Activities of Medical Consultants
CHAPTER V
SouthwestPacific Area
Henry M. Thomas, Jr., M.D.
Part I. AdministrativeConsiderations
The medical history of the SWPA (Southwest Pacific Area)and the part played in it by the medical consultants must be viewed in thelight of conditions as they existed in this area. These conditions includedwarfare in the tropical jungle; ainphibious island hopping; stupendousengineering feats by which jungle was cleared and a whole series of isolatedbases built, complete with airstrips, roads, docks, and supply dumps; and theconduct of a war 7,000 miles from the United States, with relatively littlemanpower and relatively little materiel of any kind.
The best of planning could not have prepared for theunique developments in Australia, New Guinea, and the Philippine Islands. Noone could have foreseen that hospital personnel would have to build their ownhospitals, sometimes even clearing the jungle, grading and draining the area, andinstalling plumbing and electricity. No one could have anticipated thatshipping and air transportation would be so scarce and over such greatdistances that equipment which was usually considered essential, as well as keypersonnel, would sometimes be left behind to make room for ammunition andminimum food allowances. No one could have planned for the evacuation ofcasualties with even minor wounds 500 to 1,000 miles by water or air. No onecould have anticipated that there would be a constant struggle to provideenough hospital beds for patients who constituted what proved to be a low sickand wounded rate. Yet all of these things came to pass, and as a resultattention was focused, first of all, upon the procurement of basic essentials.
ORGANIZATION OF THE MEDICAL DEPARTMENT
The medical organization in the SWPA, which eventuallygrew to considerable size, began as USAFIA (U.S. Army Forces in Australia),with only a few officers. Early in 1942, Col. (later Brig. Gen.) Percy J.Carroll, MC., who was on duty in the Philippines when the war began in December1941, collected a group of patients just before the fall of Manila andevacuated them on the small U.S.A.H.S. Mactan (fig. 158). When hearrived in Australia, he was made responsible, as ranking medical officer inthe area, for Medical Department activities of USAFIA.
On 28 February 1942, the 4th General Hospital and anumber of casual medical officers arrived and set up in Melbourne, Australia.In April, the 1st and 10th Evacuation Hospitals landed, together with severalsmall station
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FIGURE 158.-U.S.A.H.S. Mactan upon herreturn to Manila, Philippine Islands, June 1945.
hospitals. In early June, a miumber of other station hospitals landed inMelbourne, on the U.S.S. West Point, which also brought three affiliatedhospitals. These were the 1,000-bed 105th General Hospital, the 500-bed 118thGeneral Hospital, and the 500-bed 42d General Hospital. From this time, untilmore than a year later, only a few casual Medical Corps officers and a fewnonaffiliated station hospitals were sent to SWPA. It is small wonder that,during the early days, it seemed to many medical officers in this area thatthey had been left to struggle along as best as they could, since they hadrelatively little help in the form of either materiel or personnel.
During 1943 and 1944, certain peculiarities of thecommand organization in SWPA, which succeeded USAFIA on 18 April 1942,explained certain medical difficulties in this area, including the limitationof the consultants\u0019 activities.
The Commander in Chief of the Allied Forces, SWPA, Gen. Douglas MacArthur, hadas his staff the personnel assigned to General Headquarters. Under GeneralHeadquarters (chart 4) were the United States and Australian Forces. On theU.S. side, directly under General Headquarters, were the U.S. Navy and USAFFE(U.S. Army Forces in the Far East). On the next level under USAFFE were thefollowing components:
1. Ground Forces, consisting mainly of the Sixth U.S.Army. This army, with its predecessor commands, the Alamo Force (United States)and the New Guinea Force (Australian), did all the land fighting in New Guinea.The Eighth U.S. Army was organized in the course of the New Guinea campaign:
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CHART 4. - Simplified organization chart, SWPA,1942-45
it saw major action in the southern Philippines but played a smaller rolethan the Sixth U.S. Army on both Leyte and Luzon. Both the Sixth and EighthU.S. Armies had been assigned roles in the invasion of Japan.
2. The Fifth Air Force, later the Far East Air Forces.
3. USASOS (U.S. Army, Services of Supply).
When Col. (later Brig. Gen.) George W. Rice, MC, arrivedin Australia and became Surgeon on the staff at General Headquarters, SWPA, hisposition was entirely advisory, and he had no office personnel. There was noactual theater surgeon, although the Chief Surgeon, USASOS, ostensibly filledthe position. All operational activity was centered in his office, but therewas little if any collaboration between it and the Office of the Surgeon atGeneral Headquarters, SWPA.
USAFFE, which was intermediate between these twoheadquarters, was a small headquarters in which the surgeon\u0019 s office consistedonly of one lieutenant colonel and one or two secretaries. This headquarterscoordinated the activities of the various forces but did not initiate polices.
Minor changes in this organizational structure wereintroduced from time to time, but it was not until the end of the war, when theSurgeon\u0019 s Office in Headquarters, USAFPAC (U.S. Army Forces, Pacific) wasplaced on the General Headquarters level and was given a sizable table oforganization, that the theater surgeon\u0019 s office achieved a position from whichit could function effectively.
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During the period of reorganization in the Pacific in thespring of 1945, General Headquarters, SWPA, and USAFFE were combined to formAllied Forces Pacific, and SWPA was changed to U.S. Army Forces, Western Pacific.
Professional Services Division
In February 1943, Col. Maurice C. Pincoffs, MC,Commanding Officer, 42d General Hospital (fig. 159), was moved to the Office ofthe Chief Surgeon, Headquarters, USAFFE, to serve as Chief, ProfessionalServices. By this time, Colonel Carroll had been transferred from his positionas Chief Surgeon, TJSASOS, to the position of Chief Surgeon, USAFFE, where hewas to remain until his return to the Services of Supply Headquarters inSeptember 1943.
Colonel Pincoffs, by both backgrounid and experience, wasadmirably suited for his new position. In World War I, he had served withtroops in an aid station and had been awarded the Distinguished Service Crossfor bravery. Between the World Wars, his position as professor of medicine atthe University of Maryland Medical School, Baltimore, Md., had given him heavyteaching and administrative responsibilities. When World War II began, heorganized a 1,000-bed general hospital, recruited from the staff of theUniversity of Maryland. When it became apparent that a unit of such size wouldhave a long wait for oversea duty, he persuaded The Surgeon General to divideit into two 500-bed hospitals and to send them overseas promptly. His trainingwas rounded off by firsthand experience with the problems of his own hospitalafter it arrived in Australia, where he had some contact with casualtiesreturning from New Guinea.
Almost overnight, Colonel Pincoffs became director of allphases of professional medical operations in the Office of the Chief Surgeon,Headquarters, USAFFE. He performed many of the duties of consultant in medicineuntil the arrival of Col. Henry M. Thomas, Jr., MC (fig. 159), in October 1943.Colonel Pincoffs represented the Chief Surgeon on all professional matters,particularly those that required cooperation with other headquarters or otherbranches of USASOS. With Col. Howard F. Smith, U.S. Public Health Service, healso represented the Chief Surgeon on the Combined Advisory Committee onTropical Medicine, Hygiene, and Sanitation. This committee, which was attachedto General Headquarters, SWPA, and reported directly to General MacArthur(chart 4), was composed of representatives of the armies, navies, and airforces of the United States and Australian commands. Its chairman was BrigadierN. Hamilton Fairley of the Royal Australian Army Medical Corps, aninternational authority on tropical disease.
Colonel Pincoffs edited technical bulletins. He reviewedall reports, including those from various research projects. He handledarrangements for the United States of America Typhus Commission (p. 526). Hedirected the policies and activities of the Preventive Medicine Section, whichconsisted of a single health officer, with almost no army experience, a situationwhich could not be corrected because of lack of contact with the Office of theSurgeon General. Colonel Pincoffs also advised with the surgical andneuropsychiatric
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FIGURE 159.-Consultants in medicine, Southwest Pacific.
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consultants; reports from the Dental, Veterinary, and Nursing Sectionspassed over his desk.
Colonel Pincoffs continued to perform these responsibleand onerous duties in Headquarters, USAFFE, until June 1945 except for theperiod between 1 October 1943 and 21 January 1944, when he served in the samecapacity in Headquarters, USASOS.
In the early days, when SWPA was in the formative stage,it was both necessary and practical for this widespread diversity of duties tobe handled by one person. As time passed and complex problems began to developin rapid succession, each duty grew larger, and bottlenecks developed andpersisted. There was no one to rearrange duties and delegate authority, for theChief Surgeon, the Deputy Surgeon, and the Executive Officer were all fullyoccupied with necessary planning and operations in their office.
In January 1944, when Brig. Gen. (later Maj. Gen.) Guy B.Denit (fig. 160) was appointed Chief Surgeon, USASOS, and also designated ChiefSurgeon, USAFFE, it had seemed that a step was being taken toward coordinationof the various units of the theater medical service. Only in the Office of theChief Surgeon, Headquarters, USASOS, however, was there adequate personnel foroperational functions, and the general status of the medical service thereforeremained substantially unchanged.
In January 1944, when Colonel Pincoffs returned toUSAFFE, the various consultants were instructed to report directly to the ChiefSurgeon, USASOS (fig. 161). This change in organization, which was designed togive the consultants greater scope in their activities, did not materiallyalter their duty functioning, but it added so greatly to the Chief Surgeon\u0019 sroutine duties that the consultants, with the rest of the office staff, wereplaced under the direction of the Deputy Surgeon. His duties left him no timefor professional matters, and the situation was as unsatisfactory as it hadbeen before General Denit\u0019 s appointment.
Growth of the Consultant System
From time to time in the early days of the war in thePacific, Colonel Carroll transferred officers from hospital units to duty inhis office at USASOS or used them to form base surgeon\u0019 s staffs when bases wereformed throughout Australia and later in New Guinea.
In June 1942, Lt. Col. (later Col.) William B. Parsons, MC,and Lt. Col. (later Col.) Samuel A. Challman, MC, were sent from the UnitedStates and assigned to USASOS, Colonel Parsons as consultant in surgery andColonel Chailman as consultant in neuropsychiatry.
A month later the young, inexperienced captain in theMedical Reserve Corps who had been sent from Washington, D.C., to act asconsultant in medicine, USASOS, was replaced by Lt. Col. (later Col.) Joseph M.Hayman, Jr., MC, Chief, Medical Service, 4th General Hospital, who acted inthis position until 11 October 1943. On that date, Colonel Thomas, formerlyconsultant in medicine, Fourth Service Command, reported to GeneralHeadquarters,
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FIGURE 160.- Brig. Gen. Guy B. Denit
SWPA, and was assigned to the Office of the Chief Surgeon, Headquarters,USASOS, as consultant in medicine.
When Colonel Thomas assumed his duties as consultant inmedicine, SWPA, in October 1943, he had been greatly assisted by the 2 daysspent with Colonel Hayman, who had been serving as consultant in medicine andwho had recently returned from a useful tour of instruction in hospitals inAustralia and New Guinea. His explanation of the overall situation in the areaproved extremely helpful.
When, therefore, Colonel Thomas requested and was granteda replacement during the reorganization of the area in the spring of 1945,rather than embark on a new and possibly lengthy undertaking, he performed thesame service for Col. Roy H. Turner, MC, the newly appointed consultant inmedicine. Colonel Thomas remained for 5 weeks in the Chief Surgeon\u0019 s (GeneralDenit\u0019 s) Office while Colonel Turner visited several bases and becameacquainted with office procedures and personnel. During this period, the ChiefSurgeon, the Sixth U.S. Army surgeon, and several consultants attended aconference in Washington on medical problems in the Pacific.
Colonel Thomas arrived in San Francisco, Calif., on 21September 1945.
Assistant consultants. - When the consultantservice finally began to function with some degree of adequacy, it wasimmediately apparent that one of the most useful functions performed byconsultants was the visits they were making to hospitals operating in remotebases in New Guinea. These visits served for both instruction and moralebuilding. When Colonel Thomas
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returned from his first visit to forward areas in New Guinea, he recommendedan increase in consultation service, by the appointment of two clinicians ofsuperior ability to serve as assistant medical consultants on temporary duty,who would spend most of their time visiting medical installations in forwardareas. This plan was approved and was also adopted by the surgical consultantservice. It proved increasingly useful as the fighting moved farther along inNew Guinea and more and more bases were turned over to USASOS by various taskforces.
On 4 January 1944, Colonel Hayman and Lt. Col. (laterCol.) Eugene C. Eppinger, MC, were flown to New Guinea, each to serve asmedical consultant for two bases. Late in 1944, these officers were replaced byMaj. (later Lt. Col.) Myles P. Baker, MC, from the l05th General Hospital, andMaj. (later Lt. Coi.) Frederick T. Billings, Jr., MC, (fig. 194, p. 548) fromthe l18th General Hospital. Major Baker was later Chief, Medical Service, 54thGeneral Hospital, and Major Billings, Chief, Medical Section, 118th GeneralHospital. Their work as assistant medical consultants was of great value tothem in their subsequent assignments as well as to the units which theyvisited.
The bases in New Guinea were under a command known asIntermediate Section. The Surgeon, Col. Raymond O. Dart, MC, a Regular Armypathologist, who had been in command of the 105th General Hospital, wasextremely helpful to all professional consultants, and his cooperation greatlyaided them in performing their duties.
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Consultant system, Sixth and Eighth U.S. Armies. - Inthe SWPA, because of the command organization (p. 475), the Chief Surgeon,USASOS, was on the level of the Surgeons of the Sixth U.S. Army and the AirForces. Each new task force was largely staffed by the Sixth U.S. Army,accompanied by Navy groups and the Fifth Air Force. Each task force functioneddirectly under General Headquarters, SWPA, without control from USAFFE orUSASOS.
This arrangement made for innumerable difficulties andeffectively prevented the consultants from having any contact with the armysurgeons. All reports, requisitions, and requests from the Surgeon, Sixth U.S.Army, went directly to General Headquarters. There was no routine communicationbetween what was supposed to be the theater surgeon\u0019 s office (Chief Surgeon,USASOS) and the surgeon of the combat troops (Surgeon, Sixth U.S. Army). Thetheater consultants\u0019 activities were therefore strictly confirmed to unitsunder USASOS control unless specific requests for assistance were received fromthe Surgeon, Sixth U.S. Army.
On the surface, it would seem that these difficultiescould readily have been resolved if the appropriate officer from the Office ofthe Chief Surgeon, Headquarters, USASOS, had visited forward headquarters(Sixth U.S. Army) with instructions to cooperate in every way possible withrespect to the medical needs of the combat troops. If General Denit\u0019 s trip toNew Guinea had not been cut short by a severe attack of dengue, which requiredhis return to Australia for convalescence, it is quite possible that thesituation, which had developed before he was assigned to SWPA, would have been altered.
By July 1943, when the need for a medical consultant inthe Sixth U.S. Army had become apparent, Col. (later Brig. Gen.) William A.Hagins, MC, assigned to this position Lt. Col. (later Col.) Garfield G. Duncan,MC, Chief of Medicine, 52d Evacuation Hospital, an affiliated unit thenassigned to the Sixth U.S. Army. Colonel Duncan was later decorated with theLegion of Merit by the Sixth U.S. Army commander, particularly for his fielddemonstration of the efficacy of Atabrine dihydrochloride (quinacrinehydrochloride) in suppressing malaria and for his educational and supervisoryactivities concerning its use in combat troops.
When the Eighth U.S. Army was forming, while it was stilla skeleton organization, Lt. Col. (later Col.) Worth B. Daniels, MC, was sentfrom the Zone of Interior to serve as medical consultant to the Army Surgeon.By virtue of his background in internal medicine and his accomplishments asChief, Medical Service, Station Hospital, Fort Bragg, N.C., he was unusually wellfitted professionally for consultant duties in a combat army. The closest andmost profitable kind of cooperation grew up between him and Colonel Thomas asthe result of numerous conferences and long discussions.
In January 1945, when vacancies for medical consultantsexisted in both the Sixth and the Eighth U.S. Army, Col. Bruce P. Webster, MC,and Colonel Eppinger were requested for this purpose. Colonel Eppinger at thattime was assigned to the Office of the Chief Surgeon, Headquarters, USASOS, asassistant
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to the Chief, Professional Service, and both he and Colonel Webster weredeclared indispensable by the Chief Surgeon. After a lapse of several months,two excellent young lieutenant colonels were assigned from the Zone of Interioron the recommendation of Brig. Gen. Hugh J. Morgan, Chief Consultant inMedicine to The Surgeon General.
FUNCTIONS OF THE MEDICAL CONSULTANT
Before discussing the functions of consultants in theSWPA, it might be well to mention briefly the plight in which the Medical Corpsfound itself in the early days of the war, when it was obliged to care for thehealth, both on and off the battlefield, of some 10 million citizens who hadbeen suddenly culled away from their civilian pursuits and made into soldiers.With very little help from line officers, who had all that they could do intheir own fields, the Medical Corps of the Regular Army found itself directingthe military training and functioning of the civilian physicians who hadentered the service and who were to provide most of the specialized care whichsoldiers required.
These civilian physicians, by virtue of theirprofessional status, had been accustomed to giving orders, not taking them.They did not take kindly to discipline. They disliked redtape. They wereusually oblivious, because of their training, to everything but the welfare ofthe sick and wounded. Many of them were slow to learn that wars are not won bysick and wounded. The business of keeping fighting soldiers in condition tofight was a new point of view for them. They comprehended only vaguely themorale-building value of preventive and supportive medical service. They hadsuddenly been transported into an exacting new environment, in which they wererequired to perform uniformly as well as efficiently. Left to themselves, manyof them would never have learned how to find the sick and wounded, how totransport and house and feed them, and what to do with them after their medicaltreatment had been completed. In short, they had no idea how much they did notknow or what they had to learn about military organization.
For their part, the Regular Army medical officers werefaced with serious problems. It was these officers who, often without firsthandexperience, had to command hospitals, a position which even the best of theaffiliated units often had difficulty in filling satisfactorily from their ownpersonnel.
Under the circumstances, misunderstandings wereinevitable, and unlimited patience, tact, and effort were needed to resolvethem. Consultants could have served profitably on the staffs of command surgeons,filling the important professional gap between the surgeon of the command andnewly inducted medical officers. It is unfortunate that all consultants werenot appointed earlier and that their functions were not more clearlyunderstood.
The consultants themselves, however, were in a ratherdifficult position. They had not had any previous experience in their duties,and they had no experience in overall military organization and operation.There was no position for them in the table of organization, and the ChiefSurgeon, USASOS,
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acting as theater surgeon, was allowed only about a third of the officerpersonnel he needed in his office. He therefore gave the consultants assignedto it many and various duties. They were given various routine duties,including checking disposition board proceedings for physical disabilityexaminations for candidates. The surgical consultant was given the task oforganizing the writing of the medical history, a task which was later takenover by a lieutenant in the Medical Administrative Corps sent from Washington.Until after the visit in May 1943 of Brig. Gen. Charles C. Hillman, Chief,Professional Services, Office of the Surgeon General, the consultants could notleave the office to visit hospitals.
There was constant pressure from higher headquarters tolimit the table of organization. To comply with this pressure, the consultantswere placed on the rosters of various hospital units in which positionvacancies existed and were brought into the Office of the Chief Surgeon,Headquarters, USASOS, on temporary duty. This was not a desirable arrangement,for a number of reasons. It eliminated chances for promotion of medicalofficers in the hospitals to which the consultants were assigned. Because theywere not on the headquarters table of organization, the consultants were notadequately provided with office space or secretarial service. As a result, eachconsultant functioned individually. When, after General Hillman\u0019 s visit, theconsultant was given some freedom of movement, he spent part of his timetraveling around the area to obtain information and give instruction and partat headquarters, where, almost singlehandedly, he prepared reports andrecommendations and attempted to accomplish \u001c completed staff action.\u001d Often onhis return he found on his desk for such action the very reports which he hadhimself made during his tour.
In January 1945, in an informal report, Colonel Thomasoutlined his impressions of the function of a consultant in medicine, basedupon his own 15-month experience in this position, as follows:
Improvement in the care ofthe patient and the conduct of the hospital can be attained by the consultant\u0019 sprecept and example, by his supervision, by his explanation of the principleslaid down in the technical memorandums circulated by headquarters, bydiscussions of the medical literature, by the awakening of interest in thestudy and treatment of disease, and by the proper handling of the soldierpatient so as to improve his morale and prevent the condition known as hospitalitis.
The chance to discusstheir observations and ideas with more experienced medical men is welcomed withreal enthusiasm by the few well-trained clinicians in small hospitals. For lesswell trained medical officers, the opportunity to widen their knowledge is ofthe utmost importance in their present and future careers in the practice ofmedicine.
The work of the wholeservice in a hospital is raised to the level of efficiency of the individual chiefof service when he realized that an important part of his duties is carefulbedside supervision, in order to provide for good case histories, thoroughphysical examinations, appropriate laboratory tests, suitable therapeuticmeasures, and, finally, prompt and correct disposition of patients. Worthwhileclinical experience then can be obtained by all members of the service.
Colonel Thomas commented, at the end of this report,that, at present, most chiefs of medical services were well-trained men, whoseonly lacks were
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experience in teaching and in running a service. These timings they couldlearn. In the few instances in which chiefs of service had insufficientprofessional training, adequate replacements could be provided.
Redistribution of medical officer personnel. - Onthe whole, well-trained professional personnel were scarce in SWPA and werechiefly concentrated in the group of general hospitals affiliated with medicalschools (Harvard, Johns Hopkins, University of Maryland, College of MedicalEvangelists). Each of these hospitals had among its personnel highly qualifiedsurgeons and internists who were fully competent to perform as chiefs of servicesbut who were assigned as chiefs of sections or, in some instances, as wardofficers. In addition, occasional station and evacuation hospitals had amongtheir personnel several officers competent to serve as chiefs of services. Incontrast to this plethora of skilled and well-trained medical officers, manystation and evacuation hospitals were completely lacking in competent surgeonsand physicians.
In September and October 1944, Colonel Eppinger, who wasthen serving as assistant consultant in medicine, Headquarters, was directed bythe Chief Surgeon, USASOS, in collaboration with other consultants, to make asurvey of existing assignments and to make recommendations for reassignment ofmedical officers throughout the theater. The objective of the survey andredistribution of personnel was to strengthen the weak units without weakeningthe strong.
In November 1944, on orders from the Chief Surgeon,USASOS, more than 100 medical officers were transferred to new assignments. Thereactions to these transfers were varied. Many officers were givenopportunities to assume positions commensurate with their abilities and wereput in line for promotions. Others were loath to be separated from their units.Still others, unfortunately, became displaced persons, losing both theirpositions and their seniority.
By 1945, the affiliated units had been so reduced in keypersonnel that some of them had difficulty in functioning efficiently. On theother hand, the excellent performance of the reconstituted units during theremaining fighting in New Guinea and the campaigns in the Philippines justifiedthe drastic reshuffling of officers.
Upon the completion of this survey, Colonel Eppingervisited all the New Guinea bases, advising with the disposition boards of thehospitals and responding to requests to function as medical consultant.
Summary and Analysis
In retrospect, the following points impress one asexplaining many of the professional difficulties encountered by consultants inthe SWPA in the performance of their duties:
1. The type of warfare necessary in the jungle and thelong water or air travel between bases introduced unusual problems oforganization, construction, hospitalization, evacuation, and supply.
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2. General Headquarters, SWPA, did not concern itself toany great extent with medical problems.
3. There was no authoritative surgeon at the theaterlevel, and command organization led to indirect and conflicting relationsbetween the medical branches of USASOS and the Sixth and Eighth U.S. Armies andthe Fifth and Thirteenth Air Forces.
4. In the Office of the Chief Surgeon, Headquarters,USASOS, most professional problems were directed by a single officer, a stateof affairs which persisted even after the theater had grown large.
5. Medical officers in the area during its formative dayswere inexperienced in administrative duties.
6. The functions of consultants as a group were poorlyunderstood by all concerned. Regular Army medical officers were inclined to thinkof them chiefly as inspectors, and they were usually treated as such by thecommanding officers of the units that were visited. The professional staff weremore inclined to consider them as professional consultants, as in civilianlife, and to accept them as instructors and advisers. Instruction and advicewere frequently needed by the chiefs of service in respect to supervision ofthe professional activities of their officers, personnel problems, and supplyproblems.
An additional difficulty was that the consultants in thevarious specialties arrived in the SWPA at different times, with differentconcepts of their own and each other\u0019 s functions. The administrativedifficulties under which they labored and the wide areas that separated themduring most of their duties delayed their learning to function cooperatively,and there was no one to give them the assistance they needed. Owing to lack ofdefinition, their efforts at cooperation with various sections of the ChiefSurgeon\u0019 s Office were often ineffectual.
7. The SWPA, not without reason, came to believe thatmedical care had to be provided in an area in which neither materiel norpersonnel would be adequate until Germany had been defeated. General Morganvisited the theater in the very early days of the war, but he had so muchground to cover that he was unable to clarify many of the problems which thenexisted. A second visit from him at a later date would have been very useful.When the Consultant in Surgery, Office of the Surgeon General, visited the SWPAin 1944, the circumstances of his visit prevented his spending much time onthese matters. There were other occasional visitors, but they did not stay longenough to find out why the policies and procedures they criticized were beingemployed, and their visits were too short to be really helpful.
In spite of these difficulties and serious handicaps,however, the Medical Department in SWPA performed courageously and to goodeffect.
ACTIVITIES OFTHE MEDICAL CONSULTANT
Colonel Thomas\u0019 first week at Headquarters, USASOS, afterhis appointment in October 1943, left him with a somewhat confused picture ofthe war in
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SWPA. Brisbane, a pleasant, middle-sized Australian city, had a climate notunlike Baltimore, Md. Most of the ranking officers, in addition to GeneralMacArthur, were billeted at the single modern hotel, Lennon\u0019 s. The two generalhospitals nearby had a few interesting cases, but their personnel were ratherbored by nothing but routine duties, far from the combat zone, and wereinclined to be critical of evacuation policies, especially those forneuropsychiatric patients.
All headquarters were then located in Brisbane exceptthose of the Sixth U.S. Army, which had moved to Goodenough Island. One wasdepressed by the feeling of isolation from Washington and the Army in the restof the world, and by the indirect relationship between the Office of the ChiefSurgeon, Headquarters, USASOS, and the medical services of the fighting forces.It was stated that since General Hillman\u0019 s visit to the area in May 1943, theconsultants had been allowed more freedom of movement, but it was still evidentthat their functions and possible usefulness were not well understood.
First tour of New Guinea hospitals. - When ColonelThomas was about to set out on his first tour of New Guinea hospitals, theproblem of transportation was simplified by the arrival of the team from theUnited States of America Typhus Commission, which had been sent out to studytsutsugamushi fever (scrub typhus) and was about to be flown to its station atDobodura, New Guinea. After a long wait at the airstrip near Brisbane, in theearly morning darkness, the C-47 took off with its passengers in straplessbucket seats. At Townsville, Australia, 700 miles north, the plane stoppedbriefly for fuel, and then flew straight across the Coral Sea to land, afteranother 700 miles, at Port Moresby, New Guinea. That night, the group wasbilleted in the dormitory of a small officers club, and on the followingmorning, the scrub typhus team, headed by Dr. Francis G. Blake and Dr. KennethF. Maxcy, took off to fly through the gap of the Owen Stanley Range toDobodura.
By this time, Port Moresby and Milne Bay had becomestaging areas and transportation terminals. The war had moved on past Buna andDobodura up toward the Markham Valley and around the coast toward Finschhafen.It was at about this time that Bases D, A, and B (Port Moresby, Milne Bay, andOro Bay) were designated as Intermediate Section, USASOS, and provided with asmall headquarters.
The surgical consultant, Colonel Parsons, who was justfinishing a trip in New Guinea, went out of his way to assist the new medicalconsultant on his first tour. He accompanied him to Milne Bay and introducedhim to the Surgeon, Base A, and to several of the local hospital commanders.This was cooperation of a positive nature, which was most helpful at animportant time of adjustment to a new and strange environment.
As Colonel Thomas visited the station hospitals in NewGuinea (fig. 162) and talked to the various medical officers in them, he foundthat disease problems fell into a pattern quite different from the patternwhich had been anticipated. When a Japanese force of some 11,000 troops hadcrossed the Owen Stanley Range, over the Kokoda Trail, in August and September1942, and had come
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FIGURE 162.-117th Station Hospital, Port Moresby, NewGuinea, October 1943.
within 32 miles of Port Moresby, it was stopped at Ioribaiwa by threeadverse forces, (1) valiant Australian troops assisted by U.S. forces, (2)semistarvation, and (3) disease. The two diseases which were known to havewrought havoc in Japanese troops, and which also affected U.S. troops in thearea, were malaria and dysentery.1
Work at headquarters. - On his return to Brisbane,Colonel Thomas prepared memorandums on a number of subjects, including commonmistakes in the suppression and treatment of malaria; the diagnosis andtreatment of scrub typhus; the problems of psychoneurosis as they concernedmedical and line officers; and fungus infections of the feet. A reply was alsoprepared to a request from the Office of the Surgeon General for information onfilariasis in the Southwest Pacific. All of this material was submitted to theChief, Professional Services, USASOS.
Colonel Thomas, during his stay at headquarters inBrisbane, visited the 14th General Hospital in Melbourne, the 118th GeneralHospital in Sydney, Australia, the l05th General Hospital in Gatton, Australia,and two station hospitals. By special arrangement with Colonel Duncan, he alsovisited the Sixth U.S. Army Reconditioning Center at Rockhampton, Australia(fig.163).
1 Asa matter of convenience, descriptions of all diseases observed by ColonelThomas in his tours of hospitals are concentrated in part II of this chapter.
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FIGURE 163.-5thStation Hospital, one of medical facilities at Rockhampton, Australia, May1944.
On 4 January 1944, with two temporary duty consultants,he left Brisbane for a second round of visits to New Guinea hospitals.
Second tour of New Guinea hospitals. - In January1944, the base at Milne Bay (Base A) was visited, and local medicalinstallations were inspected in the company of Colonel Eppinger. Short visitswere paid to the 227th Station hospital, the 268th Station Hospital, the l24thStation Hospital (fig. 164), and the l25th Station Hospital.
Three recent sudden outbreaks of diarrhea in threeseparate units, each numbering from 50 to 75 cases, were under investigation bythe base area surgeon. Shigella flexneri had been recovered in the firstoutbreak, and bacteriologic studies of the other outbreaks were in progress. Nobreak in sanitary techniques had been discovered, and no water or food could beincriminated. The medical consultant was asked to suggest further studies whichmight be indicated.
Conferences were held with the Surgeon, Base A, whoexpressed his appreciation for the help being given by the consultants to thevarious hospitals, as well as to his office through the information gained ontheir previous visits. He had already realized the weakness in the professionaltraining of some of the hospital units.
Tour in Leyte.- After Leyte was turned over to theEighth U.S. Army and to ASCOM (Army Service Command), Colonel Thomas wasrelieved of tem-
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FIGURE 164.-124th Station Hospital, Milne Bay, NewGuinea, May 1944.
porary duty with the Sixth U.S. Army and spent the first 3? months of 1945in Base K (Tacloban, Leyte) (fig. 165), working with general and stationhospitals and with the Base K surgeon on professional problems. He had beengreatly pleased when space was provided for him to accompany the staff of theSurgeon, Sixth U.S. Army, and the attack force sailing from Leyte Gulf to Luzonon 6 January 1945, but orders arrived the day before embarkation transferringhim back to USASOS and ordering him for the present to remain at Leyte. This,in fact, was proper, since 90 percent of a medical consultant\u0019 s activitiesconcern the care of the sick who require hospitalization and are of noimmediate concern to a combat army. The other 10 percent concern observationswhich might be valuable in some future military operation or might be used forthe information of the theater surgeon\u0019 s office in planning to take over a basewhen the army turns it over. The surgical consultant takes an active part inthe early care of the wounded. The neuropsychiatric consultant is much moreeffective after the smoke of battle has cleared away.
Many problems were studied. Trained laboratory officersand technicians were badly needed by all hospitals. Several Drinker respiratorswere installed at the l26th General Hospital, and active cases of poliomyelitiswere treated there. Assistance was given to Col. Alvin J. Tillman, MC, Chief,Medical Service, of this hospital in preparing a condensed outline of treatmentof infestation with varying combinations of intestinal parasites. Copies ofthis
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FIGURE 165.-Office of the Surgeon, Base K, Dulag,Leyte, Philippine Islands, December 1944.
outline were distributed to the hospitals in Base K and, later, to hospitalsin Bases X (Manila) and M (San Fabian, Luzon).
Amebiasis was observed in all hospitals, and particularlyfruitful work on this condition was done at the 133d, 44th, and 118th GeneralHospitals (p. 539). Infectious hepatitis was frequent in all hospitals, and thepatients were, of necessity, transferred during the active stage of the diseaseto the 2d Convalescent Hospital, Leyte, or evacuated to rear bases. There werea few relapses, but most of the patients did surprisingly well under the ratherrapid treatment that the exigencies of war imposed.
Tour in Manila. - When the Chief Surgeon\u0019 s Officemoved to Luzon, on 12 April 1945, the consultants followed Manila was a pile ofdust and debris. The destruction of large parts of the city, the U.S.bombardment, and Japanese demolition in their retreat completely wiped out thedistribution of water and electricity and, of course, destroyed all sanitation.The victors found themselves in possession of a public health situation bestcompared to a volcano filled with dynamite. The danger of ravaging outbreaks ofcholera and all manner of dysenteric diseases was enormous, and local publichealth agencies had been either destroyed or demoralized.
This problem was the responsibility of Colonel Pincoff\u0019 s,who had been assigned as director of public health in Luzon, and his successfulmanagement of this unplanned-for emergency is a story of great importance. Hebrought with him the consultant in dermatology, Maj. (later Lt. Col.) John V.Ambler,
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MC, who also functioned as venereal disease control officer after the incumbentofficer, Lt. Col. (later Col.) Ivy A. Pelzman, had been evacuated fordermatitis.
Due credit must be given to the Army Air Forces forcooperation in repeated dusting of the entire city and its environs with DDT(fig. 166), which kept the fly population well controlled and prevented spreadof disease. In the disorganized filth of Manila, however, an unprecedentedincrease in venereal disease was inevitable. Soon several station hospitalswere filled with patients requiring specialized treatment. Dr. Joseph E. Moorewas sent out to observe the situation and offer advice. The whole problemrightfully belonged to the Preventive Medicine Section, but this office wasinadequately staffed, with a single officer of little experience, and liaisonand communication with the Office of the Surgeon General were poor.
Hospitals were established in Manila in buildings whichhad been left standing, one of them the grandstand of the Manila Jockey Club(fig. 167). Except for two field hospitals, all the units sent to Manila wererelatively new in the theater; some had arrived directly from the UnitedStates.
Colonel Eppinger, with 20 officers recruited from 10different hospitals and about 35 nurses, had arrived in Manila to care for theinternees of Santo Tomas shortly after their liberation (fig. 168). When thismission was completed, he returned to the Chief Surgeon\u0019 s Office and soonthereafter departed for the Zone of Interior, where he was assigned to duty inthe Medical Consultants Division, Office of the Surgeon General. Colonel Thomasrequested that an assistant consultant be assigned to serve as executiveofficer of the consultant section at Headquarters, USASOS, in Manila. Therequest was approved, and the difficult position was ably filled by Maj. (laterLt. Col.) Wilson M. Wing, MC.
Routine duties kept Colonel Thomas in his office atHeadquarters,USASOS, a large part of the time. One of these duties was a reviewof the MOS (Military Occupational Specialty) classification of every medicalservice officer, an arduous task, since it had to be performed all at one time.A comprehensive chart of the officer personnel of the medical services of allthe hospitals was completed and was taken to the Office of the Surgeon Generalby the Chief Surgeon in July 1944. It showed graphically the extreme weaknessin the area of B-3139 officers, who were the better trained internists.
Hospitals in New Guinea were closing and moving to thePhilippine Islands and the new general hospitals arriving in the area werepoorly staffed and inexperienced. Colonel Baker, Chief of Medical Service, 54thGeneral Hospital, was again placed on temporary duty as assistant medicalconsultant. He performed an essential service visiting the hospitals in andaround Manila and also made one visit to northern Luzon. Teams were establishedto brief the newly arrived general hospitals on administrative and professionalmatters.
A preliminary plan for the creation of an Army school oftropical medicine in Manila had been submitted to the Chief Surgeon, USASOS, bythe medical consultant, who had been assisted in formulating the detailed plansby Lt. Col. Charles A. Armbrust, MC. The purpose of the school was to emphasizethe
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FIGURE 166.-DDTdusting of Manila by C-47 aircraft, April 1945.
teaching of the clinical and laboratory aspects of tropical medicine, as wellas the preventive aspects, and it was hoped that it might become a permanentfixture in the peacetime Army Medical Department.
Plans for the school were approved, and the opening datewas set for 12 December 1945, but V-J Day came before the opening day, and theplans were dropped.
Billets.- The consultants were itinerants. Theyleft their footlockers at Lennon\u0019 s Hotel, USASOS Headquarters in Brisbane, andtraveled only with two musette bags. When they were found to be away a largepart of the time, they soon lost these accommodations, particularly since onpaper they were assigned to some distant general hospital and were atHeadquarters, USASOS, only on so-called temporary duty. in the field, they hada variety of accommodations, sometimes in the commanding officer\u0019 s tent,sometimes with other medical officers (fig. 169). Mosquitoes made it necessaryto sleep inside of nets. The large field rats called bandicoots often prowledthrough the tents at night. Mud or dust was the rule.
HOSPITALS AND MEDICAL SERVICE
In general, hospitals in the theater retained theirauthorized bed capacity, expanding and contracting according to needs of themoment. In a few instances, in the fall of 1944, evacuation and large stationhospitals were expanded to general hospitals; the changes were made before theconsultants
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FIGURE 167. -49th General Hospital at the JockeyClub, Manila, Philippine Islands, April 1945
and officers in the Professional Service Division, Office of the ChiefSurgeon, Headquarters, USASOS, were informed of them.
New Guinea - After visiting the 54th General Hospital, Colonel Thomassubmitted an informal report to the Chief Surgeon, USASOS, on 25 November 1944,containing the following (summarized) information:
The 54th General Hospital now has a census of 2,100patients-700 medical, 170 neuropsychiatric, and 1,230 surgical. In allprobability, this census will increase to between 2,500 and 3,000.
The table of organization provides for 44 medicalofficers for the professional services. At present, 4 officers are assigned tothe neuropsychiatric service; 1 or 2 more will be necessary. This leaves 40officers for the medical and surgical services-23 surgical and 17 medical. Themedical service would them consist of 21 to 30 wards, with 1 chief of service,1 assistant chief of service and 15 ward officers. Such a service couldfunction by using abbreviated clinical histories, a minimum of laboratorytests, rapid group boarding methods, and supervision of only the seriously illpatients by the chief, with weekly or fortnightly circulation through thewards. When all personnel are well trained and capable of that most difficultclinical procedure consisting of a rapid short clinical history and physicalexamination and an intelligent reduction of laboratory tests to the bareessentials, then a service such as this can provide good medical care.
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FIGURE 168. - Santo Tomas University, Manila,Philippine Islands, February 1945
The surgical service was visited by the surgicalconsultant, who would render a separate report. Many of the more than 1,200patients on this service were severely wounded or needed surgery. The chief ofservice was the only highly trained surgeon on the service, and only a few ofthe medical officers assigned to it were capable of serving as satisfactoryassistants to him. A partial solution to this difficulty had been found in theutilization of the services of officers staging in the base. At one hospital,officers from three ship platoons were lending valuable assistance. At another,officers from a single ship platoon were reporting irregularly, and theirservices were not satisfactory. At this hospital, officers reporting for dutyat two new evacuation hospitals which were staging were also helping out.
In the past, the busiest period experienced by hospitalswas immediately after they were opened. The jump from a census of 0 to one of2,000 patients in the course of a few weeks represented a huge volume of work.Later, as the war moves forward and the base stabilizes, the hospital remains busybut returns to a more normal existence.
It is of the utmost importance that hospital staffs beaugmented in the early days of operation, when the casualty load is excessive,and that the augmentation be accomnplished by design rather than by chance. Ifunits are not available in the base from which temporary duty personnel can bedrawn, then the necessary officers can be temporarily attached from units inother bases in which the load is lighter or in which units are staging.
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The need to help these hospitals with additionalpersonnel is simply to enable them to perform their professional dutiessatisfactorily, not to spare them hard work. They are all willing to work toexhaustion when the need arises, but after a certain time the caliber of theirwork suffers. It is hoped that teams of surgical and medical officers can beattached to hospitals opening in new areas, to augment their staffs for thefirst 2 months after they start admitting patients.
The Chief Surgeon, USASOS, approved the reinforcement ofhospitals in periods of overloading and transmitted his approval to theSurgeon, Intermediate Section, for consideration. No action was necessary, asthe war moved on and these hospitals did not become overcrowded.
Leyte. - Letters written to General Denit inDecember 1944 and early January 1945 by Colonel Thomas, when he was attached tothe Sixth U.S. Army on temporary duty and served as acting medical consultantto the Sixth U.S. Army, indicated, as he expressed it, \u001c how the pieces weregradually falling into place.\u001d The letters contained, among other items, thefollowing (summarized) comments on the hospital situation.
Early in December, the Sixth U.S. Army was almost readyto relinquish its responsibilities to the Eighth U.S. Army and to ASCOM orUSASOS. Two evacuation hospitals, the 36th and 58th, the field hospitals, andthe collecting and clearing companies would then come under the Eighth U.S.Army. At
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the same time, general hospitals, station hospitals, the 27th MedicalLaboratory, and the responsibility for evacuation of patients from Eighth U.S.Army hospitals would come under Base K (Leyte).
Clearing the area, sawing down trees, building roads,drainage, and putting up buildings, including plumbing and lighting, would haveto be accomplished without benefit of heavy equipment and with only irregularnative labor to help. Vehicles were being taken from the hospitals for themotor pools. The 133d General Hospital, for instance, came in four LST\u0019 s,borrowed hinge trailers, and moved all their equipment into a slightly clearedarea. They were ordered to take patients in 3 days and did so. On the otherhand, the 44th General Hospital came in with pup tents and K-rations. The 118thGeneral Hospital came in with tenting, basic mess equipment, a jeep and watertrailer, and one truck, and all their equipment was in the harbor for want oftransportation from the docks to their area. All of these difficultiesdeveloped because engineering problems were several times as great as had beenanticipated, and there were no engineers for hospitals. Even if the hospitalshad had their own medical engineers, Colonel Thomas added ruefully, they wouldprobably have been taken away from them, on the ground that those who had werebeing obliged to give to those who had not.
Three general hospitals, the 44th, the 133d, and the118th, landed on the beaches at Leyte during a heavy Japanese air raid onD-plus-27-day. Negotiations for a favorable building site had been carried onwith maps before the landings, but these arrangements had to be countermandedunder the pressure of battle needs. The 118th and 133d General Hospitals werelocated near the main road running along the eastern edge of the island, andthe 44th was placed near three small airstrips formerly used by the Japanese,and intended for reconstruction for use by U.S. planes. Actually, theseairstrips, which were suitable for the light, small Japanese planes, turned outto be on soft earth which defied and finally, after weeks of frantic work,defeated the engineers.2 Meanwhile the Japanese dropped paratroopersinto this area, and the 44th General Hospital found itself defending, fromrapidly dug trenches, part of the frontline perimeter. By bad luck, thesetrenches were dug in an area which was heavily impregnated with hookworm (Ancylostoma)larvae and Endamoeba histolytica left from a recently evacuatednative village. The ensuing epidemic of acute hookworm infestation will bedescribed later.
In the same letter, Colonel Thomas reported that theSixth U.S. Army had conducted several dispensaries for native civilians as wellas two civilian hospitals, one beyond the headquarters and the other in an oldschoolhouse (fig. 170) near the 36th Evacuation Hospital. They were staffed bypersonnel of the 250-bed station hospitals, with a census of about 120 patientseach, which were supposed to be absorbed by the 133d General Hospital.Personnel of the PICAU (Philippine Island Civil Affairs Unit) had no idea howmedical care was to be supplied to the Filipinos or how to decide who was tohospitalize
2 This delay resulted in 10 days without any air defense after the Navywith its flattops had been ordered away.
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them (fig. 171). It was understood that six Filipino physicians were workingin the area, but obviously they were not enough to take over.
The 44th and 118th General Hospitals, it was reportedlater, were getting their equipment slowly. The 124th Station Hospital washelping the 36th Evacuation Hospita1. The 133d General Hospital was buildingwhile at the same time housing 400 patients. All the prospects of engineer helpconsisted of blueprints. Colonel Thomas was experiencing difficulties in someof the forward hospitals because of transportation problems; on some of histrips, water buffaloes were used to ferry his vehicle across streams.
Colonel Thomas reported that Colonel Hagins, at hissuggestion, was planning to attach a team of one officer and three techniciansfrom the 26th Medical Laboratory to an evacuation hospital which was to go inon D-plus-1-day or D-plus-4-day behind each of the corps in the next operation;the laboratory would revert to its parent unit when that unit was ready tofunction. These laboratories would provide service similar to the excellentservice provided by 1st Lt. Walter L. Barksdale, SnC, on detached service, whoprovided the only clinical laboratory service available until the 27th MedicalLaboratory began to function. He helped both the survey units and thehospitals. Colonel Hagins was very much pleased with his work, and thecommanding officer of the 36th Evacuation Hospital wanted to keep him.
Medical care near the front. - During his tour onLeyte, Colonel Thomas paid several visits to the front. The Consultant in Medicine,Sixth U.S. Army, had returned to the Zone of Interior on rotation, and thenamed request for his replacement had been refused. Colonel Thomas thereforeperformed some of the duties of Army consultant in medicine during this period.
Transportation was provided for his various missions,although it was in short supply. The poor condition of the narrow muddy roadsand the paucity of good airstrips also made for difficulties. One trip wastypical. At dawn, a small L-5 observation plane taxied along the beach to thetent in which Colonel Thomas was billeted and flew him across the island to theOrmoc (MacArthur) area, where it landed in a flat pasture. Fighting was stillbrisk on this side of the island (fig. 172), but the jeep driver knew--or saidhe knew-- where to drive very fast to get by Japanese snipers. The fieldhospital, set up in a churchyard at Ormoc, where the consultant spent thenight, was badly bombed the following night. Even the Sixth U.S. ArmyHeadquarters area on the east coast was frequently darkened by air alerts.Once, a Japanese plane was shot down in clear sight and fell into the sea aquarter of a mile down the shore while most of the staff was at mess. The smallgroup of U.S. night fighters spent many hours in the air.
In a report to General Denit early in January 1945,Colonel Thomas made the following (summarized) observations on medical carenear the front:
In the Ormoc area (the combat zone on the western side ofLeyte), he was much impressed with the commanders of two divisions from thePacific Ocean Area. They were very medically minded and appreciated theimportance of preventive medicine measures in the present campaign. Among thesemeas-
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ures were daily replacemmnent, of socks; provisioim of spectacles for thetroops, who were chiefly older men; dental care; provision of morphine-filledSyrettes for line sergeants; provision of waterproof paper bags to use inhelmets when diarrhea developed in foxholes; taking a clearing companyaugmented by a portable surgical hospital forward with the troops; cleaning upareas; and the use of vitamin tablets. Both of these line officers were veryenthusiastic about their medical officers and enlisted men, and they told aboutlifesaving surgery in the case of one of their valuable officers.
Colonel Thomas was not too imnpressed with the medicalservice provided in the clearing companies and field hospitals which he visitedin one area. The medical officers were chiefly young, poorly trainedphysicians, who had fallen into careless, superficial habits because of lack offacilities, pressure of work, and absence of professional supervision. They hadto keep seriouisly ill patients because of the long and extremely difficultevacuation. In another area, the field hospitals were better, and the servicewas good.
A laboratory visited had good talent but needed to bepulled together. Lieutenant Barksdale was being transferred to it from the 36thEvacuation Hospital, which was closing down.
Hospitals for natives. - While he was at Port Moresby,Colonel Thomas visited a hospital for natives run by ANGAU (Australian NewGuinea Administrative Units) (fig. 173). There were numbers of these smallhospitals scattered through different areas of New Guinea, each able to houseabout 20 patients and each capable of treating a large number of outpatients.For the duration of the war, ANGAU had been taken into the Australian Army.
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FIGURE 172.-Collecting station near frontlinesat Ormoc, Leyte, Philippine Islands, December 1944.
At the hospital in New Guinea, there were 2 young medicalofficers, an experienced warrant officer, and 10 attendants on duty. Several ofthe attendants were able to speak English as well as pidgin English.
Construction of these hospitals varied from area to area,but in the one at Port Moresby, the buildings had chiefly tin roofs and wallsand wooden floors. In addition, three small wards, with thatched roofs and opensides, were built out on poles over the water. This arrangement was unnecessarybecause the shore rose abruptly from the beach, and, as frequently happens inNew Guinea, there was a paucity of level ground on which to build. The patientslay on the floor, on blankets or on thin, palm-woven mats. Colonel Thomas wastold that they preferred this to any kind of bed.
The various diseases were more or less segregated, withdysentery and tuberculosis in one ward, lymphopathias in another, and tropicalulcers and yaws in another. There was a large group of arthritides, some fromdysentery and many from the indigenous strain of gonococcus which was said tobe very widespread but only occasionally to cause urethritis or ophthalmia.Most patients had hookworm; one was said to have 1,300,000 red blood cells per cubicmillimeter and 15 percent hemoglobin; the highest healthy hemoglobin was 70percent.
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Malaria knocked these patients down when they moved to newareas and became infected by a strain different from the one to which they hadimmunity. The Australian medical officer on duty intended to try ourtherapeutic dosage of Atabrine, as he was not supposed to use quinine.
Tuberculosis was said to be on the increase, hygiene being practically impossible to teach and many tribes back in the jungle not yet having had any contact with white men. The natives in Japanese territory were fairing badly, as their food was taken from them, and many developed beriberi and scurvy. Filariasis was encountered, and Colonel Thomas observed an instance of brawny edema of the breast said to he due to this condition, though in his opinion it looked more like tuberculosis. He saw little skin disease, though one patient had tinca imbricata covering the whole body. There was said to be a great deal of pneumonia, which responded well to sulfadiazine.
LABORATORIES
The whole laboratory problem in SWPA was difficult. Eachhospital had its own laboratory, which in station and evacuation hospitals wasusually under the control of a young medical officer with no more than theaverage medical training. Techncians were locally trained, and, in manyinstances, laboratory work was not reliable.
This was not the situation, of course, in units set upprimarily as medical laboratories (fig. 174). One such unit (or a part of one)was usually assigned to each base, but it had no direct official contact withthe laboratories of the various hospitals in the base.
Colonel Thomas recommended that a consultant be appointedto arrange for correlation of laboratory work throughout each base and forproper training of technicians to be appointed to medical laboratories.Although this recommendation was not approved, a school was set up in NewGuinea to train technicians in tropical medicine procedures. it was aconsiderable time before this school was established, and, when it was opened,the number of already fairly well trained technicians sent to it learned agreat deal of tropical medicine which they did not need in that particulararea.
Colonel Thomas concluded that if he were confronted withthe same situation again, he would persist in attempts to set up localarrangements in each base whereby well-trained laboratory personnel couldinstruct poorly trained personnel with the simple purpose of improving theirtechniques in such everyday problems as the diagnosis of malaria by thick-smearpreparations. In a fast-moving war, there is time only for first things first.
Medical general laboratory. - When it was learnedin 1944 that a request had been made to The Surgeon General for a medicalgeneral laboratory to be sent to SWPA, plans were made for its most effectiveutilization. Colonel Pincoffs\u0019 idea was that a 250-bed station hospital shouldbe erected in close proximity to it and should function as the Hospital of TheRockefeller Institute functions in connection with the large Institutelaboratories. Patients with
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FIGURE 173.-Natives receiving treatment inhospitals operated by ANCAU.
rare clinical conditions could be assembled in this hospital and wouldreceive superior clinical observation and treatment while they were under studyby the special personnel and with the special equipment available in the largegeneral laboratory.
There were a number of practical difficulties attached tothis plan, but it was thought that they could be overcome. One concerned rank.The medical general laboratory would be under the command of a Regular Armycolonel of real professional stature, while the clinical problems would be theresponsibility of the chiefs of the medical and surgical services in thestation hospital, who would be Reserve majors in the Medical Corps. Thisdifficulty never arose because the laboratory never functioned in the capacityintended. It could have been settled readily by the issuance by General Denitof instructions to the commanding officer of the laboratory to support clinicalresearch in the hospital.
Another objection to Colonel Pincoffs\u0019 suggestion wasthat the construction of the proposed station hospital would be atime-consuming operation, for which no personnel would be available except thepersonnel of the hospital and the general laboratory. By the time theconstruction work was completed, it was pointed out, the war would have progresseda long way up the island and possibly even into the Philippines. This is justwhat did happen. By the time this unusual organization was ready to function,the war had almost slid off the tip of New Guinea and was about to invade thePhilippines.
The medical general laboratory therefore split up intosections and followed the invading forces as best it could. Its officers werevery useful in studying special problems on the spot as they developed, andlater they per-
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formed good services on the outskirts of Manila. By this time, conditions inlocal laboratories had greatly improved.
While this plan had been in preparation at headquarters,Colonel Thomas, then in New Guinea, sent in a request for Maj. (later Lt. Col.)A. McGehee Harvey, MC, of the 118th General Hospital, to be made available tosupervise a special clinical research problem in a New Guinea hospital.Instead, Major Harvey was recruited by the Office of the Chief Surgeon,Headquarters, USASOS, to serve as chief of the medical service in the researchstation hospital planned, an assignment in which his special abilities couldhave been fully used. Maj. (later Lt. Col.) Frank Glenn, MC, was recommended byColonel Parsons, Consultant in Surgery, USASOS, to serve as chief of thesurgical service.
As time passed and the research unit was not ready tofunction, Major Harvey was made available temporarily for the project for whichhe had been requested and joined with Capt. (later Maj.) Frederik B. Bang, MC,in an excellent clinical and laboratory study of the relation of Atabrine toatypical lichen planus (p.549).
CONVALESCENT CARE IN NEW GUINEA
The general care of soldiers no longer ill enough torequire hospitalization but much too weak to return to the frontlines was aproblem encountered in every hospital visited in New Guinea. On 29 February1944, Colonel Thomas submitted the following (summarized) report on the problemto the Chief Surgeon, USASOS, directed to the attention of Colonel Pincoffs,Chief, Professional Services:
1. The important problem of convalescent care of patientsin New Guinea involves features peculiar to the area.
2. A beginning has been made by setting up the l39thStation Hospital (50 T/O-150 actual beds) in Oro Bay (Base B) (fig. 175) andthe 90th Station Hospital (50 T/O-150 actual beds) in Lae (Base E). Similarunits are needed in Milne Bay (Base A) and Finschhafen (Base F), even ifgeneral hospitals are later established in these areas, since all patients whoremain in station hospitals 2 weeks or more require supervised physicalreconditioning before they return to their units. Tent facilities can beexpanded as the need becomes evident.
3. The supervision and direction of patient activities inthe proposed units should be in the hands of especially adapted medicalofficers who are outstanding in physical stamina, leadership, knowledge ofmilitary discipline, and comprehension of the psychology of the soldier. Thistype of officer is not common. Much might be done by training promising youngmedical officers.
4. At the present time, an excellent convalescent unit isfunctioning at the 105th General Hospital, and a similar unit formerlyfunctioned at the 42d General Hospital. Essential practical experience wasgained in both
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FIGURE 175.-139th Station Hospital, Oro Bay, NewGuinea, June 1944.
hospitals, and officer personnel of other general and convalescent hospitalswould profit by being attached to them for short periods of observation andinstruction in this specialty.
5. Three specific recommendations were made, as follows:
a. That an officer experienced in commanding units forconvalescent care be designated to organize the operation of the 90th and 148thStation Hospitals.
b. That a smallhospital installation be constructed as soon as possible in Base F to functionsimilarly and to grow in size as needs develop. These hospitals will notattempt rehabilitation of patients suffering from nervous disorders, althoughpatients with mild conditions of this kind might well be able to return to dutyafter a short stay.
c. Station hospitals intended for convalescent careshould be located in areas in which facilities for outdoor work and recreationare available.
The only direct action taken on these recommendations wasthe provision of two large convalescent hospitals in the Philippines, whichprovided much needed facilities for the overflow of general hospitals, leavingtheir beds for more acutely ill patients.
EVACUATION
The evacuation of sick and wounded casualties fromforward bases in New Guinea to Intermediate Section and thence back toAustralia was an important problem, about which more than a little confusionarose. Once, for instance, a station hospital in the base at Oro Bay (Base B)sent patients
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for evacuation to a general hospital in Australia. A station hospital in thebase at Port Moresby (Base D), however, where these patients were awaiting airor water transportation, studied them again and sent them back to duty withtheir unit in Base B. In other instances, an air force unit commander refused,on the advice of the unit medical officer, to keep patients, and the process ofevacuation was begun again for them.
These and similar experiences made it evident that finaldecision concerning evacuation must be left to one station hospital or another,and it was decided locally that the hospital which studied the case earliest inits course and was most familiar with the unit status should make the finaldecision. After the base surgeon had approved the decision, it would not bechanged in any station hospital which subsequently received the patient. Underthe evacuation conditions peculiar to New Guinea at the time, this procedureworked smoothly and efficiently.
Confusion also arose when hospitals in advance sectionsand bases evacuated patients to general hospitals with \u001c G.I.\u001d inscribed on boththe Field Medical Card (Form 52c) and, in red pencil, on the Field MedicalRecord Jacket (Form 52d). Many errors were made, some due to hurriedevacuation, some due to the unfamiliarity of units newly arrived in New Guinea,and some to the paucity of professional personnel in small forward hospitalswith the qualifications and experience to make such decisions.
It became evident that final decisions must be made bythe first large hospital to which the casualties were admitted, since therewould be available in it both the professional staff and sufficient time forproper evaluation of the needs of each case. Correction of these improperpolicies had not previously been effected because authority to instruct orcorrect advance bases rested in Headquarters, USASOS.
The principle requiring reevaluation and sorting ofpatients in each hospital in the line of evacuation was sound in itself, but inNew Guinea it led to delay and, many times, to improper therapy. In some cases,for instance, casts had to be removed many times.
Since responsibility for proper treatment and dispositionrested on each hospital, most hospital staff members were reluctant to releasepatients to the rear without first attempting to accomplish as much treatmentas possible. This policy caused delay in the patients\u0019 arrival at generalhospitals and sometimes actually jeopardized the end result. Sorting ofpatients, if properly carried out, requires mature judgment and wide clinicalexperience. If these requisites are available, sorting can be properlyaccomplished in several hours. It was necessary to emphasize repeatedly thatmedical officers should not attempt final sorting or treatment of patientssuffering from clinical conditions beyond the scope of their professionaltraining to handle.
In a report to the Chief Surgeon, USASOS, dated 27January 1944, Colonel Thomas described this situation and made certain specificrecommendations which may be summarized as follows:
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1. Since evacuation follows the line of supply both byair and water and since the line of supply changes for military reasons, thewhole problem of evacuation requires careful supervision on the part of baseand port surgeons. The difficulties must also be called to the attention of,and fully explained to, the Surgeon, Intermediate Section, and surgeons of allbases and ports.
2. Surgeons of bases and ports should refer individualcases for factfinding to suitable consultants whenever they are available.
3. Base surgeons, acting with the advice of suitableconsultants, should designate individual hospitals in their bases for thetreatment and disposition of certain types of cases.
4. Problems of air evacuation should be freely discussedbetween the local flight surgeon and the base or port surgeon, to settle suchmatters as conditions unsuitable for air travel; the selection of patients whorequire special preparation or care in transit; facilities for treatment whichmay or may not be available in transit; and care of property such as clothing,bed clothing, litters, and special equipment which may be in short supply.
5. Ship platoon surgeons and other medical officerscharged with caring for patients during evacuation by water should report tothe local base or port surgeon\u0019 s office for discussions and advice.
6. Reports should be made to the Chief Surgeon, USASOS,through channels, by commanding officers of station and general hospitals,these reports to contain pertinent facts concerning the condition of patientsevacuated to their hospitals.
As a result of these recommendations and observations, anofficer was appointed to supervise evacuation throughout the theater from theOffice of the Chief Surgeon. Thereafter evacuation proceeded in a much moreorderly and efficient manner.
Utilization of bed space. - By the middle of thesummer of 1944, the Chief Surgeon had become more than usually concerned overthe difficulty of providing sufficient hospital bed capacity for casualties inforward areas. In an area composed of many small bases, some of which developedlater into very large supply and staging areas, the problems of transporting,building, and supplying hospitals were not simple.
There was a constant struggle with staff officers atGeneral Headquarters and other headquarters to obtain authorization forsufficient hospital beds in the planning stages. Every step was difficult.There was never enough transportation or engineering to meet all the needs, andpriority always went to combat projects.
The scarcity of hospital beds required that patients beevacuated at the earliest moment that was safe and sensible. Basic rules ofevacuation, however, sometimes had to be transgressed, and patients who shouldnot have been moved, sometimes because their condition was too serious andsometimes because it was not serious enough for evacuation, were sent longdistances to the rear. On the other hand, at every hospital, ward officers wereguilty of retaining patients longer it an was really necessary.
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To augment faster disposition of patients, Colonel Thomasprepared the following (summarized) letter which was approved by the ChiefSurgeon on 2 August 1944 and was forwarded to hospitals through base sectionsurgeons:
1. While every effort must be made to retain in the areapersonnel capable of performing useful functions, valuable bed space should notbe utilized for the care of men with time-consuming conditions when theirsubsequent usefulness is doubtful or likely to be seriously impaired.
2. To a recent publication from the Office of the SurgeonGeneral, it was stated that patients who required more than 120 days ofhospitalization would be evacuated as quickly as possible, the majority between30 and 60 days and all by 90 days. In the SWPA, however, only 27 percent ofevacuees had left the area by 60 days and only 54 percent by 90 days, while 28percent were evacuated after 120 days. Obviously, patients requiring evacuationwere being held in the SWPA much too long.
3. It is therefore desired that all patients be carefullyscreened, with a view toward evacuating those who will require an unusuallylong convalescence as soon as they can be transported safely. Such patientsshould be brought before a disposition board early, and all otheradministrative procedure should be completed promptly. These cases should bereported on the Weekly Bed Status Reports as awaiting evacuation to the Zone ofInterior, so as to avoid all possible delays in evacuating them as soon as theyare transportable. Only patients who give promise of being returned to dutywithin the area evacuation policy should be retained in hospital.
NURSES
As soon as the station and evacuation hospitals in NewGuinea had their tents and portable hospitals erected and the base had beencleared of the last lurking-and usually starving-Japanese, the nurses assignedto these hospitals were sent for (fig. 176). Even then, the danger from enemysnipers and air attacks, while less, still existed. Electricity was providedsoon after the hospitals were set up, but, every night, the buildings were keptblack most of the time for fear of bombings.
Living conditions were always rugged, although everyeffort was made to make them tolerable (fig. 177). The overall motif was mud.In the early rush for locations for various installations, hospitals had totake what they could get, and their personnel had to get used to mud. For along time, there was no running water. Shower baths were improvised from oildrums or Government-issue cans, but they made little impression on the mud.Facilities for laundry were scant. Security measures were complicated.
Even after transportation to the base was available andnurses were housed, there were no facilities for them to visit other units.Each little group was isolated, and work, laundry, and letter writing were theonly occupations. When casualties were received in large numbers, there wastime only for work.
Many of the nurses suffered from physical and nervousfatigue, but the sick rate among them was very low, and their efficiency, senseof duty, and
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FIGURE 176.-Nurses from 251st Station Hospital, whowere first to reach New Britain, 24 July 1944.
cheerful endurance of hardships were high. Every unit visited was proud ofits nurses, and nurses continued to catch up with their units as soon aspossible.
On one occasion, a C-47 carrying nurses and officersacross the Coral Sea from New Guinea fell into the ocean, and the plane sent tosearch for it did not return.
VISITORS TO THE AREA
Visitors to the Southwest Pacific were always welcome butwere not numerous, for a variety of reasons. Seats in planes crossing thePacific were few and hard to obtain, and repeated requests for visits byprofessional personnel to New Guinea were not answered.
In September 1944, a large part of Colonel Thomas\u0019 timewas spent with Lt. Col. (later Col.) Francis R. Dieuaide, MC, from the Officeof the Surgeon General, in New Guinea and later in headquarters in Brisbane.His visit, the only one in almost a year by a medical or surgical consultantfrom this office, was greatly appreciated. His fresh point of view wasstimulating, and his years of experience with tropical diseases in Chinaprovided background for interesting comparisons.
When the war in Europe was finally won, The SurgeonGeneral, accompanied by the chief of his Preventive Medicine Service, Brig.Gen. James S. Simmons, arrived to inspect the area (fig. 178). The SurgeonGeneral visited
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the surgical services, particularly those on which orthopedic casualtieswere under treatment, in a few rear-area New Guinea bases, after which he wentto Leyte, where USASOS Headquarters had been left when the fighting moved toLuzon. His request to the Commander in Chief of the Allied Forces, SWPA, forpermission to visit his forward headquarters was refused on the ground thatthere were no tents or officers available to take care of visiting dignitaries.
Meantime, Colonel Thomas spent several days with GeneralSimmons, who was very much interested in the work being (lone by the malariacontrol units on schistosomiasis (fig. 179). He was, however, somewhatdisdainful of the small and weak Preventive Medicme Section.
When a request for permission to visit Luzon was denied,General Kirk, The Surgeon General, and General Simmons left the area. There wasuniversal regret that their visit had not occurred 2 years earlier.
BLOOD BANK
During his tour in Leyte in December 1944, Colonel Thomaslearned from Major Glenn, Assistant Surgical Consultant, Sixth U.S. Army, thatlarge
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amounts of blood had been required by recent Navy casualties; several hadrequired 3,000 cc., and one had received 5,000 cc. At this time, 80 pints dailywere being received from the Zone of Interior, with additional amounts fromBase G (Hollandia) and Base H (Biak). The prospect was that the needs in Base M(San Fabian) would be even greater, since there were likely to be moreshell-fragment wounds and fewer rifle wounds.
The situation in respect to blood bank supplies wassomewhat complicated. Capt. Albert T. Walker, MC, USN, Surgeon, 7th FleetAmphibious Force, had not heard officially about the visit of the blood bankofficer from the Zone of Interior and was somewhat annoyed. Captain Walker wasjustifiably proud of the past blood bank performance in the SWPA, and, ifpossible, he would like it to continue as a local operation. At the moment,this seemed a formidable undertaking to Colonel Thomas. LST 464, which had beensupplying the blood, was busy with casualties from harbor and Navy personneland could not get donors. In addition, there were other problems oftransportation, supplies and containers. It was Colonel Thomas\u0019 idea that themajor portion of the blood needed by the task force should be supplied for theinvasion by the San Francisco Blood Bank, with augmentation from local suppliesas unnecessary (fig. 180).
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SUPPLIES
In spite of the obvious difficulties and problemsattending their delivery, there were few shortages of supplies in the SouthwestPacific. Certain medical supplies were short in some items for the first timein Tacloban (Base K). Here such drugs as emetine, Diodoquin(diiodohydroxyquin), hexylresorcinol crystoids, and Fumadin (stibophen), aswell as some surgical supplies, became exhausted. The shortage was promptlyrelieved by items flown from San Francisco. The shortage was accounted for bythe unexpectedly long and extensive Leyte campaign and the constant remountingof shipping (fig. 181).
CLINICAL INVESTIGATION
Clinical investigation was not encouraged byHeadquarters, USASOS. It is true that medical personnel was always in shortsupply in the SWPA, particularly during the first 2 years. It is also true thatmedical officers in units stationed in forward areas did not have appropriatetraining for chemical research. There were a number of occasions, however, whenit seemed to the medical consultant that, with very little effort, suitableofficers could have been sent up to well-established station hospitals in whichthey could have made useful observations and collected valuable information.
Recommendations to this effect were seldom approved. Oneof the exceptions was the study made by Major Harvey and Captain Bang onatypical lichen planus (p. 549). Captain Bang had been sent to the area topursue research in malaria. His reports went directly to the Chief,Professional Serv-
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FIGURE 181.-A medical supply depot in thePhilippine Islands
ices, Office of the Chief Surgeon, Headquarters, USASOS, and were not seenby the Consultant in Medicine.
A skin test for filariasis was developed at the 52dEvacuation Hospital while stationed on Woodlark Island, New Guinea (p. 550).
Various chemical observations were made on early acutecases of schistosomiasis, and an epidemiological survey of a large outbreak ofhepatitis was carried out. On the whole, fortunately enough, the war moved toofar too fast to permit much investigation.
Part II. ClinicalConsiderations
GENERAL OBSERVATIONS
Before proceeding to the discussion of special diseases,it might be well to outline a few of the variety of problems which medicalofficers encountered in the Southwest Pacific, particularly after the invasionof the Philippines. Many of them were residual.
The tropical native houses seem in the Philippine Islandsas well as in New Guinea consisted of a single room raised 4 or 5 feet abovethe ground on stout bamboo poles (fig. 182). This elevation insured a certainamount of protection against such unwelcome visitors as snakes, ants, and pigs.Mud was less of an annoyance, and free ventilation was permitted in the usualheat of day.
Sanitary arrangements were primitive. One slidingfloorboard provided egress for all refuse and excreta, which eventually werecleared away by the pigs and dogs or spread around by surface rainwater. Underthese conditions,
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it was small wonder that each native as well as domestic animals carriedthree or four varieties of intestinal parasites, in addition to flukes andmosquito-borne organisms.
In New Guinea, the infrequent, small native villages usually were situmated inlittle clearings back of the forest, and they constituted no problem insanitation to the U.S. Army except through stream pollution. By contrast, inLeyte, most available ground was raised above surrounding swampland used forcultivation of rice, and this land was spotted with groups of these littlehouses. Since the Filipino was a respected ally of the United States, therecould be no invidious regulations and no off-limits areas. Fortunately, thehospitable natives had little to offer U.S. soldiers, and the soldiers hadlittle time or energy left from their exhausting military duties. Otherwise,few would have escaped some tropical ailment, and a considerable number, ofcourse, did not escape.
In Leyte, the area assigned to the 44th General Hospitalwas heavily impregnated with hookworm larvae and E. histolytica leftfrom a recently evacuated native village. Within a week or two, there was anoutbreak of febrile bronchitis and general malaise accompanied by eosinophilia.It was suspected, and later proved, that the condition represented an outbreakof early, severe hookworm disease. At the 133d General Hospital, the residuarylegacy was a large crop of E. histolytica infections. The 118th GeneralHospital, which had landed at the same time as the other hospitals, encounteredschistosomiasis.
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Observations at the 76th Station Hospital in Leyte weretypical. Diarrhea accounted for over a third of about 3,000 admissions.Dysentery accounted for 400 admissions (bacillary, mostly Flexner type, in 190cases; amebic, all trophozoites, in 21; and cause undetermined in the remainingcases). There were 130 cases of common diarrhea and 475 cases of acutegastroenteritis. The cause was not determined in any of the cases of thisgroup, but it included syndromes that in some hospitals were diagnosed asinfluenza or dengue. Other diseases observed included malaria, poliomyelitis,balantidiasis, giardiasis, ulcerative colitis, and regional enteritis. Therewere three cases of syphilis, all new, and some other venereal diseases, but nogonorrhea. A possible case of scrub typhus with rising Proteus OXK titerwas also observed.
In some hospitals, a condition was observed which for thefirst 2 or 3 days looked like influenza. Abdominal cramps and diarrhea thendeveloped, but neither amebae nor salmonellae could be found in the stools. Virusstudies were planned for these patients.
MALARIA
General considerations. - Malaria was not adisease which could readily be dismissed. In various areas of New Guinea, themalaria rate was as high as anywhere in the world. A good many of the nativeswere infected with filariasis, practically all of them had intestinalparasites, and malaria infection was almost universal. It was impossible toprevent contact of the U.S. soldiers with them, for they were very useful tothe Army in helping to clear the jungle (fig. 183) coconut groves and inapplying thatched roofs to rapidly erected buildings of native type.
The particular strain of Plasmodium vivax encounteredin New Guinea was extremely virulent, and mosquito control was particularlydifficult under the conditions imposed by war. The military program wasgenerally to neutralize the Japanese troops in a given area; to turn the baseover to USASOS; to push back the jungle to make room for staging areas,airstrips, supply dumps, and hospitals; and, at the same time, to rid the areaof malarial mosquitoes. The soldiers worked under great difficulties. The heatwas intense. In some areas, it rained almost daily, the downfall totaling 180inches per year in the Milne Bay area. Bulldozers and labor battalions workedin shifts around the clock, and their rations were limited to what could beshipped infrequently from Australia, where very little canned food wasavailable because not much of it was used.
Preventive measures. - It is an amazing fact thatwithin 3 or 4 months, the U.S. malaria survey and control units, with the helpof Army engineers, were able to convert the most highly malarious area in NewGuinea, around Milne Bay, to an area in which the monthly malaria rate wasfrequently lower than anywhere else in the island. This was accomplished by avariety of precautionary measures. Natives working on Army projects were movedaway from them for distances of 2 miles or more when daylight began to wane and
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FIGURE 183.-Pushing back the jungle.
malarial mosquitoes began to appear in numbers. Mosquito bars were required.Some outfits patrolled their areas and moved sleepers away from the bars whenthey had rolled against them. It was required that the body be constantlycovered with clothing and that the shirts be worn with collars buttoned andsleeves rolled down, which seemed inhuman in the tropical heat. Repellents wereused on exposed surfaces. These regulations were difficult to enforce in anisolated spot like New Guinea, but those who escaped being infected withmalaria, in spite of visiting new bases before malaria control measures were insatisfactory operation, did so by obeying these regulations as well as by theuse of Atabrine.
Atabrine administration. - For a long time, thetechnique of administration of Atabrine was faulty and left much to be desired.To the ordinary enlisted man, this rule, like the others for mosquito control,was senseless. A silly rumor spread among the troops that this drug destroyedlibido and potentia. They heard that Atabrine sterilized the bloodstream ofmalaria, and it was only a short step to the belief that it also sterilizedmen. Troops pretended to swallow the pills but spit them back into the cup orspit them out along the road as they walked away from the Atabrine line. Ittook a long time and much discipline to discover and thwart all the tricksemployed to evade suppressive treatment (fig. 184). Men in the Army Air Forceswere particularly casual in their disregard of malaria control procedures.Before the lesson was learned-the hard way-the 32d Division and other unitsbecame completely riddled with malaria and had to be sent back to Australia tobe demalarialized.
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FIGURE 184.-Atabrine publicity campaign, 363d StationHospital, March 1944.
Treatment. - The management of malaria in SWPA isa fascinating historical episode, the complete description of which is beyondthe scope of this chapter. Quinine, which formed with Atabrine and Plasmochinnaphthoate (paraquine naphthoate) the so-called Middle East treatment, wasstill the therapy of choice in the British and Australian Armies. Quinine,however, was in short supply for U.S. Army personnel. On the other hand, theuse of Atabrine was entirely new, and the original dosage-6 pills a week-leftmuch to be desired. It was eventually determined that suppressive doses, takenregularly, eliminated all forms of malaria other than that caused by P.Vivax and suppressed clinical symptoms of that variety during therapy. Thedosage for treatment of malaria attacks had to be established by trial anderror. It is of considerable interest that the schedule finally worked out inSWPA, of large doses for several days (at first, 0.2 gm, every 4 hours)followed by maintenance doses, proved to be identical in principle, though slightlylarger in dosage, than the schedule elaborated in the United States, with thehelp of blood-level determinations on treated patients, by Dr James A. Shannon.Lieutenant Bang, equipped with photofluorometer, was able to provide accuratedata for the final determination of optimum dosage schedules.
Research studies. - Malaria received moreattention and had more manpower effort devoted to its prevention than all otherdiseases put together (fig. 185). The results were good. There were only twoother cases of cerebral malaria and only a few of backwater fever. It is nottoo much to say that
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FIGURE 185. - Continued. C. Demonstration DDTspraying. 1). Laboratory work.
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the effort devoted to malaria played a major part in enabling the U.S. Army toperform its role in winning the war in the Southwest Pacific.
Lieutenant Bang, in addition to the photofluorometricstudies just mentioned, carried out other studies of fundamental significance.
The Australians, under the direction of BrigadierFairley, set up elaborate clinical experiments at Cairns in northern Australia.When a malaria commission consisting of Dr. Fred C. Bishop and Dr. Robert B.Watson visited the area in July 1944 and were invited by Brigadier Fairley tovisit this research unit at Allied Land Forces Headquarters, Colonel Thomas wasallowed to accompany them. New Guinea mosquitoes were used to transmit NewGuinea strains of Plasmodium to volunteer Australian soldiers. The goodand bad points of treatment of malaria with quinine and Atabrine and of itssuppression by these drugs were clearly defined, and Atabrine was finallyadopted as preferable. Other interesting observations were also made at Cairns.
One of many studies on malaria suppression conductedindependently in U.S. Army hospitals was carried out in a general hospital thenstationed in Australia. A group of 10 officers took large doses of Atabrine andsubmitted to daily examinations of the optic fundi for expected signs ofchanges in the optic nerves. No such changes occurred, but 1 serious and 4 mildpsychoses developed among the volunteers. Since toxic reactions to Atabrinewere seldom encountered, except for occasional men who suffered from vomitingand unfortunately influenced psychologically susceptible companions to followsuit, it was concluded that these volunteers had become confused and then, inerror, had taken excessive doses.
Toxic delirium from Atabrine, although it wasoccasionally observed, must have been extremely uncommon. At one generalhospital, Major Harvey, chief of a section of the medical service, detected anddescribed a group of patients who presented peripheral neuritis, which is alittle-known complication of malaria. The association of atypical lichen planuswith malarial suppressive therapy by Atabrine is described elsewhere (p. 549).
More studies would have been carried out if the twophotofluorometers in the area had been released, as requested, to the generalhospitals which had arranged for their requisition. On 27 February 1944,Colonel Thomas made the following (summarized) observations to the ChiefSurgeon, USASOS, on malaria:
1. Many questions relating to suppression, treatment,cure, and immunity in malaria remain unanswered. The Office of the SurgeonGeneral recognizes that many of them can best be sought when large groups ofnonimmune soldiers enter highly malarious areas. Malariologists trained inspecial branches of malaria research have therefore been sent to the theater,and requests have been made for observations on particular phases of thedisease.
2. It is recommended that one or more hospitals situatedin highly malarious areas in which environmental malaria control measures haveonly recently been initiated should be designated for the hospital study ofmalaria.
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Major Harvey, of the 118th General Hospital, is suggestedas an officer well suited to supervise such a study because of his thoroughtraining in clinical medicine and his brilliant record as a research worker inpharmacological and physiological subjects. Lieutenant Bang, is suggested as apart-time or full-time laboratory consultant to the group of workers proposed,and Lt. Col. (later Col.) Gottlieb L. Orth, MC, is suggested as consultant inproblems dealing with infection, suppression, and mosquito control. A smallnumber of technical laboratory personnel will also be required.
3. It was also recommended that a training center beestablished, in connection with all training of divisions which had beenextensively exposed to mosquitoes infected with malaria parasites, for thepurpose of rehabilitation and further study of soldiers experiencing primary orrecurrent attacks of malaria. Followup studies can be made by the medicalofficers attached to these centers.
4. The last recommendation in this letter was thatfrequent and rapid correspondence concerned solely with professional matters becarried on with appropriate officers on duty in the Office of the SurgeonGeneral.
This recommendation was included in an effort to open updirect communications between specialists working in the United States on allthe problems involved in malaria and their opposite numbers in the SWPA. Suchcommunication was forbidden for military reasons, and only routine monthlymedical reports and similar correspondence were permitted. This restriction wasa real handicap in the management of malaria, and it was responsible for someof the delay in establishing a satisfactory Atabrine regimen. Interchange ofinformation by airmail would have been most helpful in this and in othermedical fields.
So far as is known, there was no direct action on any ofthese recommendations.
DYSENTERY
Dysentery was never a majorproblem in the U.S. Army while it was in New Guinea or the Philippines. Throughthe foresight of Brigadier Fairley, the Australian authority on tropicaldiseases, Australian troops were provided with an ample supply ofsulfaguanidine, which was most effective in suppressing dysentery. On the basisof this experience, the U.S. Army stockpiled large quantities of this drug, and,with its use and careful sanitation, the condition was usually under control.
There were occasional breaksin sanitary technique, usually when one unit moved away from a location in ahurry and failed to observe adequate precautions in the final 2 or 3 days inthe area. Then when another unit moved into the same area, outbreaks ofdysentery were apt to occur before the area could be satisfactorily policed.Credit for the fact that so little trouble was encountered from dysentery inSWPA belongs directly to the routine sanitary measures insisted upon by theArmy Medical Department.
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In October 1943, when the hotweather became even hotter, a few cases of dysentery were observed in Base A.In Base D, while diarrhea diminished slightly, the number of cases of Shigadysentery increased relatively, and one fatality occurred, after the patientwas admitted to the 1l6th Station Hospital. Shigella dysenteriae (Shiga)was recovered from most patients, and treatment with large doses ofsulfaguanidine usually brought about recovery.
Because Colonel Thomas hadbeen greatly impressed by the therapeutic effect of intravenous sulfadiazine inthe treatment of another infection, meningococcic meningitis, he was anxious totest the effect of this drug in severe cases of bacillary dysentery, and chiefsof medical services in various appropriately placed station hospitals wererequested to try it. In the only suitable case found, an immediate curativeeffect was observed.
DENGUE
Dengue was widespread in anumber of areas in New Guinea. Since this disease is transmitted by Aedesaegypti, which is not affected by measures commonly used to reduce oreliminate malarial mosquitoes, nothing much could be done except to give thepatients symptomatic care. Although some characteristic breakbone fever caseswere observed, with the typical secondary rise in temperature and extremelysevere headache, most attacks were mild. The short duration of the attack andthe absence of severe sequelae prevented dengue from being an important medicalfactor in New Guinea. This statement might not be concurred in by GeneralDenit, who suffered one of the most severe attacks of the disease whichoccurred in SWPA.
SCRUB TYPHUS
One of the most dramaticdiseases encountered in SWPA was scrub typhus (tsutsugamushi fever). Small,scattered outbreaks developed steadily as the fighting progressed throughoutNew Guinea. A very virulent outbreak occurred onn Goodenough island, where theSixth U.S. Army had set up headquarters in November 1944, and another verylarge one occurred on Owi, in July and August 1944 (fig. 186).
Personnel of the 9th GeneralHospital had cleared an area on Goodenough Island, and, with some help fromengineers, they had erected their own buildings. They worked in fields coveredby kunai grass which, though it was unknown at the time, harbored the rodents(fig. 187) and the deadly little mites that transnnit scrub typhus. Some 30 or40 cases developed among the personnel of this hospital, and there were anumber of fatal cases, one in a medical officer.
At the time this outbreakoccurred, treatment was symptomatic, and the precise pathological lesions andderanged physiological functions were not known or understood. Later, as postmortem material was collected and it became evident that the widespreadinvolvement of the capillary blood vessels produced lesions in all organs ofthe body, the signs and symptoms were more
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understandable. Early in the experience with thisdisease, patients were seen to die from heart failure or from shock, withvarying degrees of cyanosis and of moisture in the lungs.
Ways and means of usingoxygen, digitalis, and infusions of plasma or salt solution were widelydiscussed and variously employed. The dangers inherent in all these methodswere very real and occasionally apparent. In Colonel Thomas\u0019 opinion, theoutcome in each case depended upon the virulence of the micro-organism presentin the particular location rather than on the particular form of nonspecifictherapy employed. In the large outbreak on Owi, the case fatality rate was 0.6percent, but in the Goodenough Island outbreak and in another in theFinschhafen area, it was 35 percent.
Early accounts of theextensive but mild outbreak on Owi were reported casually because of thegreater seriousness of the disease as it was experienced elsewhere and thevigorous and time-consuming measures which had to be taken against it. Whensick reports from the task force under Maj. Gen. Horace H. Fuller, which washaving a particularly difficult time dislodging the Japanese from caves alongthe coastal cliffs and hills of Biak (northwest of New Guinea), began to showalarming numbers of cases of scrub typhus, the Chief, Professional Services,USASOS, sent a radiogram under the signature of the Commanding General, USAFFE,to the Sixth U.S. Army offering medical officers, nurses, and supplies. On 2August 1944, under the signature of Lt. Gen. Walter Krueger, it was stated thatonly one medical officer was necessary at the time and Colonel Thomas was requested.
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FIGURE 187.-Bandicootrat, host of mites transmitting scrub typhus
This incident typified theunfortunate lack of understanding between the Office of the Chief Surgeon,USASOS, and the Sixth U.S. Army Medical Section. The offer of medical officers,nurses, and supplies was, in fact, impractical. On Owi, excess medical officerswould have been a nuisance, and there was no place for nurses to live, even ifsafe transportation had been available. As for supplies, they became indequateas soon as they could replace essential ammunition on cargo aircraft. ColonelHagins, however, could readily have used a medical officer to serve as one ofhis own staff, to keep him informed of the situation, and to make suggestionsto him.
On the night the radiogramfrom the Sixth U.S. Army was received, Colonel Thomas boarded a plane, carryinghis musette bag and a cage containing 24 white mice. Early or doubtfuldiagnoses of scrub typhus were to be proved by inoculation of these laboratoryanimals.
As already mentioned, thislarge outbreak was associated with the unprecedentedly low case fatality rateof only 0.6 perceint. The fright among line officers resulting from it,however, hastened cooperation in measures of prevention. Scrub growth wasrapidly cleared and mite repellent freely used (fig. 188). Steps were takemn toobtain impregnated clothing for future operations in the same type of terrain.
A number of useful lessonswere learned from this mild outbreak. Another medical officer continued thestudy which Colonel Thomas had begun, and he prepared an account of theclinical picture and the distribution of cases among the troops assigned to thetask force.
Special investigations- The group sent from the United States of America Typhus Commission to NewGuinea to study scrub typhus was headed by Dr. Blake and Dr. Maxcy and includedentomologists, parasitologists, and well-trained laboratory personnel (fig.189). Preparations for their arrival included the setting up of laboratories innew portable buildings in conjunction
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with a station hospital in Dobodura, an area inwhich scrub typhus had been prevalent (fig. 190). Here the disease was studied,the location and transmission of the mites were determined, new forms of miteswere described, and, finally, methods for the prevention of typhus wereelaborated and clearly described (fig. 191).
Technical Memorandum No. 9,published by the Office of the Chief Surgeon, Headquarters, USAFFE, 6 August1944, included a brief description of the disease, detailed explanations of thevector and reservoir hosts, and instructions for control and prevention. Thesubject had been previously dealt with in Circular No. 117, Office of the ChiefSurgeon, Headquarters, USAFFE, 31 December 1943; War Department TechnicalBulletin (TB MED) 31, 11 April 1944; and an article in the Bulletin of theU.S. Army Medical Department in May 1944.3
Impregnation of clothing.- Circular No. 117, just mentioned, contained the following (summarized)information on the impregnation of clothing and blankets with methyl phthalateemulsion:
Experience with massimpregnation of clothing with a soap emulsion of methyl phthalate has beenacquired in recent field tests with troops and as a
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3Scrub Typhus. Bull. U.S. Army M. Dept. No. 76, May 1944, pp. 52-61.
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FIGURE 190.-Facilitiesof U.S.A. Typhus Commission. A. Laboratory building. B. Insectory.
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FIGURE 191.-Testingmite repellents. A. Method of rearing mites B. Testing repellents in the field.
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control measure in a recent outbreak. As a resultof these experiences, it is recommended that this metinod be used in all troopsbefore their participation in combat or in combat training. In bothcircumstances, it is considered to offer the best protection available at thistime. Engineer troops working in suspected areas and staging troops among whomtyphus has appeared should also have the added protection of this measure.
Methyl phthalate in 1-gallontins is now being received in this theater for clothing impregnation. The issueis on the basis of 10 ounces per man per month. Issue is restrictedi to troopsdesignated for duties which will involve exposure as just described (fig.192).Requisitions should be accompanied by details of the circumstances which renderthe use of this agent advisable.
It was something of a triumphto persuade the fighting man to adopt andl carry out the painstaking measureswhich prevented scrub typhus (fig. 193). The complete story entails the pioneerwork accomplished by the Australians; extensive research by the group from theUnited States of America Typhus Commission as well as by others; overcomingSixth U.S. Army objections to the time-consuming and complicated controlmeasures; and, finally, the mass impregnation of clothing by Army laundries.The story of prevention and control is told in detail in the preventivemedicine volumes of the history of the U.S. Army Medical Department in WorldWar II.
Rehabilitation anddisposition. - Patients recovering from scrub typhus were found to presenta real problem in rehabilitation. The disease had acquired a fearsomereputation, and convalescent patients, as well as many medical officers, werefrequently convinced that they had suffered some permanent damage to the heartor other vital organs.
Technical Memorandum No. 10,published by the Office of the Chief Surgeoin, Headquarters, USAFFE, 29 August1944, advised a carefully supervised program of physical reconditioning forthese patients, combined witin ressurance as to their ultimate recovery, asfollows:
Reassurance may be soundlybased on the careful studies carried out in this area on large series ofconvalescent patients in whom the physical signs, the X-ray findings, theelectrocardiograms, the vital capacities, and the exercise tolerance tests werecritically evaluated to determine the frequency of residual cardiovasculardamage. The results of these studies indicated that there is no evidence ofpermanent organic damage and that functional neurocirculatory symptoms were nomore frequent than they are after other severe febrile illnesses. It may beconcluded that, though vascular and perivascular lesions occur in the heart aswell as in the lungs, brain, and other tissues during the active stage of thedisease, the recovery from these inflammatory processes is complete, with veryoccasional exceptions. When permanent disability persists, as it does in thesevery occasional cases, it takes the form of varying degrees of deafness,diminished vision, involvement of the peripheral in nerves, or other residualdamage, chiefly of the nervous system.
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Recommendations for disposition consisted ofgrouping the patients as follows:
1. The first group consists ofpatients in whom the course of the disease has been sufficiently mild towarrant the estimate that they will be in condition to return to generalservice at some time within 6 weeks after admission to the hospital. Theyshould spend their convalescence in the convalescent section of the hospital orbe transferred to a convalescent hospital within the same base. Careful medicalsupervision should be maintained over their progress through a graded scheduleof exercise, recreational activities, and other measures of physical and mentalupbuilding.
2. The second group consistsof patients whose course has been of medium severity and who would require atleast a month of reconditioning after hospital treatment was no longernecessary before assignment to duty. Such patients should be transferred to ageneral hospital or a designated station hospital to be recommended, as soon astheir condition permits, by a disposition board, for transfer to the FirstTraining Center, Replacement Command, Oro Bay. Officers below the grade oflieutenant colonel as well as enlisted men should be so recommended fordisposition.
Hospital patients transferredto the First Training Center should be able to care for themselves withoutnursing attention and to perform light camp
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FIGURE 193.-Poster urging preventive measuresagainst scrub typhus.
duties. It was desired that full advantage betaken of the resources of this center for the reconditioning of all long-termpatients no longer requiring hospital care but not yet fit for return to theirformer assignment. The center provided a graded schedule of physical activitiesunder medical supervision, a hospital scale of rations, and recreational andeducational features. Training was carried on in an environment of militarydiscipline until the convalescent was determined to be fit for reassignment.
Careful judgment had to beexercised to be sure that patients who could not be expected to perform anymilitarily useful service, even after rehabilitation, were promptly evacuatedto the United States.
3. The third group ofconvalescents from scrub typhus fever consists of those who because of theextreme severity of their illness or the development of complications wouldplainly be unfit for military service within a period of 120 days, counted fromthe day of their admission to the hospital. These patients were to betransferred to a general or designated station hospital, to be evacuated to theUnited States on the recommendations of a disposition board.
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DIFFERENTIAL DIAGNOSIS OF ACUTE FEVERS
Mild attacks of dengue werediagnosable only by the association of the patients with patients who weresuffering more severe attacks. The same was true of mild attacks of many otherfebrile diseases encountered in New Guinea. The diagnostic difficulties, infact, were such that the medical services in many station hospitals began toenter large numbers of cases as \u001c fever of undetermined origin\u001d (FUO). At onetime, there were so many such diagnoses that Colonel Thomas wins instructed bythe Office of the Chief Surgeon, Headquarters, USASOS, to investigate thematter. In every case which he observed, the diagnosis was in real doubt,though occasionally there was a fairly well founded suspicion that the diseaselay in one or another special category. In his opinion, very few of these casesrepresented mild breakthrough attacks of malaria.
In view of the importance ofaccurate classification of disease, both for proper treatment and statisticalpurposes, Colonel Thomas prepared the following (summarized) material on thedifferential diagnosis of acute fevers, which was published as TechnicalMemorandum No. 7, Office of the Chief Surgeon, Headquarters, USASOS, 21 March1944:
Malaria. - A positivesmear should be obtained in as many cases of malaria as possible. If the firstsmear is negative, additional smears should be taken at daily intervals. If thegeneral condition is good, it is proper to withhold treatment for several daysin the effort to get a positive smear, but, whenever this is done, the patientmust be watched very closely; in primary falciparum infections, althoughparasites may be very scanty in the peripheral blood, he may pass into aserious condition within a few hours.
The desirability of getting apositive smear before antimalarial treatment is begun must not preventtreatment in any patient who presents symptoms strongly suggestive of malaria,particularly a tertiary fever. Such cases should be reported as \u001c malaria,clinical diagnosis.\u001d Symptoms of cerebral malaria demand prompt treatment,irrespective of what the smear shows.
Withholding suppressiveAtabrine for 2 or 3 days in an effort to get a positive smear is likely to beineffective. Withholding the drug for a longer period is unjustified.
When patients are treated onthe presumption of malaria without a positive smear and the temperature doesnot remain normal after 48 hours of treatment, another cause for the fevershould be seriously considered. Some patients with malaria will run a fever for3 or more days, it is true, but they constitute only a small group.
Dengue. - This proteandisease is characterized by 5 to 7 days of fever, either so-called saddlebackor continuous; headache; retro-orbital pain; conjunctival suffusion; backacheand periarticular muscular pains; and a rash, which usually appears on thefourth to the sixth day. While there is considerable variation in the severityof symptoms and duration of fever, the diagnosis of dengue when the temperatureelevation lasts less than 4 days
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should be viewed with suspicion. Very mild,afebrile cases of dengue probably do occur, but the differentiation of themfrom other short fevers is not reliable.
Upper respiratory diseases.- Common nasopharyngitis, sinusitis, tonsilitis, and bronchitis are usuallyreadily distinguished as such if the examination is adequate. Fever may persistfor several days. Upper respiratory symptoms are usually minimal in dengue. Atthis time (March 1944), influenza had not yet been recognized in the forwardarea.
Diarrheal diseases. -Diarrheal diseases are usually readily recognized. Fever is frequentlyassociated with diarrhea and usually associated with dysentery, but diarrheaalso occurs in malaria, dengue, and typhus. In the diarrheal diseases, feverand diarrhea either begin together, or the diarrhea precedes, rather thanfollows, the onset of fever. The degree and duration of the fever may be out ofproportion to the number of bowel movements.
Effects of heat. -Certain persons, particularly if unseasoned to hot weather, may develop fever,headache, abdominal cramps, and muscular pains after working in the heat. Thepicture observed un New Guinea, however, frequently does not correspond withtextbook descriptions of heatstrokes, heat exhaustion, or heat cramps from lossof salt. Diagnosis should not he difficult when the history shows a definiterelation between the onset of symptoms and heavy work in a hot atmosphere and whenthe response to rest and the administration of salt is prompt.
Typhus. - Typhus may bedifficult to diagnose in the first few days of the illness. The onset is likelyto be more gradual than in dengue, with the fever rising gradually for thefirst 2 or 3 days and then persisting for 10 to 14 days or even longer.
Helpful points in diagnosisinclude the presence of an eschar, which can be found on careful search in mostcases; adenopathy, particularly if it increases over a period of a few days;and the rash. Confirmatory evidence is obtained by agglutination with ProteusOXK, which is usually present by the 10th day and which reaches a maximum 2or 3 days after the temperature has returned to normal. A titer of 1:80 isconsidered suspicious, and a titer of 1:160 on greater is usually considereddiagnostic. The diagnosis of typhus when the fever lasts less than 10 days isseldom justified, and the same holds for cases in which the fever lasts longerbut there is no eschar and the OXK agglutination is negative.
Enteric fevers. - Onlya few cases of the enteric fevers (typhoid and Salmonella) have occurred up tothis time, but these diseases must nonetheless be borne in mind. They are to bedistinguished from typhus by the absence of an eschar; the differences in theskin rashes; the negative Proteus OXK agglutination; the increasingtiter in the Widal test; and positive blood, stool, urine cultures.
FUO. - The differentialdiagnosis of many of the fevers mentioned cannot be made on admission. In casesof short duration, the diagnosis is often best made when the patient isdischarged, when the clinical course, the symptoms, and the character of thetemperature curve can be carefully reviewed. Even
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then, a critical clinical appraisal may still notmake it possible to place the case in any particular category.
Cases of this kind may berecorded as FUO. Even under adverse conditions, however, the number of casesthus diagnosed should not constitute more than 10 to 20 percent of all febrileadmissions.
INFECTIOUS HEPATITIS
Infectious hepatitis began tobe a problem in the spring of 1944, with the development of isolated cases inareas far removed from each other and with no apparent method of spread.
The first large group of caseswhich might be described as epidemic occurred in the task force which invadedthe neighboring islands of Biak and Owi, areas in which a scrub typhus epidemichad occurred. Although a few cases of hepatitis developed before the first caseof scrub typhus was observed, from then on, the two outbreaks paralleled oneanother until the scrub typhus was controlled by eliminating the mites, whichwas accomplished by clearing away scrub growth and tall kumai grass, and byimpregnating clothing with methyl phthalate. In July, August, and September1944, the outbreak of infectious hepatitis assumed notable proportions.
The invasion of Leyte tookplace just after the height of the outbreak on Owi, and all the hospitals inthe Leyte area received a great many patients suffering from hepatitis.
Clinical and Epidemiological Studies - With the concurrence of Colonel Hagins, Sixth U.S. ArmySurgeon, the outbreak of hepatitis in Biak and Owi was studied by Maj. James L.Borland, MC, gastroenterologist from the 105th General Hospital, and Lt. Col.(later Col.) William B. Vandergrift, MC, Chief, Laboratory Service, 118thGeneral Hospital. They spent about 6 weeks in August and September 1944,collecting information, observing patients, and making exhaustive laboratorytests. They also attempted to cultivate a virus. Their preliminary reports,which included all the data available, were sent to the Surgeon, Sixth U.S.Army, in October and November, and their final report was sent to the ChiefSurgeon, USASOS, 18 December 1944.
While in Brisbane, ColonelThomas prepared material for the area ETMD (Essential Technical Medical Data)and also wrote Technical Memorandum No. 16, which was published on 1 October1944 by the Office of the Chief Surgeon, Headquarters, USAFFE. The data oninfectious hepatitis contained in these various reports and other publicationsmay be summarized as follows:
Historical note. -Outbreaks of jaundice have been reported for at least 100 years and have beenparticularly numerous in armies in wartime. Over 52,000 cases were reported inthe Union Army during the Civil War in the course of 3 years. Outbreaks haveoccurred in World War II in British troops in the Middle East and among U.S.troops in North Africa and practically all other areas.
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Epidemiology. -Opportunity for study has led to increased knowledge of this disease in recentyears. It is now believed that the etiologic agent is a filterable virus orgroup of viruses, although attempts to cultivate it (or them) have beenunsuccessful.
The disease has been passedfrom patients to volunteers by several methods, including nasal insufflationand intracutaneous inoculation of serum and whole blood. More recently,filtered excreta have been shown to contain the virus and have produced thedisease upon ingestion by volunteers. Thus observation has introduced animportant concept concerning the possible transmission of the disease bycontaminated water or food.
The special epidemiologicstudies in the investigation, just referred to, of the outbreak on Biak and Owirevealed no common water points, swimming areas, or messes. The affected unitswere not in closely adjacent areas and had no common meeting places exceptoccasionally at open-air motion pictures. There were no common prior stagingareas. The only Navy personnel who developed the disease had been ashore in theinvolved area. It was concluded that the virus had probably been brought in byU.S. soldiers and sailors and that the variety of spread pointed to a vector.The common fly and a species of Phlebotomus were suspected, especiallythe latter. The incubation period was between 3 and 5 weeks and was most often4 weeks.
Clinical picture. -When infectious hepatitis occurred in outbreaks, the clinical picture followeda definite and characteristic pattern. The onset in the majority of cases wascharacterized by fever, often followed by a latent period during which thepatient might feel perfectly well. The onset might also occasionally becharacterized by a chill, headache, and general malaise. Then would come anacute phase, from the fifth to the seventh day, ushered in by anorexia, nausea,sometimes vomiting, weakness, and pain in the upper abdomen. Jaundice ensued,associated with an enlarged and tender liver in about two-thirds of all casesand, occasionally, an enlargement of the spleen. About a third of the patientshad a slight temperature elevation at this stage.
About a third of all thepatients observed had no history of a preliminary febrile stage and becameaware of the disease only when they noticed yellow scleras or dark-brown urine,usually associated with a distaste for food and slight lassitude.
In from 1 to 5 weeks, thejaundice began to clear, and recovery was usually rapid, lasting not more thana month. The mildness of the illness and the length of convalescence werethought to be directly proportional to the amount of rest. Patients kept in bedon Owi until the jaundice finally cleared practically all did well. The onlyfatalities and complications occurred in patients who were evacuated. It wasthought that return to duty before the jaundice had fully cleared predisposedto relapse and prolonged the convalescence.
In theoccasional fatal case, a sudden lapse into delirious semicoma took place 4 to10 days before death occurred from acute yellow atrophy of the liver.
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In December 1944, ColonelThomas observed two patients on Leyte who died of jaundice with unusualfindings. Both died suddenly and unexpectedly after they had been jaundiced for5 days before admission and 2 or 3 days in the hospital. Neither had fever, andneither was apparently very ill. Clinically the cause of death was acutepulmonary edema. In both cases, autopsy showed that all five lobes of the lungswere totally involved in an early bloody pneumonia. The trachea and bronchiwere pale and did not contain pus. One patient had hemorrhages throughout thekidneys and in the interventricular septum, suggesting a sudden cardiac death,but these findings were not present in the second case. No pathogens (plaguebacilli) were present in smears from the lungs, but inclusion bodies-a weakreed to lean on-were suspected. The liver in each instance showed minimaluniform cloudy swelling.
Diagnosis. - During theoutbreak of infectious hepatitis, it was possible to suspect the correctdiagnosis during the early febrile stage. Confirmation was obtained byobservation of bile in the urine several days before jaundice became evident.
No instance of Weil\u0019 s disease(infectious hepatitis caused by Leptospira icterohaemorrhagiae) wasfound in these outbreaks. The organism, however, was isolated from threenatives of New Guinea by a U.S. medical officer. In each instance, the clinicalpicture was typical of Weil\u0019 s disease, and all the patients responded promptlyto treatment with penicillin.
Treatment. - Treatmentof infectious hepatitis consisted chiefly of rest and diet. Rest in bed wasenforced as soon as the condition was suspected, and unnecessary movement ofthe patients was strictly prohibited.
It was of major importancethat a satisfactory state of nutrition be maintained. The diet was kept low infat, but the addition of small amounts of milk, cream, or butter waspermissible if the increased palatability thus obtained enabled the patient toemit more food. Polyvitamin capsules were administered twice a day.
Fluids were taken freely. Ifvomiting interfered with an adequate intake, 5-percent glucose in physiologicalsalt solution was injected intravenously in amounts sufficient to produce adaily output of 1,200 cc. of urine. Plasma was of possible value in thepresence of ascites, but this complication was both late and unusual.
When thehospitals on Leyte began to receive patients with infectious hepatitis, woundedsoldiers required major attention, and many of the patients with hepatitis, whowere less seriously ill, were transferred rapidly to a huge convalescenthospital, long before their jaundice had cleared up and in some instances evenbefore it had begun to lessen. In this hospital, the patients were forced towalk long distances to and from meals. They had absolutely no nursing care andeven had to take care of their own beds.
It wasinteresting to Colonel Thomas and others, who were watching this situation withsome misgivings, to note that these patients went on to complete recovery andthat very few developed serious complications. In only a few cases did thedisease progress to the chronic stage. The final word
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on these cases could, of course, come only fromfollowup studies, which were not practical.
While he was on Leyte, ColonelThomas received some of the voluminous reports on studies of hepatitis in theMediterranean theater. The military situation on Leyte prevented following anyof the recommendations contained in these reports, and the cases just describedtherefore may be considered to have served as a rather interesting controlseries.
Control. -Recommendations for control of infectious hepatitis, Colonel Thomas pointed outin his October 1944 report, were difficult to make in the present state ofknowledge. It was thought that transmission might be by droplet infection, butattempts had also been made to incriminate an insect vector. On the other hand,demonstration of the infecting agent in the stool, and possibly in the urine,of patients with the disease suggested the prime importance of methods designedto prevent contamination of water and food. The following recommendations weretherefore made:
1. All the usual sanitarymeasures should be strictly enforced.
2. Bathing in fresh-water streamsshould be prohibited.
3. Hospitals should institutethe isolation measures used in typhoid fever, with proper disinfection anddisposal of patients\u0019 excreta. Nurses and ward attendants should wash theirhands thoroughly after every contact with a patient or his excreta. Thisrecommendation was most important, for several nurses had contracted thedisease in hospitals in which these patients had been cared for.
4. Since the duration ofinfectivity was unknown, patients should be instructed to observe specialmeasures of cleanliness during convalescence, to avoid possible contaminationfrom their excreta.
AMEBIASIS
In June 1945, Colonel Thomaspaid a short return visit to Leyte with the double object of facilitating thework of the subcommission and other groups studying schistosomiasis and ofsetting up a study throughout the base on amebiasis, with particular referenceto its prevalence and the correctness of diagnosis and treatment in the varioushospitals.
The amebiasis program wasaccomplished by arrangements with the base area surgeon to have Col. JamesBordley III, MC, Commanding Officer, 1l8th General Hospital, instructed to makea survey and submit a report on this disease. In addition to factfinding,Colonel Bordley, in the course of his investigation, was able to disseminate agreat deal of useful information and to institute valuable clinical andfollowup studies.
Essential Facts of the Disease
The following facts are takenfrom a lecture on the subject which Colonel Bordley gave at the Office of theSurgeon, Base K, 25 June 1945:
Incidence and epidemiology.- An increasing incidence of amebiasis has been reported in Base K amonghospital patients, including not only cyst
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carriers but patients with active amebicdysentery. This increase may be due in part to greater awareness of the diseaseand better diagnostic study of all patients with diarrhea or abdominal complaints.Cases which formerly escaped attention have unquestionably been brought tolight by (1) multiple stool examinations and rectal smears, (2) more frequentuse of the sigmoidoscope, and (3) more frequent surveys of foodhandlers. Theincidence of amebic dysentery is relatively, though not alarmingly, high atthis time.
As far as can be determinedfrom recent stool surveys of the civilian population made by malaria units onLeyte, the cyst carrier rate is somewhere between 5 and 10 percent, no higherthan might be found in certain sections of the United States. Possibly thesefigures are too low, since the surveys were not made with particular attentionto amebiasis. There does, however, appear to be an alarmingly high carrier rateamong civilians, though nothing approaching the high rates reported for Schistosomaeggs and Ascaris.
If the amebic dysentery rateis high (in troops) and the cyst carrier mate is low (in civilians), then theremay be some special explanation for the dysentery. It is known that inexperimental amebic infections in animals, dietary and other factors may playan important role. According to Faust, there is no evidence to indicate thatthe amebic organisms in a community may suddenly become more virulent. It wouldtherefore seem that a high carrier rate (in the Army) associated with arelatively low carrier rate (in the population) must probably be explained byfactors other than the virulence of the organism. Among these factors may be:
1. Decreased most resistancedue to combat conditions and injuries and specific debilitating diseasesprevalent here, particularly infectious hepatitis and schistosomiasis. A34-year-old sergeant, for instance, was admitted to the 118th General Hospital,2 January 1945, 48 hours after the onset of chills and fever. He was jaundicedand had an enlarged, tender liver and an enlarged spleen. On the third day ofhis illness he developed abdominal pain and diarrhea, which were thought to bepart of the symptomatology of acute infectious hepatitis. He died on the 10thday of hospitalization, after a stormy illness. At autopsy, he presented whatwould be interpreted as an extraordinary example of reduced host resistance to E.histolytica. There was an enormous swelling, with extensive ulceration, ofthe wall of the colon, all layers of which were heavily infiltrated with theorganisms, which had also infiltrated the walls of the small mesentericarteries and veins, with resultant thromboses, and were also present in theregional lymph nodes. The liver was studded with small necrotic and hemorrhagicfoci containing amebas.
2. Alarge infecting dose. There was certainly ample opportunity for veryconsiderable contamination of drinking water during the early days on Leyte.Because of the shortage of potable water, shallow wells were dug hurriedly inpopulated areas, and there was great difficulty in keeping them from becomingcontaminated by surface water during the heavy November and December rains. Theexperience of the 133d General Hospital was typical of the results of theseconditions. This unit arrived soon after the landing and
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began to establish itself in a populated area onthe highway on the southern edge of the village of Palo. Personnel had constantcontact with muddy ground that had been the repository of the feces of thedisplaced populace. The native laborers doubtless contributed further to thecontamination during the early period of hospital construction. Flies were allabout. Meals were prepared and served in open, unscreened tents. Water camefrom 10-foot wells dug in low ground, where the ground-water level was only 2or 3 feet below the surface. Amebic cysts were actually found in a sample ofwater from one of these wells. The report is perfectly credible, since none ofthe native huts removed from the area or still surrounding it had any sort oflatrine. The well could easily have been dug through earth which had once beenan informal latrine for a native family.
It is not surprising that theincidence of dysentery was very high among the original personnel of thishospital. It was extremely difficult for them to staff their kitchens andmesshalls because a survey of their foodhandlers showed that 23 were amebiccarriers.
A stool survey was made of twogroups of the personnel of the 133d General Hospital by Maj. (later Lt. Col.)Irving J. Glassberg, MC, of the hospital laboratory. In the first group wereapproximately 200 officers and men of the original contingent which had been soheavily exposed; stools were positive for E. histolytica or trophozoitesin approximately 37 percent. In the second group were approximately 150 nursesand enlisted men who had come from the United States to join the unit about 3months before the survey was undertaken. In them, the incidence of E.histolytica was less than 2 percent.
Conditions at this hospitalwere subsequently improved. Natives were moved from the immediate area. Waterwas piped in from the mains of the Palo municipal water system. Messhalls andkitchens were adequately screened and flies reduced to a minimum. Tent floorsand raised walks, finally, kept the personnel out of the mud.
Base Kserved as a hospital center for both combat and garrison troops on otherislands and received large numbers of patients from Mindanao, Mindoro, Cebu,Negros, Luzon, New Guinea, Palau, and other islands, on which the carrier ratewas unknown. The sanitary conditions on some of the more recently occupiedislands were still much as they were on Leyte during November and December.
Many of the patientshospitalized at the ll6th Station Hospital were members of a combat divisionsaid to have acquired their infections in Palau.
Diagnosis. - As wasgenerally suspected, the most recent survey of hospitals showed a widedivergence of understanding about the reporting of amebiasis. In conformitywith Army Regulation (AR) 40-1025 (12 December 1944), there were three choices:(1) dysentery, amebic; (2) amebic infection, nonintestinal location; and (3) E.histolytica carrier.
The survey disclosed thatearlier a number of cases had been reported as amebic dysentery instead ofamebic infection. Over 900 patients were presently under treatment in hospitalsfor amebic infection, but there seemed to
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be not more than 167 cases of amebic dysentery among them. A certain proportionof these patients undoubtedly had nonspecific diarrhea, and thorough stoolexaminations had disclosed a few amebic organisms.
The differentiation betweentrue amebic dysentery and diarrhea in amebic carriers is not always easy.Furthermore, the accuracy of the diagnosis cannot always be determined byreviewing the case records because the clinical notes often are notsufficiently detailed. In questionable cases, the diagnosis of amebic dysenterycan best be established by demonstrating the typical ulcers through thesigmoidoscope or by studying the character of the exudate (pus and blood) inthe feces.
It is therefore stronglyrecommended that particular attention be paid to the character of the excretaand that sigmoidoscopic examinations be performed as often as necessary. If apatient with acute diarrhea does not have blood and pus in his feces and doesnot present demonstrable ulceration of the lower bowel, the primary diagnosisshould be recorded as \u0018 \u0018 diarrhea, causes undetermined, acute,\u001d and thesecondary diagnosis as \u001c E. histolytica, carrier.\u0019 \u0019
It must, of course, be assumedthat the specific bacterial dysenteries have been ruled out by culture of thestools before this diagnosis is made. The reports all seem to indicate asurprisingly low incidence of bacillary dysentery on Leyte. This is puzzling inview of the sanitary conditions which prevailed during the first several monthsafter the landing. In November and early December 1944, many causes of acutediarrhea went unreported and were certainly not adequately studied. Amongpersonnel of the 118th General Hospital, which established itself in Novemberin an area not much better than that described for the 133d General Hospital,diarrhea was very common, but it was seldom accompanied by fever orconstitutional symptoms. Most of the personnel accepted it and did not reportsick. Many, during several nocturnal air raids, were personally faced with thedecision whether to take the long, muddy walk to the latrine or to in head forthe slit trench. Yet there was no bacillary dysentery, at least of a clinicallyrecognizable type, because of settling in an area of poor sanitation. Perhapssome of this good fortune was due to the fact that the sulfa drugs were handedout liberally to the personnel of most units.
Unlike bacillary dysentery,amebic dysentery does not make its clinical appearance during the early,poor-sanitation period of a campaign. This should be borne in mind in makingthe diagnosis. Owing to the bug and variable incubation period, manifestationsdo not appear for weeks or months, whereas in bacillary dysentery, theincubation period is usually 2 to 7 days. In volunteers who were fedamebic cysts by Walker and Sellards, the incubation period varied between 20and 100 days. The prevalence of amebic infections is therefore likely to becomeevident gradually and insidiously, as in the famous Chicago outbreak and ashappened on Leyte. There was none of the explosiveness which characterizesoutbreaks of bacillary dysentery.
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Results of Survey
Colonel Bordley\u0019 s final reportcontained a detailed survey of the various hospitals studied; an analysis ofdivergent methods of diagnosis, including the use of such devices as purges,sigmoidoscopes or proctoscopes, and an elongated glass eyedropper forcollecting material for microscopic examination techniques of treatment,including reported successes varying from 60 to 100 percent in ridding feces ofcysts and trophozoites; and criteria for cure, disposition, and sanitaryprecautions.
The survey created a greatdeal of interest in the hospitals on Leyte and raised the standard of medicalpractice in this particular disease. Had the war lasted longer, the usefulnessof the investigation would have been extended to other areas.
Colonel Thomas and ColonelEppinger prepared a technical memorandum4 on amebiasis which wasissued on 21 November 1944.
DIPHTHERIA
On his way to Australia inOctober 1943, Colonel Thomas had stopped for a brief visit at the 18th GeneralHospital, then stationed in the Fijis. Col. Benjamin M. Baker, MC, Consultantin Medicine, SPA (South Pacific Area), gave him a full account of theprevalence of skin diphtheria in that area. Many of the early cases had beenmissed in the wards of the various hospitals scattered through these islands,but when medical officers were alerted to the possibility of the conditions,many more cases were brought to light, and the diagnosis was confirmed byculture. When he arrived in Australia and later went to New Guinea, ColonelThomas passed on this information, particularly to officers of dermatologicalwards in which cultures of suspicious lesions had been made.
The first active cases recognizedin SWPA were observed on visits to Finschhafen and Hollandia in October 1944;there had been small outbreaks in each of these locations. Previously, cases ofperipheral neuritis following skin ulcers or so-called jungle rot had beensuspected but not proved to be caused by the toxin of the diphtheria bacillus.
The following (summarized)information was prepared for Technical Memorandum No. 17, issued by the Officeof the Chief Surgeon, Headquarters, USAFFE, 23 October 1944, and was alsoincluded in a section prepared for ETMD\u0019 s:
1. An increase in the numberof reported cases of clinical diphtheria has recently occurred in SWPA. In onebase, there has been a small outbreak of the disease in a virulent forminvolving the larynx and bronchi. The attention of medical officers is directedto these facts, so that individual cases may be promptly recognized.
2. In tropical areas, thediphtheria bacillus attacks the respiratory tract but also, not infrequently,attacks any ulcerative skin lesion or open wound.
4 Technical Memorandum No. 20, Office of the ChiefSurgeon, Headquarters, USAFFE, 21 Nov. 1944.
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Its presence in such lesions may readily goundetected. In some instances, outbreaks of pharyngeal diphtheria have beentraced to contact with cases of diphtheritic skin infection.
3. The frequent occurrence ofperipheral nerve palsies and pharyngeal paralysis due to diphtheria has alsobeen reported from another tropical area. In some instances, investigation ofthe cause of the motor nerve lesion has led to culture of the throat or of thebase of skin ulcers which proved positive for virulent diphtheria bacilli. Thepossibility of this association should be borne in mind.
4. All patients with sorethroats should have throat cultures taken when they are admitted to thehospital and should be isolated pending receipt of the laboratory report. Allskin lesions or infected wounds with suspicious characteristics should also becultured, and necessary isolation should be maintained until the laboratoryreport is received.
5. Throat cultures,nasopharyngeal cultures, and cultures from granulations at the base of ulcersor infected wounds should include routinely streaks on L?ffler\u0019 s media or othermedia selective for diphtheria bacilli, such as tryptasetellurite plates ifthey are available. Whenever necessary, hospital commanders should request theassistance of the nearest medical laboratory in the Army or the CommunicationsZones in establishing this technique. All positive cultures obtained inhospital laboratories should be forwarded to the nearest medical laboratory forcontrol and for necessary virulence tests.
6. Hospital commanders shouldimmediately report the occurrence of clinical diphtheria in their commands tothe Base or Task Force Surgeon. The institution of measures to prevent thespread of the disease within the hospital and in other units of the command isthe responsibility of the Base or Task Force Surgeon.
A few isolated cases ofdiphtheria were encountered in New Guinea and in the Philippine Islands, butthe disease caused no further serious trouble.
POLIOMYELITIS
The first cases ofpoliomyelitis encountered in SWPA were observed on Leyte in November 1944. Itwas known that the disease is endemic in the Philippine Islands, and that itmight assume a particularly deadly form in the U.S. population.
When the first cases occurred,it was thought that they might represent one of the more uncommon varieties ofvirus diseases, such as Japanese B disease or equine encephalomyelitis. Forthese reasons, on 20 November 1944, the Surgeon, Sixth U.S. Army, requestedthat a team be sent to Leyte, to study the outbreak. Colonel Thomas wasdispatched with this team for the purpose of making clinical observations onthese cases. Two virus bacteriologists, an epidemiologist, an entomologist, andfour specially trained laboratory technicians departed from New Guinea, 25November 1944, and arrived at Tacloban 48 hours later. All members of the teamexcept Colonel Thomas
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were personnel of the staff of the 19th MedicalGeneral Laboratory. A report was sent to the Chief Surgeon, USASOS, on 17December 1944. The following (summarized) data are taken from it.
Incidence. - Between 13November and 17 December 1944, 43 cases were observed in U.S. troops on Leyte,in personnel of Army and Marine Corps units scattered along the eastern coastfrom Taclobab down beyond Dulag to Abuyog. The cases were scattered throughoutthe task force, but no organization had more than one case except for ahowitzer battalion of the Marine Corps, which had two cases. In 33 cases, therewas residual paralysis. In the other 10 cases, the symptoms and signs consistedof headache, pain in the lumbar region, weakness, fever, and an increasedspinal fluid cell count, but there was 110 residual paralysis.
When three of the first fivepatients died early in the acute stage of the disease from bulbar involvementand a fourth died after 3 weeks in a respirator, the virulence of theprevailing microorganism could not be doubted. Subsequently, milder cases wereobserved. The mortality rate among troops previously staged in New Guinea, whowere fighting in the northern part of Leyte, was extremely high, 61 percent,whereas among troops staged in Hawaii, who were fighting in the central part ofLeyte, it was unusually low, only 5 percent.
Ultimately, the rate per 1,000average strength in the Philippines was to rise to 0.43 in 1945 and 0.84 in1946, an incidence not exceeded in the Army until 1947, when it reached 0.98 inKorea.
Diagnosis. - Specimensfor virus study and for gross and microscopic examination were obtained fromautopsies in six cases, and the virus team, in addition, collected stool andblood specimens from patients with the disease as well as from suspectedabortive cases and from contacts. Injections were made immediately intolaboratory animals, including monkeys from a neighboring island, and materialfrom all specimens was sent to the 19th Medical General Laboratory and the ArmyMedical School laboratory. Preliminary reports of tissue examinations promptlyconfirmed the clinical diagnosis.
The virus of poliomyelitis wasisolated at the laboratory of the Army Medical School, Army Medical Center,Washington, as well as by Dr. John R. Paul, Director, Commission on NeurotropicVirus Diseases, Army Epidemiological Board, from two fatal and two nonfatalcases in the paralytic group. No pathogenic viruses were obtained from the 10patients with preparalytic polio myelitis, although the clinical picture in allrespects, including pleocytosis, was the same as in the paralytic group. InJune 1945, a final and very exhaustive report of the laboratory studies inthese 43 cases was made by Maj. Ray E. Trussell, MC, and his group on the virusteam from the 19th Medical General Laboratory.
A number of cases similar tothe cases in the preparalytic group were observed among contacts who were notadmitted to hospitals or who did not have lumbar punctures. Many such caseswere undoubtedly diagnosed as typical dengue. In fact, retro-orbital pain andbackache occurred in many
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of the paralytic cases, and the prevalence ofdengue in the area made the mistake in diagnosis almost unavoidable.
Evidence of meningealirritation led to the diagnostic lumbar puncture in six cases. In the remainingcases, flaccid paralysis or unmarked weakness of one or more of the extremitiespointed to the diagnosis.
Source of infection. -The source or reservoir of this infection was a baffling question. No recentcases of poliomyelitis in Filipinos were discovered by visits to civilianhospitals, and none had been reported by the Philippine public health service.Certain facts pointed to the possibility that the disease might have beenbrought in by carriers among troops from the United States, where it wasepidemic. In one area, the condition developed 5 days after the soldier hadarrived on Leyte. In another area, three cases treated and discharged aslymphocytic choriomeningitis developed 2 weeks after the arrival of the men;these cases preceded the paralytic cases in that area by about a month. Abouthalf of the cases were in soldiers who had lived on farms or in very smallrural communities. Although many individuals who had been in contact withpatients who developed paralysis showed signs indicative of preparalyticpoliomyelitis, only one man, a medical corpsman, developed the paralytic typeof disease after contact with patients. He had attended poliomyelitis patientsin respirators from 3 December to 6 December, and he came down with the diseasehimself on 17 December.
Observations in the Middle andFar East, made during the war and subsequently, showed that similar outbreaksof poliomyelitis occurred in troops foreign to the particular country withoutany apparent increase in incidence in any age group in the indigenouspopulation.
It was impossible to make aproper investigation in the heat of battle, when distances were so great,transportation so difficult, and other duties so pressing. One could onlyconclude that, barring some extraordinary influences from previous militaryservice in raising individual resistance to a virulent strain of poliomyelitisvirus, the outbreak in the troops in the Dulag area was caused either by one ormore very atypical poliomyelitis viruses of mild virulence or by one or moreneurotropic viruses capable of producing the Guillain-Barr? syndrome.
Clinical picture. -Clinically, the disease followed the pattern usual in adults. The age variedfrom 19 to 35 years, with an average of 23.5 years.
The initial invasive phase wasnot observed, although several patients reported having had slight colds a fewdays before becoming ill. In 10 cases, the onset was not unlike dengue, and thepatients, in fact, were admitted to hospitals with this tentative diagnosis.They complained of intense headache, pain on moving the eyes, backache, andfever. Five patients had chills. Severe headache was the presenting symptom in17 of the 33 paralytic cases and in all 10 of the preparalytic cases. Fivepatients were admitted complaining of severe abdominal pain; in this group, theadmission diagnosis was appendicitis in three cases and gastroenteritis in theother two. One patient was
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thought to have a back strain, and another washospitalized because of recurrence of a perirectal abscess.
The majority of patients whodied, as well as three who survived, had some involvement of respiration, andanother patient had some involvement of the thoracic muscles on the left side.Abdominal respiration was absent in at least two of the fatal cases and in onepatient who recovered.
In the cases in which recordsof the temperature were available, there was a fair correlation between theheight and duration of the fever and the severity of the disease. In threefatal cases in which the temperature was known, it was up to 103? F. in apatient who died on the 3d day; up to 105.8? F. in a patient who died on the26th day, after being completely paralyzed and maintained in a respirator; andup to 103? F. In a patient who died on the 11th day. Most of the patients whorecovered had fever no higher than 101? F., but two had fever up to 102? F. andthree fever up to 104? F., for several days, with early residual paralysis.
In 10 cases, paralysis waslimited to one or both of the lower extremities, associated in three instanceswith weakness of the abdominal muscles. In three of the fatal cases, the legs andtrunk were not involved. In another case, paralysis was limited to the pharynxand muscles of deglutition. In the other cases, involvement represented somecombination of legs, trunk, thorax, arms, or cranial nerves. One patient had atransient facial paralysis, which cleared in 48 hours. Another had involvementof the 6th, 7th, and 10th cranial nerves, which disappeared entirely in a fewdays.
In addition to the fatalcases, two other patients had evidence of bulbar involvement. Lethargy or deliriumwas present in three cases and insomnia in one.
Six patients had to becatheterized, and two could not defecate without enemas. Three patients, two ofwhom were constantly in respirators, developed decubitus ulcers. In one case,jaundice appeared on the 11th day; it was thought to represent infectioushepatitis unrelated to poliomyelitis, since many sporadic cases of the kindwere occurring at this time.
The white blood cells werecounted in 12 cases. They varied between 6,500 and 16,400 cells per cubicmillimeter.
There was no correlationbetween the number of white blood cells in the spinal fluid and the extent ofearly residual paralysis. In fact, seven patients with definite residualparalysis had fewer than 10 cells, with an average of 5. In contrast, in two ofthe preparalytic cases, the cells were over 100 in one and 330 in the other.The highest counts in the paralytic cases were 347, 458, 547, and 700; 10 otherpatients had more than 100 cells. Lymphocytes predominated, usually in therange of 75 to 95 percent. In a few early punctures, the spinal fluid showed apredominant and marked shift to lymphocytes.
DERMATOLOGICAL CONDITIONS
Skin diseases constituted aworrisome problem for most units, few of which had the services of a traineddermatologist. Every unit expressed the desire for
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FIGURE 194.-Consultants in medicine, SouthwestPacific.
a consultant in dermatology, and the large numberof faulty diagnoses and the amount of overtreatment of skin diseases observedby Colonel Thomas confirmed this need.
When a consultant indermatology, Maj. (later Lt. Col.) John V. Ambler (fig. 194) reached the areaearly in 1944, he performed a most useful service
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in improving and standardizing the diagnosis ofskin diseases, which were most difficult to manage in a tropical climate underthe stress of wartime Army life.
Atypical Lichen Planus
A study of 26 cases ofatypical lichen planus in December 1944 from the Malaria Research Unit, 3dMedical Laboratory, was of considerable interest. When this unusual form ofskin disease made its appearance in New Guinea, no cases had been seen in SWPA,nor were others known to exist. Before very long, the suspicion arose thatthere was sonic connection between the long continued use of Atabrine tosuppress malaria and the development of atypical lichen planus. The informationwas deliberately suppressed, because Atabrine discipline was extremelydifficult to maintain and because this drug had to be employed to prevent themilitary handicap of a high malaria rate.
Reports on the subject werewritten by one or two dermatologists serving with hospitals in New Guinea, andfinally, at the suggestion of Colonel Thomas, the subject was studied and reportedby Major Harvey, Captain Bang, and Lt. (later Maj.) John M. Myer, MC, with thehelp of several Sanitary Corps officers. Their work showed that some atypicalpatients with lichen planus in which Atabrine therapy had been interruptedexhibited an acute flare up of the lesions when the drug was resumed. Thisobservation was substantiated in various studies on patients who were returnedto the United States. In these studies, it was also found that lesions whichhad completely cleared reappeared after several months of renewed Atabrinetherapy.
The study of Harvey, Bang, andMyer was the first to give some clear-cut evidence of the connection betweenatypical lichen planus and the long-continued ingestion of Atabrine. It wasColonel Thomas\u0019 opinion that this sort of clinical research, limited andpragmatic though it was, which was set up as the problem developed and theopportunity permitted, was about all that could be hoped for in an area likeSWPA.
There were good reasons, asthe Chief Surgeon, and the Chief, Professional services, USASOS, pointed out,for not publicizing the connection between Atabrine and atypical lichen planus,as follows
1. The number of cases was small,and the patients were all receiving careful study and treatment.
2. If even a rumor of such arelationship became widespread among the troops, it would result in stillfurther evasion of the instructions to them that they must take Atabrine (p.518).
3. The use of this drug wasabsolutely essential to prevent large bodies of troops from being incapacitatedby malaria, and, therefore, no such statement, based, as it still was, largelyon inference, should be made official or circulated.
The situation in respect toAtabrine and atypical lichen planus was typical of the misinformation andmisapprehension which were always recurrent and troublesome in this area.
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FILARIASIS
On his first trip to New Guinea, in October 1943, ColonelThomas learned that cases of filariasis contracted on Tongatabu Island in SPAwere under observation in the 52d Evacuation Hospital, which was then onWoodlark Island, off the eastern tip of New Guinea, under the Sixth U.S. Army.With the assistance of Colonel Dart, then serving as Surgeon, IntermediateSection, in New Guinea, Colonel Thomas obtained permission from the CommandingGeneral, Sixth U.S. Army, and Colonel Hagins, the Army Surgeon, to proceed tothis island. On the way there, and again on the way back, profitable visitswere paid to Colonel Hagins at Sixth U.S. Army Headquarters on GoodenoughIsland.
Maj. (later Cob.) Joseph B.VanderVeer, MC, Chief, Medical Service, 52d Evacuation Hospital, arranged ademonstration of the patients with filariasis then under treatment. Only one ortwo then showed activity in the form of swollen lymph nodes and lymphangitis.The information collected on this visit was incorporated in the ETMD, SPA, forOctober 1943, as follows:
Since occupation of WoodlarkIsland by U.S. forces, about 30 cases of an atypical epididymitis and vasitiswere observed, all in men who had previously served in Tongatabu.
This disease is peculiar andatypical in the following respects: In a large number of cases, there is nohistory of a previous urethral discharge. Vasitis, evidenced by lower quadrantpain, is the first manifestation. The spermatic cord is involved to a muchgreater degree than is usual in a gonorrheal epididymitis. An inflammatoryhydrocele is generally present in the early stages of the disease.
A single microfilaria (Wuchereriabancrofti) was observed in a wet blood smear (coverglass technique) fromone of these patients. The specimen was secured from the peripheral blood at2100 hours, and the presence of the microfilaria was confirmed by threequalified medical officers. No microfilariae were observed on stained bloodsmears, many of which were taken at various times through the day and night.The disease was presumed to be due to filariasis (Bancroft\u0019 s) on the basis ofthe observation of the single microfilaria just mentioned and the fact that allthe patients with the syndrome had previously served in Tongatabu, where thisdisease was prevalent.
The clinical manifestationsbegan with a dull, aching pain in one of the lower quadrants, which graduallyradiated down the spermatic cord of the affected side. The abdominal pain wasfollowed by painful swelling of the epididymis and vascular structures of thecord, without involvement of the vas deferens. About 30 percent of the patientsdeveloped hydroceles, two of which were of such size that aspiration wasnecessary for relief of pain.
These patients were isolatedin the hospital at the time of Colonel Thomas\u0019 visit, and further studies werebeing carried out in an attempt to substantiate the presumptive diagnosis.Their infectivity could not be readily determined, and since their period ofhospitalization would be longer than 30 days and
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treatment in a temperate climate was probablyindicated, it was desired that a high echelon decide upon their disposition.
Colonel Thomas suggested toMajor VanderVeer that an antigen be made from a lymph node subsequently shownto contain filariae and that it be used cautiously for skin testing. Thesuggestion was carried out, and a report on the experiment was submitted to theOffice of the Surgeon General for publication. Permission for publication wasrefused, for two reasons, that the photomicrograph submitted could not bedefinitely identified as showing filariasis and that experts did not believethat the antigen used would have given positive results in the patients andnegative results in a control series, as was reported. The reasoning wasperhaps sound, but it was felt that a piece of clinical research accomplishedin the jungles of New Guinea, without benefit of equipment or consultation ofthe medical literature, deserved some commendation and encouragement.
On the recommendation ofColonel Thomas, these 30 patients were transferred to the ll8th GeneralHospital in Sydney, where they were carefully studied and later reported byMaj. (later Lt. Col.) Thomas McP. Brown, MC. The return of some of these troopsto a nonfilarious tropical location 6 months after their symptoms haddisappeared, showed that this interval had served to desensitize them to thelymphangitis syndrome..
Filariae were observed inthick smears taken in malaria surveys among New Guinea natives, but no otheractive cases were encountered by the medical consultant. No case is known tohave developed among U.S. military personnel in the SWPA, no doubt owing to theactive avoidance of contacts between soldiers and natives and to the sanitaryregulations which reduced flies as well as mosquitoes in camp areas.
SCHISTOSOMIASIS
Schistosomiasis constituted amajor clinical problem in the Philippines. The risk of infestation with Schistosomajaponicum flukes had been anticipated before the invasion of Leyte, andboth medical and line officers had been warned not to drinnk or wash with waterfrom streams and not to eat native or any uncooked food. It was not always easyto obey these regulations. The terrain through which the early fighting tookplace necessitated standing for days in wet rice paddies and drinkingunfiltered water. Superchlorination of drinking water was advised, but it couldnot be supervised. Doubtless, too, the sight of civilian Filipinos standingwaist deep in all the streams while they washed their clothes encouragedcarelessness. Before suitable shower baths were provided, many soldiersprobably washed with water from streams.
By the time the campaign inthe Philippines was concluded, it was estimated that more than a thousand U.S.Army personnel had been infested with S. japonicum. They represented thefirst cases of this infestation in the U.S. Army. The majority of casesdeveloped during the early days of the invasion, when, as already mentioned,the troops had to fight through infested rice paddies and Army engineers had towork in water up to their armpits repairing bridges
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that the retreating Japanese had destroyed. Therewas no known way that these men could have avoided contact with the cercariae,which were abundant in most of the fresh water on the eastern side of theisland.
Research and Publications
At a meeting of survey unitscalled by the Sixth U.S. Army malariologist, Maj. David R. Minter, MC, inNovember 1944, a far-advanced case of schistosomiasis in a native waspresented, and a number of pertinent questions were raised. Among them werewhat forms of clothing other than rubber boots could prevent infection; doessuperchlorination purify water; and what measures should be used to eradicatesnails. It was agreed that very little was known about the early stages of thedisease and that local bites and urticaria were likely to be overlooked bytroops who had been immersed in water for 5 to 7 days.
Capt. Malcolm S. Ferguson,SnC, made a survey of the coast and found water available in some wells and tworivers free of cercariae. He found no snails on the west side of the island.The snails were small, about 0.5 cm. long, and about 1 in every 200 to 300 wasinfected (fig. 195). The technique was to dry them 2 days, then mash them andexamine them under a low-power microscope. The Japanese were making anelaborate survey of schistosomiasis when they were interrupted; they were usingGerman stains, which were better than those available in U.S. laboratories.
Fortunately, records of acareful survey of Leyte for snails infested with Schistosoma cercariae madein 1939-40 by the Philippine bureau of health from Manila were foundundisturbed by the Japanese Army. These records showed areas up and down theeastern coast of the island and well up the Leyte Valley harboring the snailhost, Oncomelania quadrasi. Captain Ferguson confirmed this, finding asmany as 1 infected snail inn every 75 to 100 snails examined near houses insome areas.
Captain Bang transferred hisinterest from malaria, which was not a problem in Leyte, to schistosomiasis,and was given small but quite adequate facilities at the 118th GeneralHospital. Here he and his associate, 2d Lt. Nelson G. Hairston, SnC, togetherwith Captain Ferguson and the 5th Malaria Survey Unit, made interestingobservations on the effect of treatment in schistosomiasis japonica in laboratoryanimals. They also made some progress in establishing methods for the use ofrepellents when infested water could not be avoided.
At the 126th General Hospital,Colonel Tillman, Chief, Medical Service, studied and reported a series ofpatients who showed signs of early cerebral involvement. At the 117th StationHospital, Maj. Albert S. Johnson, Jr., MC, and Maj. (later U. Col.) Maxwell G.Berry, MC, discovered and described the sigmoidoscopic picture found to hepathognomonic of acute schistosomiasis. Maj. (later Lt. Col.) Mark M. Bracken,MC, Chief, Laboratory Service, 27th General Hospital, published originalobservations on fatal early cases. In the spring of 1945, after Colonel Thomashad returned to Manila
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from the Sixth U.S. Army, he and Major Brackenprepared an article on schistosomiasis for the newly planned USAFPAC monthlymedical bulletin. This article summarized the historical, clinical, andlaboratory observations made on the disease in various hospitals andlaboratories in New Guinea and Leyte.
As a result of observations onthe first acute cases of schistosomiasis (p.551), Colonel Thomas prepared apaper with the help of Capt. David P. Gage, MC. It had been hoped that thisreport would prove instructive to medical officers throughout the theater, butpublication was delayed in the Office of the Surgeon General because thearticle recommended that treatment based on a conclusive clinical diagnosis beinstituted even before mature ova could be demonstrated in the stools. The needfor the earliest possible treatment to put a stop to tissue damage from furtherdeposition of ova was regarded in the theater as a real and urgent problem. Thepaper was finally published in the Bulletin of the U.S. Army MedicalDepartment.5
The information contained inTechnical Memorandum No. 15, 6 prepared by Colonel Eppinger andColonel Thomas in October 1944, is summarized elsewhere.
5Thomas,H. M., Jr., and Gage, D. P.: Symptomatology of Early Schistosomiasis Japonica.Bull. U.S. Army M. Dept. 4: 197-200, August 1945.
6 Technical Memorandum No. 15, Office of the Chief Surgeon, headquarters, USAFFE, 21 Oct. 1944.
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On 25April 1945, the Subcommission on Schistosomiasis, of the Commission on TropicalDiseases, Army Epidemiological Board, arrived in Leyte and was housed in prefabricatedbuildings in Tacloban. The members of the Subcommission were Dr. Ernest C.Faust, professor of parasitology, School of Medicine, Tulane University ofLouisiana; Dr. Willard H. Wright, Division of Zoology, National Institute ofHealth, U.S. Public Health Service; Dr. Donald B. McMullen, associate professorof hygiene and public health, School of Medicine, University of Oklahoma; Maj.George W. Hunter III, PhC; Sgt. Preston W. Bauman; and Sgt. James W. Ingalls.Their work was implemented by the use of laboratory animals transported by airacross the Pacific, and much gratitude is due the medical supply section of theChief Surgeon\u0019 s Office, USASOS, for its effective cooperation. TheSubcommissiomm studied the clinical observations made in Army hospitals andconfirmed and amplified Captain Bang\u0019 s observations.
Early observations. -All medical officers had been instructed to look out for early clinical casesof schistosomiasis, even though it was hoped that protective clothing,particularly shoes, leggings, trousers, shirts, and in some instances rubberboots, would prevent penetration of the skin by S. cercariae and thatother precautionary measures would reduce the chances of exposure to a minimum.
Early in December 1944,Colonel Thomas was asked to see two patients with possible earlyschistosomiasis in the 36th Evacuation Hospital. They had been in rice paddies(not yet surveyed for snails) for about 4 days. Later, when they lay down ondry ground, they bad severe itching about the hips, which they thought due toants. Still later, they were in foxholes filled with water for about a week. Aweek before Colonel Thomas saw them, they had developed severe cramps in theabdomen, without fever or diarrhea; the single loose stool each had passed waswithout mucus or blood. The leukocytosis was 40,000 to 50,000 per cubicmillimeter, with 30 percent eosinophiles in one case and 20 percent in theother. There were numerous hookworm ova in the stools in both cases. Theformaldehyde test on blood serum was negative, as was the euglobulin test. Noschistosoma ova were found. The lungs were clear, and the abdomen was negativeexcept for one fingerbreadth hepatic enlargement; the liver edge was smooth.
It was concluded that thesepatients had hookworm and, possibly, schistosomiasis. About the same time,Colonel Thomas examined several late cases of the disease in Filipinos.
In other patients, the firstsuspicious clinical entity was generalized urticaria, with or without abdominaldiscomfort or diarrhea and with or without leukocytosis and eosinophihia. Theclinical symptoms cleared up promptly, and stool examinations were eithernegative or, as in the cases just described, revealed hookworm ova. The caseswere regarded as suspicious, and the soldiers were told to return in 2 weeksfor repeat stool examinations.
Meantime, on 30 December 1944,in the laboratory of the 36th Evacuation Hospital, a specimen stool from anofficer patient was found to contain ova
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with characteristics of immature Schistosoma ova,and 2 days later, another officer from the same unit presented similarfindings. The summarized histories of these patients follow:
Case 1. - A 25-year-old MedicalCorps captain, serving in a portable surgical hospital, arrived in Leyte on 20October 1944. His unit supported a division which fought from the beach landingnear Tacloban through rice paddies along the road to Palo. Later, the unit wascamped near Dulag on the road to Abuyog.
About1 November, the patient had a mild attack of dengue, from which he recovered in5 days. He remembers swimming in a stream for 20 minutes on 15 November. Thecurrent in midstream was too swift for swimming, so he and his companion (case2) stayed in the still water near the bank. Two hours later, he took a showerbath and washed with soap.
Duringthe first week in December, he, like many of the soldiers throughout the taskforce, suffered a mild attack of dysentery, which lasted 4 days. The illnesswas characterized by anorexia, diarrhea with blood and mucus, urticaria aroundthe waist and thighs, and fever. He seemed to respond to the usual course ofsulfaguanidine. About 10 days later (16 December), however, he noticed vagueupper abdominal discomfort, and his appetite became poor. He also developed adry cough.
Hewas sent to the hospital on 27 December. Here his temperature rose daily fromnormal in the morning to 101? F. in the evening; one evening it reached 102? F.Examination was negative except for a slightly enlarged, tender liver. Thespleen was not palpable, and the lungs were clear. Roentgenograms of the lungson 28 December showed a few very small areas of infiltration in the centralportion of the left lung. The findings on 3l December were the same.
Blood counts, which revealed no anemia, were asfollows:28 December, 12,300 white blood cells per cubic millimeter; 67 percentneutrophiles, 13 percent eosinophiles, and 20 percent lymphocytes.
31 December, 12,750 whiteblood cells per cubic millimeter; 56 percent neutrophiles, 23 percenteosinophiles, and 21 percent lymphocytes.
Stool examination on 28December was negative for blood, pus, ova, or cysts. A repeat examination on 30December, after magnesium sulfate, was positive for Schistosoma ova.
After ova had been found ontwo other stool examinations, treatment with Fuadin was begun 2 January 1945.
Case 2. - A 33-year-oldMedical Corps captain, serving in the same portable surgical hospital as thepatient just described, had the same history of swimming on 15 November, andhis movements were the same. During the last week in November, he washospitalized with what was thought to be dengue; he returned to duty in 10days. For some years he had had a smoker\u0019 s cough, in which there had been norecent change.
On23 December, this patient began to run an evening fever, with chillysensations, and 5 days later he was admitted to the 36th Evacuation Hospital.There his temperature curve was similar to the curve described in case 1. Onphysical examination, the lungs were clear, which was confirmed byroentgenograms. The abdomen was slightly distended, and there was well-markedtenderness over the liver, best demonstrated by fist percumssion over theepigastrium and just below the right costal margin. The spleen was not palpable.
Thered blood cell count was 4,200,000 per cubic millimeter. On 28 December, thewhite blood cell count was 14,400 per cubic millimeter, and on 1 January 1945,it was 14,450. The neutrophiles were, respectively, 64 percent and 41 percent;the eosinophiles, 22 percent and 34 percent; and the lymphocytes, 14 percentand 24 percent.
Stoolexaminations on 24 December and 31 December were negative. On 1 January, aftermagnesium sulfate, the examination was positive for Schistosoma ova.
Treatmentwith Fuadin was begun on 2 January.
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At this time it was notthought that swimming in a large, swift river, in the still water near thebank, was sufficiently significant to eliminate the need for carefulinvestigation of these patients\u0019 activities to search for other possible causesof their illness.
Clinical Considerations
The etiology, clinical aspects,treatment, and prevention of schistosomiasis had already been described. InTechnical Memorandum No. 5,7 31 March 1945, clinical aspects of thedisease, laboratory refinements in diagnosis, and precautionary measures weredescribed in more detail. Observations of U.S. Army troops had indicated acharacteristic clinical syndrome upon which in presumptive diagnosis might bemade before the ova of S. japonicum could be demonstrated in the feces.This was important in initiating early treatment, for the period of diagnosiswas sometimes prolonged, even in patients with severe symptoms. The diagnosiscould not be properly made from clinical findings alone unless there was aclear-cut history of exposure in waters known or suspected to be infested. Persistentefforts should be made to demonstrate ova in feces when treatment had beenstarted on the basis of a presumptive diagnosis.
A summary of the clinical andlaboratory data in Technical Memorandum No. 15 follows:
1. Clinical symptoms leading tothe diagnosis of schistosomiasis appear during the sixth, seventh, or eightweek after exposure and are of varying severity. Some patients are seriouslyill, with high fever and great loss of weight. Other patients are asymptomatic,and their disease is discovered only in the course of routine stool and bloodexaminations. More severe manifestations apparently appear earlier afterexposure and may represent massive infections. In an analysis of 40 cases,symptoms in order of frequency were fever in 38, headache in 33, anorexia in30, nonproductive cough in 27, chills in 21, abdominal cramps in 12, urticariain 10, diarrhea and backache in 7 each, and pruritus in 4. It should be notedthat neither urticaria nor diarrhea is a frequent symptom.
2. Physical examinationreveals a slightly or moderately enlarged liver, which is nearly always tenderto palpation or heavy percussion. The spleen is felt early in the disease inabout a quarter of all cases. The lungs are usually clear, though occasionally,coarse rales or bronchi can be heard. Roentgenologic examination of the lungsoccasionally demonstrates scattered small areas of infiltration.
3. The temperature is usuallylow in the morning but rises in the afternoon, reaching from 101? to 105? F.,depending upon the severity of the toxemia in the individual case (Katyamadisease). A septic, spiking temperature curve is very characteristic, butelevations may be irregular. The fever falls by lysis after the second week. Itis affected only slightly by treatment. The
7 Technical Memorandum No. 5, Office of the TheaterSurgeon, Headquarters, USAFFE, 31 Mar 1945.
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pulse rate is proportionate to the fever. In afew cases, the respiratory rate is elevated, and respirations many be somewhatshallow.
4. On proctoscope examination, characteristicpseudotubercles can be seen in the wall of the rectum on lower sigmoid in abouttwo-thirds of the proved cases. Biopsy of these nodules which is not advised isa routine procedure yields groups of ova. In appearance these nodules resemblethose seen in the bladder wall in cases of Schistosoma haematobium.
5. The stool is normal orsoft. Schistosoma ovum are found for the first time from 6 ? to 10 weeksafter exposure.
A simple technique for stoolexamination follows: From 15 to 20 gm. of stool is emulsified in 300 cc. ofnormal salt solution, then filtered through six levels of gauze and allowed tosettle for one-half hour. The supernatant fluid is poured off, the specimen iswashed twice more with normal salt solution, and the sediment is examinedmicroscopically. This technique gives excellent results. Direct smear of fecalmucus yields only about a third as many positive examinations as theconcentration method.
Under high power, the largeovum (60?\u0003 to 80?\u0003.) is seen to contain a well-differentiated miracidium whichmay exhibit movement, and so-called flame cells can be made out . Immature ovaare found in the stools fairly often. They may be much smaller than mature ovaand only be confused with ova of other worms such as the fish tapeworm (Diphyllobothriumlatum) or the roundworm (Ascaris lumbricoides). This finding shouldbe recorded as \u0018 \u0018 Immature ova - possibly S. japonicum,\u0019 \u0019 but it shouldnot be accepted as conclusive diagnostically. Subsequent examinations usuallyreveal mature ova.
6. Eosinophilia is present innearly every case. A rapid rise in the total number of eosinophiles ischaracteristic of the acute phase, in which they often reach 20,000 per cubicmillimeter. In this phase, an increasing leukocytosis accompanied by anincreasing percentage of eosinophiles (from 50 to 70 percent and sometimes 90percent) is almost pathognomonic. In later stages, the eosinophile count oftenfalls to 5 to 10 percent.
High eosinophile counts mayalso be encountered in the acute phase of infestation with hookworm or Ascaris.There are other differences in the clinical picture, however, whichdistinguish schistosomiasis from these diseases.
7. In occasional cases, ahitherto undescribed syndrome has been associated with cerebral involvement.There is slight or moderate disorientation, or even coma. The arms are weak,and one or both seem paralyzed. The legs are ataxic. Deep reflexes areexaggerated, and there may be ankle clonus. Sensation is usually normal.Cerebellar symptoms may be present. There is low-grade fever, as well as acharacteristic leukocytosis with eosinophilia. The spinal fluid may contain afew lymphocytes or may be normal.
Treatment
Standard forms of treatment for schistosomiasis were outlined in USAFFETechnical Memorandum No. 15.8 It was recommended that treatment be
8Seefootnote 6, P. 553.
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started in typical cases even before ova weredemonstrated in the stools. A preference for one drug or another could not beexpressed at this time. Both tartar emetic and Fuadin were used.
Tartar emetic had caused anumber of unpleasant reactions, and it was recommended that it be used withcaution. The solution could be made by adding chemically pure tartar emetic topyrogen-free distilled water which had been brought to a boil. In severalhospitals, it had been found useful after the first three doses to dilute thetartar emetic in 1,000 cc. of 5-percent glucose solution and administer itslowly over the course of an hour. Injections were stopped if a reactionoccurred. Coughing was not a serious reaction, but vomiting, undue nervousnesswith shrinking, severe arthralgia, or collapse with fall in blood pressure wereserious, if they occurred, the next dose should be reduced by 0.03 or 0.06 gm.
Fuadin, to date, had been welltolerated. The efficacy of emetine had not been proved, and Anthiomalinelithium antimony thiomalate) was still on trial.
All patients with a diagnosisof schistosomiasis should be given a complete course of treatment beforearrangements were made for their subsequent care.
Disposition
Seriously ill patients andthose with involvement of the central nervous system were evacuated to theUnited States without delay. Those who had persistent clinical signs orpositive laboratory findings after a course of treatment should also beevacuated. Patients who appeared to have been cured and to have regained theirhealth could be returned to duty but required frequent examination of theirgeneral condition and of blood and stool specimens, in accordance withinstructions in a letter from Headquarters, USAFFE.9
Preventive Measures
Before the invasion of thePhilippines, an attempt at widespread distribution of information concerningschistosomiasis had been made, but so many troops were on the move that largenumbers did not receive adequate information. This situation was correctedpromptly when the troops arrived on Leyte (fig. 196). The Sixth U.S. Army hadtaken pains to inform all its medical officers concerning this disease beforethe invasion. That the forewarning was not in itself adequate protection wasclearly apparent. As soon as possible, all fresh water streams and rivers wereposted with signs and cartoons depicting the dangers of schistosomiasis, butdrivers of Army motor vehicles persisted in washing their vehicles in theseinfected streams (fig. 197). It seemed, when the plan was instituted, that thehorrors of schistosomiasis were made to sound almost too dreadful when theywere broadcast through the wards of hospitals in which patients with the diseasewere being treated, but past experiences
9 Letter, Col. R. E. Fraile, AGD, Adjutant Genera1,headquarters, USAFFE, to commanding generals of major commands, 5 Mar. 1945,subject: After-care of Patients With Schistosomiasis.
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FIGURE196.-Schistosomiasis exhibit and demonstration on Leyte
with the difficulties of maintaining Atabrinediscipline suggested the necessity of employing the most drastic warningspossible.
The personnel of the 118thGeneral Hospital was particularly well informed about schistosomiasis. Thecommanding officer had stopped by the Office of the Surgeon, USAFFE, atHollandia, when the unit was en route to Leyte, and he had passed on to eachmember of the hospital all the information hr secured. This hospital set up inan area directly bounded by a fresh water stream which was highly infested.Lectures to all the personnel were given on a number of occasions, and theywere warned against any contact at all with water from this river. Swimming waspermitted in the ocean. Later on, when a large number of enlisted men in theunit came down with schistosomiasis, it was learned that they followedinstructions and went swimming only in the ocean, but some of them could notresist washing the salt water off their bodies with a little fresh water out ofthe river, and they were the ones who contracted the disease. That no officeror nurse in this unit, only enlisted men, were affected must be an example ofone of the cardinal laws that define the limitations of preventive medicine.
PSYCHONEUROSES
Causative Factors
In New Guinea, Army troopslived under unusual stresses and strains even when they were not engaged inactive combat. These included the equatorial weather, which was always hot andhumid and usually rainy; the broken
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FIGURE 197.-Prevalence of snails in Philippinestreams and ponds
sleep, under mosquito bars; the work under constantpressure to get things done; the long hours without time off; the stringentlimitations of recreational facilities; the feeling of being a long way fromhome, possibly for the last time; the constant repetition of big and littlefrustration; the sapping of one\u0019 s own energy in the effort to give the otherman a lift; the frequently observed Army tradition of working late into thenight 7 nights a week; the feeling of being far up in front without anyunderstanding of the situation from headquarters in Australia; all of the worryabout strange diseases such as so-called jungle rot and elephantiasis; and thebright-yellow hue of the skin which so many of the soldiers developed fromAtabrine. All of these things, and many others, combined to provide continuednervous strain. In addition, frontline troops had to fight in repeated taskforce engagements of landing operations followed by jungle warfare (fig. 198).
It is no wonder that thehospitals were partially filled with neuropsychiatric patients. Many haddeveloped an ill-defined form of acute psychosis which was similar in manyrespects to acute schizophrenia. Surprisingly, however, these patientsrecovered when they were removed from the area of stress and strain and givenreasonable psychiatric nursing care.
Management
For some time, in the absenceof correct diagnoses and proper psychiatric care, patients with borderlinemental conditions were evacuated from New Guinea for time long distance back togeneral hospitals in Queensland, Australia.
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After quick rehabilitation, they were returned to duty, only to report to sickcall again and repeat the same process. After several failures of this sort,many of these men were evacuated to the United States until it finally becamenecessary to forbid evacuation for psychoneurosis alone.
The neuropsychiatric service was gradually built up withstation hospitals provided in New Guinea for the sole purpose of treating minorpsychiatric disorders. Later, when the general hospitals moved closer to thecombat areas in New Guinea and in the Philippines, they also helped provide theearlier diagnosis and treatment that are of such great value in these cases.
Medical ward officers wereconfronted by all possible forms of minor psychiatric disorders and were poorlyprepared, either by training or experience, to handle them. The psychiatricservice could give only limited help, it had more than it could do to arrangefor the simplest and crudest care of seriously ill neuropsychiatric patients inNew Guinea.
Colonel Thomas sent a concisereport of this situation to the Chief, Professional Service Division, Office ofthe Surgeon, Headquarters, USASOS, but the report was not commented on. A yearlater, Colonel Thomas learned, from the neuropsychiatric consultant himself,that the report had been interpreted to mean that the medical consultant didnot recognize the limits of his responsibility and wished to take over psychiatryas well as medicine. Colonel Thomas, who had worked closely in the FourthService Command with Col.
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(later Brig. Gen.) William C. Menninger, MC, Consultant in Neuropsychiatry,Office of the Surgeon General, had naturally done nothing to correct thiserroneous impression since he had been entirely unaware of it.
In the Sixth U.S. Army, therewas similar misunderstanding of the value of a consultant in psychiatry to anarmy on the march. It does not seem likely that the same difficulties will everoccur again from lack of understanding and cooperation between the medical andneuropsychiatric services. In the isolated and farflung area in which the NewGuinea fighting occurred, consultants seldom encountered each other, and theywere left to solve their own problems, with no one to guide or help them.Unfortunately, from the standpoint of the Army neuropsychiatric service,peacetime provides more of the stresses which cripple soldiers during war. TheMedical Corps, as well as the whole medical profession, should not forget theimportant lessons it learned the hard way from its experiences, both positiveand negative, in psychiatry during World War II. Enlightened chief consultantsand medical consultants can and should contribute to progress in this field.
Conclusion and Recommendations
So that the same situationdoes not recur, areas of cooperation and ways and means for combined effortshould be elaborated in some detail for the future instruction of militarymedical consultants. During one period at Headquarters, USASOS, Colonel Thomasprepared a preliminary draft of a report on the recognition and treatment offunctional symptoms. Because there was no opportunity to rewrite it inconjunction with the neuropsychiatric consultant, the report was neversubmitted for approval and publication. The proposals made in it, however,pointed to a borderline problem which needed the combined attention of thesenior consultants in neuropsychiatry and medicine.
The substance of this reportwas as follows:
1. The organization of specialstation hospitals for the treatment of nonpsychotic psychiatric patients wasrequired in SWPA by the shortage of trained neuropsychiatrists and the need foradditional facilities for treatment. Most station, evacuation, and fieldhospitals had no neuropsychiatrists. Unearthing, recognizing, and handlingproperly the functional aspects of medical and surgical states was theresponsibility of members of the hospital staff and was the greater becauseofficer patients with functional complaints were not treated in the specialstation hospitals.
2. Most medical conditionshave, to use a simple term, an important psychological side. Neuropsychiatristsreported that patients received from medical and surgical services in otherhospitals have not been benefited psychologically during their hospital staybut instead have been actually impeded. This correctable state of affairsrequires prompt attention.
3. Great improvement in thediagnosis and care of functional disease can be effected in medical andsurgical wards if chiefs of service will keep the problem uppermost in theirminds. They should familiarize themselves with
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available technical memorandums and articles incurrent medical journals on this subject. Opportunities should be madeavailable to attend staff meetings at psychiatric hospitals and to obtainformal and informal instruction from consulting neuropsychiatrists.
4. Much so-calledpsychotherapy consists of studying the patient\u0019 s psychologic reactions andgiving him appropriate encouragement, an explanation of his position, or both.This is no easy matter but one that requires understanding and tact. There are,however, a few primary rules which should govern the approach to every hospitalpatient, as follows:
a. The medical officer shouldtreat every patient as a soldier, with due regard to his rank, branch ofservice, and Army experience. That is, the patient should be given full creditand suitable complimentary comment - often better implied than expresseddirectly - for bravery or interesting experiences or simply endurance when thegoing was tough. Such an approach shows the patient, as well as other patientson the ward, that his Army career is recognized as of primary importance; it isthe reason he is in the hospital and is the reason for his getting out of it asquickly as is consistent with his disease or wound.
This attitude is the hospitalmedical officer\u0019 s biggest contribution to Army morale. It does not mean rigidmilitary formality, but it does mean punctilious observance of a respectfulattitude to the patient as a soldier.
b. The medical officer should be alert for indications of worry,discouragement, discontent, or anxiety and, when he observes them, shoulddevelop a technique for drawing the patient out. This holds not only for thepatient with a majority of functional symptoms (often loosely calledpsychoneurotic) but also for the patient with organic disease colored by, orassociated with, minor but still important psychologic difficulties. Every goodhistory should reflect the patient\u0019 s state of mind as well as of body.
c. Many battle injuries anddiseases, if not most of them, in combat troops introduce new psychologicalsituations. Perhaps, for the first time, the individual\u0019 s physical integrity isthreatened, and he develops concern and a feeling of insecurity. On the otherhand, he may develop a sense of relief at merely being wounded and not killedand may have-at least in his own eyes- an available and justifiable excuse forescaping from further danger. Everyone has, in some way or other, used illnessas an escape mechanism or as a means of obtaining sympathy or attention. Theseand other psychological effects of disease and wounds required carefulconsideration and treatment.
d. Prompt and thorough studyof each case from an organic point of view is essential. Unless this is done,the patient\u0019 s doubts are unresolved and magnified. As time drags on, he sensesuncertainties on the part of the medical officer, and having had time to learnthe ways of the ward, he subtly takes control of the management of his owncase. These developments complicate the solution of the psychological problem.In a station hospital, 5 days should be sufficient to reach a stage in thediagnostic study at which immediate disposition can be determined; that is,transfer to a general hospital (though not necessarily at once), or furthertreatment in a station hospital with a view to
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return to duty or transfer to a convalescenthospital, or consultation with a psychiatrist to help outline furtherdisposition.
5. Specialists in the care ofborderline psychiatric cases have been assembled in special station hospitalsdevoted to psychiatric diagnosis and treatment. Here, accurate differentiationof cases into various scientific subdivisions takes place. Seriously ill psychoticstates are quickly diagnosed, and the patients are transferred to generalhospitals. Milder cases are divided into psychoneurosis, simple adultmaladjustment, and constitutional psychopathic state, and appropriate treatmentis accorded each group. Group psychotherapy, occupational therapy, exercise,and controlled relaxation provide essential features to augment a limitedamount of individual treatment.
These hospital units have provedhighly efficient and are returning 85 percent of patients to duty in an averageof 16 days.
6. The function of theoriginal field, evacuation, and station hospitals is to assist this program by consideringevery patient a potential psychological problem. This attitude will save agreat deal of time in the first hospital to which the patient is admitted, and,more importantly, it will save even more time in the special hospitals.Finally, it will return to duty some patients who must otherwise be crowdedinto special hospitals, and it will make all other patients leave the hospitalwith improved morale.
In New Guinea, as might havebeen expected, medical units were also affected by the tremendous stressesalready listed, and in some instances, officers broke down. A medicallaboratory, in one such instance, lost its commanding officer, who wasevacuated on the diagnosis of psychosis-confused state, and the next seniorofficer, a major, assumed command. When the laboratory was investigated duringa routine visit by an inspector general, it was immediately apparent that hehad neither the administrative nor the professional ability requisite for theposition. None of the subdivisions of the laboratory was receiving appropriatesupervision. No one could accomplish effective work. The morale was so bad thatone excellent officer was found guilty by the inspector general of havingconsumed a considerable part of the laboratory alcohol. Had it not been for thetimely visit of the medical consultant, this young officer might have beenfound guilty by a court-martial and returned home in disgrace. When he wastransferred to another unit, however, he found a congenial metier in working onscrub typhus, and he did brilliantly thereafter and was finally promoted to therank of major.
PartIII. Conclusions and Recommendations
ANALYSIS AND CONCLUSIONS
During wartime, theprofessional activities of the U.S. Army Medical Corps, which from numericalnecessity are carried out chiefly by recently inducted civilian physicians,require supervision and correlation. This fact has been demonstrated and iswidely accepted.
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in World War II, the machinery that developed toaccomplish this supervisory and correlative function, in large part through theefforts of General Morgan, consisted of a loosely organized body ofconsultants. The group, which began with consultants in medicine and surgery,and, somewhat later, in neuropsychiatry, in this office, was gradually extendedto include the theaters, service commands, armies, and base sections. Theprogram developed without a table of organization, without an establishedstanding operating procedure, and without any individual direction. It answereda different need in each command and assumed a different position in relationsto each local organization.
The consultant systemblossomed under some surgeons and struggled under others. It correlated thework of good units, and it supervised and, through training and education,improved the work of poor units. In the end, it played a major role in themedical activities of all commands.
The success of the system wasbased on three factors, as follows:
1. It fulfilled a need.
2. Its personnel was chosen on the basis of professionaltraining and competence and, to some extent, on the basis of militaryexperience, not on the basis of academic or military rank.
3. It operated on theprinciple that the visiting of units was its starting point and that visitsmust be painstaking and helpful. From their own firsthand study of actualsituations, the consultants discovered and attacked existing problems.
A consideration of theconsultant system as it operated in SWPA leads to certain general conclusions,and these conclusions, in turn, suggest methods for effecting improvement.
The Professional Consultants\u0019 Position in the Army Organization
Consultants are staff officersserving on the staff of a surgeon. Their province is professional services,each in its own specialty. In a sense, they perform the well-understood Armyfunction of inspection, including visits to units, with subsequent reports andrecommendations. In addition, they accomplish another new and less wellunderstood function, that of instruction.
The consultants in World WarII were drawn from the faculties of the leading medical schools in the country.They encountered questions from newly inducted medical officers, and theyassumed tine role of instructors by force of necessity.
The types of advancedinstruction needed in wartime Army hospitals included bedside, ward, and clinicdemonstrations, as well as instruction in Army methods of admission,disposition, and recording. To fulfill this function in a single unit requiredtime-several days\u0019 time-in each unit. At the end of this time, the consultantknew the unit medical (or other) service, and the service knew the consultant.Each learned from the other, and morale was strengthened. This was a new kindof Army inspection.
The surgeon should know andrely on his consultants. They in their role as staff officers, should advisehim and should understand him and each
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other. Whenever practical, the surgeon shouldpersonally select his staff officers. Having chosen them, he should require andbring to pass the closest cooperation among them. This applies possibly more tothe chief professional consultants than to other staff officers because theirduties involve the initiation of innovations as well as varied intersectional cooperationand contact with major commands.
Whenever surgeons have chosentheir own consultants, often with advice from higher headquarters, theresultant relations have been agreeable and have been functionally successful.Whenever practical, newly appointed surgeons should therefore be permitted toselect their own consultants. The three chief consultants to The SurgeonGeneral should combine to help to provide the most suitable group ofconsultants in the various headquarters at lower levels.
Other staff officers spendfrom 90 to 98 percent of their time performing staff duties at headquarters.Professional consultants\u0019 major functions are performed away from headquarters,in the hospital units themselves. Difficulties then arise in developing theminto competent staff officers
Consultants who spend half ortwo-thirds of their time in the field find themselves writing reports andmaking recommendations which are returned to their own desks for implementationand completion. The need for close cooperation between the consultant sectionand the sections of personnel, plans, supply, preventive medicine, and recordsrequires constantly available officer personnel in the consultant section. Ittherefore becomes important to establish the consultant system in the overheadtables of distribution and to provide adequate personnel for the accomplishmentof the duties that are to be performed at the various headquarters on thedifferent levels.
The Place of Consultants in the WartimeMedical Corps
In World War II, theapproximately 1,300 medical officers in the Regular Army were used to fillimportant command and staff positions. As it ultimately developed, thedirection of practically all professional matters relating to medicine,surgery, and neuropsychiatry became the responsibility of a consultant systemcomposed entirely of civilian physicians called to active duty. This was nottrue of preventive medicine, dentistry, veterinary medicine, nursing, nor wasit true of other activities such as planning and training, hospitalization, andmedical supply.
Since the final responsibilityin practically every major command rested in a Regular Army command surgeon andsince staff action at the highest level was often involved, it would have beenvaluable to have officers in the Regular Army Medical Corps integrated into theconsultant system. Officers such as Brig. Gen. Henry C. Coburn, Jr., Col. FrankL. Cole, MC, and Colonel Dart would have contributed greatly to theeffectiveness of the system and would have relieved inducted civilianspecialists of many of their staff duties, which were always time-consuming andwhich at first were poorly accomplished.
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Specific Delegation of Duties to Consultantsat Various Levels
The actual operationalactivities of the consultants, as already mentioned, varied widely at variouslevels. On the other hand, they overlapped in many particulars and requiredclarifications and delimitation. The preparation of technical memorandums anddirectives is an illustration.
Before the Leyte campaign, inOctober 1944, a number of surgeons prepared technical memorandums calling theattention of medical officers to important professional matters. Thus, thesurgeon of the 24th Division, the medical consultant of the Eighth U.S. Army,and the medical consultant, USASOS, all prepared and circulated materialrelating to schistosomiasis japonica. Later, in June 1945, a TB MED on the samesubject was published by the Office of the Surgeon General. Similarly,directives relating to malaria, scrub typhus, amebiasis, infectious hepatitis,and other subjects were circulated from the offices of a number of differentsurgeons
In addition to the wastefulduplication and the confusion of conflicting recommendations, this overlappingof function led to misunderstanding between various officers in the consultantsystem. Cooperation between consultants at different levels on matters pertainingto professional subjects should have been close and clearly understood, as itwould have been if their duties at each level had been clearly defined.
Functions Relating to Personnel
The consultants came to play alarge part in the evaluation and assignment of professional personnel. This isanother function that should have been carefully considered and fully describedas part of the standing operating procedure of consultants.
Should the need again arise tocall 40,000 or more Reserve or civilian physicians into the Army, it would bewise to obtain the services of a prominent civilian physician to serve asdeputy chief of the personnel section in the Office of the Surgeon General.Only in this way could direct, immediate contact be established with the localsources of new personnel to obtain information necessary for the most efficientutilization of these personnel. Direct cooperation between consultant andpersonnel sections is simple at the army level. At the theater level, it will reflectthe system that is in operation in the Office of the Surgeon General. To havethe part the consultants are expected to play in the control of professionalpersonnel clearly outlined in a manual or other official publication will domuch to eliminate the difficulties in this regard that existed in World War II.
RECOMMENDATIONS
The following recommendationsare made with a view to eliminating these and other difficulties and increasingthe efficiency of the consultant system:
1. A standing operatingprocedure should be delineated for wartime consultants separately at the levelof each headquarters.
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2. Tables of distribution ororganization should be authorized for necessary consultant personnel at thelevel of each headquarters.
3. An assistant consultant orexecutive officer should be added to the consultant section in higherheadquarters, to remain at headquarters and be available to implement theduties and recommendations of the consultant there.
4. The activities of all consultantsin a given headquarters should be placed under a deputy surgeon incharge of consultants. This officer should not be burdened by other dutiesusually handled by the chief of the professional services division.
5. Surgeons of major commandsshould have a prominent part in the choice of their medical consultants, justas they have in filling other staff positions.
6. Medical, surgical, andneuropsychiatric consultants in the Office of the Surgeon General should combineto help provide each headquarters with a suitable group of consultants capableof cooperating with each other.
7. In time of emergency, inall sections of the Office of the Surgeon General and particularly in thepersonnel section, a deputy chief should be drawn from nationally prominent andspecially trained civilian specialists.
8. Consultants should berotated from theaters into the Office of the Surgeon General to serve asassistant chiefs of appropriate sections.
9. Consultants in higherheadquarters should have as one of their primary duties the assistance of\u0019 consultants at lower levels by visits to various headquarters and by themaintenance of close communications.
