Activities of Medical Consultants
CHAPTER VII
Central Pacific Area
Verne R.Mason, M.D.
The campaigns in the Pacific Ocean Areas 1 during World War II were of peculiar medical significance for a number of reasons. The attacks were made by amphibious landings of relatively small task forces to capture the coral islands and were, in general, combined actions of the Army, the Army Air Force, the Navy, the Naval Air Force, and the Marines. These assaults on the beaches of the Pacific islands called for highly coordinated activities of the medical services of the various components of the Armed Forces. In general, the islands were parts of coral atolls, and the climate was hot and humid. Potable fresh water was practically never available. Sanitary conditions were primitive in all areas occupied by the Japanese forces, and after the campaign had lasted a few days these areas became dangerous for the assault troops owing to the increase of arthropods wherever unburied dead were numerous. On one or another of these islands, practically every exotic disease of military importance was encountered.
The campaign in the Ryukyu Islands was the first in the Pacific in which adequate amounts of whole type O blood were available. It is probable that during this action wounded troops received more blood by transfusion per battle casualty than in any previous campaign. During the early part of the assault, the field hospitals and smaller installations were the only medical facilities available. Moreover, patients in shock must be treated at the earliest possible moment after injury. For these reasons, some comments have been made here on the organization and equipment of the field hospital.
The exotic diseases encountered in the CPA (Central Pacific Area), map 5, have been described chiefly as they occurred in relation to military campaigns. No attempt has been made to write a detailed description of diseases of military importance in this area. Such information is readily available elsewhere. What has been attempted is a discussion of the occurrence of such diseases under the battle conditions of World War II and methods evolved to control them.
A study of Japanese B encephalitis on the island of Okinawa is described in some detail because of its inherent interest. So, also, are the epidemics of dengue fever that occurred on Saipan and the method of mosquito control that
1 The command Pacific Ocean Areas during most of World War II consisted of the following three subordinate command areas: South Pacific Area, Central Pacific Area, and North Pacific Area. This chapter pertains to medical consultant activities in the Central Pacific Area. U.S. Army Forces in this area were under the command known as the Hawaiian Department from 1939 until August 1943, when the command U.S. Army Forces in the Central Pacific Area, was established. This command became U.S. Army Forces Pacific Ocean Area in July 1944, and in July 1945 it was redesignated U.S. Army Forces Middle Pacific. The term 'Central Pacific Area' will be used throughout the chapter unless specific reference to one of the foregoing Army commands is indicated.
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was devised to stamp out the disease. Someaccount is given of the cases of infectious hepatitisseen after nearly every assault on the Pacific islands; of dysentery,particularly in patients fromthe Marianas, the Philippines, and Okinawa; of filariasis, particularlyin the Gilbert Islands; ofdiphtheria; of venereal diseases; and of other problems in internalmedicine. There is somediscussion of the consultant system and its relation to the medicalservices of the Army inwartime.
This brief history of internal medicine in the Central Pacific in World War II has been compiled from documents in The Historical Unit, U.S. Army Medical Service, from large numbers of reports by medical consultants and other medical officers; from relevant War Department general orders; from ETMD (Essential Technical Medical Data) reports; and from theater memorandums. In addition, some material has been obtained from the files of the author and from the reports of medical consultants with other organizations in the Central Pacific. From these sources, objective original data have been incorporated. Since much official military correspondence does not identify the actual writer, attribution could not be given individuals in many instances.
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EXPANSION AND ORGANIZATION OF THE MEDICAL SERVICE
The war in the Pacific began in the Hawaiian Islands, on the island of Oahu, on the morning of 7 December 1941. The Japanese bombing of Pearl Harbor was unexpected, although frequently predicted, and came as a complete surprise to both Army and Navy forces on Oahu. Since the casualties were extremely high, the Army medical service on Oahu began to function immediately. Some events of that fateful day and of a few subsequent days were recorded in diary form on the blotter of the secretary to the Surgeon, Hawaiian Department. These notes, with the addition of information written down during telephone conversations, are reproduced here for their historical interest.
7 December 1941:
0915 hours.- A medical officer left Fort Shafter for Honolulu, T.H., to get 10 civilian physicians and 6 operating surgeons. These 16 physicians were sent to Tripler General Hospital, in Honolulu.
0940 hours. - Bellows Field reported 6 wounded in action and 1 killed in action.
0950 hours.- Wheeler Field reported 57 casualties. There were 5 killed in action and 20 seriously wounded.???
0955 hours, - Sixty casualties were sent to Tripler General Hospital. Of these, 3 or 4 were dead on arrival. Many casualties were being reported, and some of these were civilians.
1020 hours. - Reports of 300 wounded and at least 50 deaths were received. The civilian physicians of Honolulu offered the services of the blood bank and, in addition, gave what plasma was on hand to the Army. The supply of ambulances from various Army sources was adequate. <>
1135 hours. - A request was made to have Kamehameha School, Honolulu, prepared for a hospital.
1140 hours. - Hickam Field (fig. 220) reported from 300 to 400 wounded and from 50 to 75 killed. About 25 hospital beds at Waimanala were taken over by the Army.
1305 hours. - There were 75 casualties at Station Hospital, Schofield Barracks, T.H., and 470 at Tripler General Hospital. There were 22 dead at Schofield Barracks and 46 dead at Tripler General Hospital.
1445 hours. - There was considerable difficulty getting enough ambulances.
8 December 1941:
0001 hours. - Arrangementswere made to openup Saint Louis College, Honolulu, as a hospital.It was directed that 1000 hospital beds be installed.
0522 hours. - Two surgicalteams were formedand sent to the Kamehamena School.
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0810 hours. - FromSchofield Barracks,reports showed 36 dead, 25 seriously injured, and 75lightly wounded. From Wheeler Field, 35 dead, 56seriously wounded, and 50 with minorwounds were reported.
9 December 1941:
1105 hours. - Tripler General Hospital reported 152 dead, 55 seriously wounded, and 125 slightly wounded.
1850 hours. - All useful apparatus from the Japanese hospital was sent to Saint Louis College.
Following the Japanese air raid on Pearl Harbor and on the airfields on Oahu, there were 713 battle casualties of whom 225 died. Following are data on the disposition of casualties from 0800 hours on 7 December 1941 to 2400 hours on 10 December 1941:
Number of patients in hospital prior to 0800,7 December 1941 Admission: Battle casualties (seriously and slightlywounded)-.......................... Other than battle casualties............. Number of dead upon arrival athospital........................................... Number who died upon admission. Disposition: Battle casualties to duty................. Allothers....................................... Total number of beds vacant......... Total known dead since 7 December1941.............................................. Total seriously wounded since 7 December1941............................ Total slightlywounded since 7 December1941............................ Total battle casualties since 7 December 1941............................ 1 Surviving. 2 On 10 December, 237 additionalbedswere set up at Schofield Barracks 3 Includes 44 dead taken directlyto the morgue | Tripler General Hospital 456 340 10 132 11 9 243 642 143 75 265 | Schofield Barracks 531 121 62 27 11 51 336 2 819 38 38 83 | Hickam Field 29 27 3 0 0 13 23 37 0 1 26 | Total 1,016 488 75 159 22 73 602 1,498 3 225 114 374 713 |
Organizational data. - The Surgeon'sOffice, HawaiianDepartment, was comparatively smallat the beginning of the war. The Surgeon and 9 other officers, togetherwith 8 enlisted men,made up the staff.
On 7 December 1941, the staff was divided into a forward and rear echelon. On that date, the rear echelon, consisting of the bulk of the administrative section, moved into offices at Farrington High School, Honolulu. A file clerk and guard remained with the records at Fort Shafter, T.H. The forward echelon moved into Aliamanu Crater with the commanding general and other members of his staff.
The Surgeon, Hawaiian Department, on 7 December 1941 was Col. (later Brig. Gen.) Edgar King, MC. During the last part of 1941 and the early part of 1942, Col. Clarence E. Fronk, MC, acted as professional consultant.
All professional activities were consolidated in the office of the professional consultant. Medicine, surgery, orthopedic surgery, neuropsychiatry, and
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FIGURE 220.-Destruction at Hickam Field,Hawaii, 7 December 1941.
other specialties were all under thesupervision of Colonel Fronk. As more professionalpersonnel were made available by the War Department, specialconsultants obtained from Armyhospitals on the island and from the United States were added to theSurgeon's staff. Their dutiesconsisted of supervision, training, and advisory work in connectionwith clinical practice in theirspecialties.
As of December 1942, officer personnel in theSurgeon's Office consisted of General King,Surgeon, and a number of Medical, Sanitary, Veterinary, Dental, MedicalAdministrative andArmy Nurse Corps officers. At this time, Lt. Col. (later Col.) CharlesT. Young, MC (fig. 221A),was acting Consultant in Medicine; Lt. Col. (later Col.) August W.Spittler, MC, was actingConsultant in Surgery, and Capt. (later Lt. Col.) Robert C. Robertson,MC, was Consultant inOrthopedic Surgery.
Requisitions for necessary personnel were submitted to the War Department at monthly intervals and, in emergencies, by radiogram. The shortage of military personnel was, in fact, very acute in the early months of the war and necessitated the employment of local civilian personnel.
A unique assignment in the Surgeon's staff was that of civilian-liaison officer. As envisaged in the organization planned by General King, civilian doctors were vital to adequate care of military casualties in case of disaster. Also under mobilization plans, the U.S. Army Medical Department was responsible for civilian casualties including gas casualties. Plans were accordingly
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made to control all hospitalization, bothcivilian and military, to establish first aid stationsthroughout Oahu, and to provide for supplementary professional care ofmilitary personnel bycivilian doctors residing in the Territory. To accomplish all thisrequired constant liaison withcivilian agencies, and the officer placed in charge was responsible forproper planning, fortraining, and for execution of all policies formulated by the Surgeonand leaders of the HonoluluMedical Society.
In March 1942, service commands were established to administer the military affairs of the other islands of the Hawaiian group. A surgeon was appointed to each of the following service commands: Hawaii, Maui, Molokai-Lanai, and Kauai.
Medical supplies stored at Fort Shafter were generally adequate and of excellent quality. When a shortage occurred, reserve stocks were ample to fill it. Wartime requisitioning procedures on the mainland (continental United States) had been established before 7 December 1941. During 1942, branch depots were established on the islands of Maui, Kauai, and Hawaii to supply the service commands of those districts. At the branch depot at Schofield Barracks, the construction of five additional warehouses brought the total to nine. A warehouse was also completed at Fort Ruger. Stocks were further dispersed in the various hospitals of the Hawaiian Department for security in case of attack.
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The Surgeon was appointed anti-biological-warfare officer in addition to his other duties. This appointment made it possible to consolidate many activities in that field already receiving General King's attention.
On 7 December 1941, the Surgeon had been made adviser to the Commanding General, Hawaiian Department, in all matters concerning potential danger from contamination of food or sources of drinking water. Military personnel and civilians over 6 months of age were immunized with smallpox, typhoid, paratyphoid A, and paratyphoid B vaccines. All chemical poisons were impounded and their sale and distribution kept under strict control. The principal water-supply systems of each island were investigated in detail. Fencing and the number of guards were immediately increased. The department laboratory daily performed tests for common poisons on water collected from the main sources of supply. Purchase of fresh milk for Army messes was prohibited.
The general impression derived from an examination of the records during this period is that many functions were centralized in the hands of the Surgeon, owing both to the lack of personnel and to a tendency to concentrate duties in a single office.
Operation of the medical plans, under the general mobilization plans, functioned with great smoothness and efficiency, and this did much to alleviate the effects of the Japanese attack.
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Expansion ofthe Hawaiian Department and the Central Pacific Area
TheFarrington High School in Honolulu, a group of new concrete buildingsin the Kalihidistrict, was taken over to provide expansion wards for Tripler GeneralHospital on 7 December1941. On that date, approximately 200 convalescents were transferredfrom that hospital'spermanent buildings, and messing facilities were established in theschool cafeteria. Maj. (laterCol.) Donald C. Snyder, MC, was placed in charge of Farrington wards.The bed capacity wasapproximately 300.
A part of the Kamehameha School was takenover as Provisional Hospital No. 1 on 7 December1941. Later (4 August 1942), the hospital became an integral part ofTripler General Hospital.Two operating rooms for reserve use were established on 7 December 1941in the schoolinfirmary but were not put into active service. The concrete dormitorybuilding of this schoolhad 240 single rooms making a hospital capacity of 240 beds. However,the precipitous nature ofthe terrain and the arrangement of the drives, paths, and stairwaysmade it difficult to adapt thishospital to surgical use despite the advantages offered by itsexcellent infirmary, which wasreadily adaptable for extensive surgery (fig. 222).
Saint Louis College, in the Kaimuki district of Honolulu, was taken over as Provisional Hospital No. 2 on 8 December 1941. This was established later as the 147th General Hospital.
On 14August 1943, the Hawaiian Department was expanded and changed toUSAFICPA (U.S.Army Forces in the Central Pacific Area). During the following 12months, the MedicalDepartment provided support for the offensive actions conducted by theArmed Forces of theCentral Pacific. The average strength of the theater increased 30percent during 1943, and thearea controlled was extended to include the Marshall, Gilbert, andMariana Islands (fig. 223).Medical facilities were expanded to provide for task forces andgarrison forces on newlyoccupied islands until the number of hospital beds in the CentralPacific was nearly twice thatfor the Hawaiian Department in 1942.
In providing logistic support for operations, it was the responsibility of the 5th Medical Supply Depot to equip the various divisions for amphibious operations. Each division was supported by one 400-bed field hospital and one provisional portable surgical hospital. Garrison forces were furnished with many hospitals, from a 2,000-bed general hospital to 100-bed station hospitals. A hospital ship, The Mercy (fig. 224), was converted from an ambulance-type ship to a surgical hospital ship.
Plans were worked out to insure procurement of medical supplies from the continental United States. Also, arrangements were made to ship directly to Saipan from the continental United States.
Medical supply activities were the responsibility of the 5th Medical Supply Depot, with teams of that organization dispersed throughout the theater. A total of 36 warehouses was occupied, although it was planned to
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centralize both storage and issue during 1944-45, since the tactical need for dispersion was past. Stocks were consistently rotated. A 195-day level of supply was maintained.
On 1 July 1944, CPBC (Central Pacific Base Command) was organized within and charged with the logistic support of USAFICPA. The immediate command and training of troops were delegated to major echelons of command. The headquarters became primarily a planning headquarters, coordinating the activities of these subordinate echelons.
On 1 August 1944, the USAFISPA (U.S. Army Forces in the South Pacific Area), formerly a separate area, came under the command of the USAFICPA and was redesignated SPBC (South Pacific Base Command). On the same date, USAFICPA was redesignated USAFPOA (U.S. Army Forces, Pacific Ocean Areas).
After the reorganization, most of the personnel of the Surgeon's Office remained in the CPBC with General King, including, as of 1 August 1944, Col. Kermit H. Gates, MC, deputy surgeon; Col. Walter S. Jensen, MC, consultant. in aviation affairs; Col. Ashley W. Oughterson, MC, surgical consultant; Lt.. Col. (later Col.) Moses H. Kaufman, MC, neuropsychiatric colisultant; and Colonel Robertson and Major Young.
On 17 November 1944, Brig. Gen. John M. Willis became Surgeon, USAFPOA.
In addition to the consultants at Headquarters, USAFPOA, surgeons and consultants in the chief specialties were on duty with the Tenth U.S. Army;
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the XXIV Corps; the 7th, 27th, 77th, 81st,96th, amid 98thi Infantry Divisions; base commands;and Army garrison forces.
The forward areas at this time consisted ofthe following islands and were chiefly under Navycontrol: Kwajalein, Saipan, Guam, Tinian, Anguar, Makin, Esp?rituSanto, Guadalcanal, and theFiji lslands.
ArmyGarrison Force, Iwo Jima, was added to USAFPOA in February 1945, andArmy GarrisonForce, Okinawa, was added in April 1945.
On 25 April 1945, the Marianas, Iwo Jima, and the Palau Islands were consolidated into WPBC (Western Pacific Base Command), with Col. Eliot G. Colby, MC, Surgeon. In the middle of July 1945, the 821st Hospital Center arrived on Tinian in the Marianas, in anticipation of the assault on Japan. This center, consisting of 5 general hospitals with an authorized bed capacity of 5,000, was 40 percent completed when hostilities ended.
On 1 August 1945, Army Garrison Force, Okinawa, was transferred to the control of USAFWESPAC (U.S. Army Forces Western Pacific), with USAFPOA becoming USAFMIDPAC (U.S. Army Forces in time Middle Pacific). Army Air Forces, Pacific Ocean Areas, became Army Air Forces, Middle Pacific Area.
The Surgeon's Office, USAFMIDPAC, continued to increase in size and complexity. As of 1 October 1945, the following officers, among others, were
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included: General Willis; Col. Arthur B. Welsh, MC, deputy surgeon; Col. (later Brig. Gen.) Elbert DeCoursey, MC, laboratory consultant; Col. John B. Flick, MC, surgical consultant; Col. Verne R. Mason, MC (fig. 221B), medical consultant; Lt. Col. William H. Everts, MC, neuropsychiatric consultant; Lt. Col. Charles F. McCuskey, MC, anesthesiology consultant; and Lt. Col. (later Col.) Edward J. Ottenheimer, MC, historical consultant.
Organization of Medical Services in the Middle Pacific
Responsibility for medical service in the Middle Pacific was delegated to five major echelons of command. The Commanding General, SPBC, was responsible for providing medical service to all units in his area during the roll-up of SPBC. The CPBC had a primary mission of administration to all units in the Hawaiian area and was responsible for furnishing medical services for Army garrison forces, reserve beds for battle casualties from forward areas, and medical supply support of combat operations. Headquarters, Army Air Forces, Middle Pacific, furnished and was responsible for medical services for all air forces in the Middle Pacific with the exception of hospitalization, which was the responsibility of the command in which Air Force units operated. The WPBC's responsibility for medical service was to provide for adequate hospitalization of casualties from combat zones and medical supply support for combat operations, including support to troops mounting from WPBC. Medical service at Okinawa was the responsibility of the Tenth U.S. Army. When the combat phase was completed, the Army Garrison Force, Okinawa, took over the medical responsibility for units in time Okinawa area.
At the time the medical service of CPBC was established, 10 August 1944, the following units were assigned: The North Sector General Hospital (formerly Station Hospital, Schofield Barracks), Oahu, T.H., Tripler General Hospital, Honolulu, T.H., 204th General Hospital, Oahu, T.H., and 147th General Hospital; the 22d, 129th, 165th, 266th, 284th, 289th, 290th, and 337th Station Hospitals, and the 31st, 36th, 38th, and 69th Field Hospitals.
During the following months, numerous medical units were assigned to the medical service of CPBC. Some of these belonged to divisions and other large units which were staging or training in Hawaii before going into combat. The medical units of these were given in service training as part of their preparation for combat.
These units consisted of various station hospitals, medical service companies, field hospitals, portable surgical hospitals, malaria survey units, medical collecting companies, medical service detachments, motor ambulance companies, several general hospitals, and numerous other medical units.
Medical Activities and Expansion of Hospitals in the Hawaiian Islands
The history of themedical service of the U.S. Armyduring World War II began with theJapanese. attack on Oahu on 7 December 1941. On that historic day, themedical officers of TheGeneral Hospital, under the capable leadership of the chief of themedical service, took over thesupervision of
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FIGURE 224.-Continued. C. General Ward. D.Well-equipped laboratory.
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all surgical wards and expeditiously organized and controlled the entire ward service for the preoperative and postoperative care of the wounded, thereby making emergency therapeutic measures quickly available to battle casualties. The medical service of the Station Hospital, Schofield Barracks, also acted as a supplement to the surgical service in triage and as a shock team in the treatment of the casualties from Wheeler Field and from Schofield Barracks.
Subsequent history is one of rapid expansion of all the medical facilities in the Pacific area to permit proper care of the numerous sick and wounded who flooded the hospitals in the Central Pacific during the many operations following the declaration of war and up to the end of hostilities.
In the early part of 1942, Tripler General Hospital expanded to 1,000 beds, and its medical service was divided between two different geographic areas. One was located in the Kamehameha area and the other remained in the original Tripler area, opposite Fort Shafter. Each of these areas cared for certain categories of medical patients. The Station Hospital, Schofield Barracks, expanded from 422 beds to 1,000 beds, and the name was changed to North Sector General Hospital on 21 March 1942. This expansion was made possible by establishing a hospital annex 1 mile away from the main building, which provided five 100-bed wards for the medical service.
In June 1942, the 147th General Hospital arrived in the Territory of Hawaii and became part of the Hawaiian Department, thus increasing the bed capacity of the medical service of this area. It absorbed all the activities of Provisional Hospital No. 2, and it was set up at Saint Louis College, located in the southwest area of Honolulu. The medical service at the beginning consisted of 200 beds, but, on 7 December 1942, 500 additional beds were available for medicine, so that the total bed capacity ultimately approximated 700 medical beds.
In the absence of military operations at this time in the Central Pacific, all the medical services functioned largely as a medical screening facility for units staging in this area. The effect of training on limited-service personnel and relatively untrained troops threw a large burden on the medical service. The gastroenterologic section doubled its admissions, psychoneurosis became a problem, and respiratory infections became frequent but were not serious.
With the influx of troops for training in the Hawaiian Islands, additional hospitals arrived and were assigned duties on some of the outlying islands. The 1st Station Hospital arrived at Canton Island on 10 February 1942. On 12 March 1942, the 22d Station Hospital arrived at Kunului, Maui.
During the year 1943, preparations were made for the future campaigns in time Pacific. Changes in personnel were frequent, and medical officers were evaluated and trained by the medical services of the various hospitals for duties with troops in forward areas.
Medicalscreening continued through 1943. No sizable epidemics occurred.Contagious diseaseswere common among troops arriving from the continental United States.Scattered cases oftyphus fever were seen during September and October of that year. Therewas no threat frominterior
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poliomyelitis or influenza. Patients withmalaria were seen frequently. These were usually casesof malaria with relapse which responded promptly to treatment. Malariawas never a problem inthe Central Pacific. Patients with filariasis acquired in ApamamaAtoll, Gilbert Islands, madetheir appearance in the Central Pacific, and a study of this disease onthat island was made andreported.
On 1 November 1943, the 22(1 Station Hospital was reorganized and. was designated as a 750-bed unit.
Tripler General Hospital continued to function as one of the most important general hospitals. Expansion continued, and Provisional Hospital No. 3 located at Kuakini was taken over by Tripler General Hospital and designated as the Contagious Disease Center for the South Sector of Oahu.
During the year 1944, there were many military operations in the Central Pacific Area.. 1n the early part of the year, patients were admitted from the forward area (Kwajalein and Eniwetok) , and during the summer the influx increased with activity on Guam, Saipan, and Tinian. With each campaign, because of the geographic beat location, interesting diseases (which will be described later) were seen in general hospitals.
As has been noted, CPBC was established on 1 July 1944 to include Canton, Christmas, Fanning, and Johnston Islands and all the islands of the Hawaiian group.
The training of Medical Department. personnel, both commissioned and noncommissioned, progressed. The medical services continued to expand. Tripler General Hospital took over the station hospital at Kane, Oahu, on 15 May 1944, thus increasing the medical service by three wards. In addition, two other wards were kept in reserve for medical emergencies. In August 1944, 115 patients with filariasis were evacuated to these emergency wards. The medical service in this area also served to segregate and treat minor outbreaks of diarrheal diseases occurring in the Kaneohe section of the island.
In September 1944, Tripler and North Sector General Hospitals were officially expanded each to 2,000 beds, were each allotted a staff of 80 officers, 166 nurses, 2 warrant officers, and 641 enlisted men, and were redesignated the 218th and 219th General Hospitals, respectively. The capacity of the 148th General Hospital, Oahu, T.H., was increased to I ,500 beds.
The increasing demands for medical beds on the outlying islands were met by this arrival of the 230th Station Hospital. This unit arrived on Oahu on 28 September 1944, and, after a short period at Koko Head Concentration Center, departed for Kamuela, Hawaii, on 17 October 1944. This hospital took over the function of the 26th Station Hospital.
The increased activity as a result of the arrival of patients from forward areas necessitated the transfer of the 22d Station Hospital from Maui, on 21 September 1944, to Waipie, Oahu. The capacity of thus hospital was increased to 1,000 beds, and functioned as a general hospital, relieving the burden of the 218th amid 2l9th General Hospitals.
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Before the departure of the 22d Station Hospital, the 8th Station Hospital arrived on 19 August 1944 to take over the area about to be vacated. The 8th Station Hospital, which arrived on 12 February 1942, at Bora-Bora, Society Islands, was moved on 14 April 1944 to New Caledonia, and later in the year, on 2 August 1944, arrived for duty on Oahu.
During 1944, the incidence of respiratory infections was minimal. One convoy in June brought a severe strain of measles, but spread of the disease was prevented by segregation of the patients. With the capture of Saipan, there was an increase in cases of infectious hepatitis and also in patients convalescing from dengue fever. Intestinal parasites were common findings in patients evacuated from the forward area. Psychoneurosis continued to be a problem, and anxiety states and battle fatigue resulting from combat were frequently observed. Penicillin became available in April 1944 and proved to be an appreciable advance over other remedies, including the sulfonamide drugs. In the latter part of 1944, the Philippine campaigns (Leyte and Mindora) added to the large number of patients already hospitalized in the Central Pacific.
In 1945, the military operations on Luzon, Iwo Jima, and Okinawa led to the evacuation of patients with diseases heretofore not seen in the Middle Pacific. Schistosomiasis and amebiasis (with liver complications) were encountered. The arrival of Japanese and Korean prisoners of war added to the array of tropical diseases. Cases of filariasis, paragonimiasis, and infestation with Clonorchis sinensis were seen. 1n addition, the Central Pacific received patients from New Guinea, New Caledonia, New Hebrides, the Russell Islands, Tahiti, the Cook Islands, and from similar small scattered areas throughout the Pacific.
On 1 March 1945, with the transfer of the 230th Station Hospital to Oahu, Tripler General Hospital transferred its Kaneohe medical facilities to this station hospital. On 1 February of the sane year, the Kuakini facility was returned to civilians for use as a civilian hospital. An epidemic of influenza caused by virus B occurred on the island of Oahu, but it was not serious and with the help of civilian consultants from the continental United States was soon under control.
With the approach of V-J Day, preparations were made by CPBC to return to their original owners the public and private schools that had been used as military hospitals. As a result, the l47th General Hospital was transferred to Schofield Barracks on 25 August 1945. The medical service was established in one of the buildings that had formerly housed a general hospital unit.
The 218th General hospital made similar plans to evacuate the Farrington area and to transfer its medical service from the Kamehameha area. The entire 218th General Hospital subsequently functioned in the original Tripler Hospital area until it moved into its new home, the New Tripler General Hospital.
The close of the war inthe Pacific thus ended 3years and 9 months of
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FIGURE 225.-Occupational therapy at 204thGeneral Hospital, Hawaii
tremendous medical expansion, medicaltraining, and treatment of the sick and the wounded.
THE MEDICALCONSULTANT'S FIELD
In the great movementacross land and sea, the placeof the medical consultant was defined byhis assignment to advise the theater surgeon on the quality oftechnical medical and sanitaryservices of all Army installations. His specific functions became clearin practice. Some idea ofthe geographic range of his activities in this area is indicated by theitinerary of Colonel Masonfrom April to December 1945.
From 4 to 26 April 1945, the 147th, 218th, and 219th General Hospitals and the 22d and 8th Station Hospitals were visited. Ward rounds were made with members of the staffs, the laboratories were inspected, and all internists and pathologists were assigned MOS (Military Occupational Specialty) ratings, where indicated, for final action by the Surgeon. Between 29 April and 4 May, Colonel Mason visited the blood bank, the 204th General Hospital (fig. 225), the 18th Naval Base Hospital, and the 289th and 373d Station Hospitals on Guam. On 7 and 8 May, he visited the 232d General Hospital, the 41st Station Hospital, and the 38th Field Hospital on Iwo Jima.
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FIGURE 226. -Medical ward, 148th GeneralHospital, Saipan.
Between 11 May and 19 May,visits were made to the148th and the 39th General Hospitals(figs. 226 and 227), the 5th Convalescent Hospital, the 94th FieldHospital, and the 369th StationHospital on Saipan. Between 20 and 31 May, Colonel Mason visitedmedical installations onOkinawa. On 1 June, the 374th Station Hospital was visited on Tinian.0n 20 July, the authorwent to Okinawa for 10 days to study Japanese B encephalitis; on 17September, he went toJapan to study medical effects of the atomic bomb at Hiroshima; and on6 December 1945 hereturned to headquarters at Honolulu.
The professional medical consultant to an area, a theater, or a service command had many duties to perform during the period of hostilities. He gained much by the study of new methods, new therapeutic techniques, and new approaches to the study of disease. In certain instances, suitable data were available for the statistical approach to the solution of medical problems. In many cases, however, general impressions gained by study of large numbers of patients and by exchange of ideas with well-informed clinicians (fig. 228) had to be relied upon in making decisions.
When World War II began, the scope of therapeuticactivity of the sulfonamides was not clearlydelineated; penicillin was a novel product, so far untried; and plasmaand type O blood had beenadministered by only a few. In addition, the civilian physician, exceptin a few instances, was notfamiliar by training or experience with the large number of diseasespeculiar to the tropical andsubtropical climates. Furthermore, at the onset of time war, theoverall problem inherent in therelation of the supply of specialists of various categories to thedemand for them in civilianpractice and in the Army had to be resolved. For example, the number ofpsychiatrists,epidemiologists, and specialists in tropical medicine and in thecontrol and treatment ofcontagious diseases was woefully inadequate to serve both the civilianand military popu-
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lation. Accordingly, it was necessary totrain Medical Corps officers in specialties required formilitary needs. This placed a. peculiarly difficult burden on a largenumber of physicians whohad to learn a new field of medicine, in which frequently they had nogreat interest, by means ofshort and intense refresher and training courses. The manner in whichthese problems were metdeserves more recognition than these patriotic physicians will everreceive. The amazingly lowmorbidity and mortality in military zones occupied by U.S. troopsshowed how well the task ofthese officers was accomplished. The development of ideas and theirapplication to theprophylaxis and treatment of disease in the Second World War fill asignificant page. in thehistory of medical science.
Fundamentally, military medicine is the practical application of medical knowledge to military needs. Of the contributions made to scientific medicine by Army physicians during the war, a few of the more important may be mentioned. The introduction of Atabrine (quinacrine hydrochloride) in malaria suppression, the use of penicillin in the treatment of gonorrhea, the use of sulfadiazine in the control and treatment of epidemics of meningococcal meningitis, and the investigations of acute rheumatic fever prove the value of the scientific in conjunction with the practical approach to medicine.
The Central and South Pacific Areas included the Hawaiian Islands, all of Micronesia, Iwo Jima, Okinawa and neighboring islands in the Ryukyu chain, New Hebrides, New Caledonia, the Fiji Islands, and the Society Islands. These islands are of variable origin, are variable distances from the equator, have diverse climates, and are populated by peoples of different races and different cultural levels. In addition, the arthropod vectors and transmitters of disease and the human carriers and reservoirs of disease in these islands of the Pacific Ocean are extremely varied. Many medical officers had the opportunity to observe a large number of exotic diseases and their effects on native populations and on military personnel who had entered areas of high endemicity. These diseases included malaria of all types, filariasis both periodic and nonperiodic, yaws, leprosy, scrub typhus, schistosomiasis, ancylostomiasis, amebiasis, leishmaniasis, Japanese B encephalitis, beriberi, protein starvation, dengue, intestinal helminthic infestations, and various types of blood-fluke infestations.
Since numerous data on many of these diseases are tobe found in other volumes of this history,there has been no attempt at exhaustive discussion in this chapter.Rather, the diseases have beenmentioned as they were seen in the hospitals of the Hawaiian Departmentand now will bediscussed as they presented problems in the Central Pacific. Later willbe mentioned more detailsconcerning their course and treatment or their control and prevention.
MEDICALPROBLEMS
Filariasis. - Thisis a disease of high incidence on Samoa, Bora-Bora, and also onOkinawa.Numerous troops who had contracted the disease in the
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FIGURE 227.-Continued. D. Interior,laboratory. E. Red Crossre-creation room.
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FIGURE 228.- Medical officers onOkinawa,meeting to exchange ideas and discuss problems, May 1945.
cord, and usually a history of a few areas ofretrograde erythema amid induration. Diagnosis byfinding the filaria in the lymph nodes or by finding micro filaria inthe blood was extremely rare.The probable diagnosis was made by inference, after studying thepatient and his symptoms anddetermining his previous geographic location. It was the policy of theSurgeon General's Officeto transport soldiers who had acquired filariasis on a Pacific islandto the continental UnitedStates for treatment. There was no valid reason to believe that thedisease would progress orcause any appreciable disability if the patient was removed from anendemic area. Thepossibility that it might become established in the United Statesexisted since the arthropodvector is present in many localities (fig. 229). In fact, the diseasehas existed in Charleston, S.C.,for more than 50 years, and its appearance in some other area in theUnited States was, therefore,a remote possibility. The native Okinawan represents a huge reservoirfor the spread ofWuchereria bancrofti. Surveys of time civilian population ofthat island and of Okinawanlaborers taken prisoner during the military campaign proved that themicro filaria might be foundin the blood at night in approximately 20 percent of the individualsexamined. For that reason,Okinawan prisoners who had been evacuated to Oahu were returned fromtime Hawaiian Islandsto Okinawa, and no other Okinawans were sent to
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FIGURE 229.-Experiment conducted at 219th Malaria Survey Detachment to determine the role of mosquitoes in the transmission of filariasis, Okinawa, July 1945. Containers house about 75 mosquitoes
camps on Oahu. There is a small endemic area of filariasis on thewindward side of Oahu,although time vector there is relatively inactive. Transmission of thedisease to inhabitants ofOahu by military personnel has not been proved (p. 688).
Schistosomiasis. - Anumber of patients who had acquired infection by Schistosomajaponicumduring the Leyte campaign were hospitalized in Tripler GeneralHospital. These patients all hadfever, severe abdominal cramps, frequent vomiting or diarrhea, painover the liver, andtenderness in the hepatic area. All had marked eosinophilic at. thisstage of the disease. One hadsevere headaches with optic neuritis, soft-tissue swelling about theright eye, and weakness ofthe extremities, especially the arms. They were all treated with Fuadin(stibophen), and allrecovered. It is, however, too early to state what. their ultimate fatemay be. The prognosis,based on time probable length of life of the flukes in the blood is ofsome seriousness in thesecases owing to late cirrhosis changes in the, liver that often occur inpatients who remain inendemic areas for considerable periods of time (p. 670).
Plague andleprosy. - Plague is endemic on the island of Hawaii, but noinstance of the diseaseoccurred in any member of the Armed Forces (p. 667). Leprosy alsooccurs on the HawaiianIslands. A few individuals with the
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disease, all of whom were Asiatic in origin,were inducted into the Army and later discharged fordisability.
Dengue. - Serious epidemicsoccurred in the Hawaiian Islands, in the Marianas, and to a smallextent in Okinawa during time war (p. 678). The disease is of seriousimportance in militarymedicine owing to the large ineffective rate suddenly produced amongtroops and to a ratherlong convalescent period. Its control by aerial spraying of DDT(dichlorodiphenyltrichloethane)gives some foresight of the probable use of insecticides during future.military campaigns.
Infectious hepatitis. - Acute catarrhal jaundice or epidemic hepatitis occurred in more or less severe epidemic form following nearly every minor or major campaign in this area. It presented the same clinical characteristics that have been described in other military campaigns and in this area had, apparently, no seasonal incidence.. No convincing data have been found associating the disease with a known vector or a known reservoir. It has been proved that the excitant of the hepatitis may be present in the blood and the stools of patients who have recovered from it, but its natural mode or modes of transmission to human beings are not yet known. The disease never appeared in this area in large epidemics. No case following transfusion by type 0 blood had been reported during the early stage of the campaign; and later, with increasing use of transfusions, it was difficult to determine whether the hepatitis occurred naturally or following parental injections of serum (p. 667).
Dysentery. - Sporadic instances of amebic dysentery were seen in all the hospitals in the area. Studies of the location of the homes of these soldiers and surveys of the civilian populations in the neighborhood of the posts in the Pacific where patients had been stationed were of considerable importance in attempting to determine where the infection was acquired. However, it. seemed reasonably certain that a considerable number of soldiers acquired amebic dysentery first in time Pacific area and that the disease will be of importance in the veterans' hospitals for years to come. No new drugs or new methods of treatment were developed in thus area. The value of emetine the acute stage of the disease and in the early stage of amebic hepatitis was amply confirmed.
THE ASSAULT ON OKINAWA
Medical Aspects, Particularly Shock
Extensive medical planning had been done for time Okinawa campaign.
Six hospitals, with a total bed strength of 6,650 were ready on Saipan alone to accommodate casualties from the operation. No major Army Medical Department organizations were staged on Saipan; however, nurses from the 69th, 74th, 75t.im, 76th, 31st, and 36th Field Hospitals were placed on temporary duty in Army hospitals on Saipan until such time as their transportation to Okinawa could be obtained. Medical supplies sufficient for 10,000 men for 30 days were set in reserve for the operation but were not used.
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Blankets, litters, pajamas, sutures, anddextrose, and certain other medical supplies, not availableto the Navy base, were furnished Navy hospital ships and other surfacecraft. In addition, 1,274Navy and 2,707 Marine patients were hospitalized in Army hospitals. OnGuam, in turn, Navyhospitals accommodated 7,825 Army patients in the course of the Okinawacampaign.
The medical problems of a major campaign were observed during the battle of Okinawa. What follows are the personal impressions of Colonel Mason, who was director of a shock service during the First World War.
In 1917 and 1918, packaged type O blood was not available, and all blood for transfusions was obtained from soldiers or convalescent patients. It was matched by the use of stock sera of types II and III, and no serious results owing to possible mismatching were seen. Blood of group IV (type 0) was given to any patient with no serious reactions. Sterile solutions of gum acacia were also furnished but were used in only a few instances. It was believed that the gum acacia was of little value in shock, and, in addition, it was highly pyrogenic. By the end of the First World War, the value of the use of whole blood in shock following either trauma or hemorrhage was well established. At that time, it was known that plasma escaped from the blood vessels, capilllary stasis occurred, blood volume was reduced, and hemoconcentrat.ion occurred in secondary shock. It was not. fully realized, however, that whole blood was the best. colloidal solution known to replace lost, blood or to restore blood volume.
At the beginning of the Second World War, there were still many unknown factors concerning shock. It was the accepted belief that adequate quantities of plasma could be substituted for whole blood in most cases. This opinion was based on experience in the use of plasma in burns and in shock following surgical operations when the loss of blood was not great.. Early reports from the campaigns in Africa, Italy, and Europe did not substantiate this belief, and further reports by many observers showed that battle casualties reaching a hospital in shock (excluding those with lesions of the nervous system) had lost quantities of blood much larger than had previously been suspected and that plasma was far inferior to whole blood in their treatment. As suggested by that experience, blood of type O was collected on the Pacific Coast of the United States and transported by airplane directly to Okinawa, after re-icing at Oahu and Guam. Thus, adequate quantities of type O blood were available at all times.
In modern warfare, ifbattle casualties received early are to betreated adequately, theorganization and equipment. of field, evacuation, and stationhospitals, as originally authorizedin World War II, must. be altered. Training in the parenteraladministration of whole. blood andin all aspects of shock should be given to at least 3 or 4 shock teams.Each team should consistof a trained internist, a laboratory officer, an assistant competent touse the copper sulfatemethod to determine specific gravity of the whole blood, and alsoseveral nurses. The treatmentof shock is not necessarily the function of the internist, but. underbattle conditions it is almostinvariably true that every
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available surgeon is overloaded with work inthe operating room. It is also the usual opinion thata competent internist familiar with laboratory methods is the mostsatisfactory chief of the shockservice. In field, evacuation, or station hospitals near the scene ofbattle, a shock ward,completely equipped, should be established by trained personnel, andall patients in shock orwith serious wounds should be admitted to that ward. Each patientshould be examined, theblood pressure taken frequently, and the specific gravity of wholeblood and plasma determinedas necessary. Careful records should be kept., especially of all testsand all administrations offluid.
In general hospitals, a shock ward is seldom necessary although shock teams should be formed to treat patients in shock in any ward throughout the hospital.
During an active campaign, it is desirable to delegate the responsibility for the early care of wounds of the chest and lungs to a medical officer especially trained in that field or to the chief of the shock service, if no other officer is available. Careful study of the fluid from the wounded chest by the copper sulfate method and bacteriologic, examination will often give data of great value in the treatment of thoracic injuries.
When blood is plentiful, as during the campaign on Okinawa, over transfusion becomes a possibility. It. was the impression that in a very few patients this may have been the cause, or, at. least, a contributing cause of death. On the other hand, there is no doubt that a very large number of lives were saved by large, repeated transfusions (fig. 230).
The indications for the use of intravenous crystalloid solutions are not frequently met in war injuries under usual conditions. They may present themselves in patients in hot and humid areas, when thirst and sweating have been excessive or occasionally after repeated vomiting. Otherwise, crystalloid solutions should be used cautiously and usually only when whole blood is either unavailable or available only in small quantity.
Shock teams and the shock ward in the field hospital
The varying degrees ofmobility of modern warfarewill often alter considerably the funct.ion ofthe field hospital. The usual channel of evacuation of the wounded isfrom the aid station to thecollecting and clearing stations and then to the evacuation hospital orfield hospital functioningas an evacuation hospital. The wounded patient in shock must be treatedat the earliest possiblemoment if he is to be saved. Shock treatment consists of the control ofhemorrhage, the closureby some method of sucking wounds of the chest, the proper fixation ofwounded extremities, therelief of pain, the administration of parenteral fluids, and often theadministration of oxygen. Thewounded patient, having received this care and having been properlyprepared for operation, isnow transferred to the surgical service. Following operation, thepatient, in many instances, isreturned to the shock ward for postoperative care or to the generalsurgical wards if or when it. isprobable that shock is under
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FIGURE 230.-Transfusion of whole blood during application of a transportation plaster cast, Okinawa, 9 April 1945.
control. In the latter case, symptoms of shock may reappear, and if so the patient may be treated in the surgical ward.
Thus, the shock service will be called upon to initiate treatment of shock, to control triage of patients, and to assist in all postoperative care. For thus reason in field hospitals, the admission ward, the shock ward, the laboratory, the X-ray department, and the surgical facilities should be contiguous when possible.
In the Pacific area, landwarfare up to the end of the war had not beenextremely mobile. Therewas reason to believe that, even in the event a land attack were madeon the Japanese mainland,warfare would not have been of the mobile type common in Europe. Thereasons were relativelyobvious. The Japanese islands are small, the roads were mostlyunimproved, and the terrain inmany places is rough. The Japanese armed forces were not well suppliedwith vehicles or mobileweapons. Furthermore, the U.S. air superiority would undoubtedly haveseriously disrupted alltypes of communication behind the lines. The Japanese foot soldier hadshown that he wouldstand and fight where he was rather than attempt strategic withdrawalin his relatively smallmainland. It seemed likely, therefore, that in the event of landcampaigns on the mainland, as inthe campaign on Okinawa, most of the surgical treatment would be donein evacuation or fieldhospitals (fig. 231). Moreover, it seemed likely that, in general, thedistances between aidstations and evacuation or field hospitals would not be great. Thus, itwas probable that shockwards
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FIGURE 231.-69th Field Hospital, Okinawa,May1945.
in the evacuation or field hospitals would besufficient, as a rule, but that, occasionally, shockteams should be formed or made available in time clearing stations.
In each hospital, every medical officer should be familiar with the copper sulfate method of examining blood, with the use of oxygen, with the use of whole blood and plasma, and with the use of crystalloid solutions. At least 3 or 4 medical officers in each hospital should know all the important details of the use of the copper sulfate method, and as many technicians should be trained in its use. An officer should be trained in the general principles of treatment of thoracic wounds and should be especially skilled in thoracentesis for th evacuation of blood, fluid, and air and for the relief of tension pneumothorax. In general, these procedures will be carried out in the shock ward where the patient can be examined readily by the surgeon, who may decide when thoracotomy or other thoracic operations seem indicated.
Shock as a problem in military medicine
Many changes are stilltaking place in the medicomilitary conception of shock. Discussion willbe limited to certain phases of the resuscitation of battle casualties,chiefly those produced byt.rauma. It will be confined almost entirely to the procedures thatproved efficacious in the shockwounds during World War II.
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Relatively minor traumawith the loss of little orno blood and with only a reasonable amount ofpain may produce psychic shock or benign shock. Pallor, cold sweat,faintness orunconsciousness with sudden drop of blood pressure are the usualsymptoms. The relief of thepain by morphine without any other treatment usually leads to rapidvasomotor stabilization andprevents return to a state of serious shock. For that reason, relief ofpain is of great importancetherapeutically. In many wounded patients, however, the effects ofexhaustion, dehydration, andblast injury may not be readily apparent. As a consequence, thepatient's condition may be moreserious than the size or location of the wound would indicate., andwhat was considered to bebenign shock may progress rapidly into a state of profound shock.
Surgical shock produced by operations under prolonged anesthesia but without significant loss of blood is characterized by peripheral vasoconstriction, with cold, cyanotic extremities; anoxic anoxemia from the vasoconstriction accompanied by marked hypotension; leakage of protein into the tissues, probably due to anoxic damage of the capillaries; reduced left ventricular output, pulmonary hyperemia; and eventually pulmonary edema. It has been amply proved that this type of shock may be reversed promptly by administration of sufficient quantities of plasma. Experience has shown that, when moist rales are heard in the lungs, the. plasma should be given slowly in more concentrated form; namely, from 2 t.o 3 units to 250 cc. of diluent. 1n all types of shock, plasma may be given early at aid, collecting, or clearing stations where whole blood is not available, but it should be remembered that it may give a false impression of security by causing a temporary rise in blood pressure in patients who may have had severe hemorrhage and in whom only blood will be effective.
Patients with extensive burns should receive plasma in concentrated solution given slowly. Since many of these patients may have inhaled hot gases or fumes, the administration of oxygen may be important.
The patient with extensive single or multiple wounds almost without exception has lost a large amount of blood before he reaches the field hospital. Direct measurement of blood volume is not yet. feasible in the battle zone, but there is much indirect evidence of importance. In one instance, the calculated amount of whole blood lost by 20 casualties having wounds not involving abdominal or thoracic viscera averaged 50.4 percent of the total blood volume, and the blood loss in 16 cases with perforating abdominal wounds averaged 24.4 percent. These figures at first sight seem excessive. However, in many wounded patients observed 2 to 4 hours after injury, hematocrit readings were 30 to 35 and would have been much lower at the end of 48 hours or later. Some of these patients followed through to rear areas still had hematocrit readings of 25 or lower after 2 or 3 weeks and after a number of subsequent transfusions. Early drop in the specific gravity of the whole blood, as determined by the copper sulfate method, together with drop in blood pressure and acceleration of the pulse are usually reliable signs that the blood loss has been considerable. ????
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In another instance, itwas reported that systolicblood pressures of from 50 to 60 mm. Hg werevery common in the severe cases. The general rule of fast transfusionin these cases was adopted,and blood or plasma was administered at the rate of 1 pint per 15minutes until the bloodpressure reached 110 mm. Hg. This was followed by a slower rate--1 pintin 45 minutes--untilthe blood pressure had been completely built up. It was found better,in general, to leave thebadly shocked patient with penetrating wounds of the chest alone, andvery few of these patientswere transfused. In the most severe cases, slow transfusion wasattempted. With head wounds, asimilar conservative policy was adopted. It was evident in patientseither with cranial or spinalwounds that transfusion was singularly ineffective when there was muchhemorrhage or grosstissue destruction.???
On the average, the casualties observed by Col. Walter B. Martin, MC, Consultant in Medicine, Tenth U.S. Army, received 3.5 pints of blood or about 12.5 percent of their blood volume. In spite of the large number of transfusions given to wounded men on Okinawa, few were seen with polycythemia or other evidence of overloading of the circulation. This theoretic possibility may be disregarded, except in certain types of injuries such as those just noted. If available clinical signs point to severe loss of blood, 10 or more pints of whole blood may be given preoperatively and postoperatively in from 24 to 36 hours without any evidence of injury to the patient.
It is the conviction of most medical officers whohave been in charge of shock wards that largequantities of whole blood given to seriously wounded men before,during, and after operation areof the utmost importance in reducing the death rate both fromhemorrhage and from irreversibleshock. Excessive amounts should not be given, and transfusion shouldnot be repeated after thehematocrit readings have returned to normal.????
The complicated vasomotor, osmotic, and fluid correlations in shock are not yet entirely known, and in some instances results of laboratory determinations are interpreted differently by different observers. A few physiologic principles on which all observers are agreed are applicable in shock wards in advanced medical installations. The following relatively simple observations should be of value in reaching a decision as to what parenteral fluid should be given and why:
1. With minor wounds, sudden collapse of the nature of fainting is frequent. This consists of pallor, cold sweat, extreme muscular weakness, marked drop of blood pressure, and anoxic anoxemia with some cyanosis. The hematocrit reading and blood counts are normal. The phenomenon under these circumstances is caused by widespread vasodilatation of central origin with consequent cerebral anemia.???
2. Shock without. hemorrhage or with insignificant loss of blood is frequent. Under such cir-cumstances, the hematocrit reading is high, owing to loss of protein into the tissues through the proximal arterioles and veins. There is widespread vasodilatation and probably damage of the smallest vessels due to anoxic anoxemia from blood stasis. The blood pressure falls,
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sweating is profuse, blood pools or sludgesin mesenteric and pulmonary veins, and ventricularoutput steadily diminishes. Pulmonary edema is a terminal event in thistype of severe shock, onin irreversible shock.???
3. Shock with hemorrhage is the common event in wounded soldiers. Ample experience has shown that in such instances the hematocrit reading is low even within the first 3 hours after the wound has been inflicted. Since uncomplicated shock and dehydration lead to high hematocrit readings, a low reading shortly after a wound has been received means that the blood loss certainly has been very large. Under such circumstances, sound clinical judgment must be used. The amount and speed of whole blood transfusions should be determined by clinical observation, blood pressure determinations, and frequent counting of the pulse. Plasma in more concentrated form than usually used may be helpful if blood is not available. The sovereign remedy is whole blood. An attempt should be made to replace any loss by hemorrhage as quickly as possible. Having accomplished this as nearly as can be determined by clinical observation and hematocrit readings, the condition of the patient should be reevaluated with great care. An excessive number of erythrocytes in the peripheral blood stream will produce erythema, not cyanosis. If the blood pressure remains low, if cyanosis appears and the urinary secretion rapidly diminishes, the patient is usually in irreversible shock. Examination will usually detect rales of pulmonary edema, and at this stage further whole blood transfusion will produce increased evidence of right heart stasis. At autopsy, these patients show pulmonary congestion, visceral congestion, renal cyanosis, and fluid in the serous cavities. It is probable that in few, if any, of these patients over transfusion played more than a minor role in their death. In patients with hemorrhage and shock not markedly improved by whole blood transfusions, other causes for persistent shock should be sought with great care. These include concussion injury of lungs, crushing injury of muscle, infarction of a large mass of muscle, unsuspected injury of the spinal cord, and fat emboli from injury of long bones and from extensive tearing injuries of the abdominal viscera..
Shock is a name applied to a. series of phenomena that are harbingers of approaching death. The terminal events in shock are probably always similar, regardless of the cause or of the speed with which they are elaborated. These events are unmodified and modulated by the underlying disease or injury. Shock produced by streptococcal disease, by Addison's disease, by hemorrhage, by extensive surgery, by burns, or by gangrene of an extremity probably follows the same pattern; and laboratory determinations that seem to show serious discrepancies from case to case may be correlated when the pathologic physiology of the underlying disease is carefully considered and fully understood. Shock produced by a burn, by a crisis of hypertension caused by a pheochromocytoma, or by a prolonged surgical operation all eventually produce vasodilation, hemoconcentration, anoxic anoxemia of the smaller blood vessels, osmotic imbalance in tissues with imbibition of water, drop of blood pressure, and disturbances of renal function owing to hypotension and renal
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cyanosis. The end results are pulmonaryedema, then cerebral anemia and death. In many cases,the alterations of clinical findings and laboratory determinations areeasily understood whencompared with such abnormalities already present when clinical evidenceof shock appeared.
The use of parenteral fluids, other than whole blood or plasma, in the treatment of wounded patients requires brief discussion. Before a battle casualty is given a parenteral injection of fluid other than blood or plasma, a definite indication for its use must exist. A number of such indications may be enumerated, such as alkalosis caused by vomiting and diarrhea; mild acidosis from starvation; anuria from hemoglobinuric or myoglobinuric renal damage; edema from hypoproteinemia following blood loss, malnutrition, or extensive burns; or change in electrolytic balance owing to fistulas from the stomach or small intestines. Most of these conditions are encountered rarely in active campaigns or in battle casualties and the indications for treatment are obvious. Such treatment, however, usually is of great importance. It has been repeatedly observed in hospitals that following serious wounds the patient loses much weight. Thus loss of weight is not always easily explainable. In general, it is a result of weakness, loss of appetite, unattractive or liquid diet, and loss of serum from infected or burned areas. Every effort should be made to feed such patients nutritious diets with ample protein. The routine use of liquid diets should be discouraged, and such diets should be given only to patients who are too weak to chew. All foods except milk become liquids in the stomach. Proper postoperative feeding will save many hospital days.
The treatment of wounds of the chest, except for the actual surgical operation and the postoperative care of casualties requiring thoracotomy, should be largely delegated to the shock teams except in those field hospitals that are augmented by thoracic surgical teams. The first consideration is the closure of sucking wounds of the chest and the arrest of hemorrhage by the best method available. The next is the careful and early diagnosis of the extent and nature of the wound and the determination of the intra thoracic changes. Early radiographic diagnosis is usually possible and always important. Hemothorax should be removed by early and frequent tapping. Pneumothorax, especially of the tension type, should be corrected by the use of a needle connected to a one-way valve, either the valve from a gas mask, or a piece of rubber glove correctly placed over a thoracentesis needle, or a Bunsen valve. All pleural fluids should be studied by the copper sulfate method, and, when possible, the fluids should be examined for cellular content and for micro-organisms. A careful study of the movements of the thoracic cage should be made to determine whether the wounded half is carrying on any respiratory function. Massive coagulation of the blood in a hemothorax is probably much more frequent when the respiratory muscles on that side are reflexly paretic. Massive coagulation of a hemothorax should lead to prompt thoracotomy, since when not evacuated it is followed by either empyema or constricting pleural fibrosis, necessitating a long period of hospitalization.
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Oxygen should be given toall patients with thoracicwounds when there is cyanosis, or whenmoist rales are heard at the base of the lungs, or when a satisfactoryairway cannot beestablished. Such patients should never be given large or rapidtransfusions, since these mayproduce acute pulmonary edema in cases in which the amount of pulmonarycompression isextensive. As a matter of fact, any fluid given intravenously should beadministered with greatcaution to patients who have had serious thoracic wounds.
Pathologicevidence of pulmonary edema
This discussion is basedon 100 autopsies performedat the 14th Medical Laboratory on Okinawaon soldiers who died of battle wounds or severe injuries.2 In reviewing these records, one isimmediately struck by the high percentage (72 percent) of cases showingmassive pulmonaryedema with or without pleural effusion and the considerable number withhemothorax andatelectasis that apparently had escaped detection during life. With fewexceptions, theseindividuals had experienced severe tissue damage of the head, chest,abdomen, extremities, orcombinations of these. Fifty-one percent had multiple major wounds.Table 2 gives the details oneach case as to location of wounds, presence or absence of pulmonaryedema, pleural effusion,atelectasis, hemothoraces, empyemas, and pneumonias.
Table 3 shows the relative weight of the lungs and liver in edematous and nonedematous cases exclusive of those showing pneumonia. It is evident that the weight of these organs in many of the patients with no pulmonary edema are above the accepted normals, suggesting that in some cases edema of the lungs was actually impending.
Satisfactory evidence cannot be brought forward to establish the cause of the remarkable incidence of pulmonary edema in this group. The inference is strong, however, that it is the result of the quantity or kind of fluids given intravenously or the rate at which such fluid was given. Unfortunately, accurate records of fluid intake and output are not available. In a number of patients, the amount of parenteral fluid given was certainly excessive, as was also the amount of sodium chloride. Some patients received, during their period in the hospital, approximately 62 gm. of sodium chloride parenterally. In addition to this, a large number of wounded men also received large quantities of blood. It is probable that these two factors may have been contributory to the production of pulmonary edema, particularly if the serum protein had been lowered by blood loss and subsequent dilution with crystalloid solutions.
The conditions under which the shock wardsoperated during the rush days of the campaign amply justified a wide margin of error in maintaining fluid balance andin keeping satisfactory records. Large numbers of severely wounded patients crowded the shockwards day and night. It was necessary to place great emphasis on speed and on the rapid administration of large quantities
2 Essential Technical Medical Data, General Headquarters, UTAFPAC, for September 1945, Appendix A, thereto. (These data were in large part collected by Col Walter B Martin, MC, or under his supervision while he was medical consultant for Tenth US Army)
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TABLE 2.-Autopsyreports-100 casualtiesdying from battle wounds or severe injuries
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TABLE 2.- Continued Autopsy reports - 100 casualties dying from battle wounds or severe injuries
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TABLE 2.- Autopsyreports -100casualties dying from battle wounds or severe injuries--Continued
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| Casualties | Right lung | Left lung | Liver | |||
| Average | Maximal | Average | Maximal | Average | Maximal | |
| Withedema..... Without edema...... | 839 505 | 1,400 925 | 768 455 | 1,300 700 | 1,975 1,840 | 2,750 2,525 |
of blood to as many patients as possible. Themedical personnel available in time preoperativeand postoperative shock wards were inadequate in number and, withcertain exceptions,inadequately trained. The surgical teams were overloaded with urgentoperative cases and hadlittle time to supervise the postoperative care of their patients. Toomuch cannot be said in praiseof officers and enlisted personnel of these hospitals for theirdevotion to their patients. Theyworked to the point of exhaustion through many days and nights. It isobvious, however, that anumber of patients suffered from a lack of individual attention.
Summary
The brilliant achievement of making adequate amounts of whole blood available for the treatment of shock in the evacuation and field hospitals and clearing stations brought an added responsibility to the shock service. In the campaign on Okinawa, for the first time in any area in the Pacific, more than sufficient amounts of blood were available, this being, in general, type O blood which had been flown in large amounts from the continental United States. Many lives were saved by the liberal use of whole blood. In the future, it will he more than ever necessary that shock wards be set up on a basis adequate from both the physical and professional standpoints.
Medical experience in the campaign on Okinawa was more favorable than was anticipated owing to a number of factors. Although the number and types of medical units were often inadequate to accomplish the mission of the medical service in the most acceptable manner, excellent use was made of the facilities available both in planning and in operation. In general, however, the organization and training of field hospitals as professional units were incomplete, and the shock service, especially in field hospitals, was deficient in organization, training, and in qualified personnel. Laboratory support, both from the field hospital laboratories and the more complete Army medicall laboratory, was inadequate chiefly owing to lack of trained personnel and to failure to anticipate the added burden placed on field hospitals by modern warfare.
The evacuation from the island of many 'white' (i.e., transportable) medical and. surgical patients was a significant factor in loss of manpower, since many of those with only slight wounds might have been returned quickly to duty.
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In 100 autopsies performedon soldiers whodied of battle wounds or severe injuries, 72 percentshowed massive pulmonary edema with or without pleural effusion orhemothorax. It is probablethat death in these instances was caused almost invariably byirreversible shock, and it isbelieved that the pulmonary edema may have resulted in part from thequantity or kind of fluidgiven intravenously or the rate at which such fluid was given.
It was not proved that any patient died solely as the result of over transfusion or of drowning by the parenteral administration of crystalloids. Furthurmore, it is not believed that death in the patients with acute pulmonary edema combined either with pleural effusion or hemothorax was due to these circumstances alone. Since it is more probable that death under such conditions is caused by irreversible shock, it is not logical to conclude that these patients would have been saved had they not been given large quantities of whole blood or, occasionally, of parentera1 crystalloid solutions. On the contrary, many lives probably were saved. Large quantities of blood by transfusion at this time was the only known remedy that might prevent the development of irreversible shock.
Observations by the Medical Consultant to the Tenth U.S. Army???
Following are comments taken from the report of Colonel Martin on the operations of the Medical Department of the U.S. Army during the campaign on Okinawa. lt may be noted that elaborate preparations for evacuation of the less severe transportable. cases are described as necessary to conserve for the care of the severely wounded not only beds but Medical Department personnel, who were, in fact, in short supply at Okinawa. On the other hand, accumulated experience elsewhere has shown that the time and talents of medical personnel are expended profitably on the patient who can be treated near the front and returned promptly to duty. An essential part of planning should be to provide an adequate supply of medical officers to care for such patients as well as for those in urgent need of surgery.
On L-day (the day of the amphibious assault on Okinawa), 6 April 1945, the surgical, medical, and Orthopedic consultants came ashore. Colonel Martin remained with the Surgeon, III Amphibious Marine Corps, and they had the opportunity to visit together the field medical installations in the forward areas. lt should be remembered that the assault on Okinawa (fig. 232), which began on 6 April 1945, was unopposed by the Japanese and that there were no actual casualties at the time of landing. Shortly afterward, however, heavy battle action began and continued until the. mopping up of the Japanese forces about 21 June 1945. On 14 April 1945, Colonel Martin returned to the headquarters of the Tenth U.S. Army and thereafter was concerned, together with the other consultants, with the professional activities of the medical units supporting the operation of the Tenth U.S. Army in southern Okinawa.???
On L-day, the consultants visited six of the LSTH's (landing ship tank hospitals) supporting the III Amphibious and XXIV Corps. Although the number of casualties at that time was light, it was evident that the plan of
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FIGURE 232.-Landing operations on Okinawa,4April 1945.
evacuation was well conceived and was workingsatisfactorily. This impression was confirmedby subsequent observations. The pontoons alongside these ships affordedample space for rapidsorting of the casualties and thus facilitated their transfer to AH's(hospital ships) and APA's(attack transports). It should be noted that. beginning L-day theLSTH's for the III AmphibiousCorps had been provided with additional surgical personnel of thelanding force by the corpssurgeon. This would have been of inestimable value if the casualtieshad been heavy early in thecampaign. In the latter phase of the operation, an army surgical teamwas assigned to one LSTH,used for evacuation of casualties from the south end of the island.This step proved of great.value and should be considered if similar circumstances arise in futureoperations. Airevacuation beginning on L-plus-8 and functioned smoothly andefficiently. Holding stationswere established on the beaches and at the Yontan Air Field. At. thesepoints, patients werecarefully screened as to suitability for transport by air or by water.The combined effect of airand water evacuation prevented the hospitals from being overwhelmed by"white" (i.e.,transportable) cases, surgical and medical, at a time when battlecasualties were heavy. Later,evacuation was effected directly to LSTH from certain of the northernand southern beaches.During the action in the south of the island, when transport to anyfield hospital was madedifficult by bad roads (fig. 233), evacuation by light Army aircraft.(L-5's) was successfullycarried out.
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Disease did not constitutea major problem,but there were large numbers of battle casualties(table 4). This placed a heavy load on the preoperative andpostoperative shock teams as well ason the operating teams. It was necessary and proper that officers fromthe medical service of thehospitals be used in the shock wards. Owing to the fact that, ingeneral, shock teams had not been organized or instructed in shocktherapy or in the proper physical setup and operation of ashock ward, there was at first considerable confusion and lack ofeffectiveness. Thesedeficiencies were gradually corrected. As each new unit arrived on theisland, the professionalpersonnel were briefed by the consultants on the various professionalaspects of the operation. In addition, the plan of attaching theseofficers to units already operating served to give theminvaluable training in field medicine and surgery.???
It was necessary during this period of great activity to evacuate without definitive treatment, directly by ship or plane, 5,175 of the less severely wounded. Those in the group requiring debridement were evacuated to AH's or APA's. This policy allowed the available surgical personnel time in which to care for the severe nontransportable cases. At the same time, large numbers of 'white' medical casualties were evacuated from the field hospitals in order to clear beds for the severely wounded. Even then, the situation was saved only by the assignment of the professional personnel of newly landed units to
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[Preliminary data based onsummaries ofstatistical health reports]
[Rate expressed as number of cases perannumper 1,000 average strength]
| Week ending..... | Disease | Battle casualties |
| Number of Cases | Rate | Number of Cases | Rate |
| 6 April.......... 13 April........ 20 April........ 27 April........ 4 May........... 11 May......... 18 May........ 25 May........ 1 June.......... 8 June.......... 15 June........ 22 June....... | 129 296 293 323 358 557 586 857 822 | 66.36 152.23 151.44 188.01 360.15 288.66 437.79 462.59 651.40 643.94 653.98 731.60 | 1,169 2,027 2,507 2,310 1,643 1,391 1,882 1,693 854 620 886 1,326 | 601.36 1,042.66 1,296.08 1,344.83 1,267.11 1,121.64 1,479.36 1,336.47 649.16 475.35 704.95 1,062.60 |
units already in operation. 0n an average,these additions increased the professional personnel ofthe operational field hospitals from 13 to 22.???
The Surgeon, Tenth U.S. Army, placed the responsibility for the utilization of available professional personnel entirely in the hands of the various consultants. Excellent cooperation was given by the corps and division surgeons and, in most.. instances, by the hospital commanders.
Medical casualties were light, with few seriously ill, and constituted, during the first 6 weeks of the campaign, approximately one-sixth of the total casualties. Thereafter. there was a gradual rise in the disease rate which on 28 May 1945 for the first. time exceeded the battle-casualty rate. At the same time, battle casualties were diminishing, so the increase was more relative than absolute. The low medical rate had not been anticipated and may have been due to several factors, to be discussed later.????
The quality of medical care varied in proportion to the devotion to duty and professional qualifications of the medical staff. In certain instances, the professional qualifications of the medical officer assigned had been below a reasonable standard or the organization of the service had been deficient. In most instances, the medical care was from good to excellent.
An advance unit of the 14th Medical Laboratory consisting of 3 officers and 8 enlisted technicians was landed on L-plus-8-day and was in operation on L-plus-21day. Owing to limitations on tonnage allowance, a relatively small amount of equipment could be brought in. This unit performed valuable service in support of the field hospitals in the accumulation of factual data on diseases prevalent among the natives. Of especial value was the
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autopsy service, although impaired by limitedpersonnel and equipment and by failure to providea definite plan for its direction.
ConcludingComment
The sanguinary and heroicfighting on Okinawa(fig. 234) lasted about 76 days, and the totalground casualties of the Army, Navy, and Marine Corps were staggering.The total Army andMarine Corps casualties were about 35,000 men, including 8,000 dead.According to the bestfigures obtainable, approximumately 107,000 Japanese were killed and7,400 taken prisoners. Ofthis number, according to the best statistics available, based onaverage battle casualties in thePacific areas, less than 50,000 were actually killed by U.S. troops. Itis apparent that theJapanese must have exterminated approximately 50,000 of their woundedcomrades.????
That this was common practice among the Japanese was evidenced by the very small number of Japanese wounded found anywhere on the island during mopping-up operations. No Japanese medical installations capable of handling their own expected wounded in such a campaign were ever found.
More than 5,000 prisoners of war were taken on Okinawa, and these consisted of Okinawans, Koreans, Japanese combatants, and other Japanese nationals. Of these, over 4,000 were sent to Oahu before July 1945. These
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prisoners were examined at the 18th MedicalGeneral Laboratory. The results were of somemedical interest..??????
Microfilariae, either Wuchereria bancrofti or W. malayi, were found in the blood of 16 percent of the 4,563 prisoners examined.
Three hundred sixty-five of these prisoners were examined by the rectal swab technique, and 67 (18.35 perceimt) were found to be harboring pathogens of the genus Shigella. One individual was a typhoid carrier. About. 90 percent of the stools showed one or more metazoan parasites.??
Hookworm was the most common helminth found; others included Strongyloides, Ascaris, and Trichuris. Among the protozoa found in this first group of stools were Entamoeba histolytica, E. coli, Endolimax nana and Isospora hominis.??? ??? ???
CLINICAL ASPECTS OF THE WAR
It is not. the purpose of this brief history to give details of the various diseases seen in the hospitals throughout the Central Pacific. Such descriptions and statistics will be found in other volumes of the official history of the Medical Department in World War II. It should be of some interest, however, to discuss briefly some of them, especially the exotic diseases, as they were observed in Army hospitals.
Plague in the Hawaiian Islands
Plague has been endemic in the HawaiianIslands since December 1899. The first reported caseoccurred in Honolulu, Oahu, following which the disease appeared atthe principal ports ofHawaii, Kauai, and Maui islands within the next 5 months. No evidenceof plague in rodent orman has been reported on Oahu since 1910 nor on Kauai since 1906. Ithas remained endemic onthe islands of Maui and Hawaii, as evidenced by human and rodentinfection, which at present,so far as is known, is restricted on each island to a small focal area.An increased number ofcases of plague in rodents and human beings occurred in the HamakuaDistrict of the island ofHawaii, during the year 1943. Following this small outbreak, verystrenuous rat control measureswere carried out in each of the endemic plague areas, and thesemeasures were of sufficientthoroughness to prevent any spread of plague to military personnelduring the war in the Pacific.
Infectious Hepatitis
Under the terms 'infectious hepatitis' or 'acute catarrhal jaundice' are included those cases of jaundice of unknown causation-often epidemic in appearance but also occasionally observed following the administration of yellow fever vaccine, or following transfusion with type O blood or less often with matched blood of different groups, or following the administration of pooled plasma.???
The first patients with acute infectious hepatitis following vaccination against yellow fever began to arrive on transports docking at Oahu between
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10 and 16 March 1942. Numerous investigations were made, especially in the effort to differentiate the disease from Weil's disease, before it became apparent that there was a causal relation between acute hepatic disease and the preceding vaccination.???
There were several hundred patients with postvaccinal hepatitis in hospitals in the Pacific Ocean Area, with one death recorded. The average incubation period following vaccination was about 100 days but varied between 30 and 120 days.
Small epidemics of infectious hepatitisfollowed nearly every assault by amphibious forces onthe islands of the Central Pacific or South Pacific Areas. Theincubation period of theseepidemics was not definitely determined. As a mule, however, patientswith the disease werefirst observed about 3 weeks after the assault. It is, therefore,apparent that the incubation periodof the disease acquired during assaults on coral islands was shortcompared with the incubationperiod in cases following vaccination against yellow fever. Malaise,weakness, and anorexiawere the usual symptoms, but when questioned many of the patients gavea history of fever,diarrhea, and loss of appetite about from 10 days to 2 weeks before theappearance of jaundice.These symptoms usually subsided before the onset of jaundice, and,apparently, in some patientsno overt jaundice ever appeared.
A number of small epidemics of jaundice were studied with considerable care from an epidemiologic point of view without any decisive results. Neither the exact vector nor the reservoir of the disease in the Pacific area was determined with certainty. The epidemiologic evidence would seem to favor the belief that healthy carriers were responsible for the spread of the disease during periods when sanitation was at a. temporarily low ebb, as immediately after an assault on an island.
During the late spring of 1945, a supply of immune serum (gamma) globulin was made available to the Central Pacific for use as a prophylactic in a threatened epidemic of acute hepatitis. This was not used, however, since troops who were hospitalized with the disease on Okinawa had been through the campaign on Leyte, where jaundice was prevalent, and it seemed probable that these troops by the time they reached Okinawa were too far along in the incubation period to warrant the use of gamma globulin as a prophylactic measure.
The incidence of acute hepatitis following transfusion of type O blood cannot be determined accurately from the data obtained in the Pacific area.. The problem is difficult from a statistical standpoint owing to the presence of acute hepatitis in various stages among troops in combat, who are also the same troops among whom battle casualties requiring transfusion occur. Another difficulty is the long incubation period following the causal transfusion. In the normal chain of evacuation, the majority of individuals who would develop homologous serum jaundice would be either in a continental United States hospital or would have returned to duty in the Pacific area before symptoms became manifest. With the newer knowledge of the diphasic symptom-
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atology of the disease and of the significantdifference in the length of the incubation periodbetween epidemic hepatitis and homologous serum hepatitis, iteventually became possible tocollect more accurate and significant data.
Diphtheria
Diphtheria was contracted by personnel of the 27th Infantry Division on Saipan in the Marianas. A few cases appeared about the middle of August 1944. These patients were hospitalized locally. The division left Saipan the latter part of August and arrived in Espiritu Santo in the New Hebrides on 14 September 1944. While en route, a few more cases of pharyngeal diphtheria. and an increasing number of skin lesions, most of which were ulcerative and located on the extremities, appeared among the personnel.
In the 27th Infantry Division, the following cases of diphtheria were reported: Pharyngeal, 77 cases; cutaneous, 95 cases; carriers, 9 cases. In the same division, it was observed that as patients with cutaneous diphtheria were isolated the number of patients with nasopharyngeal diphtheria decreased pan passu. In the month of November 1944, only three cases of nasopharyngeal diphtheria were reported from this division. From 25 August to 25 November 1944, pharyngeal diphtheria occurred among personnel of other organizations on Saipan, the number of cases mounting most rapidly during the first month of this period. Diphtheria in Army personnel remaining on Saipan after the departure of the 27th Infantry Division was reported as follows: Pharyngeal, 73 cases; cutaneous, 3 cases; and carriers, 6 cases up to 25 November 1944.
Cutaneous lesions giving positive cultures for diphtheria among personnel of the 27th Division were practically all ulcerative. This lesion, of the type described as tropical ulcer, was of varying diameters from about a quarter of a centimeter to several centimeters, the average diameter being 1 cnn. Lesions were frequently multiple. Cutaneous ulcers were often rounded and punched out in appearance, were surrounded by a zone of dull red or bronze pigmentation, and had indurated, rolled margins. They were usually superficial. The appearance of the lesion was not uniform or characteristic enough to enable identification without the aid of laboratory study. The lesions were crusted over or covered by a serofibrinous exudate. There was usually a thin diphtherit.ic membrane in the base of the ulcer. There was usually no systemic reaction, and the only symptoms noted by time patient were those caused by the discomfort of the skin lesion.
The nasopharyngeal diphtheria was usually typical and easy to detect. in most cases, it was undoubtedly contracted from patients with cutaneuos diphtheria. As a matter of fact, in all theaters in the Pacific area, cutaneous diphtheria occurred among the troops and especially among the natives, and it was believed that it was from patients with these lesions that the spread of diphtheria most frequently occurred in the Pacific Ocean Area. In a number of instances, evidence of peripheral neuritis with weakness and paralysis of the legs, the arms, and often of the palate and the pharynx as well as of the nasopharynx was observed in patients in whom there was no faucial diphtheria
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FIGURE 235.-Engineersconstructing bridgeacross jungle stream, Leyte Island, October 1944.
and no evidence of nasal diphtheria. In suchcases, it was believed that the peripheral neuritisfollowed the ulcerative lesions of diphtheria of the skin.
Schistosomiasis
A large number of patients were transferred to the hospitals of Central Pacific Area with a diagnosis of schistosomiasis. These men had been stationed on Leyte in the Philippine Islands and had been attached to an engineer battalion and an infantry division. They had been exposed in a fresh water stream where they were building bridges (fig. 235).
The first symptoms in most cases appeared in the middle or latter part of December 1944 and the early part of January 1945. In general, these patients became ill approximately 4 to 8 weeks after the initial exposure. Few patients noted immediate symptoms.
The period between the onset of symptoms andhospitalization varied from 1 to 30 days. Thiswas due to the circumstance that symptoms such as weakness,indigestion, and urticaria weretransitory and the patients did not seek hospitalization early. It wasonly the persistence of suchsymptoms with or without chills and fever that caused these patients tobe hospitalized. Mostpatients, however, were hospitalized from 1 to 3 days following theonset of symptoms.
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The early symptoms were varied in character. The most frequent were headache and chills and fever of the remittent type with nightly elevations. Abdominal pains and mild diarrhea were the most common gastrointestinal complaints. Skin lesions in the forum of urticaria appeared early in about 50 percent of the cases; a few patients even recalled burning and tingling sensations in the skin shortly after having emerged from the water of the stream on the island of Leyte. These symptoms were probablv caused by penetration of the skin by the cercariae of S. japonicum.
Laboratory studiesrevealed that the whiteblood count ranged from 7,500 to 18,500, the averagebeing about. 13,000 per cu. mm. There was a marked eosinophilic of thecirculating blood inall patients ranging from 26 percent to 78 per cent, the average beingabout 48 percent Thesedimentation rate was elevated in all cases. Most of these patientshad stools positive for theova of S. japonicum while they were observed on the island ofLeyte, but only a few patientshad positive stools after they had arrived in the Central Pacific Area.
Therapy consisted of intramuscular injections of Fuadin. Following this treatment, the white blood count and sedimentation rate returned to normal; the eosinophils in the blood decreased markedly, and the stools became negative. A number of patients were seen with gastrointestinal distress, enlargement of the liver, and jaundice; and a few were seen with marked evidence of involvement of the central nervous system.
VenerealDiseases
The venereal diseaseproblem in the HawaiianIslands and the CPA was of considerableimportance, and strenuous efforts were made to eradicate these diseasesby all the meansdeveloped during the past years. In general, these methods consisted ofsuppression ofclandestine and overt prostitution by closing all houses ofprostitution, by education andindividual prophylaxis, by tracing of procurers and contacts, byexamination of contacts, and byreporting and treating all individuals infected with venereal disease.
In 1911, the venereal disease rate per 1,000 per annum was 175.3; in 1941, 14.1; in 1942, 9.6; in 1943, 4.2; in 1944, 7.3; and in 1945 (incomplete), 7.1. These rates should be correlated with the number of Army troops on the island of Oahu at any given time. In November 1941, there were 39,000 troops; in July 1944, 162,000 troops; and in July 1945, 144,000 troops.
Many of these soldiers were trained on Oahuand moved on to be replaced by new troops. Thepopulation of Honolulu was increased by large numbers of Navalpersonnel, many male civilianwar workers, and relatively few female war workers. In a short time,the number of males greatlyoutnumbered the females. Under such circumstances, with relatively fewwomen in the ancientprofession, it is probable that the number of exposures remained aboutconstant but the numberof exposures per thousand troops decreased and the venereal diseaserate per thousand troops peryear naturally decreased. Study of
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contacts in the early part of 1942 showedthat 75 percent of all venereal diseases in militarypersonnel were contracted from professional prostitutes. Thus, thedecrease in the venerealdisease rate was a relative phenomenon, ascribable to a lower exposureindex per militaryperson, although the exposure rate per prostitute may actually haveincreased. The actual numberof patients with venereal disease in the hospitals remained nearlyconstant.
Eventually, the treatment of venereal disease became the responsibility of the chief of the medical service in all military hospitals, and, with the introduction of penicillin, treatment followed the general pattern observed in all other theaters of the war.
In the Mariana Islands, syphilis was rareamong military personnel, although a high percentageof the civilian population gave a positive reaction to standard testsfor syphilis. Segregationsatisfactorily prevented the spread of this disease to military troops.Included in the survey onthe island of Saipan were 27 native female hospital patients, 36Japanese prostitutes, and 14members of the civilian police force of Camp Sucupe. When it was foundthat a large number ofthe native adults gave a positive serologic reaction for syphilis, 42children between the ages of 5and 11 were examined in an attempt to ascertain whether these positivereactions were producedby yaws. Scars resembling the healed lesions of yaws were observed infive adults. All of thesepatients gave positive reactions for syphilis. Healed lesions, typicalof yaws, were found in twoof the children. Both gave positive serologic reactions for syphilis.The majority of thoseincluded in the survey were Japanese civilians. Also included were 15Chamorroan male adultsand 11 Korean adults. Of the 42 children examined, 21 were Chamorroansand 21 Japanese. Allblood samples were sent to the l8th Medical General Laboratory, wherethey were examined bythe standard Kahn precipitation test. Out of a total of 296 bloodspecimens, 5 were found to beunsatisfactory for examination. Of the remainder, 49.8 percent werepositive; 1.3 percent,doubtful; and 48.9 percent, negative. It is therefore apparent thatsyphilis is very prevalent in thenatives in the central Pacific islands. However, since healed yaws maybe followed by positiveserologic tests for syphilis, this fact must be considered in theresults of surveys where yaws isendemic.
MurineTyphus in the Hawaiian Islands
Murine typhus was neverbeen a seriousproblem in time Hawaiian Islands. Sporadic cases havecontinued to occur but never in large numbers. During the 6 years from1937 to 1942, inclusive,the incidence of endemic typhus in the civilian and military populationin the Hawaiian islandswas 37, 69, 59, 72, 81, and 78 cases, respectively. The monthly averagewas 5.5 cases for thisperiod. There was a considerable increase in the number of cases duringthe war. Although abreakdown of data for the Hawaiian Islands only is not available, forthe Central and SouthPacific Areas there were 65 cases of murine typhus reported in 1943 and35 cases reported in1944.
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Among U.S. Army personnel,at least one caseof epidemic typhus was known to have occurredin Hawaii during World War II. This case was reported by the 75thStation Hospital, SchofieldBarracks, in June 1943.
Japanese B Encephalitis on Okinawa3
The first case of Japanese B encephalitis wasseen among the Okinawan natives on 10 July 1945,and up to 26 July 1945 about 68 patients had been observed. Of these,three were U.S. soldiers.There were probably many more cases among the natives ending in deathor recovery withoutbeing referred to Military Government Hospitals. It is probable thatmore than 100 cases hadoccurred. The majority of the patients were under 12 years of age. Theyoung were equallydivided between the sexes, but the few older individuals werepractically all females. Most of thepatients originated in the north east end of the island. Two weremembers of the same family. Alarge number came from Heanza Shima and Homahika Shima. These islandsare reasonablyisolated, and but little mingling with other Okinawans had occurred.
No evidence was obtained that gave any clue to the length of the incubation period. A soldier being treated for amebic dysentery in a military hospital developed a sore throat and within 36 hours showed evidence of encephalitis. Two Okinawans, who were sisters, developed the disease-one approximately a week after the first one affected had died. There is thus a little evidence that the incubation period is short: perhaps about a week and probably less than 9 days.
A large number of thepatients were seenlater in the course of the illness, and linguisticdifficulties made exact determination of the early symptoms and thedate of onset difficult. Mostpatients were not observed until after the fifth day.
It was noted that many of the young patients had a cold with sniffling and some cough on admission to the hospital; some, however, did not. The usual history was that the patient had been ill with a headache and fever for about 5 days. Many patients also gave a history of inability to speak. A number of the younger patients had convulsions and drowsiness, and many gave a history of twitching movements of one limb or of the limbs on one side. Most had constipation, but a few had diarrhea.
Most of the patients were drowsy and lethargic, and their facial appearance resembled that seen in the 1918 epidemic of von Economo's disease (fig. 236). The face was flat, ironed out, and expressionless; and the patient was asleep because he couldn't remain awake. Ocular symptoms were frequent, especially conjugate deviation of the eyes, occasionally ptosis, and often nystagmus. The pupils were dilated or small and often unequal. Facial weakness on one side or the other was frequent. Flaccid or spastic paralysis of a single limb or of hemiplegic type was frequent. Coarse jerking of a hand or a foot or coarse
3 Personal observations made between 10 July 1945 and 31 July 1945 at Okinawa by the author.
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FIGURE 236.-Nativechild with encephalitis,Okinawa, July 1945.
tremor of an extremity was often seen.Stiffness of the neck was practically always observedearly in the clinical course. Trismus was very frequent, and it is ofinterest that the disease wasfirst recognized in a group of patients who were I thought to havetetanus. The reflexes wereusually disturbed. The Babinski sign was usually positive on one orboth sides. Ankle clonuswas frequent. The knee jerks and ankle jerks were present, absent, orexaggerated, and thus oflittle diagnostic importance. Decerebrate type of rigidity wasoccasionally seen. One patientremained in the position of decerebrate rigidity with frequentconvulsive movements of the rightleg and arm The sensorium was usually cloudy, but all except those whowere moribund couldbe aroused. The fever was usually high, 102? to 104?F., and became lower with improvement. The neurologicalabnormalities were changeable from day to day. Deepening of coma andincrease of pulse rate and temperature were grave signs. Leukocytecounts and urine analyseswere usually not made. There was constantly a pleocytosis of thecerebrospinal fluid with a lownumber of granulocytes. The total white cell count was between10 and200 in the cererospinalfluid.
The duration of the disease was not accurately known ut was probably from 10 to 21 days. No idea could be formed of possible sequelae at the time of these observations.
Afew case histories may be of interest.
Case 1. - Male,age 7 years. Headache and fever began 14 July 1945. Patient admitted tohospital on 19 July 1945. He developed convulsions and inability tospeak. His temperature was 104? F., and he was comatose.The head andeyes deviated to the right. The left arm and left leg were in partialflexion. The cerebrospinal fluid contained
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two lymphocytes. Patient died on 22 July1945. Autopsy showed many new and old petechial hemorrhages,especially numerous in the vicinity of the basal ganglia. There weresmall areas of apparent necrosis in the leftglobus pallidus.
Case 2. - Female, age 7 years. Onset of the disease was on 15 July 1945 with headache, fever, drowsiness, and twitching movements of the extremities. The patient had been unable to speak for 3 days. The neck was stiff. Temperature was 102 ? F. The patient was comatose and in decerebrate rigidity. The cerebrospinal fluid contained 17 cells, of which 3 were polymorphonuclears. The patient died. Autopsy showed congestion of the pial vessels. No petechiae were seen in the brain.
Case 3. - Male, age 12 years. About 1 July 1945, the movements of the arms and legs seemed awkward. The next day, the patient could not urinate but had paradoxical incontinence. On 4 July 1945, his temperature was 104 ? F. He complained of a headache. The neck was stiff, there was opisthotonos, and the Patient was practically comatose. On 6 July 1945, his temperature was 104 ? F. There was marked trismus. The tendon reflexes were hyperactive. There was a positive Kernig sign with flaccid paralysis of the extremities. The cerebrospinal fluid contained 84 lymphocvtes. The leukocyte count in the blood was 3,200 per cu. mm. On 10 July 1945, the patient was markedly improved.
Case 4. - Female, age 49 years. On 5 July 1945, Pat Hilt had a headache and a high fever; soon she became apathetic and unable to speak. On 7 July 1945, her temperature was 105 ? F., and her pulse was 100. She was lethargic; her eye movements were normal; there was marked trismus and stiffness of the neck. The extremities were spastic, and the tendon reflexes were hyperactive. There were at athetoid movenients of the hands. The Babinski sign was positive on rhe right . The cerebrospinal fluid contained 20 cells, all of which were mononulears. The white blood count was 6,400. On 11 July 1945, the patient was very markedly improved.
Case 5. - Female, age 24 years. This patient became ill on 7 July 1945 with headache, fever, and dizziness. She was dull and unresponsive. On 18 July 1945, she was semi-stuporous, responded slowly, and was unable to speak. There were coarse tremors of the facial muscles, especially on the right. There was pain on passive movement of the extremities. There was marked flaccid weakness of both arms with rigidity of the legs. The facies was masklike. On 13 July 1945, the cerebrospinal fluid contained 26 cells. On 20 July 1945, the patient died. At autopsy, the brain was markedly edematous with congestion of the pial vessels over the entire cortical surfaces.
Between the appearance on 10 July 1945 of the first case of the disease on the island of Okinawa and up to 26 July 1945, there were 68 cases of encephalitis of unknown causation-65 in civilians, 3 in military personnel. The mortality was about 30 percent, with no fatalities in soldiers. The onset was acute, and the incubation period was probably less than 9 days. The clinical findings pointed to widespread disseminated lesions in the cortex, subcortical areas, corpora striata, midbrain, and probably occasionally in the cord. The clinical course suggested that there should be widespread perivascular lesions without demyelination and with severe but transient injury of the motor ganglion cells of the brain.
The Military Government Hospital on Okinawa at the city of Taira was visited by Colonel Mason, on 27 July 1945. In the previous 3 days, seven patients had been admitted to this hospital. All of these were examined, and each had symptoms suggesting Japanese B encephalitis. All were between 5 and 18 years of age. One had left hemiparesis. One had athetoid movements
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of the hands. One had right facial palsy. Onehad convergent squint. All were drowsy and hadnuchal rigidity. All complained of malaise and headache. All had fever.One had 200 cells in thecerebrospinal fluid. All of these patients had the typical ironed-out,expressionless facies. Allhad disturbances of the tendon reflexes, and each had unilateral orbilateral positive Bahinskisigns. All were natives of Okinawa.
Three soldiers with headache, increased cellular content of the cerebrospinal fluid, fever, and some scattered neurological lesions were admitted to the 86th Field Hospital. All probably had cases of mild Japanese B encephalitis.
At NAMRU (Naval Medical Research Unit) No. 2 onGuam, the brains of anumber of thepatients from Okinawa who had died of Japanese B encephalitis wereexamined. They showedscattered round cell infiltration in the Virchow-Robin space. Areas ofdegeneration of the cortexand midbrain with innumerable small lacunae in the affected area werefound. These areas wererapidly infiltrated by glia cells and by astrocytes. The Betz cellswere damaged but not severely.The most marked changes were seen in the cerebellum. In addition to thelacunar type ofdegeneration there was complete cytolysis of many Purkinje cells. Therewas only a littledemyelination and that only near areas of cellular degeneration in thecerebral gray matter.
A summary as of 25 August 1945 was contained in a personal letter from Maj. Wilbur G. Downs, MC, actmg cinef of Preventive Medicine Service, Okinawa. He stated: 'There have been 18 probable instances of the disease on Okinawa among troops with 2 deaths and 6 suspected or probable examples with no deaths. All of the probable troop cases have come thus far from northern Okinawa. There have been possibly 120 examples of the disease in natives up to this date. All of the patients seen recently have originated in northern Okinawa and the focus at Nodake in the south has been quiet. The mortality rate in natives has been 25 to 30 percent. We do not know any more about subclinical infections than previously and it is still thought that many native patients who have the disease are never seen nor observed by physicians.'
Thevirus was isolated and put through several passages in mice at tileNAMRU laboratory. Itwas isolated from the brain and spinal fluid of one patient only butwas not isolated from theblood.
The complement-fixation tests on sera from patients during the acute and convalescent phase of the disease were strongly positive for Japanese B encephalitis.
The virus isolated has been determined by means of virus neutralization studies to be identical with the Nagasaki strain of Japanese B encephalitis. This is the strain from which the vaccine was prepared.
Search for insect vectors was carried on for many weeks with negative results. Search for animal hosts and reservoirs was likewise unsuccessful.
A largenumber of healthy natives were bled in order to determine time amountof immune bodyin time blood, in the hope of throwing some light on the endemic andepidemic situation inOkinawa. This work was not completed at the end of hostilities.
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It is evident fromdescriptions in Japanesetextbooks of medicine and in Japanese articles on thesubject, especially those in which Japanese investigations describeisolation of the virus afterpassage through mice (fig. 237), that the disease as it occurs in Japanis considerably different incharacter from that observed in Okinawa. Apparently, the reservoir ofthe disease is located inOkinawa. The vector is not known. When an epidemic occurs in Okinawaeach summer, theyounger children are chiefly affected, probably because the olderchildren and adults havesurvived mild or subclinical attacks in early childhrood and havebecome immune, althoughmortality from the clinical forms of the disease in very young childrenis usually high. It wasbelieved that the virus producing epidemics on the Japanese islands wascarried there byindividuals who had acquired the disease or had become carriers of itin the island of Okinawaand returned thence to Japan. Thus the epidemics on the mainland ofJapan arise in a populationin which no one has previously developed immunity from contact with thespecific virus. Oldand young alike are infected, and the death rate among olderindividuals is much higher thanamong the relatively immune older people of Okinawa.
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Coccidioidomycosis
Since large numbers oftroops had been trained inthe California-Arizona area and had beenexposed to this disease and since large numbers had come throughCalifornia and Arizona on theway to Oahu, it is remarkable that during the war only a very fewsoldiers transferred toHonolulu were on arrival found to have acquired coccidioidomycosis. Nopatient withgeneralized coccidioidomycosis was hospitalized in the Central PacificArea.
Dengue
Descriptionsof epidemics of dengue in various parts of the world have appeared inmedicalliterature since 1780. The vectors of dengue have been reported frommost of the islands in theCPA, and the disease is endemic in Makin, Tarawa (Gilbert Islands), andthe Ellice Islands. Anepidemic of dengue occurred in Honolulu ill July 1943; in 1944, therewere two outbreaks, thefirst starting in the Gilbert Islands and the second in the Marianas.
Epidemics of dengue in the Central Pacific
On 3 August1943, the Board of Health of the Territory of Hawaii was informedconcerningthree cases in which the diagnosis of dengue was suspected and, infurther observations, wasconfirmed. Several days later, another physician reported the samediagnosis in three otherindividuals who became ill On 2 July 1943. These patients resided orwere employed at theBeach Walk Inn in the Waikiki district. Later, it was ascertained thatthree flying personnel ofthe Pan-American Airlines arriving on Oahu from the Southwest Pacificwere ill on 4 July1943 with what was then thought to be influenza. These three newpatients also resided in theWaikiki district. A review of the case histories by board of healthphysicians and the attendingphysicians resulted in the decision that the diagnosis probably shouldbe dengue. These caseswere the first to be recognized as dengue in the city of Honolulu andwere responsible for theintroduction of this disease into the Hawaiian Islands. When thisknowledge came to theattention of other physicians, 17 new cases were reportedduring the week of 28 July to 4 August1943. All but two of these patients lived or were employed in theWaikiki district. This area,being primarily a resort frequented by transients, provided an idealsource of dissemination. By15 September 1943, the disease was diagnosed in a total of 17servicemen. It is of interest tonote that 11 out of the first 14 cases of Navy personnel with denguewere sailors on leave andbilleted at. the Royal Hawaiian Hotel in Waikiki. In Honolulu, the Aedesalbopictus represents60 percent of the mosquitoes found, Culex quinquefasciatus represents36 percent, and A.aegypty represents 4 percent. The overall breeding index of thecity averages 10 percent. Theepidemic of 1943 ended with I ,339 civilian and 56 military personnelwith dengue reported afterthe onset of the outbreak on 30 June 1943. This epidemic was broughtunder control byscreening of patients, curtailing interisland travel, eradicatingmosquitoes and their breedingplaces. and declaring certain places off limits.
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The second epidemic outbreak of dengue occurredduring 1944. This time, the patients wereamong the military personnel in the CPA and were evacuated to thehospitals on Oahu. InFebruary 1944, 396 patients with dengue were admitted to the hospitalson Oahu. The rateamong troops in the CPA for the month was 26.10 per annum per 1,000average strength. Thesepatients came from the Gilbert Islands where the outbreak started. Themain arthropod vectorsproved to be A. aegyptm and A. albopictus. On MakinIsland where dengue is endemic, the onlyvector detected was A. renegatus.
Again in July 1944, following the Saipan campaign, another dengue outbreak occurred resulting in the admission of 774 patients to the hospitals of the CPA, chiefly on the island of Sampan in the Marianas.
The clinical symptoms among the military personnelwho had contracted the disease in 1943resembled the typical clinical features of dengue as it occurs ingarrison troops. The disease wasmuch more severe in the patients seen in 1944 following the militaryoperations on the MarshallIslands and Saipan.
The onset was sudden with chilly sensations and headache, in the mild cases, there were several days of vague body aches and malaise. The headache was most severe in the frontal region and was usually associated with postorbital pain, which was aggravated by lateral deviation of the eyeballs. Malaise, low back pain, and joint pains were also common complaints. Break-bone pain, which is considered it cardinal symptom of dengue, was not common in the small groups of patients seen in 1943. However, those Patients who were admitted from Saipan and the Marshall Islands complained of having had this pain in the bones, which in this disease is all but unendurable and can hardly be exaggerated. The pain behind the eyeballs was much more severe in this group also. A rash was seen in only a few patients.
Temperature curves varied,with elevations of from100? to 104? F. In many of the Patients seenin 1943, the temperature reached 101? F. daily and failed toshow the classical saddleback ordromedary curve. Many patients, treated in the dispensary for severaldays, had temperaturesthat had begun to decline on admission and never showed a secondaryrise. In the patientsevacuated from the Marshall Island and Saipan, the temperature graph ina small percentageresembled the saddleback curve.
Enlargement of the lymph nodes a striking physical finding. It was not particularly prominent early in the disease but became more apparent during the later course and often developed very rapidly. The enlarged nodes seldom exceeded a maximum dimension of 2 cm. by 3 cm. Tenderness was noticeable on firm pressure.
When there was a rash, it appeared suddenly and involved a definite area of the body. The rash consisted of bright pink-colored macules, about 3 mm. in diameter, which faded on pressure. Maculopapules were occasionally observed, most often in the skin of the Negro patients. The eruption was discrete, the lesions did not coalesce and did not tend to form patterns. The rash was distributed evenly over the neck, thorax, upper' abdomen, and arms. It
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persisted unchanged for about 24 hours afterdefervescence, then faded rapidly.
The white blood count as a rule varied between 3,000 and 5,000 cells per cubic millimeter. Monocytes were present up to from 4 to 6 percent, and many irritation cells and immature forms of neutrophils appeared.
Control of dengue on Saipan
It is of historicinterest to show what methods wereemployed in the eradication of vectors ofdengue on the island! of Saipan.
Following the assault on this island on 15 June 1944, dengue made its appearance among the troops. This was expected since it was known that dengue existed on Saipan during the Japanese occupation. The incidence was low during the first weeks, however, probably owing to the fact that the rainy season had not yet begun and that mosquitoes, although present in the vicinity of villages, were not found in large numbers. By 11 August 1944, mosquitoes were abundant, and a dengue rate of 300 had been reached among garrison troops and rapidly mounted to a rate of approximately 3,500 by 8 September 1944. The early rates are not considered entirely correct-owing to lack of trained personnel and of adlequate reporting methods-and are believed to be below the actual incidence. After 13 September 1944, accurate records were available concerning the incidence of dengue covering all troops (Navy, Army, and Marine Corps) on the island. The records show that between 8 September 1944 and 6 October 1944 the dengue rate had dropped from approximately 3,500 to 182.
Mosquito control problems. - At the time of the occupation of Saipan on 15 June 1944, there was an unbelievable amount of rubble resulting from the total destruction of scattered dwellings and villages. A multitude of wells, cisterns, vats, troughs, and diverse facilities for the collection of rain water, as well as an immense quantity of such items as tins and shell cases, provided suitable locations for the breeding of certain mosquitoes.
One platoon of the 743d Medical Sanitary Company was available for sanitation and mosquito control. The program was immediately begun with the spraying of wells and cisterns with kerosene and with the removal of artificial breeding containers in Charan Kanoa and Isley Field. Wells and cisterns were stocked with small fish, which fed on mosquito larvae. A large part of the time spent by this platoon had to be expended in fly control. With the beginning of the rainy season, it was evident that the number of trained personnel available would be insufficient for adequate control of mosquitoes by these methods.
A supply of DDT wasreceived on 3 September 1944. Plans were madeimmediately to introduceDDT into the effort to control mosquitoes on Saipan. No data wereavailable on satisfactorymethods of covering large areas of ground by airplane spraying. Thefollowing procedures wereaccordingly devised and applied. A large quantity of a 5-percentsolution of DDT in kerosenewas prepared, and Army and Marine Air Force units were called upon towork out the technicalproblems involved in spraying large areas of the island. All
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M-10 tank was attached to the underportion ofthe fuselage of a C-47 airplane and used withoutdetonators or glass shields as a combination surge tank and venturitube. Seven 55-gallon oilbarrels were placed on their sides in the fuselage, connected inseries, and piped through a 1?-inch pipe to the M-10 tank. A controlvalve was placed on the line from the fuselage tanks to theM-10 wing tank, to be opened and closed by a soldier on signal from thepilot. This arrangementpermitted a flight of not less than 20 minutes carrying over 300gallons of insecticide in contrastto a flight of 25 seconds if, as had been suggested, four M-10 wingtanks were used. Theequipment. as described was installed in a C-47 airplane. As more waslearned about the weightand balance capacity of the airplane, it was found possible to doublethe amount of insecticidecarried into the air by standing the tanks on end in a cradle, eachtank being equipped with an airvent and each series being attached to a 2-inch pipeline through whichthe entire series could befilled. By this system, each series of tanks could be reloadedsimultaneously from both sides ofthe airplane and approximately 45 minutes of spraying time could beaccomplished during eachflight.. A C-47 airplane so equipped can take off and fly approximately800 miles without anoverload.
During the first test run on 12 September 1944, made with kerosene insecticide, the airplane flew at. a speed of about 140 miles per hour at an altitude of from 50 to 100 feet., covered a swath estimated at from 75 to 100 feet wide, and applied somewhat less than 1 quart of insecticide per acre. Application of DDT insecticide by airplane began on 13 September 1944. Owing to the speed of the airplane, the roughness of the terrain, and the unevenness of the shoreline of the island, it was not considered practical for the pilot to attempt to follow prearranged markers to identify swaths sprayed or to be sprayed. In determining each successive line of flight to prevent overlapping of swaths, the pilot, had to depend upon his ability to recall land markers.
The southern part of theisland,designated as Area I, is relatively flat and consists of about 9,200acres. It was sprayed by first circling the outer border and graduallyworking inward to thecenter. A total of 7 missions, on 13 and 14 September 1944, were flownover this area, using2,000 gallons of 5 percent DDT in kerosene to cover it.. Thisapplication was calculated at lessthan 1 quart of the mixture per acre for the total acreage, indicatingthat swaths had been toowidely separated in sonic places. Another application was thereforemade on 17 and 20September 1944, requiring 6 missions and 1,800 gallons of spray andcovering the area with adifferent flight pattern. The two applications totaled about 1.65quarts per acre for the totalacreage.
The populated portion of the west side of the island from Charan Kanoa through Garapan to beyond Tanapag, designated as Area II, was sprayed on 15 September 1944 in 3 missions with 900 gallons of spray. A second coverage of this area was made on 20 and 21 September 1944 in 5 missions with 1,330 gallons of spray. This area, lying along the coast, was sprayed by strip flying at. approximately from 50 to 75 yards apart. A total of about 3,000 acres was covered with 2,230 gallons of spray, averaging 2.97 quarts.
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The populated portion of the east side of the island around Magicienne Bay north to Inai Fahu and including East Field, designated as Area III, was sprayed on 16 September 1944 in 4 missions with 1,370 gallons of spray. A second application was made on 22 September 1944 in 4 missions with 1,200 gallons of spray. The total acreage in this area was approximately 3,450 acres, and it was sprayed with 2,570 gallons of insecticide, an average of 2.98 quarts per acre.
The total airplane spraying during the period from13 to 22 September 1944 coveredapproximately 15,650 acres with 8,600 gallons of spray for the twoapplications, averaging about2.2 quarts per acre, 1.1 quarts per application per acre. A heavierapplication of insecticide wassprayed upon Area II and Area III in which there was the greaterdensity of troops and heaviermosquito breeding.
Residual spraying. - Another important approach to the control of dengue sought to reduce the number of adult mosquitoes that alternately hide and bite inside buildings and tents, some among these being vectors of the disease. This was done by using DDT as residual spray; for example, a wetting spray of' DDT solution leaving a residue of DDT crystals effective in killing mosquitoes, which might. or might not. be vectors of dengue.
The Chemical Warfare Service turned over one of itstruck-mounted chemical-decontaminationpower-spray units for this work. A special spray boom, equipped with aseries of four nozzles,each with a 60-gage opening in the spray disk, was built by the 283dOrdnance Company. On 14September 1944, residual spraying with this rig began in all tents,including quarters, wards,offices, and latrines, of the 148th General Hospital. This was done inabout half the hospital area2 days prior to spraying by airplane in the same area. The procedurewas very effective, andfreedom from mosquitoes inside all sprayed tents was noted during thenights of 14 and 15September 1944. After airplane spraying on 16 September 1944, there wasfreedom from thisannoyance both outside and inside the tents.
Following the residual spraying of the 148th General Hospital, numerous other units, including the 369th Station Hospital and the 2d Marine Division Hospital, were similarly sprayed.
The 176th Station Hospital moved into theirdesignated area on 22 September 1944. This areawas within an edge of the area of the 148th General Hospital and hadbeen sprayed by airplaneon 16 September 1944. On 18 September 1944, a residual spray wasapplied to all tents that,were to be occupied by the 176th Station Hospital within the next fewdays. There was not asingle case of dengue in this unit during the succeeding 21 days, ascontrasted with a very highincidence in the personnel of the 148th General Hospital during asimilar period of time afterthey occupied this area on 10 August 1944, before spraying.
Surveys of mosquito breeding before and after airplane spraying. - Eleven species of mosquitoes are known to exist on the island of Saipan, and the breeding habits of sonic of these made control by normal methods extremely
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difficult. Of these, A. aegypti and A. albopictus have long been known to be vectors of dengue. Two additional species, A. pandani and A. vexans, have been incriminated epidemiologically in the transmission of the disease in this area. All four of these species were reared from larvae collected in artificial water containers, such as rain barrels, tin cans, turned-up helmets, and cisterns, except A. vexans, which is found as larvae in fresh-water ground pools. The majority of A. albopictus larvae are found in water contained in rot holes of trees, and the larvae of A. pandani occur most frequently in water held by the pandanus, although they are often found in artificial water containers as well as in tree holes. The greatest density of A. aegypti occurred in the vicinity of towns. A. albopictus occurred most frequently in areas of heavy tree growth, which was also in the neighborhood of towns. A. vexans was found generally over the entire island but most abundantly in flatlands or poorly drained areas. A. pandani also occurred over much of the island, but it was most frequently found in the immediate vicinity of heavy tropical growth containing pandanus.
Maximum abundance of mosquitoes about human beings occurred within the first hour of darkness. However, A. aegypti most frequently attacked man during early morning or late afternoon hours, often in the deep shade of office desks and sometimes at night in houses with electric lights of low intensity. A. albopictus often attacked man in bright sunlight as well as during daylight periods when the sun was low. No specimens were ever collected late at night. A. pandani attacked man at any time when the opportunity to suck blood was present. A. vexans was only seen biting man at night. From 16 August to 10 September 1944, before the first application of DDT-kerosene insecticide was made, it was possible to collect as many as from 5 to 36 specimens of A. aegypti from one human being during a single 10-minute period late in the afternoon almost anywhere in the vicinity of towns or villages. In addition to these mosquitoes, from 2 to 16 females of A. albopictus, from 1 to 4 females of A. vexans, and sometimes as many as 3 specimens of A. pandani could be collected during the same period from the same individual. Late at night, as many as 26 specimens of C. quinquefasciatus and 16 specimens of C. annulirostris could be collected during one 10-minute period while biting a single individual. In addition, A. vexans and A. pandani were often taken in such night collections.
Between the dates of 5September 1944 and 11September 1944, just prior to airplane sprayingwhich began on 13 September, 6 areas, 200 yards square, were chosen invarious sections of thesouthern part of the island as being representative localities formosquito breeding. Carefulsurveys were made before and after spraying. Some areas were in wartorntowns, where artificialcontainers were abundant, others were typical field or woodlandbreeding places although suchcontainers as tin cans and shell cases were to be found almosteverywhere over the island. Whenthe sureys were begun, it was impossible to determine the exact dateupon which spraying wouldbe done. Some of the areas were, therefore, checked as long as 9 daysprior to spraying. Theprespray surveys were made following several days of relatively lightrainfall, the postspraysurveys following several days of heavy rainfall, which accounted
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for the increased numbers of containers holding water, including ground pools. Surveys were made by men working side by side over an allotted strip. Records were kept of the total number of containers holding water found, the total number of samples taken, the total number of larvae and pupae taken in each sample, and the type of containers sampled. The contents of a small tin can and a tree hole, for instance, were considered as one sample. In some areas between the prespraying surveys and the postspraying surveys, some policing and woods clearing were in progress. In others, more containers had been added to the debris.
The postspray surveys were made on 15 and 16 September 1944; that is, from 24 to 72 hours following the first application of the spray by airplane. A summary of all prespray surveys indicates that 99 of 372 water-holding places, which included ground pools, rot holes in trees, pandanus trees, wells, cisterns, and miscellaneous artificial containers, produced 4,194 mosquito larvae and pupae in 600 samples. The postspray surveys indicated that 80 of 815 water-holding places produced only 1,772 mosquito larvae and pupae in 1,423 samples. This was a reduction of from 7.0 larvae per prespray sample to 1.2 larvae per postspray sample.
A total of 445 biting female mosquitoes was collected in 230 minutes, divided into periods of 10 minutes each, spread over the 30-day period prior to the application of DDT. From these data, the biting rate was estimated to have been slightly less than two female mosquitoes per minute per individual. The known and suspected vectors of dengue comprised 60 percent of the total collections made during this 30-day period. Immediately following the application of DDT-kerosene insecticide by airplane, a total of 252 female mosquitoes biting man was collected during 1,260 minutes of the 20-day period. These data indicated a biting rate of 0.2 such mosquitoes per minute. Of these 252 biting mosquitoes, only 38 percent were known or suspected vectors of dengue.
For the 10 critical days following the application of the insecticide, only 57 female mosquitoes were collected. A total of 595 minutes was spent making these collections during this 10-day period. The biting rate was thus indicated to be 0.09 mosquitoes per minute. Of these, only 40 percent were known or suspected vectors of dengue. The reduction in these mosquitoes during the 10-day period was from 1.1 (prespray collections) to 0.042 (postspray collections) mosquitoes per minute. Only two specimens of A. aegypti were collected during the entire 20-day period following the spray applications.
The total reduction in the mosquito population in the 10-day period following the insecticide application was thus from 2.0 to 0.09 biting female mosquitoes per minute. Since dengue patients are no longer capable of passing the virus to mosquitoes after 5 days, time following data are presented to show time reduction in vectors during this critical length of time following the spray application. In 200 minutes during time 5-day postspray period, 14 specimens were collected. Of these, there were 2 female specimens of A. aegypti, 2 of A. vexans, 9 of A. albopictus, and 1 of C. quinquefasciatus. Of these 14 specimens, 3 specimens of A. albopictus and the single specimen of C. quinquefasciatus
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were collected in an insectory and probably were protected from the spray. But, even including these, there was only 0.07 mosquito per minute instead of 2 mosquitoes per minute, the average biting rate immediately before the spray application.
Thus, evidence was obtained of the effectiveness of this newly originated method of dengue control. Incidental testimony to the tremendous reduction in the mosquito population was eloquently voiced by troops in every area where spraying was done. Not a single comment was heard to the contrary. All opinion was of one accord.
The incidence of dengue decreased steadily from 13September to 3October 1944. Spraying byairplane was begun on 13 September 1944 and completed on 22 September1944. Residualspraying continued following that time.
The effectiveness of spraying is illustrated by the incidence of dengue in the 148th General Hospital and in the 176th Station Hospital during a period of 21 days after their arrival on Saipan, the first having arrived on 10 August, the second on 21 September. Both hospitals were located in the same part of the island. The only significant difference between them was the date of arrival in relation to the date 13 September that spraying with DDT was begun. The strength of the 148th General Hospital was 536; the strength of the 176th Station Hospital was 318. Of the total personnel of tine 148th General Hospital, 33 percent had dengue by tine 21st day and 47 percent by the 38th day after arrival on Saipan. By the 21st day after arrival, not a case of dengue mad occurred in tine 176th Station Hospital, which had landed on Saipan 7 days after spraying began. It is evident that the epidemic was broken. Careful observations were made of 4,624 new troops arriving between 17 and 30 September 1944. Forty-one cases (0.88 percent) of dengue occurred, the rate for this group being approximately 232 for this period, as compared with an approximate rate of 3,560 for the command on 13 September 1944 and 182 for the entire command on 4 October 1944.
Conclusions. - A seriousdengue epidemic can be effectively controlled within a short time bythe use of a DDT spray.
Mass coverage of large areas with DDT could not be done satisfactorily with M-10 tanks and small airplanes as previously recommended. Cargo planes carrying a large volume of DDT solution are necessary. The method of spraying indicated may be carried out in any combat area.
Residual spraying of such places as quarters and offices is an important part of mosquito control with DDT. Airplane spraying has tine advantage of covering large areas in a short time, but work on the ground is also an essential part of tine whole program (fig. 238). It is believed that tentage, mosquito bars, beds, and stools should be impregnated with DDT before issue by the Quartermaster Corps to troops, especially during the assault phase of operations.
Commonly used methods of mosquito control must be continued and should not be considered unnecessary when DDT is being used.
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FIGURE 238.-Memberofmalaria control unit spraying weeds at edge of pond,Saipan, 1944.
Airplane spraying early inthe assault phase of anoperation could well prevent a dengueepidemic among occupying troops since nearly all adult mosquitoes canbe killed by oneapplication. The killing of adult mosquitoes is believed to be the onlyfactor necessary to break adengue epidemic.
Attention is invited to the fact that a dengue epidemic like that experienced on Saipan can, through its tremendous noneffective rate, seriously affect the outcome of an operation. One airplane and crew, a few ground crews, and a small amount of DDT can, within a few days, make it possible for large numbers of men to remain available for duty who would be otherwise incapacitated.
Diarrheal Diseases
This group of diseases maybe divided into twosubgroups; namely, the specific diarrhealdiseases (the dysenteries) and the nonspecific diarrheal diseases(enteritis and colitis). They willbe discussed as they were encountered in the Central Pacific. In thisdiscussion, dysentery willbe defined as a clinical entity characterized by an increase in timetotal number of stools per daycontaining pus and mucus and accompanied by abdominal pain andtenesmus. This symptomcomplex may be induced by several known specific agents, of which themore important aretime dysentery bacillus and the E. histolytica.
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During the occupation of Pacific atolls, under the conditions existing for the first few days of contested action, large numbers of troops may be expected to contract. bacillary dysentery. The incubation period is so short that a recently landed force may have a large percentage of its men sick. The troops also developed the disease in large numbers on two atolls where there was no enemy opposition and in spite of what seemed to be a full understanding of the danger involved. The greatest number of patients with diarrheal diseases were hospitalized in 1944, following the Kwajalein, Eniwetok, Guam, Saipan, and Tinian operations. Patients from these islands were evacuated to other hospitals of the Central Pacific Area.
A large number of small epidemics and a few large epidemics of dysentery were studied with considerable care. In the first epidemic, 34 carriers of Shigella paradysenteriae developed among 280 admissions for bacillary dysentery, a rate of 11 percent. None of these patients had received more than 7 gm, of sulfaguanidine daily nor was the drug continued after the first negative stool report. In contrast, in the second epidemic, none of 69 proved cases of bacillary dysentery became a carrier. This improvement. of the carrier rate was considered to be the result of the large daily dosage of the drug and the longer duration of treatment.
In the first epidemic, of 320 admissions for enteritis, 120 received only symptomatic care, and 21 percent of these became carriers. in contrast, only 13 carriers (6.5 percent) developed among the remaining 200 cases of enteritis, even though these patients were treated with inadequate doses of sulfaguanidine. Substantiating this evidence of the drug's effectiveness is the record of the second epidememic, in which 110 patients with active dysentery became carriers and only 2 contact carriers recurred.
No relation was apparent between the severity of the illness on admission, the number of days of hospitalization, and the subsequent recurrence as a carrier. A definite relation, however, existed between the total dose of sulfaguanidine and the subsequent remission into a carrier state. This is shown clearly when the results of treatment the first epidemic are compared with the results after the larger doses used in the second epidemic.
In the control of acute symptoms, therewas very little difference between symptomatic therapyand specific' drug therapy. Diarrhea, abdominal distress, and tenesmusyielded as readily tosulfaguanidine as to bismuth and paregoric and in about the same numberof days.
Sulfaguanidine was superior to symptomatic therapyin that patients sotreated tolerated a fulldiet. sooner. In the first series of cases in which diarrhea was verysevere, combined therapywas tried, but no advantage was noted when compared with the largerdoses of sulfaguanidine inthe second epidemic.
One finding of great interest was the discovery of a large number of carriers in units with only moderate admission rates for diarrhea, In most organizations, the number of proved carriers found equaled or exceeded the number of active cases of bacillary dysentery, The control of these epidemics depended as much on the elimination of carriers as on rigid sanitation and the
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hospitalization of acute cases. The discovery and control of carriers can be accomplished only by laboratory investigations. Stool studies must be made on every man of an involved unit. To hospitalize and follow only men with acute symptoms is to overlook this reservoir of future outbreaks.
Practically all instances of dysentery among troops were proved to be caused by micro-organisms that fall in the Sh. paradysenteriae groups. In one outbreak, however, which consisted of 53 cases among the military police, the micro-organism producing the dysentery was identified as Salmonella newport in group C.
Amebicdysentery. - Before 1944, fewcases of amebiasis were seen in the Central Pacific.There were only 19 reported cases during the combined years of 1942 and1943. However, in theincreasing number of patients hospitalized in the CPA from Saipan,Tinian, Leyte, and Okinawa,the number with amebiasis increased fourfold in 1944 over the combinedtotals of 1942 and1943.
The cases of acute amebiasis were few in number. The diagnosis was made by finding the motile forms and cysts in the stools and by proctoscopic evidence.
The bulk of the cases were classified as chronic amebiasis or as asymptomatic carriers. Many of the patients in this group never gave a history of any diarrhea. Many were admitted with vague gastrointestinal complaints, while others listed intermittent constipation, loose stools, or abdominal pain relieved by defecation as their outstanding complaints.
Nonspecific diarrhea. - The occurrence of nonspecific diarrhea or common diarrhea of unknown cause was frequent among Army personnel.
Nospecific statement of the etiology of these milder diarrheas asdistinct from the dysenteries ispossible. Dietary indiscretions or, more frequently, the character andcondition of the only foodavailable have been blamed in some instances. However, in the lattercase the actual cause of thediarrhea may be considered with more probability to have been somebacterial infective agentscontained in the food. By no means has the last word been said on thesubject of the etiology ofthese diarrheal infections of unknown causation.
Filariasis
Although the only sourceof filariasis found withinthe Central Pacific Area was the ApamamaAtoll in the Gilbert Islands, the first cases seen on Oahu were in1943, several months before theGilbert Islands operation. A total of 199 patients were received in theCentral Pacific Area fromthe Air Transport Command in the South Pacific Area for evacuation tothe continental UnitedStates. These patients remained in the Central Pacific for only a veryshort period so that carefulsurvey was impossible. Suffice it to say, the malady was mild, and itsmanifestations werealmost subclinical. The diagnosis was based upon a history of pain inlymph nodes and alonglymphatic channels, generalized or localized lymphadenopathy,occasional localized swellings,eosinophilia or positive reactions to skin tests with Diro-
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filaria immitis antigen, togetherwith a history of residence in an area endemic for filariasis.Microfilariae were not found in the blood.
Following the Gilbert and Marshall operations in 1944, the surgeon of one of the searchlight battalions stationed at Apamama reported that patients were seen with an undiagnosed condition. The typical clinical picture follows: The onset was sudden with chills lasting 5 minutes, recurring irregularly, followed by fever varying between 100? and 101? F., which was also irregular. Headache and muscle and joint pains were common. A few days later, there was enlargement of the axillary lymph nodes and inguinal lymph nodes bilaterally. Shortly afterward, red streaks, starting at a point 2 cm. below both elbows and extending to the axillae, were noted on the medial aspect of the arms. There was no edema of soft tissues. There was some soreness of the scrotum about the 10th day of illness.
Upon arrival of these patients at the Tripler General Hospital, the evidence of acute lyrnphangitis had subsided. There was slight to moderate enlargement of the nodes in the axillary and inguinal regions. They were freely movable and mildly tender on deep palpation. The left spermatic cord was found to be thickened and tender in a number of instances.
The presence of filariasis in the CPA aroused sufficient. interest, to send a group of investigators, consisting of internists, entomologists, laboratory officers, and technicians, for clinical arid laboratory survey of the Gilbert Islands.
A report of the clinical manifestations in the natives and in Army personnel and a report of the laboratory studies will be presented briefly.
Native population. - A total of 365 natives were examined on Apamama by careful inspection and palpation of the scrotum and its contents. Sixty-four (17.4 percent) were found positive for filariasis. The signs included enlargement and hardness of one or both epididymides and/or testes. Frequently, the organs could not be differentiated since a single matted mass was present. The largest such mass found was about the size of a grapefruit. Because of lack of the and facilities, it could not be ascertained if tuberculous or gonococcic epididymitis complicated this clinical picture. However, it was felt that the genital findings were characteristic enough to warrant a diagnosis of filariasis on clinical grounds alone. This diagnosis was further substantiated by blood smears showimmg microfilariae in 13 (20.3 percent.) of the 64 natives. Of 201 natives examined on Makin, 7 (3.5 percent.) showed evidence of genital involvement. It is of interest that of 46 natives with positive smears for microfilariae, 24 were found free of clinical signs.
Army personnel. - Considerable reliance had to be placed upon the hstories in suspected cases in the Army. In all cases, the histories and initial findings were corroborated by the attending medical officer. Out of 39 suspects, 27 were found to present a history and clinical findings consistent with a diagnosis of early filariasis. Those eliminated either presented vague histories and findings or else showed localized infections that could have easily accounted for the observed lymphadenitis. The earliest onset of symptoms
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was 25 days after arrival on the island. This occurred in one patient only. In the other's, the onset occurred from 1 to 2 months after exposure in a highly endemic area.
The following clinical types of onset were noted in these cases:
1. Pain in one or moreextremities, occasionally associated with a tenderlocalized cordlikestructure under the skin.
2. Pain and often swelling on various lymph nodes,especially in theaxillae.
3. Scrotal pain with an associated enlargement andtenderness of theepididymis and/or thespermatic cord and its surrounding structure.
4. Low suprapubic, cramplike pain with radiationinto the groins wasalso an initial complaintof some patients.
5. A few had an onset with urticaria whichwas persistent andrefractory to treatment withadrenalin. In two such instances, there was also angioneurotic edema offace, hands, and feet.
All of these patients had enlarged and often tender lymph nodes in one or more sites. An unusual feature was the frequeunt enlargement of epitrochlear and posterior cervical nodes. At the time of survey, these enlargements were still present. and could not be explained on the basis of local skin infection or other systemic disease. Nearly all the patients had a low-grade fever, between 99.6? and 100? F., and symptoms of generalized aching and malaise. Most. of the patients were ill 10 days to a month. in brief, the syndrome presented by these patients was highly suggestive of an infection of the lymphatic system with marked allergic manifestations. These are essentially the outstanding phmenomena in the acute episodes of filariasis.
Laboratory findings. - On Apamama, a total of 365 natives were examined for the presence of microfilariae by the thick-smear technique and the concentration method. From this group, a total of 46 natives (13 percent) was found to have microfilaliae of the species, W. bancrofti in the peripheral blood. In a group of 100 native laborers in Tarawa, 6 were found to harbor microfilariae. At Makin, out of 201 natives, 1.5 percent ad microfilariae in the circulating blood. No investigation was made periodically in the same patieimt during a 24-hour cycle, but microfilariae were demonstrated in different natives at all hours of the day between 0800 hours and 2200 hours. Filariae were found in the blood of natives who had come from the following islands: Apamama, Nououti, Tarawa, Makin, Marakei, Bern, Tabetauea, Abaiang, and Nukunau.
Thirty-nine Army suspects at Apamama were examined by the thick-smear method as well as by the concentration method, but in no instance could microfilariae be demonstrated.
Conclusions. - The evidencepresented in this survey indicates that filariasis is endemicthroughout the Gilbert Islands. The disease undoubtedly has beenspreading from the ElliceIslands. The investigations of these natives suggested that theirtransportation to different islandsfor purposes of labor had been factors in the spread of the disease tononendemic areas.
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The epidemiologic study on Apamama. led to the conclusion that filariasis could be and had been transmitted to Army personnel on that island. It was also apparent that knowledge of early phases of this disease needed to be revised and extended. The lack of this knowledge was due to the fact that few careful observations were ever made on large numbers of susceptibles suddenly exposed inl highly endemic areas.
Of interest was the fact that. this same group reported that a few adult Aedes scutellaris pseudoscutellaris and innumerable C. quinquefasciatus mosquitoes were present on the Apamama Atoll. Culex mosquitoes, which were raised from larvae, were allowed to feed on a native carrier of microfilariae, and after 11 days numerous infectious larvae were found by dissection. The scarcity of Aedes mosquitoes was thought to have resulted from several weeks of dry weather, Wild adult Aedes mosquitoes were caught after feeding on a native carrier of microfilariae, but these survived only 1 or 2 clays in captivity. Some of them were observed by immediate dissection to have taken up in microfilariae. It was the conclusion of the epidemiologic team making the study that the diagnosis of filariasis in thie suspected cases was epidemiologically sound,
The Army Garrison Force, Apamama Atoll, returned to Oahu during late October 1944. The returning group numbered 200 individuals, and they were examined for evidences of filariasis. While lymphadenopathy was present both inguinal and axillary, there were no scrotal signs or lymphangitis observed, and none of the troops had suggestive symptoms. Twenty-one men with moderately enlarged axillary lvmph nodes were examined for the presence of eosinophilia, microfilariae, and complement-fixing antibodies to D. immitis antigen in the blood, These tests were all negative.
After 13 June 1945, approximately 4,563 prisoners of war arrived out on Oahu from Okinawa (p. 666). From 15 July to 18 August 1945, a survey of microfilariae in these prisoners of war was completed on the 4,563 individuals. These blood smears were taken at night between 1900 hours and 2200 hours, stained with Giemsa's stain and examined for microfilariae, A second smear was taken 3,703 of the prisoners whose smears were negative on the first examination. Microfilariae were found in the blood of 728 individuals (16 percent) of the 4,563 examined. Six hundred and thirteen of the positive records were found on the first smear and one hundred fifteen on the second.
Both W. bancrofti and W. malayiwerefound, the former principally in the Japanese prisonersand the latter in Koreans.
In the foregoing pages, some account has been given of the medical aspects of the war in the Central Pacific, Available for this great enterprise were the resources of modern medicine and vast stores of material. Implicit throughout this discussion has been the prime importance of the third factor, the medical officer with his specialized skills confronting the special needs of the soldier-patient. It was apparent in all theaters that the excellence of medical service varied as medical officers were, or were not, properly placed. Accordingly, it seems not inappropriate to conclude with a note on a subject that was a
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particular concern of tine medical consultantbecause of its essential bearing on the quality ofmedical service of the Army in wartime.
MILITARYOCCUPATIONAL SPECIALTY RATINGS
The medical consultant was appointed by The Surgeon General to inform him concerning technical and professional aspects of medical services in the Army. Thus, it may be noted parenthetically, was not an innovation in military medicine. The German Army had professional consultants in the Franco-Prussian War, and Whilhelm His, Jr., was a medical consultant to the German Army during World War I. Also, during that war, specialists from civilian life were employed as professional consultants by the English, French, and U.S. Armies. During World War II, the U.S. Army Medical Corps was increased from about 1,200 physicians in the peacetime Army to a peak of approximately 49,000. As these civilian physicians were entering the service at a rapid rate, medical units were being formed and hospitals constructed as rapidly as possible. The first problem was, therefore, an adequate and comprehensive classification of medical officers. This was accomplished by a number of methods with varying degrees of efficiency. The individual officer first gave his own estimate of his professional qualifications; that is, whether he was a qualified specialist, a general practitioner, or possessed some proficiency not related to medical practice. He was then directed to submit certain data relative to his medical and premedical training, internships, residencies and teaching positions, membership in learned societies, and whether or not me was a diplomate of one of the specialty boards. This information together with certain other facts published in directories of the American Medical Association and the specialty boards was utilized to form a preliminary estimate of the medical officer's capabilities and of his present professional ability.
The first duty of the medical consultant was to confer with the personnel officer at the proper level and to request the assignment of individual medical officers where their medical training could be used to best advantage. Owing to the relatively small numbers of specialists in certain categories, assignments have to be made at a high echelon in order to meet the overall needs of a command. Suitable assignments are the principal factor in determining the efficiency of all medical installations. They should therefore be made only on the advice of trained medical specialists and not left to the sole judgement of personnel officers with inadequate knowledge of the technical problems involved. Reassignments should be made on the advice of the theater or command surgeon with or without lower echelon or hospital commanders' concurrence. In the latter part of the war, with the initiation and evolution of the MOS classifications, the assignment and reassignment of medical officers became more realistic.
In the future, it will be desirable to give apreliminary MOS classification to every medicalofficer on admission to the military service, this classification to berevised by the consultant andcompetent medicomilitary authority as
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soon as possible after the medical officer has been assigned to a permanent post and at. frequent intervals thereafter. The next logical step might well be the revision of all units established according to tables of organizations to require that certain positions be filled only by officers with certain MOS and proficiency ratings. This would tend to block promotions based on considerations that are irrelevant, and often inimical, to good medical care.
It is unlikely that the present trend toward specialization will be reversed, and it is certain that professional skil varies within every specialty and in every group of consultants. The MOS is the result of a search for a method of evaluating the capabilities of a medical officer in a special field of mis profession. it is not a measure of efficiency, and, although average efficiency may well be expressed by the MOS, it should not be used a job rating, nor should it be changed every time an officer is assigned to a different service. It is a measure of his qualifications and attainments after careful comparison with those of other specialists in the same field throughout the Nation. Authority to assign or change the MOS rating should therefore be delegated only to the surgeons of major commands, As a rule, the surgeon will obtain the necessary data from the professional consultants assigned to his headquarters.
The care of the sick and wounded is above all a problem not soluble solely in terms of numbers of men and amounts of materiel. It. will be best done only if the consultant is acquainted with the professional skill of each medical officer and with the uses and efficiency of all apparatus. He should inform himself also on various auxiliary services, which have large and useful functions in the care of the sick, wounded, and convalescent. soldier. He should make frequent. visits to all medical installations and make written reports on each unit he visits. These reports together with the recommendations he makes to the command or theater surgeon should materially enhance the quality of medical service. If these very important duties of the medical consultant are adequately performed, each medical officer in the theater will at all times have an MOS rating that conforms with his professional ability and may be quickly revised to reflect any change in his usefulness to the military service.
The MOS classification, as it evolved during the Second World War, was very profitably used to fill a real need. In the future, when any rapid expansion of the Army may be necessary, medical officers should be assigned MOS ratings commensurate with their ability and given rank commensurate with their usefulness, as soon as they are ordered into military service.
