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Part 9

Table of Contents

PART IX

Two Post-War Decades (1919-1939)

A PERIOD OF PEACE, PROGRESS,
AND PERIL

The two decades following World War I, viewed within the United States, appeared to be peaceful as the country was not engaged in any war. With this feeling, a draft of an account of the period from January 1919 to 3 September 1939 was captioned: "Two Decades of Peace." On the contrary, it was the superficial peace of timbers supporting an overwater pierhead while teredos were gnawing their interior substance. When globally scrutinized the period is seen to have been troubled by economic crises, disturbed by discords, roiled by violent tyrants, convulsed by revolutions, and racked by three prophetically ferocious wars in Europe, Africa, and Asia. The seeds of the Second World War were planted in the conferences in Paris and the treaty of peace of Versailles in 1919. They germinated in the first decade of the 1920's. The resulting growths in the 1930's and the worldwide economic crisis of 1929 produced World War II, among the myriad consequences of which were basic, practical, and maturing effects upon military preventive medicine.

Consideration, mostly by means of brief summaries, will be given here of some general, scientific, educational, and organizational events which contributed to the evolution of preventive medicine in the United States Army in this period. Such summaries and notes will bring this monograph to a close.

Both teaching and research were continued at the Army Medical School in Washington, D.C., at the Medical Field

 


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Service School at Carlisle Barracks, Pennsylvania, in the laboratories of the Army Medical Department Research Boards in Manila and Panama (194), and in various other military hospitals and stations. The Sanitary Corps was reestablished as a Reserve organization in 1923.

Educational resources for preventive medicine.-Educational resources for preventive medicine developed through the scientific advances of bacteriology and the facilities provided for the work in that science. In 1888, after his return to Ann Arbor from a period of study in Robert Koch's laboratory in Berlin, Victor Vaughan secured a grant from the State of Michigan to build and equip a hygienic laboratory at the University of Michigan. This laboratory was one of the first to give advance degrees in the field of sanitary science. During the years from about 1885 to 1890, a number of bacteriologists and hygienists in Ohio, Michigan, Wisconsin, Massachusetts, Maryland, and the District of Columbia provided instruction in hygiene. These men included, in addition to Vaughan, E. A. Birge, H. C. Ernst, William H. Welch, Theobald Smith, W. T. Sedgwick, and George Miller Sternberg.

Schools of public health in the United States.-In a more formal manner, schools of public health were established in the United States. The first school of training in public health and preventive medicine in this country was the Army Medical School, established by Surgeon General Sternberg in Washington, D.C., in 1893. A school of sanitarians at the Massachusetts Institute of Technology was initiated as a result of Sedgwick's epidemiological investigations in the 1890's. This merged with Harvard University in 1913 forming the Harvard-MIT School of Public Health, and became the first civilian school of public health. It was reorganized in 1918 and named the Harvard University-Massachusetts Institute of Technology School of Public Health. In 1922, it was separated from MIT and thereafter has been designated the Harvard School of Public Health. The Johns Hopkins University School of Hygiene and Public Health was formed and put into operation in 1918. In succeeding years, these were followed by

 


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schools of preventive medicine and public health at six more universities. All furnished a type of education and training that was utilized for enhancing the competence of military preventive medicine officers. Thus they served to increase the numbers of those specialists so much needed by the Army.

Epidemiology broadened.-Epidemiology as a discipline in military preventive medicine came into special prominence in the American Expeditionary Forces in France in 1918-1919, as previously noted. Epidemiology made further gains, starting about 1920, when "in the minds of many," in America and in Europe, "realization took form that disease was no longer being studied, but rather parts of disease;" that too much attention was being devoted to the infectious agents of communicable diseases to the neglect of noncommunicable diseases and the factors of host, environment, and cultural and social conditions as determinants of health and disease in groups of people. As Gordon (195) has expressed it, an epidemiology of noncommunicable diseases came into being; there was a return to a holistic interpretation of both community disease and sickness or injury to the individual. Epidemiology, now recognized as a part of medical ecology, was enriched and strengthened. In addition, sanitary engineering, called also environmental engineering, attained recognition as a discipline capable of making large contributions to the understanding, prevention, and control of numerous diseases.

Coincident with the increase in educational facilities and the rise of new ideas, several notable books appeared. Of particular value to practitioners of preventive medicine were: (1) the fourth (1921), fifth (1927), and sixth (1935) editions of the epochal "Preventive Medicine and Public Health" by Dr. Milton J. Rosenau; (2) "Military Preventive Medicine," third edition (1938), by Lt. Col. George C. Dunham, MC (fig. 38) and (3) the third (1929) and fourth (1935) editions of "Laboratory Methods of the United States Army," edited by Maj. James Stevens Simmons, MC, and Maj. Cleon J. Gentzkow, MC.

Throughout these two decades, the troops of the United

 


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FIGURE 38.-George C. Dunham (1887-1954), teacher, preventive medicine officer, author of the standard textbook "Military Preventive Medicine." As Director of Health and Sanitation, Institute of Inter-American Affairs (1942-1945), he advanced international civilian and military preventive medicine. (Portrait photograph, courtesy of the Walter Reed Army Institute of Research.)

States Army lived in well-sanitated garrisons. The overall health record was excellent, except during occasional field maneuvers when certain disease control measures could be applied only with difficulty, or inadequately.

Malaria threat recognized.-For example, the malaria rate of the total Army during 1939 was only 4.9 per 1,000 mean strength per annum, which was the lowest rate since the American Revolution. At about that time, however, it was realized that this excellent record could not be maintained if the country became engaged in a war

 


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in a tropical malarious region. For years, United States troops had contracted malaria in the Philippines and Panama, and on one occasion the field maneuvers of an infantry regiment in Panama in 1935 had to be abandoned because of the high malarial infection rates. Commenting on this, General Simmons, then a lieutenant colonel, wrote in 1938 (196):

Such occurrences show the importance of malaria as a military problem and indicate the need for the development of more effective methods for the prevention of this disease in the field. The difficulties encountered by troops living under the relatively favorable peacetime conditions which exist in the Canal Zone afford a serious warning of the dangerous situation that would undoubtedly arise should it become necessary for our Army to operate for a long period in the American tropics.

This prediction was substantiated within a few years by the tropical experience of American troops in World War II.

Atabrine introduced as substitute for quinine.-In view of the needs that developed in World War II for antimalarials other than quinine, which became scarce, it was fortunate that Atabrine (quinacrine; mepacrine) was introduced as a substitute for quinine in 1932, and that as early as 1933-1935, medical officers in Panama had an opportunity to test this new drug for its effectiveness in the treatment and suppression of malaria. This marked the beginning of extensive new chemical and pharmacological research on substances for use in combating malaria.

Chemotherapy and chemoprophylaxis.-At about the same time (1932-1935), there were revelations, almost miraculous in the field of chemotherapy and chemoprophylaxis of bacterial infections. Prontosil, and a variety of sulfonamides (sulfadiazine, etc.) were shown to cure and prevent infections by streptococci, meningococci, gonococci, and many other species of pathogenic bacteria. Powerful new antibacterial drugs became available as reinforcements for preventive medicine. Furthermore, by curing clinical, inapparent, and latent infections, these drugs

 


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eliminated carriers, thereby reducing the reservoirs of infection in populations and communities. The consequent reduction of the degree of infectious potential was a forceful new measure for the control of epidemics.

Other biological advances made in these two decades still further strengthened means for the prevention and control of communicable diseases. Particularly valuable were improvements in methods of identifying bacteria by serological typing and by bacteriophagic lysis, enabling the sanitary sleuth to follow and recognize the microbial culprit. Serological epidemiology was created by these discoveries and practices.

Penicillin discovered (1929) and antibiotics produced.-In addition, in about 1921, the science of virology was aroused by new investigations from the rather lethargic state in which it had existed since 1891 when viruses were discovered. Simultaneously there was an acceleration of acquisition of new knowledge about the rickettsiae and rickettsial diseases, such as the typhus fevers and Q fever. The more it became possible to make differentiations among micro-organisms and among communicable diseases, the more epidemiology and preventive medicine gained in precision and power. Finally, a whole array of new phenomenally curative and preventive agents-the antibiotics-became available after the discovery of penicillin in 1929.

Civilian Conservation Corps (1933-1942).-The Medical Corps, responsible for medical care and supervision of the health of the thousands of young men who served in the camps and works of the Civilian Conservation Corps from 1933 to 1942, had extensive experience in the control of typhoid fevers by the use of triple TAB vaccine. According to the final report of the investigators (197): "The influence of protective immunization in the prevention of typhoid fever has been well demonstrated in the Civilian Conservation Corps."

Status of the Preventive Medicine Unit in the Surgeon General's Office (1919-1939).-The position, or status, of the unit for preventive medicine in the organization of the

 


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Surgeon General's Office rose and fell periodically during the 20 years from 1919 to 1939. Reorganizations and juggling nomenclature were habitual with this office during that period as they were in World War II and have been since. During the two decades, there were four surgeons general, and each reorganized the office relinquished by his predecessor. Sometimes a surgeon general would reorganize his own reorganized office. From 1919 to 1925, preventive medicine was included in the Sanitary Division. In 1925, the name of this division was changed to Preventive Medicine Division and all of the professional activities of the Sanitary Division were taken over by the Preventive Medicine Division. Within a year, however, it was demoted to a subdivision or subsection of the Professional Service Division, and remained in that status until after the start of participation by the United States in World War II.

During these reorganizations there was a saving sense of the significance of preventive medicine and some recollection of the high position and reasonable independence of the subject that had been so clearly appreciated in the AEF in France in World War I. This conception came to the fore in the latter years of the second decade between wars when studies were being made of plans to adapt the Surgeon General's Office to meet demands in case of war. "The Surgeon General's Protective Mobilization Plan," which appeared in final form in December 1939, recognized the wartime importance of preventive medicine.

LEADERSHIP IN PREVENTIVE MEDICINE-
THE SIMMONS REGIME INITIATED

As no mobilization plan is self-implementing, competent men would be needed to put The Surgeon General's plan into effect at the proper time. Each section of the plan required an imaginative and forceful leader. Fortunately for the future, vast development of preventive medicine activities in the Office of The Surgeon General, and indeed in the Army as a whole, the right man for this work was already tentatively selected, prepared, and readily avail-

 


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FIGURE 39.-James Stevens Simmons (1890-1954). Climaxing a medicomilitary career as an investigator of infectious diseases, as an epidemiologist concerned with control measures, and as a resourceful, imaginative organizer and administrator, he advanced to the rank of brigadier general in the Medical Corps, and during World War II served as Chief of the Preventive Medicine Service in the Office of The Surgeon General. (Photograph of a portrait of General Simmons, painted by Walmsley Lenhard, in the possession of Mrs. James S. Simmons. Reproduced here with the permission of Mrs. Simmons.)

able at a post in the United States. He was Lt. Col. (later Brig. Gen.) James Stevens Simmons, MC. USA (fig. 39).

In 1936, at the age of 46, Colonel Simmons was at the floodtide of a distinguished Army medical career. During the previous years, he had commanded departmental laboratories, had done important microbiological, clinical, and epidemiological research on infectious disease at the

 


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Army Medical School and in the field, and had been president of Army medical research boards in the Philippines and in the Panama Canal Zone. By reputation and by personal associations he was widely known in the United States. On 28 September 1936, he was brought from Panama by Maj. Gen. Charles R. Reynolds, The Surgeon General (1935-1939), and was assigned to duty as Assistant Surgeon, Headquarters, First Corps Area, at Boston, Massachusetts. General Reynolds had gained a keen appreciation of preventive medicine through his experiences as a Division, Corps, and Army Surgeon, and as Deputy Chief Surgeon, AEF, in France during World War I. He had publicly expressed his belief that (198): "The most valuable contributions of the Medical Department of the Army have been in the field of preventive medicine. The dividends from intelligent service in the future will be no less." General Reynolds was thoroughly familiar with the accomplishments of Colonel Simmons and recognized his potentialities for leadership. It was in the direct course of destiny, therefore, that on 15 February 1940, on orders initiated by General Reynolds, Colonel Simmons (199) was "transferred from Boston, Massachusetts, to Washington, D.C., to develop the wartime Preventive Medicine Service in the Office of The Surgeon General, United States Army." He reported for this duty on 24 February 1940, and on this date the revivification of preventive medicine in the Army began. Knowing that evolution is not a completed process but a continuing one, the new chief was prepared and able to direct an ascending evolution of preventive medicine in World War II.