimbrough, however, stated that he thought this procedure was very cautious and a little bit drastic. General Hawley replied that all psychiatrists in the theater had to be agreed on this screening for if they were all allowed to send individuals directly to the recovery center, there would be no reason to maintain the neuroses center at the 312th Station Hospital. But when the recovery center was established, the 96th General Hospital as well as the 312th Station Hospital was authorized to send patients directly to this center. Eventually, after invasion of the Continent when troops were deployed over a wide geographical area, all general hospitals were permitted to send patients directly to the recovery center.
Capt. (later Lt. Col.) Robert H. Sipes, Inf., wasdesignated commanding officer, and the center was officially established on 17March 1944 as the Services of Supply Recovery Center.53
Operations at the center proceeded smoothly. Psychiatricconsultation was available from a nearby hospital. Colonel Thompson wasrequired to do little but check periodically on the type of personnel beingsent there and advise on training programs. The one problem the centerencountered lay in the fact that it belonged to no particular service. Althoughthe recovery center was rehabilitating men, it did not come under theRehabilitation Division, Office of the Chief Surgeon, Headquarters, ETOUSA,because it was not desirable, psychologically, to have it associated with themedical service.
A year after the center was established, it had receiveda total of 1,278 men for training. Disposition had been made of 996 patients,of which all except 41 had returned to duty in the theater. Approximately halfof those returned to duty went to general assignments in combat units. TheGround Forces Reinforcement Command commented very favorably on the graduatesof the center. Colonel Thompson thought that the unit made good soldiers out ofthe majority of the trainees.54
Quartermaster work battalions. - The role andimportaimce of a consultant are sometimes not clearly defined when he is notconsulted or when his advice is not accepted in a matter that concerns him.Instances can be found in both civil and military administrations. The Europeantheater also provided an example.
In September 1944, over 4,500 enlisted men and officers,mostly combat-exhaustion patients, had been assigned to the detachment ofpatients of two general hospitals and subsequently detached to a Quartermasterwork battalion. The Quartermaster battalion had placed these men in companies
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53 General Orders 37, Western Base Section, Services of Supply,ETOUSA, 17 Mar. 1944, sec. II
54 See footnote 44, p.328.
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widely scattered over all of France, and the hospitals had no further control over them. Colonel Thompson was faced with the problem of screening these men and officers in order to make a decision on each case for definite assignment or rehospitalization.
The situation had its birth in the few weeks following D-day when there was no way to dispose of combat-exhaustion patients evacuated out of the First U.S. Army except to send them back to the United Kingdom. On 12 July 1944, Colonel Thompson had already conferred with Brig. Gen. (later Maj. Gen.) Albert W. Kenner, Chief Medical Officer, Supreme Headquarters, Allied Expeditionary Force, and the Surgeon, First U.S. Army, on the objection to letting neuropsychiatric patients ‘‘escape’’ to England. On the following day, plans had been made with the Chief of Staff, First U.S. Army, to establish at an early date a recovery center similar to the one in England to handle certain patients very carefully screened by the army’s exhaustion centers.
On 23 July 1944, in reply to a proposal thatcombat-exhaustion patients ‘‘escaping’’ from an army behandled in replacement depots for rehabilitation and training, Colonel Thompsonrecommended that such patients remain under medical (psychiatric) care andtreatment until a definite decision could be made as to return to combat,noncombat assignment, on further evacuation. He qualified his recommendationsby saying that this did not preclude establishment of special labor unitscomposed of graduates of recovery centers similar to that in the United Kingdomand reiterated that patients currently being sent there were not the ordinaryrun of exhaustion patients but incorrigible psychopaths and borderline mentaldefectives.
Meanwhile, unknown to the theater senior consultant inneuropsychiatry, the Commanding General, ADSEC, had been directed in nouncertain terms by a letter from theater headquarters, dated 26 July 1944, onhow to dispose of “cases of Battle Exhaustion not immediately returnableto combat but who no longer require medical treatment and supervision * * * .”The letter directed that such patients, still capable of some service andcertified by medical authorities as not being returnable to combat for at leastan extended period, should be assigned to a detachment of patients of aCommunications Zone hospital designated by the commanding general of ADSEC andshould be formed into units for hard labor.
In a cable to the War Department, permission was thenrequested to form such labor units over and above the theater troops basis. Thecable stated that the purpose was to provide a situation more strenuous thancombat in which pyschiatric casualties could be placed. The matter was referredto The Surgeon General who strongly opposed the plan because of its punitiveimplications. The War Department accepted The Surgeon General’sopposition to the measure and disapproved the request.55
Subsequently, in a memorandum to G-1, Headquarters,ETOUSA, dated 4 August 1944, General Hawley expressed his personal views oncombat ex-
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55 Menninger, William C.: Psychiatry in a Troubled World. New York:The MacMillan Co., 1948, pp. 208-209.
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haustion. General Hawley maintained that psychoneurosis was a condition, not a disease, that its basic cause was insufficient courage, and that fear was its primary motivating factor. He ventured the opinion that if cowards were summarily executed, there would be no psychoneurosis. He singled out as the great administrative and medical problem that group of soldiers who just did not have sufficient courage to sustain themselves in battle. This group, General Hawley wrote, included those who with only very great difficulty could ever be restored to combat but who could still be salvaged for some useful service. General Hawley stated that he was unalterably opposed to returning this group of soldiers to duty in normal units, combat or service, because it would be ‘‘merely placing rotten apples in barrels of sound ones.’’ The milder cases more appropriately described by the term “combat exhaustion”--those who crack after months of acceptable combat service–“real psychoneuroses,’’ and the obviously psychotic, the General wrote, were being taken came of.
General Hawley suggested that, organized into special units under specially selected officers and noncommissioned officers and properly administered, some useful work could be had from the problem group. Such units, he contunued, “* * * should be worked hard. They should be quartered and fed under no better conditions than combat troops. There should be no attractive considerations to invite soldiers into such units.’’
The whole point of General Hawley’s memorandum wasthis. He asserted that this problem soldier would always exist in as long as hecould escape combat by recourse to psychoneurosis, that it was up to command toface this problem squarely and realistically, and that the alternativequestions facing the command were: Should this group of problem soldiers bemade use of or should they be discharged from the service to be replaced withnew drafts upon the population?
Over one thousand patients that had accumulated in theexhaustion centers of the First U.S. Army were received at the 5th GeneralHospital when it opened on the Continent on 1 August 1944. Within 3 or 4 days,1,360 neuropsychiatric patients were turned over to the 90th QuartermasterBattalion. They were screened in 2 days by a group of 9 neuropsychiatristsdrawn from staging general hospitals, and only 21 patients were hospitalizedfor further treatment. By mid-August, over two thousand patients had been turnedover to the 90th Quartermaster Battalion while still assigned to the detachmentof patients, 5th General Hospital. In late August, administrative control ofthe labor companies to which these patients had been sent was transferred tothe 96th Quartermaster Battalion, and subsequent assignment of incomingpatients was to the detachment of patients, 19th General Hospital. By the endof August, the number of patients so detached and dispatched to work units hadreached over 4,500.
With the understanding that the 130th General Hospital(p.333) was to open on the Continent on 1 September 1944, Colonel Thompson hadrecommended on 14 August 1944 that prevailing practices be allowed to continue,provided patients were sent to the 90th Quartermaster Battalion only after
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proper sorting at army neuropsychiatric units, the 77th Evacuation Hospital, or general hospitals. He further recommended that screening by psychiatrists continue at the 90th Quartermaster Battalion and that plans be made for a more definite assignment of patients placed in service work units.
Following up his recommendations, Colonel Thompson initiated plans for the screening and disposition of these patients in conjunction with the Hospitalization Division, Office of the Chief Surgeon, Headquarters, ETOUSA, and Colonel Durst of Ground Forces Reinforcement Command. A list of neuropsychiatrists to perform the screening was submitted on 6 September 1944, Captain Cohen was initially placed in charge.
Meanwhile, the Commanding Officer, 96th QuartermasterBattalion, had requested that a study be made of the condition of his men, andMaj. Roy L. Swank, MC, neuropsychiatrist of the 5th General Hospital, made alongitudinal study of 3 companies over a period of 3 weeks and conducted across-sectional, spot-check study of 13 companies comprising 3,000 men during 1week. The study revealed that many of these men still had handicappingsymptoms, many were growing more concerned about their condition, and in quitea few instances they had been curbed and held under more strict regulationsthan others doing similar work.
The screening procedure ran into the same sort ofproblems that beset setting up the l3Oth General Hospital. Almost no screeningwas done during September. Colonel Thompson conferred on 5 October 1944 withColonel Durst, Maj. (later Lt. Col.) William H. Barnard, MC, of theHospitalization Division, and Captain Cohen. He added five moreneuropsychiatrists to the screening team at the l9th General Hospital. MajorBarnard and Colonel Thompson visited the hospital on 13 October 1944 to workout more details as to the reassignment of men attached to the Quartermasterbattalion and found that only two neuropsychiatrists had arrived and just 208men had been screened. The next day, Colonel Thompson checked on thewhereabouts of the psychiatrists ordered to the l9th General Hospital andplaced four more on the list. On 17 October 1944, Colonel Thompson againvisited the hospital, this time with Colonel Menninger, who was visiting thetheater. Six psychiatrists were present, of whom three were recent arrivals.Over 800 patients had been screened, but it was discovered that most of thesewere recent arrivals at the l9th General Hospital from other hospitals ratherthan patients with the 90th and 96th Quartermaster Battalions. Word had alsojust been received that the only noncombat assignment open to those going backto duty would be as prisoner-of-war guards and military police, Colonel Dursthad to be called upon to rectify this situation.
On 1 November 1944, approximately half of the men hadbeen screened, but the process was absolutely at a standstill because NormandyBase Section had not found transportation to get approximately 2,000 men to thehospital. Nine psychiatrists were present at this time, and their need inhospitals from which they had been withdrawn was becoming critical. Moreover, halfof the patients screened had to be hospitalized. That afternoon ColonelThompson
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met with representatives of the Hospitalization Division and the Deputy Chief Surgeon, ETOUSA, and urged that the screening be expedited. It was apparent that the screening was not getting the command support it required. Colonel Thompson voiced the opinion that the Medical Department was shirking its responsibility for providing adequate treatment. Following the conference, Colonel Thompson submitted a memorandum to Colonel Kimbrough on 1 November 1944 reviewing the situation from its beginning and including recommendations and statements made in the conference.
On 3 November 1944, a letter from the theater commander directing the Commanding General, Normandy Base Section, to expedite the screening process at the 19th General Hospital was brought to Colonel Thompson’s attention. But one week later, he discovered that patients were still not being sent in from Normandy Base Section. During the remainder of the month, however, patients began arriving at the rate of some 200 per day, and the screening for all intents and purposes was completed as of the end of November. Isolated groups remained unscreened until V-E Day.
The conclusions of the examining board of psychiatrists thatconducted the screening was that these men were not significantly helped by 1to 3 months of noncombatant work therapy. Of 4,588 enlisted men examined, 2,503(55 percent) required hospitalization. Of 51 officers examined, 47 (91 percent)required hospitalization.56
A later sampling of the hospitalized group covering 467patients revealed that 41.8 percent were boarded to the Zone of Interior. Ifthis rate was reliable, the total return-to-duty rate of those who had been inthe Quartermaster battalions would still be less than 60 percent . A stilllater followup study of 1,000 cases--500 hospitalized and 500 returned to dutydirectly-- indicated that some 80 percent of the total 1,000 were on duty inthe theater.
At the same time (October 1944), the 312th StationHospital in England with its mental rehabilitation work had returned 89 percentto duty, and, significantly, the patients reaching the 312th Station Hospitalwere those who had gone through unsuccessful attempts at rehabilitation in allsubordinate echelons of the evacuation chain for neuropsychiatric casualties.
Following his visit to the European theater, ColonelMenninger commented on the method of handling these cases, as follows:
Many of these had hadinadequate treatment, having come directly from Exhaustion Centers. Despitethis fact, it was reported that these men assigned to work in ordnance jobs,stretcher bearers in hospitals, and elsewhere had made excellent records. Asuperficial survey, however, indicated that many were noticeably maladjustedand this fact, plus the irregular method of carrying them as patients from the19th General Hospital, made it necessary to develop a different plan.
In evaluating the results of the practice, he mentionedthe fact that, in such patients with inadequate treatment, ‘‘* * *their guilt reaction, their feelings of inadequacy and the atmosphere ofimpersonalness at replacement
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56 Letter, Board of Psychiatrists, 19th General hospital, to ChiefSurgeon, ETOUSA, 26 Nov. 1944, subject: Report on the Mental Status of“Combat Exhaustion” Personnel Attached to the 90th and 96thQuartermaster Battalions.
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depots can all combine to continue and increase the neurotic disability andthus convert transient neuroses into permanent, pension-seeking chronicneuroses.”57
The fact remains, nevertheless, that some of GeneralHawley’s statements were borne out by the experiment as reported by theboard of psychiatrists who conducted the screening. The more seriously illmembers of the companies tended to ‘‘re-infect’’ theothers, thus handicapping the improvement of the less ill. There was aconsiderable number of ‘‘repeaters’’--men who weretreated with apparent success in a forward medical echelon, returned to combat,and then relapsed after a very short period of time and had to be evacuated asecond or third time. Finally, as General Hawley had predicted, there could beno doubt that this extra manpower provided considerable help during a mostcritical time in gaining the initiative on the Continent.
Neuropsychiatric Education andTraining
Education and training were always continuingrequirements in all aspects of medical activities in the European theater. Anextensive program was especially needed in the field of neuropsychiatry becauseof marked differences between practice in an oversea military theater andcivilian practice. Very few indeed were the officers in the theater who, at thetime of Colonel Thompson’s arrival, possessed military experience in thisspecialty. Those who followed were in many cases equally inexperienced, as wereancillary personnel–nurses, social workers, clinical psychologists, andattendants. The vast differences in civilian training and experience alsonecessitated a training and indoctrination scheme to establish order andunderstanding; otherwise, chaos would have resulted had each been allowed topractice in his own way.
In 1942, U.S. Army medical officers were being sent to aBritish Army training center for neuropsychiatrists at Northfield, one of twoinstallations where neurotics from the British Army were being rehabilitatedfor useful duty. The course was an excellent one. However, it was believed thatthere would be distinct advantages in having a school maintained by and for theU.S. Army. First of all, the course at Northfield lasted 3 months, whichColonel Thompson thought too long. Furthermore, after completing the Britishcourse, the trainee still had much to learn about methods and procedures used inthe U.S. Army. When one considered the fact that there had been more than 250neuropsychiatrists with the American Expeditionary Forces in November 1918, itwas an obvious impossibility to ask the British to train that many or more U.S.Army officers who would make up the full force in Europe in the days to come.
The U.S. Army had established the Medical Field ServiceSchool at Shrivenham, England, and there was a similar school operated by theEighth Air Force. All training for medical elements was controlled andsupervised
57 Letter, Col. W. C. Menninger, MC, Director, NeuropsychiatryConsultants Division, Office of the Surgeon General, to The Surgeon General,U.S. Army, 13 Nov. 1944, subject: Report of Visit of Colonel William C. Menninger,MC, to Installations in the European Theater of Operations, 7 Sept. to 24 Oct.1944.
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by the Operations and Training Division, Office of the Chief Surgeon,Headquarters, ETOUSA, although the Army Air Forces school was relativelyindependent. However, a course in neuropsychiatry would not be opened at theMedical Field Service School because of the lack of qualified instructors andlack of case work. When the 36th Station Hospital arrived in England, thefacilities and personnel to operate a school of neuropsychiatry becameavailable. After preliminary discussions with the hospital’s commandingofficer, Colonel Parsons, a memorandum was submitted by Colonel Thompson on 25January 1943, proposing the opening of such a school at this hospital. Theproposal was favorably considered and detailed plans were pursued to open theschool.
In agreement with Colonel Parsons, Maj. (later Lt. Col.)Jackson M. Thomas, MC (fig.113), 36th Station Hospital, was selected to takecharge of the school. Major Thomas was a well-qualified psychiatrist, adiplomat of The American Board of Neurology and Psychiatry, and an associate inpsychiatry at the Harvard School of Medicine, Boston, Mass. Others on thehospital staff were also well qualified to instruct in particular fields.
From the start, it was the aim of the school to make theinstruction as objective and practical as possible. In short, the courses weredesigned to meet the needs of the theater. The teaching procedure wasexplanation, demonstration, application, and examination. There were lectures,clinical conferences, and ward application under supervision of the clinicalstaff of the hospital. Later, demonstration teams were organized with personnelof the hospital taking roles in depicting battlefield neuropsychiatry inaction.
Every opportunity was eagerly grasped to bring those with firsthand experience to the school so that students could hear directly about conditions under varying types of combat and with different types of troops. Officers returned from North Africa and other Mediterranean areas, either by rotation or as casualties, supplied this type of information, and reports from the consultant in neuropsychiatry in the North African theater provided excellent detail. British neuropsychiatrists, both civilian and military, aided materially.
Before the actual opening of classes, however, manydetails had to he ironed out. Complete courses of study had to be presented forapproval to the Training Division, Office of the Chief Surgeon, Headquarters,ETOUSA. There was a lack of teaching aids, texts, and reference material.Because of the limited number of neuropsychiatrists in the theater, ColonelThompson often had to make arrangements personally with commanding officers ofprospective trainees for their attendance. This sometimes involved shiftingneuropsychiatrists. temporarily, to cover vacancies resulting from anofficer’s being detached to the school. The school finally opened inApril 1943, the first medical specialist school to be opened in the Europeantheater.
The first course was for 13 neuropsychiatrists fromgeneral, station, and evacuation hospitals to satisfy the immediate needs ofthe theater, and it lasted throughout April 1943.
At the 30 April 1943 meeting of the Chief Surgeon’sConsultant Committee, Colonel Middleton informed the conferees that the firstcourse had been
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completed and that 10 nurses and 9 enlisted men from general and station hospitals had been enrolled for a course to take place during May 1943. He also reported that Colonel Thompson planned to give four courses in June consisting of 5 1/2 days each for medical officers from field units. There were to be 10 medical officers in each course. In addition, neuropsychiatrists from hospital staffs were to be sent to field medical units for a period of 2 weeks in order to gain experience and learn about life in a line unit.
General Hawley commented, as follows:
I follow with a great deal of interest the training of thegeneral medical officer and battalion surgeon in psychiatry. I hope he can begiven something helpful and a little knowledge won’t become a dangerousthing if we don’t give him the idea that he is an expert psychiatristafter a week. I think it is correct to check the scope of the instruction given* * *. I think a great deal can be done in courses like this--not attempting togo very deeply into the subject * * * give him some very practical suggestions.I think the assignment of the officers at the 3d Station Hospital in the fieldis a splendid idea. It will give them very much background. I think it mightwell be extended to other people in the hospitals. The people in the hospitalslike to know how people in the field are getting along.
All the courses that had been initiated were continued, as needed, until the end of July 1943. At about this time, a majority of the neuropsychiatnsts in hospitals had attended the school, and commanders of hospitals arriving in the theater found it difficult to release their neuropsychiatrists for 30 days so soon following their arrival. The combat units also had to curtail sending medical officers to the short courses, and two groups of flight surgeons had been instructed in their stead. Consequently, only one 2-week course for hospital enlisted men was given during August 1943. The time had come for a reexamination of the educational and training needs.
In the meantime, however, Col. Roy D. Halloran, MC,Chief, Neuropsychiatry Division, Office of the Surgeon General, U.S. Army, hadwritten on 1 June 1943 to inform Colonel Thompson of the school ofneuropsychiatry that had been established at Lawson General Hospital, Atlanta,Ga., under the direction of Col. William C. Porter, MC, assisted by Lt. Col(later Col) M. Ralph Kaufman, MC. Sometime later, Colonel Halloran wrotesuggesting that it would be a good idea to have some neuropsychiatrists with experiencein combat or in observing and treating combat neuropsychiatric casualtiesrelate their experiences at the school. Colonel Thompson agreed that it was asplendid idea but expressed his apprehension over losing permanently anyexperienced officers.
Then, on 20 August 1943, Colonel Halloran wrote toColonel Thompson as follows:
We are losing theexecutive officer of the school of military neuropsychiatry and chief assistantto Col. Porter, the Director. Lt. Col. Kaufman is being assigned to foreignduty and therefore, we find it necessary to locate someone who can teachmilitary neuropsychiatry from the dynamic standpoint. I am wondering whether wecould borrow the services of Major Jackson Thomas, whom you have been using inthis connection in your area. Naturally we would replace him with aneuropsychiatrist who could be used in a similar capacity. I have in mind MajorHoward Fabing, who is an excellent neurologist as well
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as psychiatrist and has been assistant toJohn Romano at the University of Cincinnati. In fact, he was formerly with theCincinnati Unit and is now chief of a section in one of our large stationhospitals. He is very anxious to come to your area. Perhaps some such exchangeat this time would prove mutually beneficial.
As you may understand, weare attempting to indoctrinate the large number of neuropsychiatrists that wehave on duty at the hospitals of the Ground Forces and Air Forces and adapttheir civilian talents to military problems. We feel it would be valuable if wecould have the services of someone who has been familiar with the activeproblems in a theater of operations. If you are unable to send Jackson Thomas,perhaps you could pick someone else who has teaching experience and whoseinstruction would be considered fundamentally sound.
The next letter, dated 14 September 1943, received byColonel Thompson from Colonel Halloran, stated: ‘‘I have heardindirectly that Maj. Jackson Thomas is to come to us for the purpose ofteaching at the School of Military Neuropsychiatry, which is to be moved to anew unit in New York so that advantage may be taken of study of casualtiesnewly returned from the various theaters.’’ The letter confirmed thefact that Maj. (later Lt. Col.) Howard D. Fabing, MC, was being sent and addedthat Major Fabing had experience from service in World War I, had a wideacquaintance in England, and was very anxious to serve the European theater.‘‘I believe that he will make an excellent teacher and coordinator,especially along the lines of organic neurology,’’ concluded theletter.
As a direct result of losing Major Thomas, formalinstruction at the school of neuropsychiatry remained suspended until MajorFabing arrived in November 1943. Throughout this whole period beginning in late1942, General Hawley continued to stress the need for training general medicalofficers in field units and the indoctrination of their line officers as well.It was during this largely unavoidable lull in formal educational and trainingactivities that the talents of Colonel Parsons were directed to theindoctrination of line officers, as described elsewhere. In cooperation withthe Surgeon, V Corps, a temporary measure was adopted to continue the trainingof general medical officers from line units. Major Kelley was obtained from the30th General Hospital and conducted a 1-week course using the facilities ofthree hospitals. Psychotics were seen at the 36th Station Hospital, combatneuropsychiatric casualties from North Africa were used in instruction atanother hospital, and neuropsychiatric patients who had been“combed’’ out of divisions were available at the third.
By the time Major Fabing arrived in the theater, a majorchange in the hospitalization of neuropsychiatric patients was being completed.The 36th Station Hospital was being reserved for psychotic patients whileneurotic patients and most of the staff of the 36th Station Hospital, as well,were being sent to the newly created 312th Station Hospital. This change alsonecessitated a relocation of the school of neuropsychiatry. Definite plans hadbeen announced to commence immediately extensive and concentrated training ofmedical officers in line units and mobile hospitals, but instructions had to beassumed to suspend sending trainees to the school until the new facilities were
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ready. Colonel Middleton and Colonel Thompson both gave considerablepersonal attention to helping Major Fabing and the 312th Station Hospitalprepare to resume instructional activities. Consideration now had to be givenalso to division psychiatrists. These had just recently been authorized by theWar Department. Their training was a matter of prime concern since many of themwere capable, general medical officers who had been picked for the position butwho had no real experience in neuropsychiatry.
As a year of constant buildup with its attendant problemsdrew to a close, on 28 December 1943 at the Chief Surgeon’s ConsultantCommittee meeting, General Hawley again expressed his concern and interest inthe educational program, asking particularly about the indoctrination of combatdoctors in combating battle neuroses, ‘‘It got off to a splendidstart,’’ he said. “What is its present state?’’Colonel Kimbrough and Colonel Thompson were both able to inform him that theindoctrination of medical officers in line units from the battalion level andabove and the training of division psychiatrists was to start momently. GeneralHawley said the program should be pushed.
And pushed the program was. The total effort was directedat personnel in line units and evacuation hospitals. Under the direction ofMajor Fabing, 700 general medical officers received the special 1-week coursein neuropsychiatric fist aid from 27 December 1943 to 15 July 1944. The ChiefSurgeon’s Operations and Training Division reported that, by the timeD-day arrived, practically all medical officers in combat units who would comein contact with battle casualties had been through this course. During the sameperiod--from the reopening of instruction at the 312th Station Hospital toD-day--40 evacuation hospital neuropsychiatrists, 80 evacuation hospitalnurses, and 160 evacuation hospital and clearing company enlisted men weretrained in courses specially designed for them. In addition, Major Lemkau, ofthe staff of the 3l2th Station Hospital, trained 15 division neuropsychiatristsin January and February 1944 at the school of neuropsychiatry.
While this program was going on at the school, personnelof general and station hospitals were not entirely neglected. As new hospitalunits arrived in the theater or were created, neuropsychiatric personnel weregiven the opportunity to spent 2 weeks at hospitals specializing in neuropsychiatryfor on-time-job training under experienced officers, nurses, and enlisted men.
On 7 July 1944, about a month after D-day, ColonelThompson wrote to Dr. Edward A. Strecker (fig.128), who had visited the theatershortly before, that all the invasion plans for handling neuropsychiatriccasualties had worked out satisfactorily and casualty rates were lower thananticipated. “I cannot but feel,” said Colonel Thompson,“that part of this is due to our education of the officers, and division medicalofficers.”
When Colonel Thompson was able to visit more units incombat at a later date, many officers expressed gratitude for theindoctrination they had been given. Comments made in a letter, dated 2 March1945, from the division neuropsychiatrist of the 69th Infantry Division toColonel Menninger illustrate well the sentiments of many. He wrote:
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I am sending herewith the material used in lectures on Combat Exhaustion. We are indebted to the 312th for an excellent course and this material was reproduced. Since writing I obtained their film on Combat Exhaustion and showed it to all NCO’s and officers in the 369th Med Bn as well as most O’s in the detachments.
We have been in combatsince the 10th [February and the indoctrination is paying dividends.
The film on combat exhaustion mentioned in the paragraphquoted was produced at the 312th Station Hospital in conjunction with the ArmyPictorial Service of the Signal Corps. It showed the work being done there, thespecific treatment given, the work of the mental-rehabilitation unit, and theteaching being given in the school of neuropsychiatry. There were somedifficulties with the scenario and production of the film because of its rangeand scope. The film, which was in scenario in March 1944, was completed in theautumn of that year and was first shown publicly at the Empire Theater forpersonnel in General Hawley’s office on 20 November 1944 with a runningtime of 1 hour. Later, copies of the film were distributed throughout the Armyby Signal Corps film libraries. Copies were presented to the British, who hadpreviously provided the U.S. Army with a generous number of prints of theirfilm on combat neuroses.
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Colonel Thompson lectured to almost all classes of medical officers going through the Medical Field Service School at Shrivenham. He frequently held clinics, ward rounds, and lectures at individual hospital installations, Professional meetings of medical officers of the Allied forces also presented educational opportunities.
In the waning stages of the war and the period immediately following the cessation of hostilities, the theater senior consultant arranged for participation by neuropsychiatrists in the broad educational program that was set up in the European theater. The general scope and intent of this program were described by Colonel Middleton (p.253). A school of neuropsychiatry was reestablished at the 191st General Hospital, Paris, France, to give a comprehensive review of neurology and psychiatry while paying considerable attention to recent developments in general medicine. More advanced refresher courses were arranged for U.S. Army officers at teaching centers and hospitals in England, but redeployment was so rapid that full advantage could not be taken of the opportunities that were richly provided.
Visits in the Field
Although Colonel Thompson had to devote a tremendousamount of his time and energy to staff work at the theater headquarters, hestill found or made time to visit units and installations in the field. Therewas more than enough to occupy him at theater headquarters alone. In addition,there were the obligations of liaison with representatives of the other Alliedforces, participation in projects sponsored jointly with British civil and militarymedical authorities, and the amenities in communication with these. But tosacrifice visits and inspections in the field to these other activities wouldhave meant reciprocal loss in consultant effectiveness. Regardless of thethoroughness of plans, the clarity of announced policies, or the accumulationof large amounts of data, the proof of their worth could be measured only interms of their application in the field. The feedback from visits to the fieldwas the servomechanism that directed the proper course of neuropsychiatricactivities in the theater.
In broad terms, these visits to the field could bedivided into two types, special and routine. Special visits were necessitatedor suggested by some specific problem or activity. These included such mattersas requested consultations, the solution of local personnel problems,inspection of hospital construction or modification, meeting advance parties ofunits due to arrive in the theater, and accompanying visitors to the theater ontours of installations.
The routine visits--although they could hardly be calledroutine in the sense that no two visits were exactly alike--were for the mostpart undertaken to see what was being done, to make corrections on the spot ifnecessary, and, generally, to get the consultant’s feet on the ground.They helped him better to evaluate the capabilities and limitations ofpersonnel and facilities with respect to the care of neuropsychiatric patients.Bits of information obtained on visits to individual installations or unitseventually fitted together to show
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definite trends and patterns. On particular occasions, the observations made were so significant that he would ask for a special report on the situation from the installation or activity visited. These reports, with appropriate comments by Colonel Thompson, could then be brought to the attention of his superiors in the Chief Surgeon’s Office, as well as in the Office of the Surgeon General. Thus, he was enabled to keep General Hawley and his staff informed of significant events and problems in the field in a fully documented manner. Again, these routine visits to the field provided opportunity to answer questions and establish better rapport and understanding with those who were charged with actually carrying out the neuropsychiatric policies and procedures of the theater.
At least half of Colonel Thompson’s time was spent in these special or routine visits in the field.
Personnel Management
Personnel management problems were time consuming andrequired good judgment and diplomacy. Many of the problems were obvious butwere either impossible of immediate solution or were difficult to solve becausemany restrictions and concurrences were entailed. Very close liaison wasrequired with the Personnel Division, Office of the Chief Surgeon,Headquarters, ETOUSA. Colonel Middleton also maintained close supervision overpersonnel matters, and, because of their often delicate nature, his arbitrationwas required in cases of conflicting interests and to insure the best andproper use of all personnel specialized in fields that were his concern.
There was first and always the need to know the abilitiesand location of neuropsychiatric personnel in the theater. Much of thisinformation could only be obtained by personal interview and observation of theindividual’s work. One of the first things Colonel Thompson did upon hisarrival in the theater, however, was to obtain through Colonel Halloran thecomplete listing of psychiatrists and their qualifications as established bythe National Research Council. Although this list did not help him locateindividuals, it enabled him to pick out the qualifications of those he metpersonally or impersonally as names in correspondence crossing his desk.
In late 1942 and early 1943, there were many assignmentsof neuropsychiatrists. Some were brought to Colonel Thompson’s attentiondirectly from the individuals concerned by letter, word-of-mouth, or duringinspections, and many in letters from Colonel Halloran. As late as July 1944,when the Third U.S. Army was staging for movement to the Continent, suchassignments could be found. An acquaintance of Colonel Thompson’s, and aqualified neuropsychiatrist, was a general duty medical officer in an armoredmedical battalion. Colonel Thompson wrote to this officer, as follows:
I understand that yourunit is part of the Third Army and I am writing to Major Talkington, consultantin psychiatry for that army, so that he may make contact with you and seewhether you can be placed. I shall issue the usual challemuge to him that ifyou are not needed in the army set-up we have need for psychiatrists elsewhere,but I am sure that he will find a psychiatric assignment for you.
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A most important reason for knowing who the psychiatrists were, their qualifications, and their location was to be able to fill vacancies quickly without materially interrupting services. This last was no small task when one considers that, in spite of existing shortages in the theater and losses through normal attrition, personnel had to be found to fill the positions of evacuation hospital and division neuropsychiatrists as these positions were created and to fill vacancies in station and general hospitals arriving in the theater without their full complement.
Another problem in personnel management was that of promotions. First of all, tables of organization were often extremely inadequate or inequitable in the rank given neuropsychiatrists with excellent professional training or those who were required to handle a greater load than provided for in the tables of organization. Among the latter were neuropsychiatrists withdrawn from evacuation hospitals to man exhaustion centers. In the same category were those assigned to small hospitals for convenience and placed on duty with replacement centers, disciplinary barracks, and other temporary-duty assignments of considerable importance.
A solution, albeit not entirely satisfactory, to a problemof this nature was that attempted at the 36th Station Hospital.
With reference to K * * *‘s promotion, I am still wrangling with lesser lights. The situation isthis: We are organized under a Table of Organization which left no vacancieswhatever nor opportunities for promotion. Here I have progressed to the pointof getting higher authority to admit that our Table of Organization must be aseparate or a special T/O. Our bed capacity is considerably greater than wefigured in the States and the rank appropriate will go in. In addition, I amholding that men who are trained militarily and professionally proficient to bediplomats of the American Board should hold the grade of major. By thesedevious means I hope to get him up in the not too distant future. He is thenumber one man of the list but there are several others * * * Frankly there isno valid lieutenant in the outfit. None of the men are tyros. Keep your fingerscrossed while I make every possible move to squeeze these through.58
Two commitments made by the Office of the Surgeon Generalas to personnel were rewards of Colonel Thompson ‘s trip to the UnitedStates. It was agreed that a certain allotment of graduates from the schools ofneuropsychiatry in the Zone of Interior could be sent to the European theaterupon request. Additionally, Colonel Menninger promised, whenever possible, tomake known, by name, to Colonel Thompson the officers who were being placed inunits to be activated for assignment to the European theater.
Clinical psychologists. - A personnel problem ofsizable proportions arose. In early 1945 in the commissioning of clinicalpsychologists (fig.129). Enlisted clinical psychologists began arriving in theEuropean theater in September 1944 in hospitals coming direct from the Zone ofInterior. 0n 2 October 1944, War Department Circular No.392 was publishedannouncing provisions for the commissioning of these enlisted clinicalpsychologists. On 21 December 1944, a command letter was issued by the theaterheadquarters
58 Letter, Lt. Col. F. O. Parsons, MC, 36th Station Hospital, to Dr.Winfred Overholser, 27 Jan. 1943.
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promulgating provisions of the circular to all unit commanders. In January1945, applications began to trickle in and, in February, a great numberappeared.
At first, Colonel Lemkau, who was acting consultant inneuropsychiatry during Colonel Thompson’s temporary duty in the Zone ofInterior, and then Colonel Thompson began to interview each applicant. It wasalso proposed that the applicant be given a practical test as well as aninterview because personality was so important in this specialized type ofwork, and the manner in which he approached and dealt with patients wascritical.
At about this time, a letter was also received from Lt.Col. (later Col.) Morton A. Seidenfeld, AGD, chief clinical psychologist in theNeuropsychiatry Consultants Division, Office of the Surgeon General, pointingout certain complaints he had received from clinical psychologists in theEuropean theater as to their assignments and duties. As applications increasedin number, Major Kelley was appointed Consultant in Clinical Psychology,ETOUSA, and assigned to the office of the theater senior consultant inneuropsychiatry to work under his direction. Major Kelley was admirably suitedfor this assignment. In addition to being a well-qualified psychiatrist, he wasan associate member of the American Psychological Association and was theauthor of a text on the Rorschach method of personality testing by projectivetechniques.
In March 1945, Major Kelley made a thorough study of thework being done by clinical psychologists in hospitals on the Continent, and anumber of important facts were elicited. In some hospitals, the psychiatristsand clinical psychologists were cooperating well, the psychologist assistingthe psychiatrist
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in the work of the neuropsychiatric section. In more than a few hospitals, clinical psychologists were being employed outside the neuropsychiatric services. In these cases, the commanding officer and psychiatrist did not understand how to make proper use of the clinical psychologist. In most instances of this nature, it was found that the psychiatrist was totally unfamiliar with the usual duties of clinical psychologists and consequently had not properly employed them as full-time assistants.
Since it was obvious that many clinical psychologists were not being properly employed, steps had to be taken to correct the situation. As a rule, an explanation of their functions sufficed to convince the commanding officer of a hospital to reassign them to appropriate duties. Administrative Memorandom No. 17, Office of the Chief Surgeon, Headquarters, ETOUSA, was published on 17 March 1945, to outline the duties of the clinical psychologist. A brief article on the same topic was also published in the Medical Bulletin, Office of the Chief Surgeon, ETOUSA.
In addition, meetings attended by neuropsychiatrists andclinical psychologists were held on the Continent and in the United Kingdom byColonel Thompson, Major Kelley, and hospital center neuropsychiatricconsultants. At these meetings, attempts were made to reach a mutualunderstanding as to the functions of clinical psychologists and to place theresponsibility for their proper use on the shoulders of the hospitalneuropsychiatrists.
Finally, every clinical psychologist who submitted acomplaint that he was being improperly employed was personally interviewed byColonel Thompson or Major Kelley. The subject was also made a matter of inquiryin routine hospital visits by the theater senior consultant and hospital centerconsultants in neuropsychiatry. In almost all instances, satisfactoryadjustments were made.
A special function was evolved through coordination withthe Adjutant General’s Office, Headquarters, ETOUSA, in the use of a teammade up of clinical psychologists and enlisted helpers in screeninglimited-assignment personnel who were being discharged from hospitals. Individualclassification records (WD AGO Form 20) were brought up to date to show thenature of the patient’s limited-assignment requirements, andrecommendations were made as to his future assignments. The service wasextended to all categories of limited-assignment personnel. At one hospital, ateam made up of 1 psychologist and 2 assistants, during the period from 14March 1945 to 25 May 1945, completed qualification cards and recommendedassignments on all discharged patients--medical and surgical cases as well aspsychiatric. A total of 1,190 patients were interviewed, and a followup at thereplacement depot showed that, with only occasional exceptions, the assignmentrecommended by the psychologist was followed without change.
The work of clinical psychologists was severelyhandicapped by the lack of testing instruments, and efforts to obtain them metwith only limited success. Further plans for group meetings, education, andother activities of clinical psychologists had to be discontinued following V-EDay. In all, 608 applica-
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tions were processed by Colonel Thompson and his associates as of 30 June 1945. Of this number, 533 were rejected. The remaining 75 applications were forwarded to the War Department, which rejected an additional 33, approved 15 for commissioning, with decision still pending on the remaining 27.
Research
Colonel Thompson found it well-nigh impossible to conclude anycarefully controlled, rigidly organized, research projects in the strictestsense of the term ‘‘research.’’ Basic research with theclassic design of control and experimental groups was usually out of thequestion. Proposals for conducting some well-conceived projects of this naturehad to be rejected. On the other hand, certain studies had to be done in orderto gain information necessary for the intelligent studies had to be done inorder to gain information necessary for the intelligent carrying out of theconsultant’s mission. The reader should realize that the basic treatmentmethods that were taken up and used in the theater–narcotherapy, insulintherapy, electric shock therapy, diagnosis by electro-encephalogram–wereall, to a considerable extent, applied research at that time. (Fig.130)Actually, most of the research accomplished in the theater was of this sameapplied type. Since something had to be done, a course of action was selectedusing the best information available, and the results were assessed in any waypossible for the purpose of improving techniques. Another type of researchaccomplished in the field of neuropsychiatry was in the nature of statisticalor questionaire studies.
Blast syndrome. - One of the problems that defiedconclusive results was that which became known as ‘‘blastsyndrome.” The problem arose in the first weeks following D-day. On 15July 1944, Colonel Thompson described it in a memorandum to Colonel Kimbroughas follows:
The problem of how muchsymptomatology was due to organic disturbances produced by blast, and how muchwas due to emotional factors was brought up at almost every visited center.Practicalhy nine out of ten of the psychiatric patients gave a history ofhaving been near exploding shells, and they related this to the onset of theirsymptomatology, some saying that they were blown out of the foxholes by ashell. In many there was a statement that they could not remember what happenedfor a period of time. It appeared that there was a danger of attributing toomuch symptomatology to organic damage, and thereby reverting to the oldconception of ‘‘shell shock’’ of the last war. Thegeneral opinion was expressed that unless there was evidence of damage to thecentral nervous system, as shown by neurological signs or evidence of blast inother parts of the body, as shown by ruptured ear drums, hemoptysis, or othervisceral signs, the diagnosis of blast syndrome would not be made in forwardareas. Certain other differential points were discussed such as evaluation ofamnesia which in organic conditions is usually retrograde and cannot be fullyrecovered under Pentothal [Sodium] hypnosis. Further studies of this problemwill be carried out at hospitals at the base in cooperation with the seniorconsultant in neurosurgery.
When Colonel Thompson was at the Office of the SurgeonGeneral in early January 1945, the possibility of studying blast conditionswith electroencephalograms at the front was discussed. Colonel Thompsonsuggested to Lt. Col. William H. Everts, MC, Chief, Neurology Branch,Neuropsychiatry Consultants Division, Office of the Surgeon General, that twoelectroencephalographic
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FIGURE 131.-Maj. Howard D. Fabing, MC.
machines be provided for this work near the front. One would be used at aclearing station so that records could be started as soon as possible, and theother would be further back, perhaps at the 13Oth General Hospital, where dailyrecords could be continued.
In the meanwhile, Major Fabing (fig.131), who had beenthe director of the school of neuropsychiatry, was permitted to conduct his ownstudies on blast syndrome. He found that by using Pentothal Sodium (thiopentalsodium) hypnosis and appropriate sound effects, a patient who claimed to havebeen rendered unconscious for some time by a nearby explosion could regain hismemory for the entire period of ‘‘unconsciousness.’’When this experience had been relived in detail, an injection of 10 cc. ofCoramine (nikethamide) was given, and the patient was awake in less than aminute. Eventually, the patient was able to write his own account of theepisode. By this method, Major Fabing was able to return 90 percent of his 80cases to duty.
Ergotamine tartrate studies. - On 31 May 1944, TheSurgeon General forwarded to the Chief Surgeon, ETOUSA, two excerpts frompublications that dramatically told of the use of ergotamine tartrate as aremedy for ‘‘shell shock” and “battle reaction.”The letter concluded: “We do not have any experience whatever with theuse of this and know nothing further than what these articles state but you maywant to suggest their trial in the hands of some competent individual.”
After Colonel Thompson had written to him that ergotaminetartrate was being tried out in two hospitals, on 20 July 1944, ColonelMenninger wrote:
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We want to think of Ergotamine Tartrate as being on an investigative level at the present time. In other words, we want to be sure that it is very cautiously used and we want to get the results from its use in a few places as to its indications, main effects and side eflects, and results. We don’t propose to issue it except under your authority * * *
On 3 August 1944, Colonel Thompson wrote Colonel Menninger a brief résumé of what was being done with the drug.
We have been usingErgotamine Tartrate under control conditions at the 312th Station Hospital.This work is being done under Major Paul Lemkau. A return report on this shouldbe available before long. Major Lemkau believes that there is value in thedrug--that equally good results are obtained with the insulin and narcosistherapy. I should add that a group of 10 control patients in the same wardbenefitted almost as much on sugar capsules and all the nursing attention thatthe other patients received, so maybe it is the general atmosphere and the“total push’’ methods, are the important thing, and at anyrate it is difficult to judge the value of any type of therapy in such asetting.
Colonel Thompson forwarded the report on the use of thedrug to Colonel Menninger on 24 August 1944 with the following comment:
I am enclosing a copy ofan account of our experience with Ergotamine Tartrate as written up by themedical officers of the 312th Station Hospital who did the work. Furtherinvestigation along this line is being continued and at the present moment theyare attempting to combine this therapy with modified insulin so as to give thegain in weight which seems to be necessary. The use of this drug will beconfirmed to our three N.P. hospitals until we know more about it.
These studies were examples of the type of research thatcould not be carried on except in an active theater. The acute conditionsobserved in patients recently evacuated from battle were not to be found insufficient numbers in the United States.
Morale Service opinion survey technique. - On 27October 1943, Colonel Halloran wrote to Colonel Thompson introducing Dr. SamuelStauffer and Dr. Carl Hovland of the Morale Service, Army Service Forces.Colonel Halloran stated that these were men of outstanding ability who hadworked closely with the Office of the Surgeon General and that Dr. Stauffer wasone of the first to recognize that preventive psychiatry and morale wereactually the same subject and had been instrumental in establishing liaisonbetween the Morale Service and the Neuropsychiatric Branch of the SurgeonGeneral’s Office. Colonel Halloran added: ‘‘To my mind, theopinion survey technique for studying problems of human behavior has been adevelopment of major importance in this war. It offers perhaps the mostpromising approach of any to problems of military psychiatry. Dr. Stauffer andDr. Carl Hovland are highly skilled in the use of this technique and havealready conducted surveys of considerable value in this field.”
On 24 March 1944, Dr. Kimball Young, a personalrepresentative of Maj. Gen. Frederick H. Osborn, Chief, Information andEducation Division, War Department, visited Colonel Thompson to cement furtherclose working relationships between the medical and morale services.
From this beginning throughout the life of the theater,this close relationship was maintained. In a way, it could be said that theMorale Service
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(later known as Research Branch of information and Education) provided the means for conducting studies which the neuropsychiatrist wanted to have done but for which he had no facilities for accomplishing. Their reports were read with interest from the Chief Surgeon down to medical officers in the lowest echelons.
Even the facilities of this research organization were not able, however, to conduct a survey that was particularly desired by Colonel Menninger. A questionnaire had been used for a cross-section survey of troops in the United States with valuable and interesting results. Colonel Menninger wanted to have it applied to from 1,000 to 1,500 normal subjects who had 90 or more aggregate combat days on duty with an infantry battalion in order to determine how certain factors considered peculiar to neuropsychiatric patients appear in normal troops.59 After many conferences and preliminary studies, it was advised by higher officials in the Research Branch of Information and Education that it might not be worthwhile to start the study at that particular time (March 1945). It was agreed that it should be held up until there was absolute certainty that the study could be carried through to completion, either in the European theater or some other theater.
Other studies. - In addition to theforegoing, some significant followup studies were completed, requiring thecooperation of field units, the Ground Forces Reinforcement Command, and theInformation and Education Division. A particular cogent and interesting studywas that of approaching combat exhaustion on an epidemiologic basis. This studywas, to a certain extent, prompted by the fact that some individuals in thetheater thought there would be a sudden drop in neuropsychiatric casualtieswhen soldiers found they could be evacuated for cold injuries. Col. John E.Gordon, MC, Chief, Preventive Medicine Division, Office of the Chief Surgeon,Headquarters, ETOUSA, had amassed considerable data concerning the epidemiologyof trench foot, which could be readily related to neuropsychiatric incidencefor the same periods. Like data were available at subordinate commands. Thecompleted study showed a remarkable similarity of conditions attendant on coldinjury and neuropsychiatric breakdowns.
Supply
Supply personnel were able to handle problems ofprocurement, cataloging, storing, issuing, and the like to a certain point, butwhen a decision was required as to exactly what was needed, where it had to be,and in what amounts, the answer could only come from the using parties. So itwas that as early as October 1942, Colonel Thompson made recommendations forthe amount of sedative drugs required for every 10,000 men in combat. A laterstudy revealed a lack of certain items in installations where they would beneeded, and revised recommendations were submitted on 7 December 1942.Periodically thereafter, the Supply Division, Office of the Chief Surgeon,Headquarters, ETOUSA,
59 Letter, Col. L J. Thompson, to Col. O. N. Solbart, Chief, Special Services Division, ETOUSA, 11 Nov. 1944.
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would circulate lists of items to be stocked for confirmation by the respective consultants. Sometimes substitutions or deletions were suggested. For example, on 25 April 1944, the Supply Division suggested that Nembutal ( pentobarbital sodium) be substituted for Sodium Amytal (amobarbital sodium). Colonel Thompson had to disapprove the proposal on the basis that indications differed for the use of the two drugs, and Sodium Amytal was the drug of choice in many psychiatric conditions.
Throughout most of the life of the theater, electrical machines for shock therapy and for electroencephalography were in critically short supply. Initially, three electro-shock machines were borrowed from the British. In January 1943, Colonel Thompson discovered that the 5th General Hospital had had an electroencephalographic machine but was forced to leave it in the Zone of Interior owing to shipping priorities. It was alleged that lack of shipping space was also preventing the receipt of electric shock apparatus. When it was learned that funds were available at the 5th General Hospital for the purchase of an electroencephalographic machine, Colonel Thompson visited the Bruden Neurological Institute at Bristol, England, and was ultimately able to procure one British-made machine.
Colonel Thompson brought this situation ofshortages to Colonel Menninger’s attention by letter on 2 May 1944“ * * *because I thought that you might be helpful if the requests comethrough your office.” Colonel Thompson was astonished at the reply, dated10 May 1944, which read: “To my knowledge we haven’t had anyofficial request for such and you might check on that.” By July 1944, theSupply Division, Office of the Chief Surgeon, Headquarters, ETOUSA, hadinformed Colonel Thompson that a “fair number” of electric-shockmachines were on their way. It was not until Colonel Thompson returned from histemporary duty to the United States that a specialist inelectroencephalographic techniques and electric-shock treatment from theSurgeon General’s Office came to the theater and worked out details forsupplying such machines and requirements for the personnel to run them.Finally, an additional supply of electric-shock apparatus arrived from the Zoneof Interior in early 1945.
A request submitted by Colonel Thompson in March 1945 forpsychologic tests, answer sheets, and scoring keys also was largelyunfulfilled. As of the first of June 1945, the only materials that had arrivedwere Army General Classification Tests which were already in the theater; 50sets of Rorschach cards, which were procured directly from Switzerland; and 25sets of Thematic Apperception Test pictures. More important tests, such as theWechsler-Bellevue Intelligence Scale and the Minnesota Multiplasic PersonalityInventory, were not forthcoming. Those tests that were made available had to beprovided on a priority basis to units scheduled for redeployment to the Pacificarea.
Within the armies, neither the division psychiatrists norunits used as exhaustion centers had been provided the additional or specialequipment needed to cope with the number of neuropsychiatric casualtiesencountered.
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This was particularly true of the division psychiatrist. He required facilities capable of holding and curing for some 150 casualties, but tables of organization and equipment made no provision for this, and local arrangements had to be made to obtain the equipment. Such arrangements were best made where command surgeons and other staff officers had sympathetic understanding of the need for neuropsychiatric facilities. Colonel Thompson devoted much effort toward this end on his visits to the armies, corps, and divisions. Eventually, most division psychiatrists were routinely supplied with such essential medical items as reflex hammers and ophthalmoscopes. The only means of definitely solving these problems, however, was by new tables of organization and equipment on modifications of existing tables.
Professional Publications, Meetings, and Societies
Professional literature was always in demand,particularly by Colonel Thompson and the school. Through the courtesy of Dr. C.C. Burlingame, Colonel Thompson was able to obtain sufficient copies ofabstracts published by the Institute of Living, Hartford, Conn., for his useand for use in classes in neuropsychiatry. A request submitted to ColonelMenninger for reports made by the Morale Service and publications of the JosiahMacy, Jr., Foundation was equally productive. Eventually, provision was made byThe Surgeon General to supply all division psychiatrists with a full file ofreports published by the Morale Service entitled ‘‘What the SoldierThinks.” In addition, a basic set of reference texts was provided eachdivision psychiatrist. Many individual officers subscribed to variousprofessional journals. Some subordinate consultants in neuropsychiatry alsoprocured publications for their commands.
The Editorial Board, Office of the Chief Surgeon,Headquarters, ETOUSA, was established on 21 October 1944 by Office MemorandumNo. 23. Colonel Thompson was appointed as one of its members. The board wasrequired to review manuscripts of papers to be presented for publication or tobe read before a society which published such papers in its journal. As aresult, Colonel Thompson personally read, reviewed, and commented on the manypapers touching upon the subject of neuropsychiatry that were submitted to theboard. In conjunction with the Public Relations Officer, Office of the ChiefSurgeon, Headquarters, ETOUSA, Colonel Thompson was required to advise andcomment on stories by reporters in the theater on the subject ofneuropsychiatry.
Meetings of various societies and organizations providedopportunities to exchange information and meet coworkers. They created ageneral feeling of cooperation and good will among all those attending.
The theater senior consultant in neuropsychiatry andpsychiatrists in the field participated in the activities and meetings of allthe larger organizations, such as the Inter-Allied Conference on War Medicine,the European Theater American Medical Society, and the various base sectionmedical societies (fig 132) Papers concerning neuropsychiatry presented byColonel Thompson at
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FIGURE 32.-Col. Lloyd J. Thompson, MC, meetswith distinguished neuropsychiatric consultants at the Inter-Allied ConsultantsConference, 108th General Hospital, Paris, France,15 October 1944. Left to right, Col. Lloyd J. Thompson, MC, Chief ConsultantinNeuropsychiatry, ETOUSA; Lt Col. Roscoe W. Cavell, MC, Consultant inNeuropsychiatry, Ninth U.S. Army; Lt. Col. William E. Srodes, MC, Consultant inNeuropsychiatry, First U.S. Army; Maj Ellis Bonnell, MC,Neuropsychiatric Service, 108th General Hospital; Maj. Alfred O. Ludwig, MC,Consultant in Neuropsychiatry, Seventh U.S. Army; Col. William A. Menninger,MC, Consultant in Neuropsychiatry to The Surgeon General; and Lt. Col.Frederick R. Hanson, MC, Chief Consultant in Neuropsychiatry, MTOUSA.
On 13 February 1943, a meeting of the U.S. Armypsychiatrists was held at the Royal Society of Medicine in London. In additionto the needs of psychiatric sections of general hospitals and the SeniorConsultant in Neuropsychiatry, ETOUSA, there were present the ConsultingPsychiatrist for the Royal Canadian Army Medical Corps; a representative of theConsulting Psychiatrist of the Royal Army Medical Corps; the Chief Consultantin Medicine, ETOUSA; and the Commanding Officer, the 36th Station Hospital.Colonel Thompson presided, and each psychiatrist presented a paper on someaspect of psychiatric services in this theater.
The three British services - Army, Navy, and Air Force -along with the Canadian forces had an informal organization of psychiatristswhich met every
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60 See footnote 6, p. 258
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3 months. At first, Colonel Thompson was the only U.S. Army representative at its gatherings, but, in November 1943, all U.S. Army and Navy neuropsychiatrists were invited to join, and the organization became essentially a psychiatric association of the Allied Armies in Europe. Its meetings, which were commonly referred to as the interservices meeting of psychiatrists, were held at the Royal Society of Medicine in London. One of the high points in these gatherings was the session of 25 March 1944 devoted to rehabilitation work. At this meeting, Colonel Parsons explained in detail the rehabilitation program that was being carried out at the 3l2th Station Hospital.
In addition, Colonel Thompson represented the U.S. Army at the special Psychological and Psychiatric Liaison Committee meetings held at the offices of the War Cabinet in London; at conferences of command psychiatrists of the British forces; at conferences of the British Emergency Medical Service psychiatrists; and at meetings of the Services Subcommittee of the War Cabinet’s Expert Committee on the Work of Psychologists and Psychiatrists. The latter was an extremely important association for Colonel Thompson, since the Services Subcommittee consisted of consulting psychiatrists and psychologists from all the British services.
Cooperation From Without the EuropeanTheater
This account would be incomplete if it were limited todealings with strictly medical elements and individuals within the theater. Thejob that was done, and done with a conspicuous degree of success, would neverhave been possible without outside help.
Colonel Thompson was fortunate in having and maintainingfrequent direct contact with the Neuropsychiatry Consultants Division, Officeof the Surgeon General. The benefits were mutual and extended into all spheresof military neuropsychiatric activities. At first, contact was infrequent andrelatively formal through approved military channels and by military letter,and these continued to be used for matters of importance requiring officialcognizance, particularly policy matters. However, the way was opened forinformal and personal communication in mid-1943.
On 1 June 1943, Colonel Halloran wrote Colonel Thompsonas follows:
Until recently it wasnecessary for all communications from overseas consultants to pass throughofficial channels. However, we have now received information that overseasconsultants in the field should be encouraged to communicate with this officepersonally at least once a month. In this way we may be able to familiarizeourselves with many problems and receive information which will guide us informulating advisory policies.
In reply to this letter, Colonel Thompson wrote:“It is a great relief to know that overseas consultants can communicatepersonally and directly with your office. In the past I have had considerablematerial which I thought would be of interest and value to you.”
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When Colonel Menninger became Chief, Neuropsychiatry Consultants Division, Office of the Surgeon General, in December 1943, the relationship established by his predecessor was continued. On 25 January 1944, Colonel Menninger wrote Colonel Thompson, as follows:
My stay in this office has been so short that I am still a long way from being oriented. I do have a very definite impression, however, that the lines of communication between us here and you over there have been very thin. I would like so much to know the dope from you and I presume you will be interested in knowing of events which occur around here. I’m going to try to get out a letter to consultants each two or three weeks just to let you know what we are doing and what is happening. I know that even in this country I felt very much isolated from The Surgeon General’s Office and we do want to be of as much help to you as we possibly can.
A few months later, Colonel Menninger was still intent onestablishing personal communications with Colonel Thompson on a sound andcontinuing basis, and on 22 March 1944, he wrote: “I am keen to knowwhat’s going on over there and any suggestions your have for me * * *. Somuch of our work is necessarily extremely interlaced with yours and it’sa very great handicap for both of us that we don’t know more of thedetails of each other’s planing.”
In September 1944, Colonel Menninger visited the Europeantheater. Organizations in the combat zone were the primary goals in hisitinerary. Accompanied by Colonel Thompson, he visited army and divisionpsychiatrists and inspected evacuation hospitals, field hospitals, exhaustioncenters, and clearing stations of many divisions on the line. Colonel Menningerthen viewed neuropsychiatric work in fixed hospitals with particular attentionto problems at the 130th General Hospital and the screening of patients fromQuartermaster work units at the l9th General Hospital. Wherever he went, therewere informal conferences with neuropsychiatrists in the field and directexchange of opinions, ideas, and information.
In the United Kingdom, Colonels Menninger and Thompsonwere escorted by Brigadier Rees and Lt. Col. George R. Hargreaves on a grandtour of British military and civilian neuropsychiatric facilities. Among theinstallations visited were the Army Selection Training Unit (Royal Army) atLeeds, England, the Royal Army Medical Corps neurosis hospital at Bellsdyke, aprimary training wing in the Scottish Command where the process of testing andplacing recent inductees was observed, and “Gordenburn,” theneurosis hospital of the University of Edinburgh. While in the field commandsof the British Army, the visitors took part in a meeting at York, England, ofBritish Army regional psychiatrists of the Northern Command. Two of the talksat this conference were given by the U.S. Army representatives, ColonelsMenninger and Thompson. A meeting sponsored by Dr. David K. Henderson,Professor of Psychiatry, University of Edinburgh, was held with civilianpsychiatrists in the vicinity of the university. A visit was paid Maj. Gen. J.A. Manifold, Surgeon, Scottish Command. Finally, Colonel Menninger attended aseries of conferences arranged by the British in London.
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Upon his return to the United States, Colonel Menningerwrote a complete account of his trip to the European theater.61 Inthis report he commented:
Visits From The Surgeon General’s Office
My impressions incontacts with the professional consultants in the theater, and particularlywith the medical officers in the hospitals, are that my visit was very muchappreciated because it indicated an interest on the part of The Surgeon Generalin their situation. I believe it was an indication of the need for and value ofrather frequent contacts between the professional groump in The SurgeonGeneral’s Office and the professional group in the field.
<> In December 1944, Colonel Thompson returned to theUnited States for a period of temporary duty, from 12 December 1944 to 15January 1945. While in the United States, Colonel Thompson presented the majoraddress on combat exhaustion before the Research Association in Nervous andMental Diseases, and acted as a member of the commission of the organization.Colonel Thompson spent some time at Mason General Hospital on Long Island, NewYork, where neuropsychiatric cases evacuated from all theaters were to be seen,and at the neuropsychiatric convalescent facility at Camp Upton. He attendedthe first conference of psychiatrists in charge of consultation services atreplacement training centers, which was held at Aberdeen Proving Ground. Therewas much to discuss, and many plans and special arrangements were made at theNeuropsychiatry Consultants Division, Office of The Surgeon General.
There were other visits to the European theater frompersonnel of the Surgeon General’s Office, representatives from other WarDepartment agencies, and from the Office of Scientific Research and Developmentand National Research Council. All of these visits, either directly orindirectly, eventually had profound effect on the conduct of neuropsychiatricservices in the European theater and the Army at large.
The first of these other visits was made in March 1944 by agroup headed by Maj. Gen. Norman T. Kirk, The Surgeon General of the Army. Hewas accompanied by Maj. Gen. David N. Grant, the Air Surgeon, and Dr. Strecker.Dr. Strecker was a member of the special war committee appointed by theAmerican Psychiatric Association, the president of the association, and acivilian consultant in psychiatry to the Secretary of War. He was concerned,primarily, with neuroses affecting combat aircrews. Brig. Gen. Malcolm C. Grow,Col. Elliott C. Cutler, MC, Lt. Col. (later Col.) Herbert B. Wright, MC, Col.R. B. Hill, MC, and Colonel Thompson joined the commission in its visits tofield installations (fig. 133). Practically all general and station hospitalsin England servinmg Army Air Force units were visited. Dr. Strecker interviewedpersonally many flying personnel who were patients. At all these installations,there were conferences with the psychiatrists. Of particular interest to thevisitors was the rehabilitation center of the 307th Station Hospital, which wasdoing an exceptional job in returning wounded aircrew
61 Seefootnote 57, p. 366.
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FIGURE 133.- Stanbridge Earls, Hampshire, England, rest home for officers suffering from flying fatigue.
personnel to duty, and the 347th Station Hospital, which was the special treatment center for operational fatigue of flying personnel. A highlight of the tour was the visit by the entire commission to the 312th Station Hospital where the treatment and rehabilitation of nonpsychotic patients was seen. Medical officers attending the school of neuropsychiatry were engaged in conference, and a complete presentation was given by the school’s demonstration unit of what the neuropsychiatrist might encounter at a casualty clearing station. On 20 March 1944, an evening dinner was given by Col. Rex L. Diveley, MC, Senior Consultant in Orthopedic Surgery, ETOUSA, and Colonel Thompson for members of the commission and their opposite numbers in consultation in orthopedics and psychiatry from the British services.
Some time after the visit of this commission, Colonel Thompson wrote to Colonel Menninger on 2 May 1944 and expressed the hope that Dr. Strecker had been able to call on him to tell about the visit in the European theater. “I am sure,” Colonel Thmompson ventured to say, “that he brought back with him considerable first hand information thmat cannot be expressed in writing.” In a reply dated 10 May 1944, Colonel Menninger wrote in confirmation: “Ed Strecker did stop to see us and told us in considerable detail about the <>situation. The official reports come through more slowly.”
Colonel Thompson had to decline a proposal by Dr. Strecker for holding examinations of the American Board of Neurology and Psychiatry in the European theater, desirable as this would have been. Colonel Thompson had
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indeed received more than a few applications and queries regarding suchexaminations but it would have been too difficult to find the time and placefor them at that time, when the invasion of the Continent was just 1 month old.
Brig. Gen. Hugh J. Morgan, Chief Consultant in Medicine toThe Surgeon General, visited the European and Mediterranean theaters in Marchof 1945. General Morgan was not interested in neuropsychiatric activities perSe, but his broad interests and extensive visits to units within each of thefield armies in combat brought out many observations and interviews with keypersonnel. General Morgan was able to assess keenly the types of medical unitsbeing used, the missions they were performing, and their capabilities andlimitations. In a memorandum dated 19 April 1945, he reported the results indetail to the Chief, Operations Division, Office of the Surgeon General.<>
Colonel Thompson spent the entire month of April 1945 with a special commissionsent to the European theater to study psychoneurotics. The commission consistedof Col. Lucius A. Sa!isbury, MC, IGD; Col. Peter Schmick, GSC; Lt. Col. HerbertO. Peet, IGD; Colonel Everts; and Lt. Col. Walter O. Klingman, MC. In thelatter part of 1944, a commission made up of Colonel Salisbury and fourcivilian psychiatrists had conducted a study of the treatment ofpsychoneurotics being carried out, in the Zone of Interior. As a result, theSecretary of War asked the Inspector General for a report on the same topicfrom the theaters. One commission was sent to the Pacific area, and this onehad come to Europe and was to proceed later to the Mediterranean theater.
Two days were spent in orienting the group and planning theitinerary. The first day of the tour was spent in long conferences with GeneralKenner at Supreme Headquarters, Allied Expeditionary Force, and with Col.(later Maj. Gen.) Alvin L. Gorby, MC, and Colonel Whayne, both of the 12th ArmyGroup. From there, each army in combat was visited; that is, the First, Third,Seventh, and Ninth U.S. Armies. In each army, medical as well as otherpersonnel were interviewed at all echelons from army and corps headquartersdown to units within the divisions. In this way, opinions were obtained fromcommanders of major organizations, various staff sections, and medicalofficers. Every type of medical treatment facility in use was observed fromdivision clearing stations back to exhuastion centers supporting evacuationhospitals. Early in the tour, the 51st Station Hospital, which was a specializedunit supporting Third and Seventh U.S. Armies, was inspected thoroughly. Afterthe tour through the armies, a similar thorough study was made of the 130thGeneral Hospital and its rehabilitation center, which was the terminus ofneuropsychiatric evacuation from First and Ninth U.S. Armies.
Facilities and medical staffs of Eighth and Ninth Air Forceswere also visited, including the rest homes of Eighth Air Force in the UnitedKingdom and the bomber field at Polebrook. While in the British Isles, thegroup made a complete study of treatment of neuroses as conducted at the 3l2thStation
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Hospital-the “last ditch’’ rehabilitation center for neurotic patients in the theater. The 96th General Hospital, the holding center for psychotic patients, was also observed.
The work by this group during April 1945 was the most comprehensive on-the-spot assessment possible at that time. It included all facets of the whole problem-command and medical-as it pertained to psychoneurosis in the European theater. The seriousness and interest with which the members of the group proceeded about their work proved to be a real stimulus wherever they went. The following excerpt from a letter written on 25 April 1945 by Maj. Alfred O. Ludwig, MC, Consultant in Neuropsychiatry, Seventh U.S. Army, to Colonel Menninger, shortly after the visit of this group to his area, illustrates this feeling:
I had the pleasure of meeting Lt. Col Everts when he visited us with the most recent of the many investigating committees that have “looked into” our affairs in the past two years. He, of course, was thoroughly familiar with what we have been trying to do, as well as with the various circumstances that influence the NP rates over here, but it was with very considerable satisfaction that I expounded some of our ideas to the other non-medical gentlemen. We tried to give them a very frank opinion, backed with facts and figures, as to the reasons for the situiation, and emphasized particularly some of the things over which the medical department has no control.
On 21 April 1945, another commission arrived in the European theater from the Zone of Interior, made up of civilian consultants in neuropsychiatry to The Surgeon General. Its overall mission was to study the psychodynamics of combat exhaustion. The commission was composed of Drs. Leo H. Bartemeier, chairman, and John Romano, Karl Menninger, John C. Whitehorn, and
Lawrence S. Kubie. Its raison d’être was the fact that the clinical manifestations of psychoneurosis in combat differed considerably from typical psychoneurotic reactions, and, as the clinical picture changed more or less rapidly as the patient was evacuated to the rear, reliable information was needed for correlating psychopathology in forward areas with subsequent treatment methods. It was assumed that psychiatrists in the Army, and particularly the group at the lower echelons, did not have time and might not be professionally equipped to underertake such research. The contemplated project had the complete approval of the Office of Scientific Research and Development and was strongly endorsed by Brig. Gen. William A. Borden, New Developments, War Department. Earlier durung the year, when The Surgeon General approached General Hawley on the feasibility of the project, an invitation was extended by General Hawley for a commission of this nature to be sent to the European theater.
The commission had intended to proceed in pairs or individualy to different active fronts. However, the collapse of German resistance in many areas militated against such a plan. Colonel Thompson advised the members of the group to travel together. Because he was engaged in touring with the group headed by Colonel Salisbury, Colonel Thompson obtained the services of Colonel Parsons to escort them. The civilian commission covered practically
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the same ground as the earlier commission, but its members were able to spendmuch more time at the 130th General Hospital and with Britishneuropsychiatrists. Unfortunately for the commission, there were almost no newbattle casualties.
A complete report was made by the commission upon itsreturn, in which it noted the peculiar advantage it had in dealing withmilitary neuropsychiatric patients.62
Being civilians facilitated the obtaining of informationfrom some patients. It also enabled us to identify ourselves very readily witheither privates or officers . . . because we were not, in fact, in any one ofthese positions ourselves . . . We were not under any compulsion or obligationto find ways of gettimig men back to duty. It was our function only to studythe conditions without the necessity of serving any utilitarian purpose bywhich Army doctors are always bound and constrained.
If any one individuual outside the European theater left apermanent mark upon the theater’s neuropsychiatric activities, thatperson was Colonel Hanson, Consultant in Neuropsychiatry, NATOUSA (MTOUSA).Even before Colonel Thompson’s arrival in the theater, when ColonelHanson had been assigned to the North Ireland Base Section, ETOUSA, he hadwritten a letter to the Chief Surgeon, ETOUSA, on 10 August 1942 citing theneed for a much better organized, equipped, and extensive neuropsychiatricservice in the European theater. The letter so impressed General Hawley that hehad used it as the basis for requesting a full-time neuropsychiatric consultantof suitable high caliber to organize and operate such a program as proposed bythen Captain Hanson.63
It has been mentioned previously that, before departing forthe North African theater, Colonel Hanson, with Colonel Thompson, had workedout a plan to be used in combat that was amazing in its foresight. When theEuropean theater was in the process of making firm plans for mounting theinvasion of the European Continent, Colonel Hanson had accompanied ColonelThompson back to Europe from North Africa and helped sell the basic system,which was ultimately used in all field armies in Europe. At the same time, hegave lectures to students at the school of neuropsychiatry that were most acuteand timely. His reports, verbal and written, were the basis for a significantpart of the indoctrination of line medical officers and neunropsychiatrists inmobile hospital units at the school of neuropsychiatry.
When Colonel Menninger visited the theater, Colonel Hanson was able to join himwith Colonel Thompson and make the visit more fruitful, both in terms of whatColonel Menninger was able to find out on his trip and the immediate benefit ofthe trip to neuropsychiatrists in field units with whom conferences were held.Forms devised by Colonel Hanson were used with but
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62 Report ofPsychiatric Mission, Office of Scientific Research and Development, EuropeanTheater of Operations, 16April 1945-16 July 1945.
63 Letter,Col. Paul R. Hawley, Chief Surgeon, ETOUSA, to Surgeon General, US. Army, 15Aug. 1942, subject Neuropsychiatric Treatment in the Theater of Operations.
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slight modifications in the European theater. When Colonel Thompson was askedto recommend tables of organization and equipment for division psychiatrists,hospitals to be used as examination centers, and special general hospitals forneuropsychiatrists, he found it good practice to ask for Colonel Hanson’sadvice with respect to these matters.
An indication of the regard which Colonel Thompson had forColonel Hanson may be found in the following letter which Colonel Thompsonwrote to Colonel Hanson on 24 February 1944, after Colonel Hanson’s firstreturn visit to the European theater:
I should have written to you before this time to thank youfor all time help which you gave psychiatry in this theater. The men at ourN.P. hospitals are still talking about your visit and the good your talks didfor the personnel. You certainly did help getting things over to Colonel Spruit,and the plans which we made with him are going forward in spite of the factthat he recently moved on to another assignment.
Following Colonel Hanson’s second visit to theEuropean theater, Colonel Thompson wrote, on 11 November 1944: “Once morelet me say that your visit in this theater was extremely helpful andstimulating. We all look to you as the pioneer in things that we are now tryingto do.”
In concluding this section, the aid given by the Britishforces, the Morale Services of Army Service Forces, and the AdjutantGeneral’s Office should be mentioned. Their contributions have beendescribed in other parts of this survey. Colonel Thompson, in turn, foundoccasion to give advice and counsel to consultants in neuropsychiatry from theother Allied nations. The London office of the Rockefeller Foundation alwaysmaintained an enlightened and active interest in neuropsychiatric educationalactivities of the theater. The Josiah Macy, Jr., Foundation and the Instituteof Living were always helpful in providing much needed literature.
Finally, another passage from the report of the commissionheaded by Doctor Bartenmeier may he quoted here, for it summarizes the singulareffectiveness of the arduous task of saving manpower and relieving neunropsychiatriclosses as it was carried out in ETOUSA.64 The report reads:
Among the most recent statistics which the commission havewere those presented by Col. Lloyd J. Thompson, and Col. W. S. Middleton, at ameeting with Maj. Gen. Paul R. Hawley, the Chief Surgeon, and his consultantsin Paris on 24 May 1945. The commission attended this meeting and learned that17 percent of those casualties in the ETO who were returned to the Zone ofInterior were suffering from neuropsychiatric disabilities. (This is incontrast to figures of 42 percent said to have been reported from othertheaters.) The commission also learned that 80 percent of all NP. cases inETOUSA have been returned to various kinds of military duty. Perhaps even moredramatic was the report from one of the special U.S. military hospitals to theeffect that 5,000 men were returned to some kind of military duty from thisinstallation during the period of one year. If these thousands had not beentreated they would have presumably been lost to the theater and would havereturned home chronically ill. It is the opinion of the commission that thisreport is a high tribute to the effective work of army psychiatrists.
64 Seefootnote 62, p. 392.
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SUMMARY IN RETROSPECT
Lloyd J. Thompson, M.D.
Perhaps the Senior Consultant in Neuropsychiatry, ETOUSA,should have been a chief consultant on a level with the Chief Consultants inMedicine and Surgery, ETOUSA. Such an arrangement would have been in keepingwith the situation that existed in the Office of the Surgeon General. However,at no time during my 3 years in the European theater was there any difficultyin working “under” Colonel Middleton. In fact, on numerousoccasions there were distinct advantages aind always I had the feeling ofworking “with” Colonel Middleton. With other personalities thismight not have been true.
I want to express again my great appreciation of thegenerous help and loyal cooperation given by Brigadier Rees of the Royal ArmyMedical Corps. Colonel van Nostrand of the Royal Canadian Army Medical Corps,and by their fellow officers throughout the war in Europe. In my first contactwith Colonel Middleton I suggested that psychiatry should be concerned withprevention and the earliest possible treatment and should not wait forpsychiatric casualties to be admitted to general hospitals. I soon found thatthe English and Canadian psychiatrists had been applying this idea since thebegirmning of the war.
My appreciation of the loyal and prodigious assistance givenby the numerous neuropsychiatrists in our own army was expressed verbally andindividually long ago but should be recorded here.
The first great surprise and challenge that came afterreporting for duty in August 1942 was the discovery that the position ofdivision psychiatrist had been dropped from the table of organization someyears previously. Having known several of the division psychiatrists of WorldWar I and having heard their accounts, it seemed that this position would stillbe a key one, although the type of warfare had changed. Looking back onsubsequent experiences, I feel certain that eacd division could have used twopsychiatrists to great advantage. Of course, there was not the quantity oftrained personne to permit even an experiment in this direction.
Originally it was thought that when necessary, divisionneuropsychiatric casualties would be evacuated from the clearing stations toevacuation hospitals. Apparently, this was standard operating procedure.However, at this level a great deal of experimenting was done. The First U.S.Army pioneered (on the basis of experience in North Africa and Italy) inestablishing exhaustion centers manned mostly by psychiatrists from theevacuation hospitals. In contrast, the Third U.S. Army kept psychiatricservices in its evacuation hospitals, but established in one convalescenthospital a holding and treatment center fom neuropsychiatric patients. Therewere still other modifications of service at this level and argumentsconcerning the best plan may still be going on. At the end of thewar, it appeared that the Third U.S. Army plan had been best for its particulartype of combat in its sweep from Normandy into Germany. In the First U.S. Army,as well as in the other armies where exhaustion centers
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were established, their plan worked equally well and seemed suited to theirfunctions.
The establishment of the specialized neuropsychiatrichospitals just back of army areas, with their emphasis on rehabilitation,certainly had strong support from General Hawley regardless of opposition fromother sources. The plan to have such a rehabilitation center just back of theFirst and Ninth U.S. Armies and another just back of the Third and Seventh U.S.Armies seemed logical. Because of delay in establishing these centers andbecause of their use for other purposes, the plan never came to full fruition.On the other hand, the specialized neuropsychiatric hospitals in Englandfulfilled their functions beyond expectation. While speaking of theseneuropsychiatric hospitals, the brave action of Colonel Parsons, commandingofficer of the 130th General Hospital, during the Battle of the Bulge should berecorded again and again. He remained behind as the only medical officer withpatients who could not be evacuated while the German Army swept by and beyondhis hospital.
Having these separate neuropsychiatric units-exhaustioncenters within the armies, rehabilitation hospitals just back of army areas aswell as in England, and at the same time, adequate psychiatric services inevacuation, general, and even station hospitals-may have seemed like“having your cake and eating it, too.” Considering the magnitude ofthe psychiatric problems as well as the results obtained, this apparentoverlapping seems to have been necessary.
Psychiatric participation in organizations outside ofMedical Department activities, such as replacement depots, and disciplinarycenters was a much needed function that was fulfilled in a somewhat makeshiftmanner. Most of these functions had to be ‘‘sold’’ andwhen ‘‘bought’’ the lack of psychiatric personnel aswell as of command backing often produced embarrassing situations.
The formation of units for hard labor came as a surprise topsychiatrists and perhaps to the majority of medical officers. Who was todecide just which combat-exhaustion soldiers should be assigned to laborbattalions and which should be treated as casualties and receive psychiatriccare remained an open question. This unanswered question is of tremendousimportance in all branches of the services and at all times. The answer liesnot only in the moral fiber of the individual but in the atmosphere of morale,leadership, and motivation that surrounds the individual from the time ofinduction until signs of breakdown appear. In respect to this question,psychiatrists were often considered as being too soft. At times and undercertain individual circumstances, such may have been the case. Generallyspeaking, however, we attempted to steer a common-sense middle course.
The part played by the theater school of neuropsychiatry andother educational efforts is worthy of further commendation. The numerousdivision psychiatrists, ftontline medical officers, and many others whoreceived indoctrination at the school were responsible for enhancing thesuccess of the neuropsychiatric program. The accomplishments of Major Thomas andlater Major Fabing in carrying out the mission of the school were far beyondexpecta-
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tions. They were ably assisted by other psychiatrists, but I shall not listtheir names for fear of slighting someone by an inadvertent omission.
It remains my conviction that an assistant in the office ofthe theater senior consultant in neuropsychiatry could have been used to greatadvantage. An assistant in neurology was asked for, anticipating that thismight be a neurropsychiatrist who would have adequate knowledge aboutneurology, electroencephalography, hospital organization, physical therapies,and even clinical psychology. Such an assistant could have carried on manyfunctions while the senior consultant was out of the office.
My visits to North Africa, from 13 November to 21 December1943, and to the United States, from 12 December 1944 to 15 January 1945, weresurely essential. Visitors coming into the theater contributed immeasurably tothe neuropsychiatric and other programs, but it is to be recognized, withoutdetracting from their valued assistance, that time had to be spent with them.The Surgeon General of the Army and the Air Surgeon, accompanied by Dr.Strecker, were present during March 1944. Colonel Menninger arrived inSeptember 1944 for a tour of duty lasting about 6 weeks. His visit gave impetusto many sagging operations and started new ones. A group of visiting officersundcr Colonel Salisbury came early in April 1945 to study the functions ofneuropsychiatry in the European theater. Their through investigations wereextremely helpful. Before these visitors had departed, another group ofcivilian psychiatiists under Dr. Leo Bartemeier came for further studies. Thelatter group remained until 4 July 1945. Later, they produced a very valuableand well documented report on many aspects of neuropsychiatry in the Europeantheater.
The foregoing account concerning visits and visitors hasbeen given mainly to record the great value received from those who came andstayed to help, as they did, but the account seems to indicate also that thesenior consultant needed an assistant in his office.
Acknowledging the betterment of neuropsychiatric servicesduring the war in Korea but hoping that another war will never occur, whereinour examples will again have to be referred to, I want to close this briefpersonal summary by expressing thanks to and admiration for my immediatesuperior officers, Colonel Middleton, Colonel Kimbrough, and General Hawley.
Part IV. Senior Consultants in Infectious Diseases andTuberculosis,andMedical Consultation in Subordinate Commands 65
The preceding parts of this chapter first reviewed theoverall medical consultant system in the European theater and continued withdetailed dis-
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65 The narrative for this part was compiled by Maj. James K.Arima, MSC, The Historical Unit, U.S. Army Medical Service, Incollaboration with Yale Kenneland, Jr., M.D., and Theodore L. Badger, M.D., former SeniorConsultants In Infectious Diseases and Tuberculosis, ETOUSA, respectively. Drs.Kneeland and Badger contributed summaries in retrospect in mid-1956.
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FIGURE 134.-Consultants in medicine, Europeantheater. (Left) Lt. Col. (later Col.) Yale Kneeland, Jr., MC, Senior Consultantin Infectious Diseases, Office of the Chief Surgeon, ETOUSA; Consultant inMedicine, Office of the Surgeon, Southern Base Section; and Consultant inMedicine, Office of the Surgeon, United Kingdom Base. (Right) Lt. Col. (laterCol.) Theodore L. Badger, MC, Senior Consultant in Tuberculosis, Office of theChief Surgeon, ETOUSA; and Consultant in Medicine, Office of the Surgeon, NormandyBase Section, ETOUSA.
cussions of the work of the two full-time Senior Consultants in Dermatology andNeuropsychiatry, ETOUSA. Almost all the others-whether senior, base section,regional, or hospital center consultants-held dual positions.
Col. Yale Kneeland, Jr., MC, Col. Theodore L. Badger, MC(fig. 134), and Cob. Gordon E. Hein, MC, the Senior Consultants in InfectiousDiseases, Tuberculosis, and Cardiology, ETOUSA, differed in the role eachplayed to a limited degree among themselves and to a considerable degree fromthe two full-time theater senior consultants, Colonels Pillsbury and Thompson.As a group, they were more concerned with the investigation of specificproblems and the establishing of theater policy in their respective fields of specialization,while overall operational and administrative functions were assumed by theChief Consultant in Medicine, ETOUSA, Colonel Middleton. No regional orhospital center consultants were appointed in medical specialties other thandermatology and syphilology and neuropsychiatry. Supervision and consultationat hospital and field army level were accomplished by regional, hospitalcenter, or army consultants in general medicine. The regional and, later,hospital center consultants were, in turn, supervised by base section medical
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consultants, who, for a major part of the active life of the theater, were alsothe theater senior consultants in their specialties.
Finally, there were many medical officers with unusualtalents assigned to specific projects or studies in conjunction with thesolving of theater medical problems. Their participation in the theater’sconsultant activities must be mentioned to round out this account.
Accordingly, this final section of the history of medicalconsultants in the European theater will discuss the more significant medicalproblems in the context in which they occurred, except for those special fieldsalready covered, in an endeavor to indicate the contribuntion of eachconsultant to the solution of a particular problem and to show in properperspective the integrated functioning of the consultant system as a whole.
BUILDUP IN THE UNITED KINGDOM
Atypical Pneumonia
One of the first medical problems to strike the fledglingEuropean theater was an increasing number of cases of atypical pneumonia in theearly fall of 1942. At that time, the specific characteristics of the diseasewere far from common knowledge among members of the medical profession atlarge. It was only in the mid and late 1930’s that atypical pneumonia hadbeen recognized as a distinct entity with an unknown causative agent, which wasdefinitely not a pneumococcus. In both England and the United States, theresistance of some pneumonias to sulfonamide therapy had emphasized thisdistinction. The Secretary of War, upon recommendation by The Surgeon General,had appointeol a small civihiamm commission to study an epidemic of pneumoniaat Camp Claibourne, La., in the summer of 1941. The commission concluded thatthe epidemic was one of atypical pneumonia. Following recommendations by thiscommission, The Surgeon General established the Commission on Acute RespiratoryDiseases. As a result of preliminary studies by these bodies, theclassification “Primary Atypical Pneumonia, Etiology Unknown” wasadded, for the first time in March 1942, to the list of diseases reportable onthe weekly statistical health report.
In the fall of 1942, the disease was appearing inever-increasing numbers in the European theater. Cases occurring at this timewere often mild, and symptoms varied considerably. There were no specificdiagnostic manifestations to make identification simple. In spite of theusually benign course of the disease, convalescence was relatively bong,frequently requiring hospitalization for a month or more. Little was known ofthe residual effects of atypical pneumonia, and there was the possibility thatsome soldiers were being returned to duty without sufficient rehabilitation.
On 20 October 1942, Coboneb JIiddbeton wrote to AirCommodore Alan F. Rook, RAF, asking for information on British experience withthe disease. On 22 October 1942, Colonel Middleton wrote to each of the medicalofficers
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who were concernedwith the diagnosis and treatment of atypical pumeumonia in the theater’sthree general and two station hospitals.66 He informed them of theincidence of atypical pneumonia in the five hospitals; told them of a surveybeing done by the Preventive Medicine Division with participation by theProfessional Services Division, both in the Office of the Chief Surgeon,Headquarters, ETOUSA, and the assistance of the 3d Station Hospital; andconcluded with the following:
Clinical, X-ray and laboratoryobservations must be accurately recorded to capitalize upon the currentexperience in the interests of better service to the soldiers. In the light ofcertain observations, it is suggested that X-rays of the chests of soldierssuffering from apparently mild respiratory infections be taken, particularlywhen they report from units in which atypical pneumonia has occurred. There isreason to believe that an appreciable percentage of these patients will show pneumoniitis to theX-ray. This office will serve as a clearing house for such clinical experiencesas you may wish to report.
By November 1942, the incidence of atypical pneumonia seemedto be reaching its peak. Medical officers at the hospitals continued to submitrepoits in reply to Colonel Middleton’s letter of 22 October. On 21November 1942, in a memorandum to General Hawley, Colomel Middleton recommendedthat a committee be appointed to coordinate and pursue the study of atypicalpneumonia from its epidemiologic, clinical, and laboratory aspects, andsuggested as members Colonel Kneeland, Colonel Gordon, and Major Muckenfuss.Colonel Kneeland was Chief, Medical Services, 2d General Hospital, and had beenone of the members of the Secretary of War’s special commission which hadmade the preliminary investigations at Camp Claibourne, La., in 1941. ColonelGordon was Chief, Preventive Medicine Division, Office of the Chief Surgeon,Headquarters, ETOUSA, and Major Muckenfuss, an experienced virologist, wasCommanding Officer, General Medical Laboratory A.
General Hawley quickly approved the proposal, and SpecialOrder No. 23 establishing the committee was published by the Office of theChief Surgeon, Headquarters, ETOUSA, on 23 November 1942.
With Colonel Kneeland serving as president and chairman,Major Muckenfuss as the recorder, and Colonel Gordon as the third member, thecommittee met at General Medical Laboratory A on 12-13 December 1942. First,the committee decided that a circular letter should be prepared embodyingmaterial recently published in War Medicine 67 and directing thatundue incidence should be reported directly to General Hawley’s office.This directive was to be prepared by Colonel Gordon and to be published byGeneral Hawley. Next, the committee considered the possibility of there being achange in clinical character of this disease and a greater influence of secondaryinfection in the days to come. Colonel Kneeland agreed to discuss with thenecessary individuals the need to observe cases closely for such changes.Finally, it
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66 Letter, Lt.Col. Wm. S. Middleton, to Lt. Col. Yale Kneeland, 2d General Hospital, Lt. Col.T. H. Badger, 5th General Hospital, Lt. Col. Gordon E. Hein, 30th GeneralHospital, Maj. James R. May, 3d Station Hospital, and Capt. Sidney G. Page,Jr., 151st Station Hospital, 22 Oct. 1942, subject: Incidence of AtypicalPneumonia.
67 Moore, G.B., Jr., Tannenbaum, A. J., and Smaha, T. G.: Atypical Pneumonia in an ArmyCamp. War Med. 2: 61.5, 1942.
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was resolved that laboratory investigations directed towards identification ofthe etiologic agent should be governed by the general principle of doing onlythose things that could be carried out to advantage in a theater of operations,avoiding the intensive type of investigation that would duplicate studies underway by the special commission in the Zone of Interior. Direction of laboratoryinvestigations on the disease in the European theater was the province of MajorMuckenfuss.
The circular letter on atypical pneumonia was completely inDecember and published by the Office of the Chief Surgeon, Headquarters,ETOUSA, on 7 January 1943, as Circular Letter No. 2. It gave a brief history ofthe disease; noted prevailing epidemiologic factors; discussed clinicalfeatures, differential diagnosis, management of hospital cases, pathologicstudies, and related virus infections; and closed with a paragraph on specialreporting procedures. The medical officer responsible for the medical serviceof a company, or a detachment of similar size, was ordered to report directlyto the Office of the Chief Surgeon, Headquarters, ETOUSA, by telephone theoccurrence of three or more cases of primary atypical pneumonia within 1 weekin the company or detachment concerned. Likewise, whenever a hospital admittedthree or more cases in any one week from a company or detachment, the hospitalcommander was directed to report the fact by telephone directly to the Officeof the Chief Surgeon, Headquarters, ETOUSA.
In the meanwhile, Lt. Cob. Joseph C. Turner, MC, 2d GeneralHospital, had been assigned to Medical General Laboratory A to conductlaboratory studies on atypical pneumonia. By mid-February 1943, he had made adiscovery that appeared to throw light on the immunology of the disease. On 16February 1943, Colonel Kneeland wrote to Colonel Gordon as follows:
Thanks ever so much for your letter reporting on AtypicalPneumonia. The disease seems to have dried up here except for one veryseriously ill officer-which is rather bad luck, for Joe Turner has just gothold of a serological change which, if it turns up in other cases of thedisease, might be very interesting indeed. He’s going over to the 2dEvac. tomorrow to get blood from their new cases, and if the thing lookspromising he’ll be very anxious for more material. Therefore, do yousuppose you could let me know of any new cases you hear of, particularly severeones?
In reply, Colonel Gordon was able to provide ColonelKneeland immediately with “what is essentially a complete list ofatypical pneumonia cases since Feb. 1st.”
By the end of April 1943, Colonel Turner had gathered enoughdata to show with considerable reliability that there was an increase in coldagglutinins (autohemagglutinins) in patients convalescent from primary atypicalpneumonia. The minutes of the 30 April 1943 meeting of the ChiefSurgeon’s Consultant Committee, record Colonel Middleton reporting asfollows: “It has been shown that there is a development of coldagglutinins after one week of illness, with a building-up and then subsequentfalling-off. The process is found in a few other conditions and may have widerramifications and contribute to our knowledge of immunology.” ColonelTurner was able to publish
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his findings in a British publication 68 at about the same time that the results of independent studies on the phenomenon were published in the United States 69
The studies conducted in ETOUSA demonstrated again the place of research in a theater of operations during wartime. Soon after the results had been obtained, the technique of a cold-agglutinin test as a promising aid in the differential diagnosis of pneumonia was promulgated in the European theater.70 Had this preliminary work not been done, months might have elapsed before the theater could have put the test to practical use, and, by that time, the invasion of the European Continent would have precluded any efficient trial of the method.
Prior to publication of the technique, the atypical pneumonia committee had met at the 1st Medical General Laboratory (fig. 135) on 19 September 1943 to consider the accummulated data on atypical pneumonia and to plan further studies, with Colonel Turner attending by invitation. The committee agreed to arrange for the collection of a large amount of data on the incidence of cases showing a rise in titer of cold agglutinins during the disease. The purpose was to obtain additional information as to the clinical value of the tests and also to accumulate records that might be used later in determining the incidence of second attacks. It was realized that there were no existing data on the question of immunity conferred by one attack of the disease. The conferees also suggested that another way to study active immunity would be to have medical officers make a special effort, in cases of atypical pneumonia, to determine by careful history taking whether the patient had ever had a previous attack. Finally, the committee suggested that the chiefs of medical services of hospitals be urged to keep the bacterial flora of the sputum from patients with atypical pneumonia under as close scrutiny as the hospital laboratory facilities would permit. It was considered important to bear constantly in mind the possibility of secondary bacterial infection and, in particular, to note any preponderant micro-organism.
In the spring of 1944, there was a sharp rise in the incidence of both atypical and lobar pneumonia without the rise in the common respiratory diseases or influenza such as commonly precedes an increased incidence of primary bacterial pneumonia. It was believed that much of the reported incidence of lobar pneumonia was due to a misdiagnosis of cases of primary atypical pneumonia. During March and April of 1944, the incidence of primary atypical pneumonia reached mild epidemic proportions but did not reach the peak of 1942. The disease always remained an important consideration in medical planning, however, because it did not have a seasonal distribution.
68 Turner, J. C.: Development of Cold Agglutinins in Atypical Pneumonia. Nature, London 151:419, 1943.
69 Peterson, O. L., Ham, T. H., and Finland, M.: Cold Agglutinins (Autohemagglutinins) in Primary Atypical Pneumonias. Science 97: 167, 1943.
70 Letter, Office of the Chief Surgeon, Headquarters, ETOUSA, to surgeons of all base sections and commanding officers of all U.S Army hospitals, 24 Nov. 1943, subject: Technique of Cold Agglutinin Test for Use in Differential Diagnosis of Pneumonia.
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FIGURE 135.-1st Medical General Laboratory(foreground) and town of Salisbury, Wiltshire, England, 1914.
In the European theater, efforts to study atypical pneumoniacontributed to increased efficiency in diagnosis and better care of the sicksoldier. Considerable data were collected, but no important conclusions couldbe drawn during the war years. However, the studies conducted by the U.S. Armyin the United Kingdom and the attention the Army gave to the disease probablycontributed also to the increased interest and better understanding of atypicalpneumonia on the part of British medicine, both military and civilian.
Tuberculosis
In World War I, rigid physical examinations of recruits hadexcluded from service some 50,000 men. Neventheless, more than 2,000 men haddied of tuberculosis in the Army, and the admission rate in Army hospitals hadaveraged 19 per 1,000 troops per year. Tuberculosis was the leading cause ofdischarge for disability because of disease. 71 In the periodbetween the two wars, much had been learned about the pathogenesis oftuberculosis and much was done to establish the superiority of roentgenographicto physical examination for screening. In the Second World War, however,information available
71 The MedicalDepartment of the United States Army in the World War. Communicable and OtherDiseases. Washington: U.S. Government Printing Office, 1928, vol. IX.
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in the European theater indicated that only 51 percent of recruits called toinduction stations before March 1941 had been examined by X-ray and that largenumbers had not been done up to January 1942. It was not until afterMobilization Regulations 1-9, dated 15 March 1942, were put into effect thatroutine roentgenograms were made of the chest of all inductees.72
There was clearly need for an early assessment of thetuberculosis problem in the European theater. Accepting the recommendations ofColonel Middleton, General Hawley, on 2 January 1943, appointed Colonel Badger,Chief, Medical Service, 5th General Hospital, as Senior Consultant in Tuberculosis,ETOUSA.
Colonel Badger appraised the tuberculosis situation and, ina letter to Colonel Middleton on 8 February 1943, reported that the BritishArmy was not using preenlistment X-ray screening. During the first 2 years ofwar, Colonel Badger found that 86 percent of tuberculosis in the British Armyhad appeared within the first year and 41 percent during the first month ofactive training. The British had considered using mobile X-ray units, butnothing had been done to implement their use as of February 1943, except in theRoyal Air Force, which was screening all enlistments with 35-mm. fluorographicunits. Wing Comdr. R. R. Trail, RAF, insisted that the procedure be supervisedand run by medical officers with wide experience in clinical chest disease;there was also a radiologic adviser to each X-ray unit. Two very significantfacts learned also by Colonel Badger were these: (1) Fresh milk in the UnitedKingdom was not being pasteurized, and 11 to 20 percent of fluid milk containedviable tubercle bacilli; and (2) manpower problems required the Royal Army tosort cases with very minimal lung lesions into those unfit for service, thosefit for light work, and those fit for only sedentary jobs.
Colonel Badger reported that the Canadian Army, on the otherhand, was examining all candidates by X-ray and was rejecting approximately Ipercent. A report by a Canadian Army medical officer in 1942 showed that, of104 cases of tuberculosis which developed in personnel while they were in theArmy, 92 percent occurred in soldiers with a negative preenlistment X-ray. TheCanadians had attempted no mass X-ray surveys after original preenlistmentscreening, but contacts of open cases were being examined by X-ray, and activecases were being boarded back to Canada. Like the British, the Canadian Armystudied small lesions at their general hospital in the United Kingdom and,wherever possible, reclassified for duty patients with such lesions.
In his report, Colonel Badger estimated that the tuberculosishazards for U.S. Army troops would be as follows: (1) Early exacerbation ofsubclinical cases admitted to service withount X-ray of the lungs; (2)association with unscreened British’ troops and civilians; (3) drinkingof infected milk; (4) the effects of combat such as excessive fatigue, changesof nutrition with
72 (1) Long,E. R.: War and Tuberculosis. Am. Rev. Tuberc. 45: 616, 1942. (2) Long, E. R.,and Jablon, S.: Tuberculosis in the Army of the United States in World WarII-An Epidemiologieal Study with an Evaluation of X-ray Screening. Washington:U.S. Government Printing Office, 1955.
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marked loss of weight, and malnutrition; and (5) time yet undetermined effectsof intercurrent respiratory infection.
Colonel Badger reported these facts at the ChiefSurgeon’s Consultant Committee meeting of 5 February 1943. In addition,he reported a reversal in the ratio of pleurisy with effusion to parenchymalinvolvement as compared with the usual ratio found in civilians. Reliable datacould only be obtained by spot surveys with fixed equipment already in medicalinstallations. He indicated that surveys of field units that had been in thetheater 1 year or more and of units that had only been in Europe 6 months wouldbe desirable. Colonel Badger estimated that these surveys would involve 2,000or more chest films.
When asked whether the use of microfilms was feasible,Colonel Badger replied that they were less accurate than full-sized films.General Hawley said that getting 2,000 or more people into a hospital for X-rayexamination would dislocate training and other hospital activities. He agreedto the survey only if it could be done by going into camps with a mobileapparatus and using it, perhaps after supper, without causing any dislocationof the work and routine of troops. He suggested that the developing could bedone at the nearest hospital during the day. Colonel Kimbrough, Chief,Professional Services Division in General Hawley’s office, said that Lt.Col. (later Col.) Kenneth D. A. Allen, MC, Senior Consultant in Radiology,ETOUSA, and the Operations and Training Division, Office of the Chief Surgeon,Headquarters, ETOUSA, could work out a suitable portable apparatus. ColonelCutler, the theater chief consultant in surgery, asked if a survey of hospitalpersonnel would suffice, and Colonel Badger replied that he thought not; hehimself, had in mind a survey of the 29th Infantry Division. General Hawley agreedthat it would be profitable to screen such men as the labor troops and theengineers who had been working in the mud. Colonel Badger then specificallyasked General Hawley if he (Colonel Badger) had the authority of General Hawleyto obtain a portable apparatus and embark on the survey. General Hawleyassented but said that before Colonel Badger went into any divisions, he(General Hawley) would first like to write to the division surgeons forconcurrence.
Colonel Badger then raised the question of milk and foodbeing provided U.S. troops by American Red Cross canteens, saying he hadobserved fresh cow’s milk being served to troops (fig. 136). Herecommended inspection of premises and employees wherever U.S. soldiers wereserved food. General Hawley said that he would take up the matter with theAmerican Red Cross comissioner in Great Britain and would ask for some sort ofsanitary control over the milk, foodhandlers, and sanitation in American RedCross establishments.
There remained two problems to be settled before ColonelBadger could embark on his spot survey. One was the matter of obtainingpermission to enter a unit to conduct the survey, and the second was thecreation of a
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FIGURE 136.-The Washington Club, premierAmerican Red Cross club, London, July 1942.
mobile X-ray unit. Regarding the former, Colonel Middleton conferred furtherwith Col. Oramel H. Stanley, MC, Deputy Surgeon, Headquarters, Services ofSupply, ETOUSA, who thought it would be desirable to avoid official channels ofcommunication on such a matter. In order to proceed with the survey, it wasagreed that Colonel Badger should write to the surgeon of a major command orthe commanding officer of a smaller unit, as appropriate to the case, andrequest permission to take chest X-rays for a turberculosis survey which hadbeen authorized by General Hawley. Colonel Stanley believed that General Hawleywould approve this procedure, and General Hawley did approve it at a laterdate.
Colonel Middleton also asked Colonel Allen for guidance inassembling a portable X-ray unit and for advice in the technical aspects oftaking, developimig, and interpreting roentgenograms. Colonel Allen was morethan willing to help since he hoped, in the future, to establish mobile fieldX-ray units himself. Colonel Badger embarked on the program in late February1943. He met only the most cordial acceptance of his proposals for making
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tuberculosis surveys in units. For example, Cob. C. W. Brenn, MC, Surgeon, VCorps, wrote to Colonel Badger on 22 February 1943, as follows:
1. The Chief of Staff, V Corps (Reinf.) has grantedauthority for you to personally contact commanding officers of units where youwish to make X-ray and/or other surveys, and to make such arrangements as maybe mutually acceptable.
2. It is suggested that you present a copy of this letterwhen first contacting a unit commander.
The mobile X-ray unit was quickly assembled using equipmentand personnel available at the 5th General Hospital (fig. 137). Capt. (laterLt. Col.) Magnus I. Smedal, MC, Chief, X-ray Service, 5th General Hospital,took an active interest in setting up this equipment, and his help later inreading the X-rays was an indispensable contribution. The commanding officer,Colonel Keeber, gave the project his wholehearted support.
As eventually constituted at the 5th General Hospital, themobile X-ray unit, which was composed of a standard Picker portable X-ray unitand a Clark-field tent, was transported in a 1/2 ton truck and set up in avacant Nissen hut at the unit surveyed. The equipment, when packed, measured 671/4 cubic feet and weighed 1,663 pounds. One carryall was used to transport theteam of 1 officer and 7 enlisted men. Of the latter, 1 was an X-ray operator; 2were darkroom workers and plate changers; 1 functioned as the runner, cassettecarrier, and truck driver; 1 prepared number strips; 1 positioned markers; and1 was a noncommissioned officer who maintained records.
The unit was customarily set up and working within an hourafter arrival. Chest films, 14 x 17 inches, were taken at the average rate of90 an hour, including a 10-minute stop each hour to rest the team. The maximumnumber of X-rays taken per hour was 137. The team was carefully trained in thetechnique of rapid mass production and worked with great efficiency. Allroentgenograms were developed at the 5th General Hospital and were interpretedthere by Colonel Badger nmntl Captain Smedal.73
During the months of February and March 1943, a total of2,542 persons was examined. Troops from fixed and field medical units, combatengineers, and the infantry made up the sample. In a letter dated 27 April 1943to Colonel Middleton, Colonel Badger reported on the results of the survey andnoted, as follows:
* * * The incidence of re-infection tuberculosis of 0.9percent is not bad. I, of course, do not have the clinical check-up of allthese cases, but repeated X-rays of not less than a month apart show either nochanged parenchymal processes or by stereoscopic vision the lesions arerevealed as dense fibro-calcific affairs.
Some of those about which I feel somewhat concerned I havecarefully avoided calling “healed” lesions. I have requested are-X-ray of the doubtful ones again in two months, and met with only thegreatest co-operation and interest. My impression in regard to this problem atthe moment has not changed from the recommendations which were submitted at thelast meeting. If there is any question of movement in the 29th Division it maybe wise to call in two of their men from strenuous field duty.
73 Letter,Senior Consultant in Tuberculosis, to Chief Medical Consultant, ETOUSA, 17 Dec.1943, subject: Annual Report of Division of Tuberculosis.
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FIGURE 137.-Demonstration of mobile X-ray unit assembled at 5th General Hospital.
I am planning to send to each of those units a report of the X-ray findings also so that they may be incorporated in their Service Records.
In his efforts to collect additional data on the tuberculosis sitiuation, Colonel Badger sent out followup letters to the 112th and 342d Engineers, the 53d Medical Battalion, and the 115th Infantry, 29th Infantry Division, on suspected caes of tuberculosis. He also asked for and received, through the Medical Records Division, Office of the Chief Surgeon, Headquarters, ETOUSA, a table showing incidence of tuberculosis in the Iceland Base Command from 20 November 1942 to 9 April 1943. A survey of the 30th General Hospital was completed, and additional enlisted men from the 53d Medical Battalion and the 5th General Hospital were examined by X-ray to complete the survey of those units. Particular attention was given to the survey of nurses in the general hospitals because of their known accessibility to infection. Colonel Badger proposed a survey of nurses of the l0th Station Hospital, but Colonel Middleton disapproved this plan for reasons which clearly expressed the purpose and limits of the spot survey. On 20 March 1943, Colonel Middleton wrote to Colonel Badger, as follows:
With the completion of the survey of the nursing personnel of the 5th and 30th General Hospitals, you will have a total of 138 subjects, which figure represents over 10 percent of the Army Nursing Corps in this Theater. This ratio will be far higher than the general
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group.Furthermore, the conditions surrounding the 10th Station Hospital nursingpersonnel are largely duplicated in the 5th General nursing group.
For these obvious reasons and the necessity of keeping thisoriginal spot survey within reasonable limits, the project to X-ray the 47nurses of the 10th Station Hospital is disapproved.
As the problem is evolved on the completion of the initialspot survey, the over-all policy for the Theater will be evolved, so that nogroup will be neglected in the long run.
On 8 June 1943, Colonel Badger also arranged with theMedical Records Division in General Hawley’s office to obtain informationas to final diagnosis of hmospital admissions in time European theaterinitially diagnosed as pleurisy, tuberculosis, hemoptysis, and spontaneouspneumothorax. Colonel Badger prepared a list of all patients on whom he wantedthe information, giving the names of each, their diagnosis, and the hospitalsto which they had been admitted.
When all these additional data were assembled andamalgamated with the original data, the total sample of officers, nurses, andenlisted men examined roentgenograpimically amounted to 3,031 cases (fig. 138).Of these, 2,143 (approximately 71 percent) had entirely negative X-ray films.Only 35 cases of reinfection tuberculosis were found (1.1 percent of timetotal). In April 1943 when Colonel Badger made his report to Colonel Middleton,the followup of these 35 lesions of reinfection was still being carried out,and final results were pending X-ray examination of units that had been on themove. Only 1 of these 35 cases was classified as minimal active tuberculosis,but it had not been necessary to remove any individual from duty because ofX-ray findings. In addition to Captain Smedal, Capt. (later Maj.) Samuel P.Asper, Jr., MC, 5th General Hospital, had helped considerably in this phase ofthe tuberculosis survey. A complete analysis of these data was submitted in aninterim report by Colonel Badger to Colonel Middleton who, in turn, had thereport forwarded to The Surgeon General.
At the meeting of the Medical Consultants Subcommittee heldon 25 June 1943, Colonel Middleton reported that Colonel Badger had found noevidence of a need for a mass survey at this time but had recommended thatanother spot survey be carried out in September or October 1943. Specificrecommendations regarding a mass survey would be withheld until after the nextspot survey which might lead to the establishment of an overall policy for thetheater. Also at the meeting, Colonel Middleton suggested that a separateproject consisting of X-ray examination of soldiers in the 29th InfantryDivision who had had no previous chest films might be carried out.
Col. Esmond R. Long, Consultant in Tuberculosis to TheSurgeon General, on 11 August 1943, in acknowledging receipt of ColonelBadger’s interim report noted that:
* * * In the 3,031 persons examined, 1.1 percent hadevidence of re-infection type tuberculosis in their X-ray films. It isgratifying to note that 90 percent of the cases discovered were in the minimalstage, and that of the entire group of 35 cases, only five were considered tobe clinically significant.
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Attention is called to thefact that the arrested parenchymal lesions noted do not necessarily representinduction errors. Mobilization Regulations 1-9 permit acceptance of men witharrested tuberculous lesions of minimal extent, provided they do not exceed 5sq. cm. in total area in flat films, and their stability has been establishedby study of a series of films. Similar regulations apply in the case ofofficers.
Further data, indicating the results of followup on thesecases, are awaited by this office with interest.
Colonel Badger had expressed the opinion at the 25 June1943 meeting of the Medical Consultants Subcommittee that not all patients withminimal lesions need be returned to the Zone of Interior, and Colonel Middletonhad asked him to prepare an outline of proposals for dealing with patients withminimal lesions. Colonel Badger had then attempted to draw up criteria fordealing with these patients in terms of the formula of the 5-sq.-cm. areamentioned by Colonel Long. Both Colonel Middleton and Colonel Allen objected toa simple mathematical formula as the sole criterion. On 25 August 1943, ColonelMiddleton wrote to Colonel Badger, as follows:
If you share my objections to this criterion of thediameter of calcified lesions, you will certainly add some qualifications, suchas the clinical history of probable activity and the age of the subject.Colonel Allen has suggested a 30 year limit, but the final definition is inyour hands. What I am driving at is avoidance of a definition that fails totake into account the vital pictures of biologic resistance, and attempts tofix eligibility according to mathematical rules.
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Final decision had to await the results of the secondspot survey, planned for September or October 1943. The survey was carried outas scheduled in generally the same manner as the first, except that itconcentrated upon medical and infantry troops-the 49th and 168th StationHospitals and the 5th Infantry Division-recently arrived in the United Kingdomafter considerable service in Iceland. In addition, considerable numbers ofpersonnel from units in the Eighth Air Force were also examined by X-ray. Totalexaminations amounted to 3,634 roentgenograins of the chest. The results againindicated that there was no significant incidemice of unrecognized tuberculosisamong U.S. troops, that a mass survey was not indicated at that time, and thatperiodic spot surveys were the most appropriate means of determining whether ansignificant changes in the incidence of tuberculosis had occurred.74
In this second survey, X-ray examination of the personnelof the 49th Station Hospital in Scotland was conducted by that hospital, andthe plates were then forwarded to Colonel Badger and Major Smedal for reading.Another innovation concerned the field trial of an experimental auxiliary X-rayunit established by Colonel Allen. Sometime before the survey was begun,Colonel Middleton also wrote, in his letter of 25 August 1943 to ColonelBadger, as follows:
I am pleased that you areaffording Colonel Allen an opportunity of testing his field unit at the time ofyour next survey. From the personal conversations, I realize that he is loathto make such requests, in fear that you may think that he wishes to encroachupon your provinces. I know that he has no such design but visualizes this isthe only project in which he can test his field unit to a useful end withoutsetting up an artificial program.
On 21 September 1943 in a formal letter from the Officeof the Chief Surgeon, Headquarters, ETOUSA, to the Surgeon, Southern BaseSection, it was requested that Colonel Badger give an experimental auxiliaryX-ray unit a 30-day field test and report on the adequacy of the equipment andthe quality of the technical work performed. Unfortunately, Colonel Allen wason temporary duty in the North African theater during the latter part ofSeptember and the first half of October 1943 ; thus, when the auxiliary X-rayunit (fig. 139) was turned over to Colonel Badger, equipment difficulties hadnot yet been satisfactorily resolved, and the three enlisted technicians werenot yet adequately trained. As a result, no field trials were conducted, butColonel Badger was able to experiment further with the equipment, train theenlisted men and make recommendations for modification.75
During the period of this second survey, the 35individuals with parenchymal lesions previously discovered were followed upthrough Colonel Long, who wits able to trace 13 preinduction X-rays and toreinterpret them in the light of subsequent findings in the European theater.No significant differences were noted, and there were only minor variations ofinterpretation, owing to poor X-ray films. This small study confirmed theaccuracy of procedures being used in the European theater that showed that verylittle of importance
74 See footnote 73, p. 406.
75 Eventually, 12 auxiliary x-ray units were employed during combat in theEuropean theater.
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FIGURE 139.-Col. Kenneth D. A. Allen’s mobile auxiliary X-ray unit set up in the field.
had been permitted to escape the induction screening. Those who had escaped detection presented for the most part old fibrotic, apparently healed lesions, which had not broken down in an oversea theater.76
Within less than 1 year, considerable data had beenassembled from the two spot surveys and the collateral studies. In addition, aspecial series of 578 chest films had been made on prsonnel of theWoman’s Army Corps in England. The total number of individuals examinedby X-ray amounted to 7,243. The senior consultant in tuberculosis could now, withassurance, submit recommendations for the establishment of theater policy onthe disposition of tuberculous patients. This he did on 12 November 1943, in aletter to Colonel Middleton, who concurred in all but one detail; namely, theplace of gastric washings in the diagnosis of tuberculosis. ‘‘If weare to take the position that any essential element in laboratory diagnosis isa ‘burden’,’’ Colonel Middleton wrote to ColonelBadger, on 15 November 1943, “we close our doors to certain invaluableaids.’’
On 28 December 1943, Colonel Badger, in submitting toColonel Middleton revised recommendations in which the ultimate decision fordisposition was placed on the individual examiner, wrote the following:
No fixed scheme of classificationfor disposition of tuberculosis covers every case of disease. Therefore thefollowing criteria for disposition diverge from MR 1-9 on the basis
76 (1) See footnote 73, p. 406. (2) letter, Senior Consultant inTuberculosis, ETOUSA, to Office of the Surgeon General, att: Chief of Divisionof Tuberculosis (Thru: Office of the Chief Surgeon, Headquarters, ETOUSA),14 Nov. 1943, subject: X-ray of Soldiers in ETOCompared With Interpretation of Induction X-rays.
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of experience gained in the E.T.O. They are presented to serve as an objective basis on which the examiner may make his decision of disposition in an active theater of operations.
Certain of the lesions described present a precarious prognosis unless followed carefully over a period of months by clinical and X-ray observation. Under battle conditions in this theater such follow-up would be difficult if not entirely impossible and the evaluation of parenchymal lesions must be carried out to the best of the ability and wisdom of the examiner at a single hospital period of observation.
In addition, Colonel Badger gave detailed recommendationsfor (1) cases to be boarded to the Zone of Interior, (2) cases to be returnedto full duty, (3) cases to be returned to noncombat duty, (4) a yardstick todetermine activity in small lesions of doubtful stability, and (5) proceduresfor the follow up under battle conditions of individuals with small tuberculouslesions.
The revised recommendations were approved by ColonelMiddleton on 9 January 1944. The salient points were published on 22 February 1944in Administrative Memorandum No. 22, the Office of the Chief Surgeon,Headquarters, ETOUSA, to surgeons of all base sections and commanding officersof all U.S. Army hospitals. The yardstick for determination of activity insmall lesions of doubtful stability, published as paragraph 6 of the directive,was as follows:
* * * The clinical,laboratory and X-ray study necessary to clarify the status of the smallparenchymal lesion, thought to be tuberculosis, should fulfill the followingminimal standards:
a. Hospitalization for atleast a week, with limited ward activity.
b. Complete historyand physical examination with special reference to tuberculosis or otherpulmonary background.
c. Four hourlytemperature, pulse and respiration, which will be charted for clearerdetection of elevations.
d. X-ray and fluoroscopicstudy of the lungs on the 1st and 7th day of admission.
e. Complete blood andurine examination.
f. Sputum examinationdaily for tubercle bacilli, except where sputum is scanty, repeated 3-dayconcentrated specimens will be used.
In addition, sedimentation rate, aspiration of gastriccontents only with guinea-pig inoculation, and the tuberculin test were listedas additional procedures, not necessary routine. The directive concluded withthe following paragraph:
X-ray and clinical follow-up of individuals with small tuberculous lesions in this theater Battle conditions in this theater do not permit of clinical and X-ray observation for follow-up. The proper evaluation of these parenchymal lesions depends upon the ability and wisdom of examiner during a single hospital period of observation using paragraph 6 as the basic yardstick for evaluation of these lesions not proven to be active tuberculosis. Individuals presenting an undue risk of reactivation or who may become a source of tuberculous infection will be evacuated to ZI.
In addition to the directive, Colonel Badger prepared an article for the Medical Bulletin, European Theater of Operations. This article explained the underlying considerations for the decisions that had been made and elaborated on some of the finer points of the directive.
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Allergy
On 12 July 1943, a letter from the Office of the ChiefSurgeon, Headquarters, ETOUSA, instructed commanding officers of all U.S. Armyhospitals and general dispensaries to send to time 298th General Hospital allallergic patients under their care who required greater diagnostic andtherapeutic facilities, making the necessary arrangements in advance with timeCommanding Officer, 298th General Hospital.
The 298th General Hospital was an affiliated unit fromthe University of Michigan. Lt. Col. (later Col.) John McF. Sheldon, MC, Chief,Medical Service, 298th General Hospital, had brought with him a small but representativeselection of testing extracts as well as some therapeutic material from theallergy clinic of the University of Michigan Hospital. Previous to thedesignation of this hospital as the allergy center, a number of allergicinpatients and outpatients had been seen by Colonel Sheldon. When it becameapparent that allergic manifestations would present an increasing medicalproblem, more material for skin testing and desensitization had been acquiredfrom the University of Michigan Hospital, and Colonel Sheldon was also able toobtain additional diagnostic British grass pollen from Dr. David A. Williams,Llandough Hospital, Cardiff, South Wales.77 Thus, the opportunecombination of the foresightedness and initiative of an individual medicalofficer and the affiliation of the unit with a university hospital had madepossible a specialized allergy center.
In evaluating the hay fever problem, Colonel Sheldonsaid, at the second conference of the chiefs of medical services held on 30July 1943:
It is a seasonal disease,particularly in reference to pollinosis. It is only within the past year thatDr. Williams, University of South Wales, has carried out adequate observationsthroughout a large portion of the country. His information is not published. Hehas shown me his data. Particularly the grass family and specifically thoseclosely pathologically related to Timothy produce pollens for a rather shortseason, approximately 6 weeks. Our experience this year has follow-ed thispattern. We had rather a high rise in late June, which dropped in July.Timothy, plantain and the orchard grass group seemed to be the predominantoffenders. * * * We do not expect to have any important seasonal pollinosis,with the exception of that occasional case of hay sensitivity. We do not expectany of those patients w-ho had difficulty with time ragweed family at home tohave any trouble here. Grass sensitive people have just as severe symptoms hereas in the States. I do not believe that it is a great problem. There is also aquestion of sensitivity to that unknown factor that occurs in old houses. Thesepatients respond markedly to dust extracts.
Following Colonel Sheldon’s remarks, Colonel Middletoncommented: “We have not enough men or materials to duplicate the study ofsensitivity in many centers. For the time being those patients who do notrespond to ordinary measures should be sent to the 298th GeneralHospital.”
During the first 6 months that the allergy clinic wasoperating at this hospital, 293 consultations were held, and 98 cases ofbronchial asthma were evacuated to the Zone of Interior. In 1944, the 298thGeneral Hospital planned
77 Annual Report, 298th General Hospital, European Theater of Operations,United States Army, 1943.
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to have a separate ward for allergy and bronchial asthma patients. The anticipated greater need for diagnostic and treatment materials precluded continuation of the former informal means of obtaining them; requisitions were made through regular medical supply channels instead. Preparations for the invasion of the Continent and a change in mission for the hospital, however, prevented carrying through many aspects of these plans.78
Influenza
At a meeting of the Inter-Allied Conferences on War Medicine,Colonel Middleton reported the following: “In November 1943, an ominoussituation confronted us in an explosive epidemic of virus A influenza.Fortunately it was an inter-pandemic episode, free from complications andmortality. Had it been the first wave of a true pandemic, the invasion of theContinent would have been handicapped by the second and complicatedsequence.” 79
Epidemic influenza in England had been appearing in theodd-numbered years with a larger wave every fourth year. According to thisschedule, a moderate outbreak should have occurred in January 1943 and a severeoutbreak in January 1945. Had this expected influenza visitation of January1945 actually come about, its effects would have been severely felt by the U.S.Army whose hospitals, at that time, were filled to capacity with surgical andcold injury cases.80
As it was, the Committee on Infectious Diseases composedof Colonels Kneeland, Gordon, and Muckenfuss, at its meeting of 19 September1943 (p. 401), had already made preliminary plans in anticipation of theoccurrence of influenza. The committee had suggested the following:
In view of the fact thatinfluenza may at any time become an important cause of disability (and with theexperience of the last war in mind), it is considered wise to keep a closewatch on influenza-like conditions under treatment in hospitals. Here one isconfronted with a disease where definition is extremely difficult, and in whichroutine reports may give a thoroughly misleading picture. As the appraisal ofinfluenza requires a uniform critique it was suggested that the consultant makeperiodic visits to station hospitals in order to keep abreast of the situation.81
As with atypical pneumonia, the committee thought that,under the direction of Colonel Kneeland, it would be wise to collect limitedamounts of sera for antibody determination. Limited-scale virus studies couldthen be made by Capt. (later Lt. Col.) Joseph E. Smadel, MC, at the 1st MedicalGeneral Laboratory.
Just as the committee had anticipated, indications ofinfluenza appeared first in the fixed hospitals of the theater. The 108th, 32d,and 5th General
78 Annual Reports, 298th General hospital, 1943 and 1944.
79 Inter-Allied Conferences on War Medicine. Progress in War Medicine Since 1939, sec. XIII. Edited by H. L. Tidy. London: Staples Press, 1943.
80 The full implications of what would have occurred and observations onwhat actually transpired have been described by Colonel Kneeland in the chapteron respiratory diseases in “Medical Department, United States Army,Internal Medicine in World War II. VolumeII. Infectious Diseases.” [In preparation.]
81 Letter, Lt. Col. Yale Kneeland, Senior Consultant in InfectiousDiseases, to Col. William S. Middleton, Chief Consultant in Medicine, ETOUSA,27 Oct. 1943, subject: Meeting of the Atypical Pneumonia Board.
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Hospitals and the 130th Station Hospital reported almost simultaneously asignificant change in the clinical expression of respiratory diseases duringthe first week in November. Major Smadel established marked increase in thetiter of antibodies to virus A in typical subjects of the epidemic disease. 82
Colonel Kneeland, attending the Chief Surgeon’sConsultant Committee meeting of 22 November 1943, commented on the spread ofinfluenza in the U.S. and British Armies in the theater, where it had aroused agreat deal of interest and some alarm. He assured the conferees that there wasno reason to regard this epidemic as anything like that of 1918. He said that abrief note was being published in the Medical Bulletin of the Europeantheater and that a directive was being promulgated.
The directive, he said, would first cover clinical aspectsof the disease, pointing out that it is mild and almost invariablyuncomplicated. Medical officers would be exhorted to give the term“influenza” a fairly limited and precise significance, applying thediagnosis on epidemiologic grounds to an explosive disease of the clinicalcharacter described, occurring in groups and not in isolated cases. Thedirective would emphasize that the precise identification of the etiologicagent could only be made by a study of antibody titers in convalescents asopposed to acute symptoms in the clinical case. Because only a limited numberof these examinations could be made at the 1st Medical General Laboratory, itwas urged that serum specimens be sent through channels, while the 1st MedicalGeneral Laboratory should be consulted as to the desirability of submitting samplesfrom various types of cases. Finally, Colonel Kneeland reported, the directivewould cover treatment by the statement that it is systematic. It would notethat sulfonamides are contraindicated as being of no benefit except incomplications, and these almost never occur.
The meeting later turned into an open discussion of the epidemiology of influenza and the possibility of identifying factors that made the current epidemic skip a year and occur so late in season. The theme underlying this discussion was, of course, an attempt to determine whether it would be possible to predict the future occurrence of an epidemic of influenza.
The outbreak of upper respiratory disease continuedthroughout November. For the week ending on 26 November 1943, there were 11,300cases of acute respiratory infection among United States elements in thetheater. Some 600 of this number were reported as influenza, although it seemedlikely that much more than this was true epidemic influenza. The peak incidenceof these upper respiratory infections was reached during this week, but thepeak in the curve of reported influenza did not occur until the week ending on3 December 1943. After that date, there was a steady decline which paralleledthe decline for all respiratory disease.83 Influenza was never againa problem. Many theories were later proposed explaining the occurrence ofinfluenza at this time which, as if by fate, coincided with that period of theEuropean theater when it could best cope with the problem.
82 Annual Report, Chief Consultant in Medicine, ETOUSA, 1943.
83 Essential Technical Medical Data, Headquarters, ETOUSA, for months of November and December 1943.
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Malaria
The 1st Infantry Division was moved from Sicily to theUnited Kingdom in the first part of November 1943. Within a month, the divisionreported over 200 cases of malaria in hospitals or on quarters. At about thesame time, 27 cases of malaria occurred in a bomber group which had recentlyarrived in the United Kingdom via the southern ferry route. There was everyindication that the number of cases would increase with the shift of moretroops to England from the Mediterranean theater. 84
Colonel Middleton obtained data as to the actualincidence of clinical malaria from hospitals where cases were appearing. Twolengthy directives (Circular Letter No. 117 dated 12 August 1943, and CircularLetter No. 142 dated 17 September 1943) had been published by the Office of theChief Surgeon, Headquarters, ETOUSA, with respect to the management ofmalarious patients, but these were generally a mere restatement of opinionsreceived from the Office of the Surgeon General. The immediate need was formore specific instructions to meet the sudden rising incidence of malaria inthe theater. Accordingly, from the data at hand, the Office of the ChiefSurgeon, Headquarters, ETOUSA, on 16 February 1944, published Circular LetterNo. 24 on the management of the convalescence of malaria. The circular letteremphasized dietary, therapeutic, and psychologic means of insuring earlyconvalescence and rehabilitation of debilitated and depressed malariouspatients while avoiding serious relapses or postponement of completeconvalescence.
Colonel Middleton was aware, however, that there weremany unanswered questions as to the course of tertiary malaria and the efficacyof various regimens of treatment. In a letter to Colonel Middleton, GeneralMorgan in the Surgeon General’s Office, suggested approaches to the studyand solution of some of the most pressing questions. Colonel Middleton calledupon Colonel Muckenfuss and Maj. (later Lt. Col.) Henry P. Colmore, MC, to meetwith him as an informal malaria committee. Major Colmore, who was then assignedto the 2d General Hospital, was undoubtedly the best qualified officer in thetheater in the field of tropical diseases. Among other positions, he hadrecently been an associate on the staff of the School of Tropical Medicine, SanJuan, P.R.
The malaria committee met at the 1st Medical GeneralLaboratory on 10 March 1944 and made plans for a controlled study of benigntertian malaria. The study envisaged a pursuit of two problems: (1) Would thenatural course of the disease lead to a spontaneous “burning out”?(2) What were the effects in various dosages of certain agents such) as quinine,Atabrine (quinacrine hydrochloride) and Plasmochin Naphthoate (pamaquinenaphthoate)? It was proposed that subjects for the study could be obtained fromvolunteers suffering relapses of malaria. It was agreed that Major Colmoreshould be placed on temporary duty at the 1st Medical General Laboratory toconduct these studies. The plan was submitted to General Hawley for approvalthe
84 Essential Technical Medica Data, Headquarters, ETOUSA, for November 1943.
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following day. General Hawley initially disapproved the study but upon further consideration reversed his decision. 85
Major Colmore was able to begin the malaria study on 14 April 1944.86 At the outset, a problem appeared which prevailed throughout the study. The first 16 soldiers queried refused to volunteer for the experiment because of their desire to rejoin their organizations and buddies. As the invasion fever reached a higher pitch, this desire on the part of individuals to return to their units increased. There were also those who refused to cooperate because of past experiences with the disease. During the 1½ month period of the study, only 24 volunteers were obtained. Among the volunteers, there were extremely few cases that met the criteria required for a study of spontaneous remission; that is, chronic recrudescent uncomplicated benign tertian malaria.
Accordingly, therapy was withheld from no individuals. In order to determinewhether the small number of chronic recrudescences was merely a chance findingin the small group of 24 volunteers, Major Colmore questioned patients at the3d Station Hospital and examined the files of the Surgeon, 2d Armored Division,where there was a record of 2,454 individuals with one or more attacks ofmalaria. He determined that the recurrence rate for benign tertian malaria wasnot a problem and that it compared favorably with figures quoted for civiliansliving under less rigorous conditions. The interviews and examination ofrecords also revealed that there was a sudden increase in the incidence ofmalaria in March, April, and May, which was attributable to the characteristiclate relapse of benign tertian infection rather than to the chronicallyrecrudescent type.
Furthermore, the study of the relative effectiveness ofantimalarial therapy, including a comparison of Atabrine and quinine, with thenecessary followup procedures, was precluded by the impending invasion.Accordingly, Maj or Colmore spent a considerable period of the malaria study indevising a code for the classification of different patterns of relapses andrecurring malaria and analyzed the records of patients using this code.
Accepting Major Colmore’s recommendations, ColonelMiddleton discontinued the study in late May 1944. Partly as a result of MajorColmore’s studies, however, it was possible to plan for the expectedincidence of malaria in the coming invasion. Plans for the reception andtreatment of casualties with relapsing and recrudescent malaria were made byColonel Middleton with Colonel Kneeland, acting in his capacity as Consultantin Medicine, Southern Base Section, and with Lt. Col. (later Col.) Neil L.Crone, MC, Consultant in Medicine, First U.S. Army. On 18 May 1944, ColonelMiddleton conferred with General Hawley and Colonel Gordon as to the missionsand functions of preventive medicine personnel vis-a-vis agencies for theclinical treatment of malaria during the coming operations. On 20 May 1944, allthe previous
85 Memorandum, Professional Services Division, for Chief Surgeon, ETOUSA,11 Mar. 1944, subject: Proposed Research on Malaria, with comment 2. thereto.
86 Letter, Maj. H. P. Colmore, 1st Medical General Laboratory, to Chief Consultant in Medicine, Office of the Chief Surgeon, Headquarters, ETOUSA, 1 June 1944, subject: Study of Malaria.
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theater directives on the treatment and management of malaria were rescindedand replaced by one comprehensive and pertinent directive, Circular Letter No.73, Office of the Chief Surgeon, Headquarters, ETOUSA.
Other Activities
Among other activities engaged in by medical consultantsin the European theater, the following are worthy of mention in concludingthese paragraph on the buildup of U.S. Army forces in the United Kingdompreparatory to the invasion of continental Europe.
Typhus commission. - Colonel Kneeland was a memberof a three-man typhus commission from the European theater which visited theNear East and the North African theater in February and March of 1944. 0thermembers were Lt. Col. (later Col.) Emory C. Cushing, MC, an epidemiologistrepresenting the Preventive Medicine Division, Office of the Chief Surgeon,Headquarters, ETOUSA, and Major Smadel. The commission made a team approach tothe study of typhus and submitted its findings, by letter, dated 2 March 1944,from Headquarters, First Medical General Laboratory, to the Chief Surgeon,ETOUSA, subject: Report of Mission on Typhus, ETO. A complete discussion oftyphus fever in World War II can be found in other volumes of this history.
Recommendations concerning heart diseases. -Colonel Hein called attention to the possibility of traumatic heart diseaseswhich could easily be overlooked. One possible source of heart damage was lowoxygen pressures at high altitudes; another was accidents, as when a heavyobject falls upon the soldier. Electrocardiographic equipment was placed in allgeneral hospitals and proved very useful in making reliable decisions for thedisposition of patients. Placement of electrocardiographic equipment, and basalmetabolism apparatus as well, in certain station hospitals was on severaloccasions recommended to General Hawley, but hie remained opposed to theextension of these functions to station hospitals. Courses in the use ofelectrocardiographic equipment were given at the European theater Medical FieldService School. As a result of recommendations on arterial hypertension made byColonel Hein, it became acceptable policy to retain in the theater thoseindividuals whose only abnormality was an elevation in blood pressure.87
Penicillin study. - Colonel Kneeland on 1 June1944, submitted a report to Colonel Middleton on a study of nearly all cases(except venereal diseases) treated with penicillin on the medical services ofU.S. Army hospitals in the United Kingdom over the preceding 8 months. Owing toshortages of penicillin, its use in medical cases was limited to those in whichit was thought essential to recovery. In only a few cases of lobar pneumoniaand one of meningitis was it used deliberately for experimental purposes as theonly therapeutic agent. It was impossible to draw any conclusions from manycases in which it had been used in conjunction with other agents; other patientswere
87 Minutes of meeting, Medical Consultants’ Subcommittee, 24 Jan. 1944.
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first treated with penicillin when obviously moribund. There were,nevertheless, some cases in which the diagnosis was unequivocal, and the effectof penicillin could be clearly discerned.
Limited as he was by the type of data available andconsidering the shortage of penicillin, Colonel Kneeland ventured to say thatthe paucity of cases for study in itself indicated that, apart from venerealdisease, there were comparatively few medical cases in Army hospitals thatabsolutely required this antibiotic. Sustaining previously known fact, therewas evidence that penicillin was the most effective agent available at the timeagainst general infectious due to staphylococcus. It also appeared to be highlyeffective against the meningococcus and the pneumococcus, although itssuperiority to sulfonamides in these fields was not unequivocably demonstrated.Nevertheless, Colonel Kneeland thought that its use was indicated as an adjunctto sulfonamide therapy in overwhelming infections due to either of thesebacteria. Lastly, Colonel Kneeland stated that, when penicillin was employed inmixed infections, the results were likely to be disappointing.
This pennicillin study concluded by Colonel Kneeland,limited as it was in many ways, was nevertheless of considerable importance inmaking plans for the next phase of operations in the theater.
NORMANDY INVASION AND CAMPAIGNS IN NORTHERN FRANCE
First and foremost in the minds of all stationed in theUnited Kingdom was an eventual assault on the Continent. As the buildup inEngland and Northern Ireland continued until it seemed as if the United Kingdomwere completely saturated with the tremendous concentration of men andmateriel, excitement over the invasion rose to fever pitch. However, the soberpicture of thousands of battle casualties and soldiers becoming seriously illunder time primitive conditions of land warfare served to temper, for themedical officer, excitement over the prospect of coming to grips with the enemyon his own ground. To insure the U.S. soldier prompt medical attentionregardless of how or when the need for it arose, plans that were flexible,practical, and always current were required. To this end, each division ofGeneral Hawley’s office maintained a policies-and-procedures document formounting the operation. Colonel Middleton, accordingly, contributed to thepolicies-and-procedures document of the Professional Services Division, Officeof the Chief Surgeon, Headquarters, ETOUSA.88
Preparatory Measures
Regardless of how worthy a plan might appear on paper, itcould never be more effective than the means available to implement it. Theprimary problem was one of personnel. There should have been qualified medicalofficers
88 Memorandum. Chief Consultant in Medicine, for Chief Surgeon, ETOUSA, 5Apr. 1944. subject: Medical SOP. for Evacuation from “Overlord.”
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in all echelons of evacuation and in all installations where casualties fromthe operations could be expected, but thus was not the case. The problem hasbeen discussed elsewhere (p. 248), but it is worthy of note here that, as earlyas February 1944, Colonel Middleton had surveyed the fixed hospitals of thetheater and had compiled a list of 89 officers who could be used to strengthenunits arriving from the Zone of Interior or transferred elsewhere as required.89Even at a time when the invasion was imminent, a survey of key fixed hospitalsrevealed the need to replace the chiefs of medicine in two general hospitals.
Forward medical echelons were provided with large amountsof diphtheria antitoxin, and motion-sickness preventives were issued on thebasis of 10 capsules per individual. In addition, a 2 weeks’ supply ofAtabrine was provided each soldier with a previous history of malaria. The U.S.Army in the European theater was dependent upon British sources for many itemsof supply, among which were respirators. Through the auspices of the MedicalSubcommittee, Army Medical Consultants, Committee of the Royal Army, ColonelMiddleton was able to obtain a promise for 18 respirators to be used in timeamphibious operation.90
Colonel Middleton and his subordinate consultants in thebase sections insisted in all their contacts with hospitals that the medicalservice must be prepared to function under the central leadership of thecommanding officer to insure teamwork under stress. In order to achieve thisflexibility, 4 officers from the medical service were trained to head shockteams working under the direction of the chief of surgical service, and 2officers from the medical service were trained in anesthesia. Thesearrangements applied to all 750-bed station and 1 ,000-bed general hospitals,with a proportionate ratio of officers to be trained for these functions in themedical services of smaller hospitals (fig.140).91
Initially, it was thought that triage of patientsaccording to their diagnoses would be possible at the hards where patients wereto be unloaded following evacuation across the Channel by ship. Accordingly,Colonel Middleton and Colonel Kneeland, the latter in his capacity as themedical consultant for the Southern Base Section, selected and designated awell-trained clinician for each point of triage. Specific plans were also madeby Colonels Middleton and Kneeland for the evacuation of patients withcommunicable diseases and all those who were seriously ill to designatedhospitals.92
After the transit hospitals were designated (p. 329),Colonel Middleton made a tour through each of them to give personal instructionin certain basic principles of reception and evacuation of medical casualties.In addition, field hospitals were to be set up in close vicinity to the hardsas holding units to
89 Memorandum, Professional Services Division, for Chief Surgeon, ETOUSA,24 Feb. 1944, subject: Medical Officers Available for Transfer to Units.
90 Memorandum, Professional Services Division, for Chief Surgeon, ETOUSA, to Mar. 1944, subject: Medical Subcommittee, Army Medical Consultants’ Committee.
91 Essential Technical Medical Data, Headquarters, ETOUSA, for June 1944.
92 See footnote 88, p. 419.
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receive casualties who could not stand the 15- to 20-mile ambulance trip tothe transit hospitals (fig. 141). 93 Colonels Middleton and Kneelandmade a survey of all these hospitals in the early spring of 1944 and drew thefollowing conclusion, which was included in the theater chiefconsultant’s evacuation plans for OVERLORD:
The qualifications andprofessional performances of the several officers of the Medical Services havebeen carefully reviewed with the Consultant in Medicine of the Southern BaseSection * * *, It is our measured judgment that the strength andprofessional abilities of the involved units are equal to the anticipated task.However, to avoid confusion under the pressure of operations, it is urged that a reserve of qualified internists beset up in the Southern Base Section for mobilization upon demand. In allprobability a number not to exceed four (4) for each of the Transit Hospitalswould meet any need.
At what turned out to be nearly the last minute, twoelements of the basic plan were charged. There was to be no medical triage atthe hards. There were to be no specialized hospitals for the treatment ofspecific conditions. The seriously ill and those with communicable diseaseswere to be sent to the most accessible transit hospital. The category ofnontransportable patients was to include the following: Communicable diseases,meningococcal infections, pneumonia and pneumococcal infections, septicemia,diabetic coma, uremia, coronary occlusion, bleeding peptic ulcer with dangerousblood loss, and serious pulmonary hemorrhage. It was expected that thesepatients after
93 See footnote 79, p. 414.
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FIGURE 141.- Receiving area, 58th Field Hospital near Weymouth, England, 12 June 1944.
appropriate treatment would become transportable within a very short time, whereupon they would be removed to a more remote hospital.94 The only triage which could be carried out was the sorting of transportable and non-transportable patients at the transit hospitals.
Throughout this whole preliminary period, ColonelMiddleton held frequent conferences with the medical consultants in the Firstand Third U.S. Armies and Southern Base Section to correlate and define theirrespective functions. This having been done, Colonel Middleton delegated theresponsibility for supervising the reception and movement of medical patientsin transit hospitals to Colonel Kneeland.
Estimate of the situation. - Only a month beforethe invasion actually took place, Colonel Middleton thought that the medicalservices of the theater would be faced with the following situation:
An accurate estimate oftime expected load of time OVERLORD OPERATION must depend upon a number ofunavailable factors. However, upon past experience in overwaters operations thecategories may be divided into three groups, namely, wet, wounded and sick.Provision should be made for the exhausted, wetsoldiers who are not sick or wounded. Past experience has indicated that theyprove a considerable load upon hospital beds for hours or at most a few days ** *
94 Letter, Office of the Chief Surgeon, ETOUSA, toSurgeon, Southern Base Section, ETOUSA, attention: Consultant in Medicine, 30Apr. 1944, subject: Provision for Care ofMedical Casualties Evacuated From “Overlord.”
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Obviously, the woundedwill constitute the overwhelming majority of early casualties. Thispredominance will probably amount to 80 percent of the total for the first 24hours. For the first week it is estimated that the total load will be 60percent surgical, and 40 percent medical. After the first week a fair estimatewill reverse this figure. On this basis, 400 medical patients may he anticipatedout of each 1,000 evacuees to the near shore. For the first week of such anoperation, a fair estimate would give an overall figure of 25 percentneuropsychiatric casualties. Hence, 250 of the 400 medical patients would beneuropsychiatric, and 150 sick. On thebasis of available data, 100 of these medical patients would be seriously illand 50 would have lesser ailments. After the first week it is predicted thatthe figures for neuropsychiatric and medical patients will be reversed.95
The Invasion and Its Aftermath
On 4 June 1944, just 2 days before the invasion, allconsultants in the Office of the Chief Surgeon, Headquarters, ETOUSA, receivedthe following directive from Colonel Kimbrough:
In the continentalliberation, the members of the consultant group will carry out their duties itsconsultants in the transit hospitals and other hospitals in echelons in therear of the transit hospitals.
The consultants’activities in echelons forward of the transit hospitals will be carried [out]at the direction of the Chief Surgeon, ETOUSA, and the surgeons of suchechelons.
These restrictions were no hardship to the theater chiefconsultant in medicine since he had, from the beginning, planned to operate inthis manner.
On D-day, 6 June 1944, Colonel Middleton by chance hadarranged for a field trip to three transit hospitals, the 38th Station Hospitaland the 48th and 158 th General Hospitals at Stockbridge, Hantshire, andOdstock, respectively. The units had received orders to evacuate alltransportable patients, and Colonel Middleton observed that they carried outthis mission with great facility and complete lack of confusion. Refrainingfrom further movement in the area of transit hospitals, Colonel Middleton, fora period of about 3 weeks, confined his activities to fixed hospitals of therear echelon of the Communications Zone. His observations, made during June1944, were as follows:
The expeditious,thouqhtful and adequate reception of hospital trains and convoys. This circumstance applied almost universally and wasmost conspicuous in new and untried units. Their pride in accomplishment wasonly equaled by the Chief Consultant’s appreciation of the strides inorganization made under pressure (fig. 142).
Condition ofpatients. As a clinician, one couldnot escape the impression of the uniformly good physical status of allpatients. Hundreds of temperature charts were reviewed, with fever as the rareexception, a circumstance in startling contrast to the experience of World WarI.
Specialproblems. Isolated instances ofhemothorax and pneumothorax led to the early suggestion of the assignment of anofficer from the Medical Service to each surgical ward receiving such patients.This opportunity for co-ordinated effort has been early implemented to theadvantage of the wounded soldier.
Minorcasualties. In the original medicalS.O.P., attention was called to the desirability of diverting “wet”soldiers from lines of evacuation. An oversight of this principle led to theoccasional movement of variable personnel well to the rear, into fixedhospitals, when a change of clothing might have returned them to active dutyfrom shipboard or at the wards
95 See footnote 88, p. 419.
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FIGURE 142.- Continued. C. Care andattention on hospital train during evacuation in England.
(fig. 143). An amazingly high incidence oftrivial wounds, that might well have received simple dressings and returned toduty, was encountered in these hospitals (fig. 144).
Morale. The general observation of extremely high moralecontrasts with reports from certain other operations. This reactionunquestionably reflects upon the quality of the command as well as thestability of the soldier. With few exceptions these men were keen to return tothe fight. It pays to have handling operations, so expensive in manpower andmateriel, well covered by naval and air protection. The soldiers commented atgreat length upon these advantages.
Medicalcasualties. The proportion of medicalevacuees from the continent has risen from approximately 3 percent for thefirst week to 5 percent for the second week and 10 percent for the third. Thesefigures are far below the anticipated level, a circumstance which may beexplained by the policy of evacuation from the far shore, or by the unusualhealth of the command in France. Certainly, we may anticipate adequate care ofthe sick, whatever the command policy may be.
Relapsing malaria has beenthe most frequent cause of evacuation. In all instances this may be traced to adiscontinuance of supervision of Atabrine therapy, although a two weeks’supply was afforded to each soldier with a previous malarial history.
A specific problempresents itself in the unexpectedly low incidence of shock neurosis. ColonelThompson’s figure of 2.4 percent contrasts rather sharply with theBritish figure of 10-12 percent for the same operation. Again, this may reflectthe unusual selection of troops for this operation, or the high morale of thesame. It will be most interesting to evaluate the experience in the light ofprophylactic measures taken against battle fatigue and neurosis us theindoctrination of line officers as well as medical officers of the First Army. 96
96 See footnote 91, p. 423.
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FIGURE 143.- ”Wet” casualties ofNormandy invasion reach English shore, 7 June 1944.
It is the customary fate of predictions that they must bemodified in the light of subsequent events, and plans based upon them must alsobe changed. For Colonel Middleton, the change was a favorable one. The lightload of medical evacuees gave him an early opportunity to survey the medicalsituation in the First U.S. Army. The Chief Surgeon, ETOUSA, and Surgeon, FirstU.S. Army, both approved an early visit by Colonel Middleton to the combat zone(fig. 145). During the period from 29 June to 2 July 1944, Colonel Middletonwas provided every facility for the observation and study of medical operationson the Continent. Upon his return to England, he summarized his findings asfollows:
Distribution ofcasualties. In the period from 6-23June, approximately 2,664 medical patients have been received in the hospitalsof the First Army. This number represents approximately 9 percent of the totalcasualties. In the same period, 2,007 (8 percent) neuropsychiatric subjectshave been admitted. The combined figure of 17 percent represents a very smallproportion of the total physical load.
Hospitalfacilities. Under combat conditionsthe establishment, activation, mobilization and movement of evacuation hospitalunits have been effected expeditiously and smoothly. This circumstance hasinsured available beds for all casualties, medical as well as surgical.
Special hospitalfacilities. Perhaps the mostoutstanding innovations in the accommodation of army hospitalization to thespecial needs have been the establishment of Combat Exhaustion Hospitals andthe utilization of the 4th Convalescent Hospital for the care of venerealdiseases, among other casualties. The diversion of these constant drains uponthe beds of mobile hospitals insures a far greater flexibility in theutilization of such facilities for the traumatic conditions of combat.
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Team work. Under the pressure of combat conditions, all ranks and grades of the Medical Corps have been welded into an effective machine for the care of the sick and wounded. Particular commendation is due the members of the Army Nurse Corps and enlisted personnel, whose arduous duties are being cheerfully and competently fulfilled. The esprit de corps is excellent.
Professionalservices. The high quality ofleadership of the [Medical] Consultant of the First Army is reflected in thestandards of medical service to soldiers in all institutions visited. Thisguidance is not only administrative but it has also taken the form of directprofessional consultation, educational effort through the Medical News Letterof the Surgeon of time First Army, and personal precept on every availableoccasion.
Special medicalproblems. No communicable disease hasyet been encountered in epidemic proportions. Occasional instances of mumps,meningitis, pneumonia (pneumococcal and atypical), dysentery and German measleshave been reported.
Malaria alone presents aproblem of numerical proportions sufficient to require special thought * * *
Pleurisy has been anoccasional problem. The [Medical] Consultant has recommended that pleurisywithout effusion (dry) be observed for a period of several days, and if thetemperature [drops] to normal within three or four days, the patients beretained in the Army. Pleurisy with effusion is immediately evacuated to fixedhospitals in the Communication Zone.
Primary atypicalpneumonia. Primary atypical pneumoniahas not been a problem, but in the absence of serious constitutional symptomsand early fall of temperature to normal, such patients may be retained in theArmy.
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FIGURE 145.- Normandy beachhead at time ofColonel Middleton’s visit, 1 July 1944.
Bacterialpneumonia, Meningococcal infectionand Infectious hepatitis will be sent to hospitals in theCommunication Zone.97
In addition to the foregoing, Colonel Middleton observedand reported on the handling of venereal disease, and neuropsychiatricpractices which have been described in Parts II and III, respectively of thischapter.
As of the end of July 1944, the medical load in the fieldand in fixed hospitals in the theater continued to be surprisingly light. Nocommunicable disease had occurred in epidemic proportions.
In a survey of 15 general hospitals with respect topersonnel professional qualifications, it was found that of 248 medicalofficers 71 had had only 9 months of internship. The deficiencies in specialskills had to be compensated by continuing the policy of moving provedinternists from units older in the theater to newly arriving units.98
As of the end of August 1944, the medical load of thetheater, including neuropsychiatric cases, was 15 percent as compared with 85percent for surgery, with relapsing malaria the only continuing problem of anyproportions. The mobility of the armies (fig. 146) and the policy of keepingtowns out of bounds had limited contacts with civilians and forestalled theanticipated increase in communicable disease, including gonorrhea and syphilis.
97 See footnote 91, p. 420.
98 Essential Technical Medical Data, headquarters, ETOUSA, for July 1944.
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FIGURE 146.- Breakthrough at St. Lô, medical personnel and equipment of Advanced Section, Communications Zone, move through ruins of St. Lô
During August, 1 station and 11 general hospitals were surveyed. For this survey, Colonel Middleton had to call upon Colonels Hein and Kneeland, who were then consultants in medicine to the Western and Southiern Base Sections, respectively. With few exceptions, the hospitals surveyed required better qualified personnel to fill the top positions in their medical services. In consequence, there was a dilution in the professional skills of the stronger, older units of the theater, but with these transfers there also came an opportunity for well-merited promotions.99
Malaria
The occurrence of malaria during this period resultedfrom two conditions in almost all cases; that is, relapses of early clinicalmalaria or clinical expressions of earlier parasitism without actual disease.Most of the cases were limited to four divisions which had previously served inthe North African theater. The more common cause was relapsing malaria. Thisoccurrence had been anticipated by providing Atabrine for suppressivetreatment, and the appearance of clinical malaria in large numbers during thisearly phase of combat operations indicated breaches in Atabrine discipline orfailure in the supply of Atabrine. Exposure, physical chilling, and theexcitement of combat (through release of
99 Essential Technical Medical Data, Headquarters, ETOUSA, for August1944.
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adrenalin by the emergency mechanism of Cannon) may have been factors in precipitating attacks.
Colonel Crone, of the First U.S. Army, divided patients manifesting clinical malaria into complicated and uncomplicated cases. Complicated eases were defined as those having more than three relapses with one or more of the following conditions: Splenomegaly, anemia, or continued debility. Patients with these conditions were discharged from the Army. The uncomplicated cases were the objects of concern as to possible saving in manpower. These patients were initially treated in immobile hospitals of the army for a period of time necessary to fit them for ambulatory treatment in the 4th Convalescent Hospital assigned to the First U.S. Army. Colonel Crone estimated that for 75 percent of the patients the period spent at the convalescent hospital was 5 days. This policy effectively and noticeably reduced evacuation of malaria casualties to the United Kingdom, while at the same time use of the convalescent hospital as a holding facility kept these patients from overburdening and clogging the main lines of evacuation.100
By the end of July, the medical service in the First U.S.Army had done all it could to control the malaria situation and to advisecommanders of necessary corrective measures. However, there was no abatement ofthe incidence of clinical malaria. The 91st Gas Treatment Battalion had beenbrought in to care for the increased load and was caring for some 400 malariouspatients at this time. By all criteria, the supply and the dosage of Atabrinehad been adequate to meet the needs for the affected individuals of the fourdivisions known to contain all of the potential malarious subjects. On 29August 1 944, Colonel Middleton was obliged to advise General Hawley concerningmalaria control, as follows:
Obviously, the problem has continued beyond reasonablelimits for causes that are now controllable. Atabrine in full doses for suppressivepurposes 0.1 gram daily will prevent the clinical manifestations of malaria inan overwhelming majority of instances. The attrition in manpower from thiscause has not been disabling, but the Command responsibility for the activeadministration of the drug should be reiterated in the interest of moreeffective control.
Tuberculosis
At a meeting of the Medical Consultants, Subcommitteeheld in January 1944, Colonel Badger mentioned his concern over a certain lackof consideration for the individual tuberculous patient in his processing andevacuation to the Zone of Interior. Colonel Middleton asked him to look intothe matter and submit recommendations at a later date. The impending invasionof the Continent and the dissolution of specialized treatment facilitiessupplied urgency. Heretofore, tuberculous patients to be evacuated to the Zoneof Interior had been transferred to the 298th General Hospital for care andtherapy until transportation became available.
100 See footnotes 91, p. 420, and 98, p. 428.
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The day after the invasion took place, 7 June 1944,Colonel Badger hastened to submit his recommendations to Colonel Middletonconcerning the treatment and evacuation of tuberculous patients. He urged thatpneumothorax treatment be used only for the emergency case of tuberculosis orwhen delay would be injurious to the patient because of hemorrhage or theprogressive nature of the disease. He pointed out that collapse therapy wasbest initiated and carried on when the course of treatment would not beinterrupted by frequent transfer of the patient from one operator to anotherand, usually, when preceded by a month to 6 weeks of absolute bed rest withgood diet and nursing care. Colonel Bad!ger noted:
The necessity for frequent refills to the early stages ofpneumothorax treatment, and the complications associated with the interruptionof treatment in the course of transport, entail hazards for the patient whichwill either cause delay in transfer to the Zone of Interior, or necessitateconduct of the case by numerous medical officers of varying ideas andexperience in collapse therapy. Delays in refills and complications associatedwith early pneumothorax treatment have been proven unavoidable during thenumerous evacuation episodes that mark the course of every transportation tothe Zone of Interior.
In addition, Colonel Badger urged that boarding andevacuation procedures be materially speeded up in patients admitted to generalhospitals with a definite diagnosis of tuberculosis. He noted also the practiceof allowing patients with serofibrinous pleurisy, whose temperature hadreturned to normal and whose fluid had been absorbed, to return to the Zone ofInterior as ambulatory cases.101 He strongly recommended that allpatients with active tuberculosis be returned to absolute bed rest for the entiretrip.
All of Colonel Badger’s recommendations wereamplified and incorporated into a directive which was issued from the Office ofthe Chief Surgeon, Headquarters, ETOUSA, as circular Letter No. 100, dated 25July 1944. This circular concluded with the statement:‘‘Recommendations for treatment at absolute bed rest for timeentire trip will be entered on the patient’s medical record by themedical officer in charge.’’
In the meanwhile, Colonel Badger had been transferred tothe Office of the Surgeon, Forward Echelon, Communications Zone, andsubsequently to the 15th Hospital Center, while still retaining his position asthe Senior Consultant in Tuberculosis ETOUSA. Shortly after D-day, ColonelBadger conducted a field through station and general hospitals in the WesternBase Section to discuss and evaluate tuberculosis problems. He had alsorequested a report from the chief nurse of the European theater, showing casesof tuberculosis and serofibrinous pleurisy among nurses who had been evacuatedto the Zone of Interior. His survey confirmed the fact that tuberculosis was atits lowest ebb and did not constitute a serious problem.102 Thereport on the incidence of tuberculosis in nurses, although not equated fordifferences in the numbers of
101 Letter, Lt. Cot. T. L. Badger, to Col. E. R. Long, Chief, Division ofTuberculosis, Office of the Surgeon General, 1 July 1944.
102 Letter, Lt. Col. T. L. Badger, to Surgeon, Western Base Section, ETOUSA, 2 July 1944, subject: Report of the Senior Consultant in Tuberculosis.
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nurses, nevertheless seemed to indicate a considerable increase in thesecond year of the theater’s activities.
In a letter to General Hawley on 14 August 1944, ColonelBadger recommended a spot survey by X-ray for tuberculosis in nurses in 2general and 2 station hospitals, which had been in the theater from 18 to 24months, and in 2 general and 2 station hospitals, which had been in the theater3 to 6 months. He assured General Hawley he would impress each hospital thatthese X-rays were to be taken at their convenience and when their workload wasslack. Colonel Allen, the theater consultant in radiology, approved the use ofX-ray films to conduct this spot survey involving 584 nurses, and both ColonelsMiddleton and Kimbrough recommended approval. General Hawley, however, repliedto Professional Services Division as follows: “I am sorry but we arefighting a very rapid war at this moment and such surveys will have to waituntil this thing slows down a bit.”
And indeed, the fighting was turning into rapid pursuit.The Allies, having emerged from the hedgerows of Normandy, appeared to be onthe verge of an unimpeded onslaught to the Rhine and into the Lowlands.
FINAL OPERATIONS
By the end of September 1944, most of the theaterheadquarters had moved to France, including General Hawley’s office. Inits wake, a separate command under Communications Zone headquarters had beenestablished in England effective as of 10 September 1944, 103 anddesignated the United Kingdom Base Section. Its surgeon was Colonel Spruit,formerly the theater deputy chief surgeon. Colonel Kneeland was named as hisconsultant in medicine. On the Continent, the Communications Zone had beensolidly established with six base sections and the Advance Section,Communications Zone. Thirty general hospitals had been moved to the Continent,of which eighteen were operating. At the front, the Third U.S. Army had enteredcombat on 1 August and was now assaulting the Siegfried Line on the centralfront south of the First U.S. Army. The Ninth U.S. Army had entered combat inearly September during the siege of Brest and other French ports, and theSeventh U.S. Army, after landing in southern France on 15 August 1944, hadadvanced northward and during September came under the operational control ofthe European theater commander. The battle for Germany itself had just begun.
This splitting of medical resources between the UnitedKingdom and the Continent placed Colonel Kneeland in a unique position amongthe medical consultants subordinate to the chief consultant in medicine. Firstof all, the evacuation policy on the Continent was 30 days, while for thetheater as a whole it was 180 days. This meant that the greater part of definitivetreatment was being carried out in the United Kingdom. Colonel Kneeland’sduties, as a member of the Professional Services Division, Office of theSurgeon,
103 General Order No. 35, headquarters, Communications Zone, ETOUSA, 15Aug. 1944.
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United Kingdom Base, were to (1) review treatment procedures, (2) select individualsfor professional training, (3) supervise research in military medicine, (4)control activities of hospital center medical consultants, and (5) inspect andevaluate professional care in the United Kingdom.104 ColonelMiddleton, engaged across the Channel, had to delegate many of his ownsupervisory functions, particularly in research activities, to ColonelKneeland. He had to delegate to him also many of his close associations withBritish medicine, both civilian and military, which had proved so profitable inthe past. For example, Colonels Kimbrough, Cutler, and Middleton, as chief ofprofessional services and chief consultants in surgery and medicine,respectively, formerly represented General Hawley at meetings of the PenicillinTrials Committee of the British National Research Council. This function had tobe delegated to the surgical and medical consultants of United Kingdom Base.
The first problem to be discussed in this periodoriginated in the United Kingdom.
Sulfadiazine Prophylaxis
The Army Air Forces in Britain requested permission ofthe Chief Surgeon to use sulfadiazine as a prophylaxis against respiratoryinfections and presented information from the Air Surgeon as to its efficacy.There were certain conditions in the theater, however, that militated againstan uncritical approval of the proposed project. The request was referred forconsideration to the Committee on Infectious Diseases which was to meet on 28September 1944. Later, the committee coordinated its deliberations with ColonelGordon, who had not been present at the September meeting.
The committee defined limited indications for the use ofsulfadiazine as a prophylaxis. Two such limitations were when pivotalindividuals had to be maintained in a state of excellent health and whencertain communicable diseases had reached specified critical levels. Thecommittee recommended a period of 4 weeks as sufficient to protect againstrisks of major epidemics and pointed out specific controls that should beobserved in administering the drug. The committee concluded its comments, asfollows:
This Committee agrees thatthe results of sulfadiazine prophylaxis may well prove to be as satisfactory asThe Air Surgeon’s memorandum would indicate. It still, however, isopposed to the idea of distributing a powerful drug on a very large scale as acommand function unless considerations of importance in regard to the wareffort warrant such distribution. It is for this reason that the Committee hastaken its position that the indications for sulfadiazine prophylaxis arestrategic.
Sulfadiazine prophylaxis admittedly does not controlvirus diseases, including influenza, and it is not strikingly efficaciousagainst secondary bacterial infections of a mixed character, includingpneumococcal infections. In the past two years, meningitis and streptococcalinfections, which are most favorably [affected] by sulfadiazine prophylaxis,have not been epidemic in this Theater. Thus when the question is considered inrelation to SOS troops in the United Kingdom, the Committee is opposed tosulfadiazine prophylaxis unless the pattern of epidemic disease is materiallyaltered.105
104 Annual Report, United Kingdom Base, 1944.
105 Essential Technical Medical Data, Headquarters, ETOUSA, for September 1944.
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The committee voiced no objection against trial use ofthe drug by the Army Air Forces. It also recommended that a small controlledexperiment on the prophylactic use of sulfadiazine be carried out in one ormore hospital units of the theater.
Col. Joseph C. Turner Chief, Medical Services, l54thGeneral Hospital, near Wroughton, England, was selected to conduct the limitedstudy recommended by the committee. He divided half of the hospital’senlisted complement into two experimental groups-one receiving 0.5 gm. ofsulfadiazine daily and the other receiving 1.0 gm. daily. The other half servedits controls. The Eighth Air Force in England conducted a clinical trial in theprophylactic use of sulfadiazine in four stations of its Air Service Command.There were a few toxic reactions, none severe. However, several Air Forcepatients who were admitted to hospitals for diseases other than upperrespiratory infection became toxic from the additional therapeuticadministrations of the drug. Colonel Spruit had to notify all hospitals to askAir Force patients if they had had experimental doses of sulfadiazine prior toinitiation of sulfonamide therapy.106
The drug trials at the 154th General Hospital and in theEighth Air Force Air Service Command were continued throughout the winter of1944-45. In the meantime, TB MED (War Department Technical Bulletin) 112, issued1 November 1944, authorized the prophylactic use of sulfadiazine at thediscretion of the theater commander, under circumstances and by methodspractically identical with those previously recommended by the Committee onInfectious Diseases. As a result, sulfadiazine was used prophylactically inother isolated instances with varying results.
In his final report on his experiments, Colonel Turnernoted that the results of such tests hinged to a considerable extent on thepattern of disease that chanced to unfold. In this case, the winter provednoteworthy for the rarity of severe diseases of the respiratory tract, andhemolytic streptococcal infection was seldom seen.
“Thus the epidemiological conditions developing inthis experiment were not strictly comparable to those obtaining for most groupsreported on by others,’’ wrote Colonel Turner. ‘‘Theyset, rather, the question of how sulfadiazine prophylaxis will influence upperrespiratory tract disease which is mild and mixed and non-streptococcal incharacter.’’
After almost 5 months of trial, Colonel Turner found theanswer to this question. He reported: “The incidence of mild upperrespiratory infection was about the same for both treated and control groups.Sulfadiazine did not appear to influence the occurrence of colds or of chronicupper respiratory infection.’’ 107
The Air Force study, on the other hand, indicated thefollowing results from use of prophylactic sulfadiazine: (1) A reduction in thenoneffective rate due to respiratory disease (patients admitted to hospitalsand quarters) as well
106 See footnote 104, p. 433.
107 Essential Technical Medical Data, headquarters, ETOUSA, for April 1945.
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as for those treated on a duty status, (2) a similar reduction in theincidence of gonorrhea, and (3) a reduction in the number of individuals thatwould probably have been affected by a diarrheal outbreak in which theetiologic agent could not be definitely identified. The results were, however,inconclusive with respect to the pneumonias. 108
Diphtheria
As the concentrated attacks on the defenses of the Germanhomeland grew in intensity, more and more prisoners were captured. Togetherwith the increased influx of German prisoners, the first sporadic cases ofdiphtheria were seen. This had been expected, and the supply of antitoxin wasadequate. By mid-October 1944, when Colonels Middleton and Pillsbury made atour through the medical installations of First and Third U.S. Armies,diphtheria was occurring in increasing numbers among prisoners of war, andcases had appeared in U.S. troops. It was observed that penicillin was provingto be remarkably efficacious in the treatment of diphtheria. To date, it hadbeen used primarily in patients sensitive to foreign serum or in the fewinstances where antitoxin was not immediately available. Colonel Middletonadvised extending the use of penicillin to patients with grave toxemia, forwhom the combined administration of diphtheria antitoxin and penicillin mightoffer a better prospect than antitoxin alone. Colonel Middleton also consideredthe possibility of penicillin application to the carrier state.
It was necessary first to gather data on the actualefficacy of penicillin in the treatment of diphtheria while discouraging itsimmediate acceptance as a substitute for antitoxin. To facilitate obtainingthis data, the Office of the Chief Surgeon, Headquarters, ETOUSA, issuedAdministrative Memorandum No. 151, dated 27 November 1944, which furnishedadvice on the consolidation of information gained from treated cases and whichrecommended the dosage to be followed. The formula advised was 25,000 unitsevery 2 hours (300,000 units a day) for 7 days. The directive also requiredprompt reports on cases thus treated.
Next, since early results its to treating diphtheriacarriers with penicillin in the foregoing schedule were indeterminate, a morepositive and directed study was obviously necessary. Prof. Sir AlexanderFleming of the Penicillin Clinical Trials Committee, British Medical ResearchCouncil, advised substituting topical applications for intramuscularinjections. He suggested using a suspension of 500 units penicillin per cubiccentimeter of normal saline solution or oil as a nebulizer for the nose andthroat. In addition, it was proposed that troches containing 500 units ofpenicillin and capable of solution in the mouth in from 15 to 20 minutes beused.
Lt. Col. (later Col.) Rudolph A. Kochier, MC, Chief,Medical Service, 203d General Hospital, Garches, France, used the spray andtroche treatment on 22 diphtheria carriers (all German prisoners of war).During the course of
108 Report, Eighth Air Force, Office of the Surgeon, 27 Mar.1945, subject:Prophylactic Use of Sulfadiazine on Eighth Air Force Personnel.
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the study, he found it expedient to double the strength of penicillin. Thespray was used every 2 hours and the lozenge every hour during the day.The Corynebacterium diphtheriae disappeared completely from the culturesof the nose and throat of 14 of the 22 carriers. The remaining eight had badlydiseased cryptic tonsils, and there was only irregular, if any, control of thenoxious flora with penicillin. Tonsillectomy effected a relief of the carrierstate in all eight of these subjects.109
The problem of diphtheria among U.S. troops was nevergreat in terms of its incidence, but many deaths from diphtheria continued tooccur during the remainder of the war. It appeared that a considerable numberof these fatalities could have been avoided. The disease now occurred soinfrequently in the United States that a new generation of clinicians hadarisen who had had no opportunity to become familiar with its various clinicalmanifestations. There was also blind dependence on laboratory confirmation ofthe diagnosis, which too frequently delayed its recognition and, for manyreasons, was itself not always infallible. Finally, The Surgeon General sent aspecial commission to study diphtheria in the European theater. Furtherdiscussion of the disease must be reserved for that portion of this narrativepertaining to the post-hostilities period, when diphtheria became a matter ofrelatively greater concern.
Cold Injury
In mid-September 1944, the Allies had attempted tooutflank the Siegfried Line at its northern terminus using two U.S. and oneBritish airborne division as the primary assault elements. The massive airborneoperation was executed precisely, but, despite the heroic efforts of theBritish 1st Airborne Division to hold a bridgehead across the Neder Rhine inthe vicinity of Arnhem, German defenses were equal to the occasion. TheSiegfried Line could not be turned, and the Allied armies along the entireWestern Front had to attack the enemy frontally. There was fierce fighting, andprogress was slow. Behind the lines, there had to be a tremendous logisticalbuildup of sufficient proportions to sustain a march to and beyond the Rhine.
Meanwhile, the weather turned cold and wet, presaging thecoldest winter in Europe in a number of years (fig. 147). There was a distinctrising trend in the incidence of upper respiratory infections amounting to from60 to 70 percent of total hospital admissions,110 For the first timesince D-day the armies were now having a preponderance of medical over surgicalpatients.” 111 In November, the evacuation and hospitalizationsituation became critical. On two occasions, there was no evacuation from armyareas for an 18- to 24-hour period because of a lack of hospital trains andhospital beds on the Continent. On four different occasions during the month,there was no evacuation from the Continent to the United Kingdom, either by seaor air. On 24 November
109 Essential Technical Medical Data, Headquarters, ETOUSA, for February 1945.
110 Minutes, Chief Surgeon’s Consultant Committee Meeting, 27 Oct.1944.
111 Essential Technical Medical Data, Headquarters, ETOUSA, for October1944.
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FIGURE 147.- Aidmen of 94th Divisiontreating injured soldier on typical cold and dreary day, near Tittingen,Germany, 15 January 1945.
1944, the l5th General Hospital was destroyed by V-1 bombs which the Germanswere raining into the northern areas of concentration. Five hospital trainsdestined for the First U.S. Army had to be diverted to evacuate patients fromthe destroyed general hospital. Another hospital train was derailed and lost tothe evacuation effort. For the last 18 days of November, there were no normalbeds available in Paris, and at times approximately 4,000 patients lay on cotsand litters in corridors, dayrooms, and offices. The appearance of trenchfootcases in overwhelming numbers placed a critical added strain on the inadequatefacilities for evacuation and hospitalization.112
In mid-December, von Runstedt launched a vigorous counterattack through the frozen forests of the Ardennes. The Battle of the Bulge had begun. The Germans had been able to muster greater strength than expected, and considerable Allied strength was required to meet it. It was not until late January that the Allies won back all the ground they had lost. At a the when surgical and neuropsychiatric casualties were at their highest, the incidence of cold injury reached epidemic proportions 113
While prevailing Army practices usually delegated thecare of cold injury to the surgeons, the brunt of this care actually fell uponthe medical services.
112 Essential Technical Medical Data, Headquarters, ETOIJSA, for November1944.
113 A complete, comprehensive, and authoritative discussion of cold injury in the European theater is contained in “Medical Department, United States Army, World War in. Cold Injury, Ground Type.” Washington: U.S. Government Printing Office, 1958.
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In the European theater, it was primarily the number of surgical casualties that naturally diverted this charge to the medical services.114 For example, the 100th General Hospital, Paris, France, during 1944 admitted 1,101 trench-foot, 20 immersion foot, and 314 frostbite cases to the surgical service, but all except those requiring amputation were cared for by the medical service.”115 The 7th General Hospital, Herts, England, in an attempt to equalize the volume of work between medicine and surgery, admitted nearly all cold injury cases to the medical service. These patients were not transferred to the surgical wards except in the event of some complication requiring surgery. In this way, the hospital reported, surgical officers were relieved of a great amount of administrative work and could devote more time to the treatment of battle casualties.
In looking back on this situation, Colonel Kneeland, the United Kingdom Base medical consultant, noted as follows:
In nearly all hospitalswithin the United Kingdom, trenchfoot was regarded as a medical problem, exceptin the small percentage of cases with extensive gangrene. With a bed occupancywell above the normal capacity, the problem of treatment and disposition ofthese cases was a very pressing one. Most of our medical officers were whollyinexperienced in this condition and much of the available technical data dealtwith more severe types of cold injury than were occurring on the Western front.Broadly speaking, the majority of cases were relatively mild. Only about 10percent had gangrene and most of the gangrene was in the form of superficialskin necrosis. In 90 percent of the cases, therefore, one was dealing withsoldiers whose skin was intact, who had comparatively few objective signs of coldinjury, but who had varying degrees of subjective discomfort.
With a demand for hospitalbeds on the one hand and a pressing need for infantry riflemen on the other,the disposition of these cases became of the utmost importance. Because of our lackof experience, the medical consultant felt on very insecure ground in givingadvice to chiefs of services and it was his duty to obtain experience andcreate a working hypothesis as rapidly as possible. This was essential for thefollowing reasons - if men were unnecessarily boarded [to the Zone ofInterior], loss in manpower would be very serious to the fighting forces, asthe great majority of cases occurred in the Infantry; on the other hand, if menwere kept in the hospital who could not be returned to duty within theevacuation policy of the theater, the congestion of hospital beds might provedisastrous. It was the duty of the medical consultant, therefore, to frame somesort of coherent policy which could be disseminated to all the hospitals.116
Colonel Middleton was particularly concerned over thelack of information on which to base a theaterwide policy. Speaking abouttrenchfoot at the 24 November 1944 meeting of the Chief Surgeon’sConsultant Committee, he said: “As you all know, not only is this animportant problem, the most important single problem in the theater at thepresent time, but we have no measurements of either injury or ofconvalescence.” At the 30 December 1944 meeting of the committee, ColonelMiddleton remarked on the prevailing idea that 50 percent of cold injury casesentering army mobile hospitals were being evacuated to Communications Zonehospitals. Of this 50 percent, anywhere from 5 to 35 percent were beingreturned to duty. Said Colonel
114 EssentialTechnical Medical Data, headquarters, ETOUSA, for December 1944.
115 AnnualReport, 100th General Hospital, 1944.
116 Annual Report, United Kingdom Base, 1 Jan. 1945-30 June 1945.
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FIGURE 148.- Chest respirator used intreatment of cold injury.
Middleton: “It is entirely too wide a variance of the ability, or ofthe opinion of the surgeon as to the ability to rehabilitate. In consideringthe work in this particular field, I think it would be very desirable to getsome criteria of injury and repair.” Colonel Cutler, the theater chiefconsultant in surgery, replied: “I don’t think we have much to sayabout it yet.”
Under the overall guidance of Colonel Knieeland, Capt.(later Lt. Col.) Robert A. Kennedy, MC, 125th General Hospital, Dorsetshire,England, was placed on temporary duty at the 7th General Hospital to conductstudies there under the supervision of Lt. Col. (later Col.) Laurence B. Ellis,MC. Captain Kennedy had had considerable experience in treating cold injury onAttu and had devised a respirator for the treatment of cold injury cases (fig.148). Colonel Ellis was an experienced physiologist and thoroughly acquaintedwith experimental techniques in physiology.
The basic principle of Captain Kennedy’s procedurewas to cause hyperventilation through negative pressure applied to the thoraxencased in an aluminum jacket. His hypothesis was that such negative pressure,transmitted to the thoracic cavity, would tend to improve venous and probablylymphatic flow from the extremities. This, in turn, would improve the oxygensupply to the damaged tissues of the feet as well as diminish the edema ofthese parts.
Supply difficulties,particularly in obtaining the exact type of respirator, preventedexperimentation on as extensive a Scale as would have been desirable.Nevertheless, early results were favorable, and patients treated in the respiratorimproved at a more rapid rate both subjectively and objectively than patientstreated by other methods. Physiologic studies of the
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circulation of patients under treatment were initiated to obtain information on the mechanism of the respirator’s action and on the pathologic physiology of the injury itself. Measurements of the femoral venous pressure showed an immediate and significant drop when the apparatus was in action.117 Later findings were an interesting commentary upon the deeper order of the pathologic changes. Relapses occurred in convalescent patients, and patients with deeper cold injuries experienced considerable pain when the respirator was used.118
The study was continued until April 1945. It was completed under the direction of Capt. (later Maj.) Mark Aisner, MC, who had previously assisted Captain Kennedy. In general, the conclusion was that this type of apparatus was of value in reducing the edema and symptoms of patients in the acute stage of cold injury, especially within the first 2 or 3 weeks after development of trenchfoot. The hospital stay of patients in this category so treated was definitely shortened, and a larger number of them returned to duty; but, in gross numbers, the method could not be considered as having been of importance during the trenchfoot epidemic. Furthermore, patients with pure frostbite and those severe cases not treated until after the third or fourth week showed little or no permanent response. Valuable information was obtained as to the effects of the treatment on periphieral circulation and its usefulness in the treatment of trenchfoot.119
Another study begun in November 1944 was to have moreimmediate effect on the treatment of cold injury. At the 110th StationHospital, Lt. Col.. (later Col.) Theodore Golden, MC, thought that if he wereto take a group of 25 patients and exercise them as soon as possible, he couldrehabilitate them faster. He found that 5 weeks after exposure all 25 patientscould actively engage in some work around the hospital and 12 of the groupcould complete a 5-mile march. Colonel Middleton reported these encouragingfindings at the 30 December 1944 meeting of the Chief Surgeon’sConsultant Committee. General Hawley wanted to know how serious the injury was.Colonel Kneeland explained that, on the whole, he would say the injury was ofsomewhat more than average seriousness. There were several patients withgangrene, but now all were walking. Colonel Cutler, in confirmation, made thefollowing statement:
In connection with thefindings of those cases described by Colonel Middleton at the 110th, many timesthere are necrotic areas on the skin which appear as black, dry gangrene, buttime has shown that in many cases this is very superficial. The foot we havestudied, microscopically, which came off a man who died of pneumonia-nottrenchfoot-revealed that the deeper tissues were in pretty good shape and thatthe superficial damage was to the capillaries. This is in line with the studiesby Colonel Golden and his group at the 110th SH who have revealed a high rateof recovery under exercise as the chief therapeutic agent.
As a result of these and other similar studies,120it soon became obvious that most cold injury cases could be returned to dutywithin from 6 to 8 weeks
117 Annual Report, 7th General Hospital, 1944.
118 See footnote 114, p. 438.
119 (1) Semiannual Report, 7th General hospital, 1 Jan. 1945-30 June 1945.(2) See footnote 116, p. 438.
120 See footnote 113, p. 437.
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if proper physical training was started early enough. Such treatment becameroutine. The 188th General Hospital in Gloucestershire, England, reported that,after such a period of observation and rehabilitation, 90 percent of thepatients suffering from trenchfoot, frostbite, and exposure were returned toeither full or limited duty.121 In summary, Colonel Kneeland wrote:
Material aid was given byLt, Col. Theodore Golden of the 110th Station Hospital, Lt. Col. Laurence B.Ellis of the 7th General Hospital, and Lt. Col. Samuel Millman of the 188thGeneral hospital. These three officers conducted active programs ofinvestigation and treatment in connection with trenchfoot and, as a result oftheir experience, the Consultant in Medicine was able to say, with someassurance, that the majority of trenchfoot cases could be returned to some formof duty in the theater, provided that active muscular rehabilitation wasstarted as early its possible. This point of view was disseminated to thevarious hospitals through the hospital center consultants in medicine and itwas believed worthwhile and undoubtedly responsible for the conservation ofmanpower. More, this active program resulted in a diminution in the disabilityof those who could not he returned to duty. Trenchfoot was far and away the mostimportant medical problem of the winter.
When General Morgan visited the theater in February 1945,he brought a plan for the study of heparin in Pitkin menstruum in the treatmentof trenchfoot. A tentative plan was established to treat 50 patients withthird-degree changes. These patients were to be selected from three differentarmies. However, a sudden change in the weather lowered the incidence of coldinjury before that treatment plan could be effected.
Although the load of cold injury cases recededdramatically with the advent of spring, problems concerning patients with coldinjury did not stop there. There was the dermatologic problem of the subsequentfate of cold injury patients which Colonel Pillsbury, the theater seniorconsultant in dermatology, found reason to be concerned about. He felt thatthese soldiers had altered skin, were subject to macerated states, and weremore susceptible to trichophytosis. There were also those soldiers whocontinued to rise the sequelae of cold injury as an illegitimate basis forrelease from forward duty. Finally, there was the smaller number of casesresulting from some soldiers’ neglect of their cold injury during thepast winter. These were stout soldiers who had resisted evacuation during thestrenuous fighting of the Bulge but whose painful feet had finally led them toseek medical attention. They showed extreme vascular changes and, usually, hadcold, clammy, blue feet with or without edema.122
Homologous Serum Jaundice
In late autumn of 1944, Capt. (later Maj.) Harold S.Ginsberg, MC, 7th General Hospital, called Colonel Kneeland’s attentionto 14 jaundice cases occurring at that hospital. Each patient had receivedplasma some months prior to the development of jaundice, and some had receivedwhole blood as well. Since the incidence of infectious hepatitis was low at thetime, Captain
121 Annual Report, 188th General hospital, 1 Jan. 1945-31 May 1945.
122 Essential Technical Medical Data, Headquarters. ETOUSA, for April 1945.
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Ginsberg suggested that the condition under scrutiny might be homologous serum jaundice. Accordingly, Colonel Kneeland requested that the hospital center consultants collect data concerning jaundice cases in the United Kingdom. 123
At the 30 December 1944 meeting of the Chief Surgeon’s Consultant Committee, Colonel Kneeland reported there had been nine cases of severe hepatitis at the 3l6th Station Hospital. Four of the patients had died. All the patients had received plasma, and seven of them had received blood transfusions.
Lt. Col. John B. McKee, MC, the Ninth U.S. Army medicalconsultant, at a meeting of the Medical Subcommittee held on 21 February 1945,expressed the opinion that transfusion reactions were more common than wassupposed. He thought that not all cases were being reported, particularly thoseoccurring in field hospitals. There was growing suspicion that thesetransfusion reactions tended to occur when the blood used was over 14 days old.Colonel McKee said that investigation was continuing.
By 1 March 1945, 49 hospitals had reported to ColonelKneeland. Nine hospitals reported no cases; the remaining hospitals reported atotal of 281 cases of jaundhce. These cases were surgical patients in whom thejaundiced condition had developed from 45 to 100 days after they had receivedblood or plasma. Twenty-one of these patients had died. Unfortunately, therewere complete records on only 146 of these 281 cases. An analysis of these 146revealed that 14 had died, a mortality of about 10 percent. Fatal casesinvariably had a duration of only from 4 to 10 days after onset. The datastrongly indicated that plasma was the source of infection. Accordingly,Colonel Kneeland conferred with Colonel Muckenfuss and Doctor Bradley, BritishMinistry of Health and a member of the Jaundice Committee of the Medical ResearchCouncil.
Doctor Bradley brought forth statistics on the occurrenceof homologous serum jaundice in British troops confirming ColonelKneeland’s findings which implicated plasma as the carrier of theicterogenic agent. Both Colonel Muckenfuss and Doctor Bradley believed thatdetailed study of the problem required tracing the plasma to its source.Admittedly, this was an impossibility in ETOUSA. The only recourse was tocontinue to gather more data so that the facts could not be questioned.
When General Morgan visited the theater in February andMarch 1945, he was apprised of the situation. The disease suggested a seriousproblem for the Zone of Interior hospitals in view of the excessively longincubation period. The medical officers who were concerned in the investigationof homologous serum jaundice in the European theater thought that thesubsequent recognition of the disease in Zone of Interior hospitals and thestudies made there were done in part to their early identification of the widespreadincidence of the disease.
123 (1) Letter, Office of the Surgeon, United Kingdom Base, to ChiefSurgeon, ETOUSA, 1 Apr. 1945, subject: Study of Homologous Serum Jaundice. (2)See footnotes 119 (1). p.440, and 1l6, p.438.
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At about this time, there was a precipitous rise in the incidence ofinfectious hepatitis. Approximately 1,000 cases occurred in February. For theweeks ending on 23 and 30 March, there were 952 and 892 cases, respectively. Inthe first two weeks of April, 965 cases occurred the first week and 979 casesoccurred the second.124 Some medical officers thought there was adirect relationship between presumptive homologous serum jaundice and naturallyoccurring infectious hepatitis. These officers pointed to the closelycorresponding curves of incidence. Colonel Kneeland found that not only thecurve of incidence but the gravity of jaundice among wounded patients was muchgreater than for any other group.125
Tuberculosis
Throughout most of the period of continuous heavyfighting, the incidence of tuberculosis in the U.S. Army in Europe continued toremain low. Hospital admission rates for tuberculosis for all troops were, infact, at their lowest since the activation of the theater, although theincidence of tuberculosis among nurses showed a persistent increase. In thelast months of the war, however, this picture was to change dramatically.
Colonel Badger had an opportunity to confer with Col.Esmond R. Long at the Office of the Surgeon General in October 1944 on policiesof the European theater as expressed in Administrative Memorandum No. 22 andCircular Letter No. 100, pertaining to the evacuation of tuberculosis patientsfrom the European theater to the Zone of Interior (pp. 412 and 431). ColonelLong considered these directives well adapted to the needs of the Europeantheater and thought that, through them, diagnosis, treatment, disposition, andevacuation were 110th simplified and expedited.126
In addition, Colonel Badger looked into the possibilityof obtaining mobile miniature X-ray units for use in the theater. Afterconferences with X-ray and supply personnel in the Office of the SurgeonGeneral, it was apparent that these units were impractical for use in theUnited Kingdom or on the Continent for a variety of reasons. The British 35-mm.mobile unit was, by comparison, a more workable outfit with value inspot-survey work its contemplated for the European theater. 127
Just previous to Colonel Badger’s departure fortemporary duty in the Zone of Interior, there came to light eight cases ofactive pulmonary tuberculosis in the 56th Fighter Group, Eighth Air Force,between August 1943 and September 1944. There was also one acute case in the78th Fighter Group, Eighth Air Force. This brought the suggestion from ColonelBadger that all personnel of these and associated units be examined by X-ray.This suggestion was executed by Colonel Kneeland in Colonel Badger’sabsence by authority of Col. Joseph H. McNinch, MC, Deputy Surgeon, UnitedKingdom Base.128
124 See footnote 122, p. 441.
125 Essential Technical Medical Data, Headquarters, ETOUSA, for March 1945.
126 Annual Report, Senior Consultant in Tuberculosis, ETOUSA, 1944.
127 ibid.
128 Letter, Office of the Surgeon, Headquarters, United Kingdom Base, toCommanding Officer, 163d General Hospital, 6 Oct. 1944, subject: Survey ofTuberculosis in the Eighth Air Force.
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The chest X-ray surveys of the 78th and 56th FighterGroups were carried out at the 163d General Hospital near Cambridge, England. 129In the survey of the 78th Fighter Group conducted by Capt. (later Lt. Col.)James S. Mansfield, MC, with Capt. (later Maj.) James P. Palmer, MC, sevencases of active tuberculosis were discovered and boarded for return to the Zoneof Interior. Captain Mansfield and Capt. (later Lt. Col.) Peter Zanca, MC,carried out the survey of the 56th Fighter Group, and found one case of activetuberculosis with positive sputum. Over 3,600 chest films were taken and read atthe 163d General Hospital during October and November 1944.
It was concluded from these two surveys by CaptainMansfield and his associates, that no common source of infection could be foundfor the total of 17 cases of pulmonary tuberculosis discovered in these twofighter groups, 9 cases prior to the surveys and 8 cases as a result of thesurveys. All of the cases were regarded as reactivation of previously existingpulmonary
tuberculosis. 130
Shortly after his return to the theater, Colonel Badgerwas assigned as Consultant in Medicine, Normandy Base Section, while stillretainimig his position as theater senior consultant in tuberculosis. InFebruary 1945, he submitted, for study by the Chief Surgeon’s staff,recommendations for a tuberculosis survey at the end of hostilities of allpersonnel who had been in the theater for longer than 8 months. Next, heprepared a circular letter to formalize procedures for the followup of contactswith active cases of tuberculosis.
This circular letter was published on 8 April 1945 by theOffice of the Chief Surgeon, Headquarter’s, ETOUSA, as Circular LetterNo. 38. It required the first hospital in the chain of evacuation making thediagnosis of tuberculosis to notify both the patient’s unit and the ChiefSurgeon, ETOUSA, of the fact. The European theater Follow-up Card (medical) (p.251) was to be used for this purpose. The tactical situation permitting, thecircular letter required examinations of all contacts, that is, persons who hadbeen in frequent close association with the afflicted individual. This circularletter assured proper followup examination and provided a simple and efficientmethod of noting cases and trends of active pulmommary tuberculosis as theyoccurred.
Recovered Soviet prisoners of war. - Meanwhile, the ThirdU.S. Army had recovered a group of Soviet prisoners of war at Sarreguemines inDecember 1944 (fig. 149). These Soviet soldiers had been captured by theGermans between May 1941 and May 1943 in the Black Sea area and in the Ukraine.After being shifted around from camp to camp in Germany as labor battalions,they had finally been sent to the mines in the Metz, Bitche, and Sarregueminesareas. Here, they had worked 12 or more hours daily with 1 day off a month whenthe coal-mining quota was filled. The men had been worked to the point
129 (1) Report, 163d General hospital, 22 Oct. 1944, subject: TuberculosisSurvey of 78th Fighter Group, 8th Air Force, and Attached Units. (2) Report,163d General Hospital, 16 Nov. 1944, subject: Tuberculosis Survey of the 56thFighter Group, 8th Air Force, and Attached Units.
130 Letter, T. L. Badger, to Col. J. B. Coates, Jr., 8 July 1956, subject: Corrections and Additions to Manuscript.
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of collapse, and, if they collapsed or relaxed their strenuous labors, they had been beaten and whipped. They had worked and slept without change of clothing. Sanitary conditions had been most primitive. Food had consisted of a steady diet of bread and tea for breakfast, thin turnip soup for dinner, and turnip soup for supper, with no bread at dinner or supper time. Potatoes had been given once a week on Sundays, and only once monthly had a small piece of horsemeat been included for dinner. In some camps or sections, there had been only two meals a day. 131
Shortly before being overrun by the Third U.S. Army, theGermans had gathered together all the sick in a hospital near Sarreguemines.Here, these patients were found by the Third U.S. Army and evacuated to the50th General Hospital, Commercy, France, arriving there on 18 December 1944,and totaling, eventually, 325. Before capture by the Germans, the men were saidto have been in excellent physical condition. Some had been in the Soviet Armyfor only a few months before capture. When they arrived at the 50th GeneralHospital, 307 were in a moribund or seriously ill condition, 16 were in faircondition, and only 2 were in a relatively good physical state. They weredirty, malnourished, and covered with all types of lice. There were severepyoderma, emaciation in marked degree, and all stages of avitaminosis. There
131 Annual Report, 50th General hospital, 1 Jan. 1945-30 June 1945.
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was generalized edema, and, in many, starvation bellies. Of the total 325,there were 136 who were diagnosed as having terminal pulmonary tuberculosiswith severe malnutrition and marked avitaminosis; 78 had far-advanced pulmonarytuberculosis with severe malnutrition; 40 had minimal, moderately advanced andextrapulmonary tuberculosis, malnutrition, and avitaminosis; and 71 hadinjuries and diseases other than tuberculosis with malnutrition andavitaminosis 132
The hospital initiated immediate measures to save life.Copious amounts of blood, plasma, glucose, and saline solutions were given.There were 170 pneumothorax treatments in 25 cases with hemoptysis, and therewere 34 thoracenteces with aspiration in 15 cases with empyema or effusion. Inspite of these measures, 28 patients died within a week after arrival, and 4had expired en route to the hospital.
Most of these patients remained at the 50th General Hospital throughout the first half of 1945. This was an isolated incident which was not to be repeated for another 3 months but which remained a local problem until March 1945. These Soviet prisoners had been recovered in a precariously held bridgehead across the Saar at the very apex of the Third U.S. Army’s advance. While they were being evacuated to the 50th General Hospital, the main effort of the German winter offensive had struck some 100 miles to the northwest, stopping further advance by the Allies in this area during most of the approaching winter. Had the German counteroffensive struck a few days earlier, these prisoners might not have been recovered at this time. This unique problem which presented itself at the 50th General Hospital was greatly overshadowed by the more pressing medical problems of the winter.
In March, however, when the Allies were once againsending the reeling German Army behind the protective banks of the Rhine, therewas a sudden influx of recovered Allied military personnel and displacedpersons (fig. 150). The brunt of the evacuation fell on the 28th and 57th FieldHospitals and the 180th and 35th Station Hospitals, mostly in the ContinentalAdvance Section and Oise Base Section of the Communications Zone. Col. RichardM. McKean, MC, medical consultant for Oise Base Section, reported that the 35thStation Hospital had found 123 cases of active tuberculosis and 80 suspects in373 dislocated nationals.133 The immediate concern was for theprotection of American personnel in the receiving hospitals. Colonel Badgerthought that the European theater Medical Bulletin would be the mostappropriate medium to warn the greatest number of medical personnel of theexisting dangers. His article, published in the April 1945 edition, read inpart, as follows:
German prisoners of war,allied nationals, especially the Russians subjected to years of forced labor,are coming to us as patients with advanced tuberculosis presenting verystrongly positive sputa. These individuals are significant sources of contagionand all hospital personnel having responsibility for their care need adequateprotection from these virulent forms of tuberculosis.
132 See footnote 131, p. 445.
133 Minutes, Chief Surgeon’s Consultant Committee Meeting, 22 Mar.1945.
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It is the task of everymedical officer and nurse to leave no stone unturned in efforts to controltuberculosis. Spread of the disease by airborne routes as well as by contactsets the pattern of control. Surely no one would dry-sweep or dust a floor wheretubercle bacilli wait impatiently to be spread around. No one would associatewith the tuberculosis patient without closing off the very source of infectionitself by a mask to baffle the bacillus. No one would be so casual as to infect“clean” areas of a ward with objects contaminated from contact withthese highly contagious cases. No unit medical officer would wish to remain inignorance of tuberculosis diagnosed along the line of evacuation in one of hismen; for only by notification of such cases is he alerted to the special dangerfor the protection of others. Patients not trained in the art of safeguardingothers need indoctrination in the technique. The education of the tuberculosisindividual concerning the nature of his disease begins early. The vigilance ofthe medical officer in its early diagnosis and prevention never ceases.
On 1 March 1945, orders were received at the 46th GeneralHospital, Besancon, France, to prepare to admit 1,200 newly liberated Sovietpatients, who were to arrive at the rate of one train load per day for 4 days.No other information was available except that they were to be predominantlymedical cases. The 46th General Hospital (fig. 151) summarized its experienceswith these patients in its annual report for 1 January through 30 June 1945, asfollows:
The patients arrived bytrainloads, and it was discovered that there were not only Russian soldiers andcivilians but personnel from most of the countries of Europe * * *.Also, the Russians came from all parts of that country: the large cities ofMoscow, Leningrad,
448
449
FIGURE 151 -Continued. C. Patient seriouslyill with tuberculosis. D. Pneumothorax treatment.
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and Stalingrad; the Ural Mountains;Turkestan; Siberia; and even Mongolia * * *, All these had to be helped andtreated without the medium of language. Signs were the only help, and in manycircumstances these were misunderstood.
During the months of March and April, 2,472 Russians, 41Poles, and 128 Yugoslavs were admitted * * *, Of the civilians, some were boysof 15 and others were old men of 65 * * * The hospital Staff was aghast at the terrible physicalcondition of these people.
Because a great number of these patients had infectious diseases, it was necessary to practice isolation techniques and maintain proper sanitary conditions in the area. This was a problem equalling or surpassing that of language. Our conceptions of modern sanitation were unknown to them * * *, Then, because of their starvation experiences, the patients would hoard any food they could lay hands on * * *
The majority of thesepatients arrived with either 110 medical records or with records so incompleteas to be practically valueless. (One complete train arrived with E.M.T.’smarked F.U.O. in all cases.) Names had to he spelled phonetically, and on 16March, with the last trainload, rosters of patients who had been sent to thisunit before arrived. Since the patients had been previously reported under thename listed on the roster, it was felt that our records should be brought intoagreement. This required hours of careful checking and correcting of records.
With the arrival of the78th Russian Citizen Regroupment Center (18 officers and 43 enlisted men) everyeffort was made to work through them * * * , Patients ready for duty wereevacuated weekly through the Provost Marshal or G-5 channels. On 5 June, twoU.S. Hospital Trains evacuated over 500 long-term hospitalization cases.
Hundreds of lives havebeen saved by the care given them; many have doubled their weight, and havechanged from listless hungry animals to almost child-like, playful humanbeings. Discipline, which was such a great problem at first because of therestrictions necessary for their proper care, is greatly improved because ofunderstanding through constant education. It is felt that as these patientsleave the 46th General hospital and return no their native land, there will gowith them a spirit of thankfulness anid appreciation for the work done for them.
By the end of March 1945, Colonel Badger had inspectedthe 57th Field Hospital and the 46th and 50th General Hospitals, and had maderecommendations concerning changes in treatment and tightening up of generalcontrol measures. He commended the 50th General Hospital for its excellenthandling of a very difficult and dangerous situation and noted particularly thegood progress which had been made at this hospital in the treatment ofrecovered Soviet prisoners of war.134
The patients at the 46th General Hospital had onlyrecently arrived and that hospital was still in the throes of establishingroutine measures for handling the problem (fig. 152) when, in addition to the treatmentand control measures described elsewhere, Colonel Badger also made thefollowing specific recommendations for contacts:
1. It is felt that theseriousness of contact with this group of cases of far advanced tuberculosis issuch that personnel of the hospitals who have been associated with theirevacuation to the 46th General hospital should be X-rayed at the present timeand reX-rayed every three months a year.
2. Personnel of the 46thGeneral Hospital have all been X-rayed and it is recommended that they shouldbe re-X-rayed on a three-monthly basis as a routine or more often if theypresent signs or symptoms suggestive of underlying tuberculous pathology.
134 Letter, Senior Consultant in Tuberculosis, ETOUSA, to Office of theChief Surgeon, headquarters, ETOUSA, attention: Chief Medical Consultant, 3Apr. 1945, subject: Tuberculosis Among Russian RAMP’s at 50th Generalhospital.
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FIGURE l52.-Routine control measures at 46thGeneral Hospital. Aseptic setup in isolation wards.
3. It is recommended thatevery measure be undertaken which will diminish the spread of infection fromthese highly contagious patients. Further, personnel of this sort willundoubtedly be recovered and it is recommended that they be transferred at theearliest moment by the shortest route, entailing the least number of contacts,to their final hospitalization place.
4. Groups of recoveredpersonnel present a serious tuberculosis problem and should not be sent to anyinstitution without adequate warning of their arrival in order that resourcesmay be assembled for the institution of proper measures of prevention and atechnique which will prevent as much spread of the disease as possible.135
On 19 April 1945, Colonel Long arrived in the Europeantheater. With Colonel Badger, he reviewed the procedures which had, by now,been fairly well stabilized in all installations where tuberculous patientswere being treated. The two officers visited the 50th General Hospital on 6 May1945 and the 46th General Hospital on 10 May 1945. At these two hospitals,where the great majority of these cases had been assembled, Colonel Badgernoted that the patients had made remarkable progress and, except for thoseseriously ill with advancing disease, their physical condition was excellent.Previously recommended control measures were being carried out meticulously,although discipline still presented a problem at the 46th General Hospital.136
135 Letter, Senior Consultant in Tuberculosis, ETOUSA, to Chief Surgeon,ETOUSA, attention: Col. W. S. Middleton and Surgeon, 0ise Section, 30 Mar.1945, subject: Tuberculosis in Russian RAMP at the 46th General Hospital.
136 (1) Letter, Senior Consultant in Tuberculosis, ETOUSA, to Office of the Chief Surgeon, Headquarters, ETOUSA, attention: Chief Medical Consultant, 13 May 1945, subject: Report of Survey of 46th General hospital Concerning the Care of Tuberculosis. (2) Letter, Senior Consultant in Tuberculosis, ETOUSA, to Office of the Chief Surgeon, Headquarters, ETOUSA, attention: Chief Medical Commsultant, 19 May 1945, subject: Survey of Russian RAMP’s 50th General hospital.
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Soon, a similar problem of equal proportions came tolight. In early April, the Third U.S. Army uncovered a notorious concentrationcamp, Buchenwald. This was only the first of such camps the Third U.S. Army wasto uncover in rapid succession during its dash across central Germany intoAustria and Czechoslovakia. Approximately 21,000 persons were in the camp whenit was overrun. They were living under most horrible conditions, and it wasestimated that the ill numbered 5,000. The l20th Evacuation Hospital, newlyarrived in the army area, was dispatched on 15 April to provide medical servicefor them. This unit, plus a clearing platoon, operated for about 10 days untilrelieved by units of the First U.S. Army.137
The 45th Evacuation Hospital, under command of Col. AbnerZehm, MC, took over where the 628th Clearing Company and the l20th EvacuationHospital were forced to leave off. Under the able direction of its commandingofficer, this hospital rapidly established aseptic techniques for processinglarge numbers of tuberculous patients that would have been a credit to anysanatorium in the United States.138 Neither the limitations of spacenor the scope of this chapter permit a discussion of the appalling conditionsthat were found at this and other concentration camps, nor would a few words dojustice to the exemplary manner in which the problem was managed (fig. 153).Suffice it to say that, from the administrative point of view, it was initiallya job for the armies, then a charge to the forward echelons of theCommunications Zone, and later a longer’ term responsibility of militarygovernment. In the final analysis, it was a problem for the German peoplethemselves who had permitted the situation to exist and to whom rightfullybelonged the obligation to rectify this afront to civilization and humanity.Although it was a great problem in its early stages to the medical service ofthe U.S. Army, every effort was made to have German facilities accept thisobligation at the earliest opportunity.
Recovered United States prisoners of war. - Tocomplicate further the patient-load problems that beset each army on the frontas a result of great numbers of prisoners of war, recovered Allied personnel,displaced persons, and refugees suddenly becoming their wards, there was alsothe happy reunion of advancing U.S. forces with their fellow soldiers who hadbeen held captive by the Germans (fig. 154). As the Allies struck deeper into Germany,U.S. prisoners of war were recovered, sometimes by the thousands. Most of themwere eventually evacuated through the Normandy Base Section. This base sectionhad designated Camp Lucky Strike as the reception center for these returnedprisoners. Here, the 77th Field Hospital was opened on 8 April 1945 with aninitial 350-bed capacity. Patients came in such great numbers, however, thatits capacity had to be enlarged to 1,000 beds by augmenting the 77th FieldHospital with the 306th General Hospital (operating during this period
137 Annual Report, Third U.S. Army, 1 Jan. 1945-30 June 1945.
138 (1) See footnote 136, p.451. (2) The Annual Report, 45th Evacuation Hospital, 1 Jan. 1945-30 June 1945, contains a full and detailed description of the unit’s activities at Buchenwald camp.
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454
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FIGURE 154.-Continued. C. Opening rationsbrought in to them by liberating forces
as a convalescent annex). Approximately 18 percent of the first 12,000recovered personnel to arrive had to be hospitalized, but in May this ratedropped to 3 1/2 percent of those coming through the camp. Nevertheless, thehospital capacity had to be expanded to 1,500 beds. The primary cause forhospitalization, in the early groups of returnees, was malnutrition, primary orcomplicated. 139
Routine roentgenograms were made only in cases requiringhospitalization. The preliminary data, complicated as they were by many unknownfactors, indicated that the incidence of tuberculosis was nearly 8 times thatof U.S. troops in 1943.140 A more detailed discussion oftuberculosis as observed in recovered U.S. prisoners of war may be foundelsewhere.141
Colonel Badger, in his role as medical consultant inNormandy Base Section, called the attention of General Hawley and hisconsultant staff to serious protein-deficient states occurring in patients,particularly in those with maxillofacial and other traumatic injuriespreventing normal ingestion of food (fig. 155). He indicated that theintravenous use of plasma in large doses (at least 4 units daily) couldovercome these deficiencies but that there was a
139 Annual Report, Normandy Base Section, 1 Jan. 1945-30 June 1945.
140 Annual Report, Senior Consultant in Tuberculosis, ETOUSA, 1 Jan. 1945-30 June 1945.
141 (1) See footnote 72 (2), p.403. (2) Cohen, B. M., and Cooper, M. Z.:A Follow-Up Study of World War II Prisoners of War. Washington U.S.Government printing Office, 1954. (3) Medical Department, United States Army.Preventive Medicine in World War II. Volume IV. Communicable DiseasesTransmitted Chiefly Through Respiratory and Alimentary Tracts. Washingtons:U.S. Government Printing Office, 1958. (4) Medical Department, United StatesArmy. Internal Medicine in World War II. Volume II. Infectious Diseases.[In preparation.]
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FIGURE 155.-Malnutrition in a recovered Allied soldier.
common tendency to use inadequate supplies of plasma. He also noted the scarcity of intravenous protein solutions. In fact, Colonel Badger stated, at the March meeting of the Chief Surgeon’s Consultant Committee, that the 60 bottles of intravenous protein in his possession represented all there was in the theater. Circular Letter No. 36, dated 19 April 1945, Office of the Chief Surgeon, Headquarters, ETOUSA, outlined the program for the nutritional management of malnourished recovered Allied military personnel and provided for the intravenous administration of 4 units of plasma and 500 cc. of whole blood in 24 hours to patients with edema who could not tolerate food by mouth.
When the first groups of recovered U.S. prisoners of warcame into Camp Lucky Strike, their nutritional management was already wellplanned. The ragged, dishevelled, and emaciated men responded well totreatment. Severely ill patients unable to take nourishment by mouth showedremarkable response to slowly increasing quantities of plasma administered intravenously.The very slow administration by the constant drip technique of a high-proteindiet in liquid form by nasal catheter through the stomach also gave excellentresults.
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The proportion of primary nutritional deficiencies was greatly diminished inthose arriving during May 1945, and respiratory infections and minor injuriespredominated as causes for admission.142
FROM V-E DAY TO V-J DAY
The war in Europe ended when emissaries of the GermanRight Command signed a document of unconditional surrender in the early morninghours of 8 May 1945. In anticipation of this memorable event, a number ofchanges had taken place as regards medicine. General Hawley’s officeannounced, in late April, that, effective 1 May 1945, the evacuation policy forthe European theater would be 60 days. Immediately after V-E Day, evacuation fromthe Continent to the United Kingdom was curtailed. The plan called for theevacuation out of Europe of all patients requiring over 60 days ofhospitalization by the end of July 1945.143 Staging of units forcombat had halted, and planning and organizing units for redeployment to otheractive theaters had begun. So rapid was the closing out of activities in theUnited Kingdom that the occupied beds in hospitals fell from 129,289 on 90 daysbefore V-E Day to 28,153 by the end of May and to a mere 8,664 on 30 June 1945.144
The activity that now demanded by far the greatest attentionfrom the theater chief consultant in medicine down to regional consultants inhospital centers was the formation of units for direct redeployment to otherstill active theaters. At least the following variables had to be consideredfor each individual before he could be assigned to a unit scheduled forredeployment: His adjusted service rating;145 physical profile;specialty, if any; professional competence; age; and grade. These factors thenhad to be considered in relation to requirements of the table-of-organizationposition to which the individual was being assigned; that is, grade, militaryoccupational specialty number, and index of professional competence. Above andbeyond the need to weigh these specific items, there was always the desire toform compatible groups of medical officers who could work together and who,collectively, could supplement each other to provide the wide range of skillscalled for by the table of organization. The magnitude and complexity of theproblem caused considerable confusion and many a headache. As stated earlier,many questions resolved themselves into a matter of supply and demand (p. 278).
The medical problem still outstanding at this time was the question of a mass radiographic survey for tuberculosis proposed in the earliest days of the theater. It had been deferred on numerous occasions as a result of Colonel Badger’s spot surveys which indicated that there was no dangerous increase in the incidence of tuberculosis. The X-ray examination of all inductees commencing in early 1943 further mitigated the need for a mass survey. 0n the
142 See footnote 139, p.455
143 Essential Technical Medical Data, Headquarters, ETOUSA, for May 1945.
144 See footnote 116, p.438.
145 The adjusted service rating was an arbitrary criterion for retentionin service calculated on the basis of number of dependents and service in theZone of Interior, overseas, and in combat.
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other hand, certain desired radiographic surveys could not be carried outduring the peak of hostilities. Now there were more data available as a resultof the Air Force surveys and other limited surveys carried out in processingofficer candidates and recovered prisoners of war. More recently, there was theimportant factor of greatly increased opportunities for contact withtuberculosis by healthy personnel in the management of large numbers ofprisoners of war, displaced persons, and refugees. Although physicalexaminations were being conducted at assembly areas in conjunction with the physicalprofiling of troops to be redeployed, the possibility was remote that anysignificant numbers of tuberculosis cases would be uncovered by this method.
All these factors, taken collectively, indicated that areevaluation of the problem was necessary. Fortunately, Colonel Long was in theEuropean theater at this time. His counsel and advice were most welcome. Theproblem narrowed down to one salient fact: The immediate need was to detect andscreen out cases of tuberculosis from units being redeployed to other theaters.Each such case transferred to another theater presented a serious liabilityinvolving future hospitalization and transportation in addition to jeopardizingthe individual’s life. If no screening by X-ray was conducted, it was estimatedthat some 200 cases of potential or active tuberculosis would be redeployed.146
In consultation with Colonel Long and in coordination withColonel Allen, the theater senior consultant in radiology, Colonel Badgerformulated a plan to effect this screening with the equipment available andunder expected assembly area conditions. Furthermore, in order to save the andX-ray film, it was thought desirable to limit the screening to those among whomthe probability of tuberculosis was the greatest. Accordingly, the consultantsdecided upon screening all personnel who had been in the theater over 18 monthsand all Medical Department personnel regardless of length of service in theEuropean theater. X-ray examination was to be carried out by field units ofhospitals located at the assembly areas. The plan was simple and yet deemedadequate to meet the current needs. Moreover, there was a surplus of some1,700,000 sheets of X-ray film, 14 x 17 inches, in depot stocks, although itwas realized that there was an overall shortage of X-ray film worldwide. Thisinventory of available X-ray film excluded those in hospital stocks. The numberof personnel and the criteria for redeployment indicated that there would be nomore than 50,000 persons to be thus examined (fig. 156) 147
The plan was quickly approved within the theaterheadquarters, a radio message was dispatched from ETOUSA on 29 May 1945 to theWar Department, and a reply was received on 31 May 1945. The plan was notfavorably considered because of the worldwide shortage of X-ray film.
General Hawley, however, heeded the oft-repeated remonstrances of Colonel Badger and approved the X-ray examination of all nurses to be directly
146 (1) Letter, Col. E. R. Long, to The Surgeon General, 28 May 1945,subject: Visit of Tuberculosis Consultant in European Theater of Operations,United States Army. (2) See footnote 140, p.455. (3) Essential TechnicalMedical Data, Headquarters, ETOUSA, for June 1945, dated August 1945.
147 Ibid.
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FIGURE 156.-Typical assembly area conditions, Le Havre, France.
redeployed--a measure that Colonel Long had also strongly recommended, informing General Hawley that the rate for nurses as a whole in the European theater, as determined by the Medical Statistics Division, Office of the Surgeon General, was twice the average rate for the Army as a whole. Colonel Long also emphasized the fact that lesions still in the incipient stage did not cause symptoms and could be detected only by X-ray examination. Circular Letter No. 57, dated 27 June 1945, Office of the Chief Surgeon, Headquarters, ETOUSA, was published implementing General Hawley’s decision and directing that the results of such surveys, with the films, be forwarded to the theater senior consultant in tuberculosis.
In the interim following the unfavorable response by theWar Department, consideration was given to the employment of captured German35-mm. equipment, which, could be brought into use within from 1 to 2 months.This idea was not pursued further because it was estimated that a substantialnumber of the 50,000 persons considered as most in need of X-ray examinationwould have been redeployed by the time the project could be set into operation.Apparently, there was no alternative but to forego any plans for even a limitedchest survey, except for nurses being redeployed (fig. 157). However, a WarDepartment message, dated 28 June 1945, that was brought to ColonelBadger’s attention on 2 July 1945 changed the picture completely. Upon reconsideration,the War Department now--a month later–approved the original request fromthe European theater, provided 14 x 17 inch film used for this purpose had anexpiration date prior to 1 October 1945.
Approximately 400,000 films of this type were availablein theater depots. Arrangements were made to centralize these stocks at pointsin proximity
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FIGURE 157.- Nurses undergoing medicalprocessing for redeployment, Camp Carlisle, Mourmelon, France, 6 July 1945.
to the Assembly Area Command and the two staging areas. Other necessaryaction was immediately taken to effect the survey as originally planned, butvaluable time had been lost, and the opportunity for a complete survey of themost susceptible group had also vanished. Before leaving the theater, ColonelBadger completed all the necessary recommendations for a circular letter onspecific measures to be followed.
Circular Letter No. 60,Office of the Chief Surgeon, U.S. Forces, European Theater, 2 August 1945,section III, subject: Chest Sumrvey of Directly Redeployed Persoimmiel, waspromulgated after Colomuel Badger’s departure from the theater. Itrequired an X-ray of the chest for all medical officers, nurses, and hospitalaidmen assigned to ward duty who were scheduled for direct redeployment toanother theater of operations. A similar requirement was made for all officersand enlisted men, male and female, who had been overseas for more than1½ years and who were scheduled for direct redeployment. Suchexaminations were to be interpreted by the roentgenologist of the responsiblehospital with proper notation of the results on the personnel records of theindividuals concerned. Implementation of the plan at the local level was made aresponsibility of the base section surgeon in the areas affected.
Soon after the plan was placed into full effect, theAssembly Area Command protested that the roentgenography of directly redeployedpersonnel was delaying the movement of some units. Accordingly, the appropriatesection of Circular Letter No. 60 was rescinded by Circular Letter No. 61,Office of the Chief Surgeon, U.S. Forces, European Theater, 8 August 1945,section 1,
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subject: Chest Survey of Directly Redeployed Personnel; section II, subject: Chest Survey of Redeployed Nurses. Only the requirement that a chest survey be completed on all directly redeployed nurses was continued. The Japanese capitulation followed soon thereafter with the resultant curtailment of direct redeployment. This automatically ended the last of Colonel Badger’s wartime tuberculosis projects in the European theater.
As Col. Osceola C. McEwen, MC, assumed the position of theater chief consultant in medicine, to help guide the transition of the U.S. Army in Europe from a wartime to occupation status, the incidence of respiratory and infectious diseases was very low. The hepatitis epidemic had well passed its peak. There was only one significant problem, diphtheria. To Colonel McEwen it appeared inevitable that with the high incidence of diphtheria among German civilians and the increasing fraternization between Americans and the German population, there would be a distinct increase in the disease among American troops during the coming winter. Furthermore, death from diphtheria continued to occur, and patients appeared in hospitals with obvious complications of diphtheria in which the diagnosis had not previously been made. Colonel McEwen enlisted the help of the War Department investigators of the disease, Lt. Col. Aims C. McGuinness, MC, and Dr. Howard J. Mueller, in, the preparation of a directive. The directive was published on 28 September 1945 as section I, Circular Letter No. 69, Office of the Chief Surgeon, U.S. Forces, European Theater. It was a comprehensive summary of general principles to be followed in the diagnosis, treatment, and control of diphtheria, with particular reference to conditions prevailing in the theater.
By the time V-J Day was celebrated, the wartime theaterchief consultant in medicine, Colonel Middleton, and his complete staff ofsenior consultants had returned to the United States, their task completed.
SUMMARY IN RETROSPECT
Yale Kneeland, Jr., M.D.
The writer was consultant in medicine for 6 months in abase section in the European theater from which a very large amphibiousoperation was launched. Following this, his sphere of activities was enlargedto include what had originally been two additional base sections, and, at onetime, the hospital bed occupancy of the area was over 129,000. He served inthis capacity for 10 months.
During each period, the office of professional servicesconsisted of two individuals-the writer and his colleague in surgery. They wereunder the command of, and responsible to, the base surgeon; but there was anadditional responsibility, of a professional character, to the ChiefConsultants in Medicine and Surgery, Office of the Chief Surgeon, Headquarters,ETOUSA. This idea of a dual allegiance is contrary to the traditional Armytheory of command. Thus, their relationship to the theater chief consultants,although intimate, was in a sense unofficial. The base surgeons, to their greatcredit,
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did not appear to object to this type of short circuit in spite of itsunconventional character.
In any complex situation, the man at the top pitches thekey, so to speak; his myriad subordinates try (with varying success) to sing intune. Be it said that General Hawley, Chief Surgeon, ETOUSA, was on the side ofthe angels. He wanted the American soldiers to have the best possible medicalcare. He believed that professional services had a great deal to offer towardthis objective. He respected his consultants and lent their opinions acritical, but invariably courteous, ear. He often implemented their adviceagainst the wishes of his administrative subordinates. The prestige theconsultants ultimately obtained was in large measure due to his influence. Butfor him, the whole of professional services might have been reduced toimpotence.
Roughly, the first 6 months of the writer’s servicewas what a bacteriologist might call the “phase of logarithmicgrowth.” At its beginnimmg, before the invasion, the number of hospitalsin the base section was small. In the course of 6 months, new general hospitalsarrived by the score. The second period was a plateau phase, where the volumeof professional work was very great but the situation in regard to hospitalunits and personnel, fairly stable. The two periods also differed in that,during the first, the writer had free and ready access to the theater chiefconsultant and could submit his decisions for approval. During the second, thetheater chief consultant was on a separate continent, and communication wasinfrequent and difficult.
To begin with, the base section consultant found himselfon a medical staff that was unused to the luxury of professional services andsomewhat suspicious at first of the innovation. It was necessary for him togain the confidence of his chief and his colleagues in other sections. It wasalso necessary for him to orient himself in a bewildering new world. He had tovisit the hospitals already set up and working, meet and appraise their medicalpersonnel, ingratiate himself (if possible) with the commanding officers, andprepare lists of qualified individuals who might be used later on to bolster theweaker units as they arrived. Many of the “old” units wereaffiliated with and had been derived from teaching hospitals. These units werestaffed by outstanding men.
The consultant had very little time to achieveorientation before the new units began arriving, and he experienced a sense ofbewilderment which never quite left him. Here, if ever, was the moment when oneneeded an orderly mind, a long memory, and a flair for indices and files. Notall the good men were in the affiliated units. They turned up in fieldhospitals and were often tucked off in very odd corners. This particularconsultant has a bad memory and a disorderly mind. Much of the time he felt asif he were looking into a kaleidoscope. He struggled and tried to overcome hisdeficiencies. The work had to be done and done rapidly. The new units arrivedpellmell, tumbled into staging areas, and then proceeded to hospital sites thatmight or might not be completed. These new units were deliberately sent outfrom the Zone of Interior minus most of the pivotal professional men; that is,the chiefs of
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services and sections. Occupants for these positions were to be providedafter the unit had arrived. It was the job of the consultant to determine theneeds of units and then try to supply them.
Thus, the newly arrived hospital units had to be“vetted” as soon as possible. In a 10-minute conversation, theconsultant was supposed to determine each officer’s educationalaccomplishments, experience, and character. It required considerable effronteryto do this, or to do it with any sense of infallibility. The consultant wasaware of the superficiality of his judgments, but there was no time for moresearching investigation.
One fell back, inevitably, upon the record of formaleducation, together with hospital and teaching appointments, and it wasremarkable how accurate these indices were, within, obvious units. Almostinvariably, the man with the best education turned in a good performance. Itwas true, of course, that some individuals were much better than their rathermediocre background would suggest. To some of these, injustice may have beendone. But in general the modern system of internships, residencies, and boardcertification made a quick appraisal far easier and more accurate than it wouldhave been in the past.
At first, an attempt was made to strengthen these newhospitals in all positions. Soon, however, it became apparent that the supplyof qualified men in the theater would run out unless this strengthening werekept at a bare minimum. On the medica! service, there had to be a reallyfirst-rate chief of service, one other really good younger man, a qualifiedneuropsychiatrist, and, if possible, someone with a working knowledge ofcommunicable disease. (Fortunately there were a good many certifiedpediatricians available for this purpose.) It was desirable that one of the twointernists be familiar with electrocardiographic interpretation. Also, anendeavor was made to provide someone with at least Army experience indermatology. It was impossible to supply each hospital with a qualifieddermatologist, and the deficiency was cared for by the establishment of a localconsulting system in this specialty. The rest of the service could be made upof general duty officers. No attempt was made to provide an allergist or agastroenterologist. (In an oversea theater, allergic disorders can be appraisedby an internist; it is impractical to attempt any special studies. As togastroenterologists, the average general hospital gets on better without one.The soldier with organic disease of the gut goes home; the soldier withfunctional dyspepsia is better off without too much study and treatment.)
Thus, the bare minimum was bare indeed, and yet it becameincreasingly difficult to satisfy. One did not want to reduce the affiliatedunits to mediocrity by too heavy withdrawals from their personnel, and yet theyhad to be the principal source. The consultant’s dilemma was increased bythe fact that many of the incoming hospitals had on their rostersprofessionally inadequate men of higher military rank than those whom oneproposed to send in to be chiefs of services. Moreover, once the necessaryshifts of personnel had been decided on, it was the duty of the consultant tocoordinate the transfers.
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This required convincing a given individual that hewanted to leave his unit for a more responsible post, persuading his commandingofficer to let him go, and inducing the new commanding officer to accept him. Aconsiderable amount of tact was necessary, and although it was always possibleto invoke the authority of the base surgeon and order the transfers to beeffected, the velvet glove was greatly preferable to the iron hand within it.Thus, coordinating took time as well as patience, and it added to the existingcongestion of a badly overworked long-distance telephone system.
Once the new men had been installed in a hospital, it wasnecessary to visit them in order to find out how things were working out-ifthey had, in fact, been given the jobs for which they were sent, and whatproblems in general confronted them. With these men, who had been assigned to ajob on the consultant’s recommendation, the consultant thereafter enjoyeda rather special relation. In a sense he stood in loco parentis to them, andthey tended, for the most part, to consult him when difficulties arose. It wasa happy arrangement.
All this activity in regard to personnel occupied thegreater part of the consultant’s waking hours during the first period ofhis service. Nevertheless, he had other occupations. He felt it incumbent onhimself to brief hospital medical services on the medical problems of theinvasion-or at least on what he thought the medical problems were likely to be.He discussed the management of the various infectious diseases, the function ofthe disposition board, and in general attempted to impart what knowledge he hadgained in nearly two years overseas. Furthermore, he served as a channel bywhich information in the possession of the chief consultants might be directedto its destination. Lastly, he did a certain amount of actual consultationwhere time and distance permitted. It is possible that some of theseconsultations were of value, if not to the patient, at least to his physician.Always, they were of value to the consultant, and he learned from them.Occasionally, frantic calls for information came in by telephone, usually onsuch subjects as viper bites, wood alcohol poisoning, or botulism with whichthe consultant had the barest nodding acquaintance. On the whole, however, hedid not regard seeing cases during his hospital visits as the ill spent. Ifnothing else, it gave medical officers a chance to present their choicestwares, which was always a source of pleasure.
There was routine office work, too. Disposition boardproceedings were reviewed until their volume became so great that it had to beabandoned. Recommendations for promotion of medical officers were also passedon, a function that gave the consultant some opportunity, at least in anegative sense, to see that credit went where credit was due. Lastly, there weremoments when his opinion was sought by other sections of the office.Altogether, during this period, he was not idle and, throughout it, receivedmost valuable advice and cooperation from the theater chief consultant inmedicine.
The last 10 months of his service as a consultant formedthe second or plateau phase. The groundwork had been done, the hospitals wereset up and working, and it now remained for them to give the very best care intheir
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power to the vast throng of sick and wounded which passed through them. Forthe consultant, it was a period of intense interest, although one in which hefelt distressingly remote from the hospital wards. His area had been muchenlarged, the hospitals were numerous, and the number of patients astronomical.He was forced to institute a system of local medical consulting based onhospital groups. (By this time, the hospitals had been divided into sevengroups, each with a center headquarters.) With one exception, each of the groupconsultants in medicine was also chief of the medical service in a generalhospital within the group. They did their consultation in addition to otherduties, and very valuable service they rendered. The consultant at baseheadquarters worked through these men and would have been quite helplesswithout them.
This was a period when the need for hospital beds becamepressing. Policies in regard to disposition were constantly changing, and thesechanges had to be implemented. At times, the administrators placed differentconstructions on various directives from what was intended. The consultant.through his local consultants, worked for uniformity in policy and harmony inthe various agencies. One problem which can be taken as a concrete example istrenchfoot. Whether the high command expected a winter campaign is irrelevantto this discussion. Certainly, the medical consultant had not, and hisknowledge of cold injuries was very slight. Moreover, the available circularson the subject left, to his mind, much to be desired, dealing, as they did,with a more severe variety of injury. Many thousands of cases were seen, butthey were mild. Only 1 in 10 had any lesion of the skin. The specific problemsthat faced the ward officer were not answered in the circulars--what to do withthe 90 percent mild injuries? The individual soldier lay on his back with 10toes pointing heavenward, and, in general, they were pretty normal toes. How totreat him? How long will he be laid up? Should he be boarded homeimmediately-for his bed was needed badly-or kept on the chance of his beingable to perform useful duty again in this theater? These were importantquestions for several reasons: Hospital beds were short, manpower was short(these patients were mostly combat troops), and the numbers involved wereequivalent to several divisions. The ward surgeons clamored for advice. Whatwas the medical consultant to tell them?
Unfortunately, he didn’t know, but in the shortestspace of time it was necessary to find out. This is not the place for adetailed discussion of trenchfoot. Let it suffice to say that many willingworkers helped the medical consultant. They set up trenchfoot wards wherepractical clinical research was carried out. Within a few weeks, it becameclear that patients in whom active muscular rehabilitation was started earlydid better than those who were permitted to remain idle. The sooner a man wasmade to walk, the better. The results of sympathetic block and the like wereequivocal, but the results of an earnest program of physical rehabilitationwere clear. Certain criteria were established by which the immediate prognosisfor return to limited duty, at least, might be guessed at. (The medicalconsultant did not know what the ultimate prognosis was.) In any case, someorder was developed out of the
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original chaos in his mind, and thereupon he could proceed-tentatively, andwith no massive assurance-to disseminate a program on trenchfoot.
There was another general category of affairs thatoccupied the consultant. The country in which his base was located happened tobe that of a very highly civilized ally and contained many learned men in manyfields, who had much of great value to impart to the American medical officer.In fact, there was much of value to both sides in the mutual exchange of information.Thus, various meetings were arranged, and, in the arrangement for suchprograms, the consultant found himself acting as a sort of liaison officer.Moreover, he had access to all the newest medical information in the hands ofhis ally; he was graciously invited to attend all relevant committee meetingsand, as a consequence, acquired a larger stock of knowledge to disseminateduring his visits to the hospitals. Eminent medical tourists from the UnitedStates usually paid a ceremonial call at his office, and he endeavored on suchoccasions to pick their brains. Altogether, the office took on the character ofa nerve center and, had the medical consultant himself been of greaterintellectual capacity, this function would no doubt have been better performed.
The consultant frequently found himself engaged withproblems in human relations, arising from the fact that most civilian doctorsare not happy in military service, particularly overseas. It has already beenremarked that relations between the civilians and the regulars were not easy.The typical product of the university clinic is idealistic, sensitive, and veryindividualistic. Often, he felt himself to be operating in an unfriendly,almost a hostile, atmosphere. One such remarked to the writer: “We allfelt like June brides when we joined the Army, but I never expected the groomwould turn out to be a gorilla.” Strong words, no doubt, but expressiveof a point of view. Often, the professional man in the hospitals felt lonely andforlorn. Frequently, he was conscious of hostility, real or imagined, on thepart of the administration, usually in the person of his commanding officer.
The hospital commanders, generally, were not drawn fromthe top of the basket, professionally speaking. Some were regulars. Many werereservists who practiced general medicine in private life. Some were excellent.Some were not. For the perfect hospital commander, many qualities arenecessary. He should have, to begin with, a firsthand acquaintance with good medicine.He should be a first-rate soldier. Add to these qualities the guile of theserpent, the softness of the dove, and a working knowledge of electricity,plumbing, landscape architecture, and international relations. Above all, hemust be a housekeeper and a leader of men. To say that some hospital commandersfell short of this ideal is an understatement.
Even with good commanding officers, the professional mencould become restless and unhappy. The consultant was the one individuual whowas in a position to apply some balm to their wounds. He stood, as has beensaid, in loco parentis to many of the professional men. They had direct accessto him. They felt him to be on their side. At the same time, a little of thereflected
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glory of headquarters hung about him, and he had, therefore, some influencewith some commanding officers. The consultant’s position was thus unique;he could, and possibly did, bring a little light into the gloom of someprovincial hospitals. At any rate, he tried.
It was also possible for the consultant to interesthimself in research, not fundamental research, but clinical investigation ofthe journeyman type. Under conditions of an active military compaign,definitive studies were very difficult to accomplish, but some usefulinformation could be compiled. In this particular base, the consultant aided inthe inauguration of certain studies. Specifically, these were homologous serumjaundice (in the wounded after D-day), some physiologic aspects of trenchfoot,sulfadiazine prophylaxis of common diseases of the upper respiratory tract, thelocal use of penicillin in infections of the mouth and throat, and antibodyformation in nephritis amongst Germans.
At the end of his tour of duty, with victory in thattheater won, the consultant was faced with the task of redeployment. The writerprefers to touch on this unhappy subject very lightly. It is not for him tocriticize the basic theory of redeployment or to suggest that planning wasinsufficiently far advanced when the cease-fire sounded. The personnel problemsof redeployment were uppermost in his mind, and there was little he could doabout them. Many factors were involved, such as theater needs, about which theconsultant knew nothing. All he knew was that his advice was sought in regardto personnel changes in the redeploying hospitals. The game had to be playedaccording to a set of rules that he had no part in creating. There were tablesof organization calling for certain specialty ratings (of which he did notapprove), there was the adjusted service rating score, and there were physicalprofiles. All of these played a part in determining the immediate future of theindividual officer. The consultant endeavored to temper justice with mercy butto little avail. He is not proud of his role during redeployment, and he gladlyrelinquished his post to his unfortunate successor when the moment came for himto return home.
The other hat which he wore during this whole period waslabeled “senior consultant in infectious diseases.” He has verylittle comment to make on this subject for the reason that infectious diseasesnever presented a major problem. There was no situation comparable to malariain the Pacific or the unfamiliar and often exotic diseases encountered intropical areas generally. The incidence of streptococcal, meningococcal, andpneumococcal infections was lower than in the Zone of Interior.Gastrointestinal infections were infrequent, and the incidence of childhoodcommunicable diseases is always low in seasoned troops. The epidemic ofinfluenza A in the late autumn of 1943 was the only major respiratory outbreak,and it presented no special problems.
So it is that as this particular consultant looks back onthe war years, it is his experience as a base section consultant thatovershadows all other activities.
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SUMMARY IN RETROSPECT
Theodore L. Badger, M.D,
Reviewing, some 12 to 15 years later, the World War IIexperiences of the writer as chief of the medical service of the 5th GeneralHospital, senior consumlant in tuberculosis of the European theater, andmedical consultant to the Normandy Base Section after the invasion, there areseveral events that have emerged from the chaos of war experiences that areexciting and important and even glamorous.
The “Fifth General,” first general hospitalof the U.S. Army to arrive in Europe during World War II, landed in NorthernIreland in May of 1942. Ironically enough for a group of Harvard men, it washoused in a rather gloomy institution for delinquent boys in Balmoral, Belfast.
The hospital arrived in Ireland in the same convoy withthe crack 1st Armored Division, a former cavalry division converted to armorand tanks. This proud offensive fighting unit of the U.S. Army was so riddledwith homologous serum hepatitis from yellow fever vaccinations, that if it hadengaged immediately in combat its effectiveness would have been seriouslyimpaired. Up to 600 jaundiced patients were on the wards of the 5th GeneralHospital at one time, and a total of some 1,600 patients with hepatitis wasadmitted in a period of 4 months. Colonel Gordon later traced this jaundice toits association with certain specific lot numbers of contaminated yellow fevervaccine.
The 5th General Hospital staff, particularly Maj. (laterLt. Col.) Charles D. May, MC, Maj. (later Lt. Col.) Charles P. Emerson, Jr.,MC, and Maj. (later Lt. Col.) Richard V. Ebert, MC, handled the medicalcasualties of this epidemic until later aided by the arrival of the 2d GeneralHospital, the Presbyterian Hospital unit from New York, with medical servicesunder the direction of Colonel Kneeland.
The epidemic of jaundice was hardly over when the firstwave of primary atypical pneumonia struck in August 1942. Two hundred andtwenty carefully studied and documented cases, with a total of close to fivehundred admissions, showed clearly its nonfatal course in this age group ofyoung soldiers as well as the ineffectiveness of penicillin and sulfadiazine onthe course of even the most severe miliary forms of the disease. It was at thistime that a chest X-ray survey of the entire 5th General Hospital personnelrevealed more than 50 instances of ambulatory “atypical”pneumonitis similar to that seen in those hospitalized for “typical”atypical pneumonia.
It was approximately June 1942, a month after arrival ofthe 5th General Hospital, when the writer met Colonels Middleton, Cutler, andGordon. This was the beginnming of a close association with all three of thesemen but especially with Colonel Middleton, since the writer was soon to beappointed as his senior consultant in tuberculosis for the remainder of the war“in addition to his other duties.”
In December 1942, the 5th General Hospital wastransferred from Belfast, Ireland, to Salisbury, Wiltshire, in southernEngland. The personnel and
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small equipment went by plane in the course of a day, while vehicles andheavy equipment went by motor and boat.
It was during this sojourn in southern England that themobile X-ray unit was organized. This unit, with the efficient medical aidmen ofthe 5th General Hospital and Colonel Smedal, the roentgenologist, proved to bea most adaptable outfit. It produced excellent chest roentgenograms with rapidefficiency in survey work and made it possible to keep track of the situationin tuberculosis with little or no dislocation of training schedules.
It was also during this long period in England, fromDecember of 1942 to the invasion in June 1944-a period of relative inactivitywhile waiting for the transchannel crossing--that the basic medical program forthe invasion matured. New medical units not indoctrinated in the needs of anactive t theater of war and variably equipped in medical talent swarmed intoBritain. It was in this period that Colonels Middleton and Cutler built up theconsultation services of the theater and initiated the reassignment of medicalpersonnel from one unit to another in such a way that each general and stationhospital had chiefs of services of sufficient ability and experience to assureU.S. troops the best medical and surgical care. At first, many, the writerincluded, objected to being “robbed” of some of their best medicaltalent. But it soon became apparent that this distribution of medical officerswith real professional ability was not only assurance for maintaining thehighest standards of medicine, but it was also an opportunity for promotingyounger officers of accomplishment. Colonel Middleton in, medicine and ColonelCutler in surgery performed an extraordinary service in the equitabledistribution of medical care to U. S. soldiers in the European theater.
It is to Colonel Middleton’s credit that heencouraged deviations from the routine in clinical investigation, teaching, andresearch as long as this did not upset the military mission of building up forwinning the war.
General Hawley’s meetings of the professionalconsulting staff at the theater headquarters will always remain memorable as anexhibition of the power of persuasion when actual benefits to the health of themilitary command could he shown. General Hawley was a hard bargainer but gavewise and judicial council in decisions concerning the military and the medical,and he required as much of his subordinates. It was a truly superb medicalservice that was established in the European theater. In retrospect, it stillappears that top military authorities failed to give full credit to the theaterchief consultants in medicine and surgery in timely promotions and appropriaterank. For example, the theater chief consultants were frequently, if notalways, of inferior rank as compared to the corresponding British consultants.The Chief Surgeon, ETOUSA, likewise, was late in receiving the rank of majorgeneral, long overdue for the service and duty he was rendering his country inthe medical operations of the theater.
The special problems of the theater senior consultant intuberculosis have been well documented in the body of this report, but two orthree things may be added. The British consultants were seriously bothered thatno one in the
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U.S. Army was allowed to touch any British milk products because ofcontamination with tuberculosis. At the London County Council in 1943, it wasrevealed that, while only 30 percent of British milk was infested with tuberclebacillus, milk in London was felt to be 100 percent contaminated. It wascollected each day by train in huge containers into which the milk supply fromeach station was dumped on its way to the big city. Thus, both clean and dirtymilk were well mixed. Furthermore, it was believed by many eminent Englishphysicians that this condition might be beneficial in building up individualimmunity to the disease itself. Pasteurization, if used at all, was done by theflash method, which was known to be imperfect being in inexperienced hands as aresult of the war’s drain on skilled manpower.
Most remarkable, however, was the plight of the Sovietprisoners of war evacuated to the 46th General Hospital. These starved,emaciated men presented tuberculosis in its most acute and fulminating forms.Rarely was a problem in prevention and isolation of tuberculosis more difficultthan in these men with little or no knowledge of modern vehicles of hygiene andsanitation and with whom there was a complete language barrier. Furthermore,their primitive practices of hygiene and sanitation had further degeneratedunder years of bestial treatment by their German captors. Protection of U.S.nurses and medical aidmen was the matter of greatest concern. To make mattersmore difficult, a Soviet medical delegation, sent ostensibly to help, disagreedwith American methods of treating tuberculosis and did its best to assumecontrol of all plans for treatment. It quickly became apparent to the seniorconsultant in tuberculosis that the sooner the Soviet command sent a train toevacuate these patients to their own “beautiful santoria” in themountains near the Black Sea, the better it would be for internationalrelations, if not for the tuberculous patients.
Most disappointing was the refusal by the War Departmentof the request for permission to survey by chest films all military personnelto be redeployed to the Far East theaters. When the request was finallyapproved, it was too late to be of much use. The ultimate, although late,acceptance of the plan by the War Department was due to the strong supportgiven by General Hawley and Colonel Middleton.
The additional assignment of the writer as medicalconsultant to Normandy Base Section deserves two comments.
First was the enormous amount of cold injury ortrenchfoot that was seen in the winter of 1944-45. In December 1942, theBritish invited representatives from the U.S. Army to a conference on coldinjury in London. There, they discussed the types and varieties of clothingthat wide experience had taught them were good in the prevention of coldinjury. During the winter of 1944-45, the British in the European theater lostonly a handful of men from trenchfoot and other cold injury as compared to U.S.losses due to cold injury. U.S. troops were ill equipped, having improperfootgear and socks for use in cold weather. Whether it was improper logisticsor unwillingness to accept
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the experience of others is not clear, but, in retrospect, it was an error,not only of judgment but of improper clothing and shoes.
The second item to be noted concerns recovered U.S.prisoners of war. April 1945, with the end of the war in sight, brought manythousand recovered American prisoners of war to Camp Lucky Strike in theNormandy Base Section. These recovered prisoners swarmed into the camp far inexcess of its medical and military resources. The early emergency care of theseemaciated men was, at first, an exploration into the conservative renovation ofthese released prisoners who were starved from a diet deficient in proteins,vitamins, and total calories. Too enthusiastic feedings precipitated acute andserious avitaminosis. Too rapid use of intravenous plasma in those unable toeat brought acute pulmonary edema and circulatory collapse. Earlier, in theNormandy campaign, the value and ease of transnasal gastric feedings of highprotein content in those depleted by injury and infection had been learned. Ahigh negative nitrogen balance could be readily remedied by this means, alesson learned from the Cocoanut Grove Disaster studies in Boston. 148This technique again proved useful at Camp Lucky Strike in the cautious,selective feeding of these starved and injured prisoners of war.
Colonel Long, the consultant in tuberculosis in theOffice of the Surgeon General, visited the European theater on 19 April 1945.It was the writer’s privilege to review with him the principal problemsof interest in tuberculosis control and disposition throughout the theater. Thediagnosis and treatment of the recovered Soviet prisoners of war at Besancon,France, and of the Americans at Camp Lucky Strike in Normandy constituted themajor acute problems of epidemic tuberculosis. To these situations, ColonelLong contributed greatly from his long experience in tuberculosis work and withhis calm wisdom in evaluating what was best for the tuberculous soldier andmost expedient for the Armed Forces. He had a forceful but pleasant andfriendly way of getting timings done, and it was helpful to the Europeantheater senior consultant in tuberculosis to have his backing from a higherechelon in problems vital to health but difficult of execution in theexcitement of the last months of the war.
The last day of the war was memorable to the writer alongwith a small party of medical officers and nurses who had gone on 7 May 1945with Colonel Long by ambulance train from Strassburg to Mannheim, Germany, topick up a trainboad of wounded soldiers.
Shortly after arriving at the Mannheim railroad station,the morning of 8 May 1945, whistles and sirens and air maneuvers announced theend of the European war. Colonel Long assembled the small group on the batteredplatforms of the almost destroyed station of that war-ravaged city and withimpressive dignity and sincerity of feeling paid deep tribute to that solemnmoment when the hostilities were over at last.
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148 The Cocoanut Grove, a nightclub in Boston, Mass., filled by a crowd ofsome one thousand persons celebrating a college football victory, was swept byfire at approximately 2015 hours on Saturday, 28 November 1942. By shortlyafter midnight victims of the holocaust had been evacuated to Boston CityHospital and Massachusetts General hospital. The official count on 6 December1942 showed 498 dead. Source: A Preliminary Report on the Cocoanut GroveDisaster, Massachusetts General hospital, 6 Dec. 1942.
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No reconstruction of the medical work in the European theater in World War II is possible without an expression of thanks to the many individuals of every rank in the Medical Department who through their loyalty and devotion contributed to the extraordinary record of medical care that was practiced throughout the theater. Among the nurses, the medical officers, and midmen are the records of unsung heroism, whether in the combat or Communications Zone. One looks back years later with some nostalgia for the experiences in the care of the sick and wounded. Medically, the wide variety of diseases and the vast number of cases was unparalleled in civilian practice. Preventive medicine was as important as curative treatment. The somewhat harassing brushes with Army procedures were temporarily frustrating, but they never dimmed the extraordinary medical experiences of the war.
It was a privilege to have been in the consulting service of the Medical Department of the U.S. Army with a chief surgeon who combined the understanding and iron determination that was General Hawley’s and under a chief medical consultant with the insight, brilliant leadership, and friendliness of Colonel Middleton. Considering the writer’s 39 months in the European theater, as long as this had to be spent in military duty away from home and the practice of medicine, they could hardly have been richer in medical experience throughout the whole course of the war.
Time heals many ills as well as the personality problemsthat arise from the close and unnatural associations of war, perhaps because itis more pheasant to remember the brighter experiences or perhaps becausedistance lends enchantment and the rough places look more smooth. Perhaps, itis just the mellowing process of age that makes the best stand out insilhouette-the writer cannot say. But it is to be hoped that the lessons, otherthan medical, learned from World War II will make it unnecessary for the risinggeneration to repeat the experience of another similar or probably moredevastating war sometime in the future.
