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Chapter II

Activities of Medical Consultants

CHAPTER II

Service Commands

Hugh J. Morgan, M.D.

    There could hardly have been found any group of Army officers of the same age and grade with more original and independent attitudes and patterns of behavior than the group selected to be service command consultants in medicine (figs. 26 and 27) by The Surgeon General on the recommendation of his chief medical consultant. However, the group had certain attributes in common. Each was distinguished in civilian medical practice and medical education; each was a loyal patriotic American, eager to serve his country; and each became a dedicated officer in the Medical Department of the Army.

    A prerequisite to their selection was that the consultants be sufficiently imaginative and resourceful to grasp in broad outline a concept of the role a professional consultant might play in the Army. After commission, however, the consultants were provided with little more than officer grade and a very vague job definition for support to establish themselves and make their way in a sometimes hostile and frequently indifferent headquarters.

    The role of the professional consultant in civilian internal medicine was a familiar one to these men. The knowledge, resourcefulness, tact, and perseverance which they required in civilian practice were essential also for their role as consultants in the Army. They went into their new assignments encouraged by The Surgeon General and his representatives to do for sick soldiers and the medical officers who cared for these soldiers what these consultants knew well how to do for patients and practitioners in civilian life. This assignment required not only professional ability but also ability to evaluate and manipulate professional personnel, to create an environment in Army hospitals conducive to high professional standards, to encourage continuing medical education in the Army, to stimulate prompt administrative disposition of convalescent patients, and, in every other way, to keep the Army noneffective rate from disease at the lowest possible level.

    The effectiveness of the medical consultants in the earliest assignments to service commands encouraged surgeons of other commands to experiment with this new kind of officer. 1 The assignments were not mandatory. The Surgeon General had no such authority over service command surgeons. Following the prompt and conspicuous success of the consultants who were assigned to the Fourth, Seventh, Eighth, and Ninth Service Commands in August 1942, other

1 Col. Henry M. Thomas, Jr., MC, was assigned to the Fourth Service Command on 1 Aug. 1942; Col. Walter Bauer, MC, was assigned to the Eighth Service Command on 19 Aug. 1942. Col. Verne R. Mason, MC, was assigned to the Ninth Service Command and Col. Edgar van Nuys Allen, MC, to the Seventh Service Command somewhat later in the same month. The First and Third Service Command surgeons were the last to request consultants in medicine. Officers were assigned to these service commands in January 1944.


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FIGURE 26.-Consultants in medicine, Service Commands.

(Left) Col. Edgar van Nuys Allen, MC, Consultant in Medicine, Office of the Surgeon, Seventh Service Command.

(Center) Col. Roger O. Egeberg, MC, Consultant in Medicine, Office of the Surgeon, Ninth Service Command.

(Right) Col. Leonard A. Dewey, MC, Venereal Disease Control Officer, Office of the Surgeon, NATOUSA; and Chief, Preventive Medicine Branch, Office of the Surgeon, Eighth Service Command.

(Left) Col. George P. Denny, MC, Consultant in Medicine, Office of the Surgeon, First Service Command.

(Center) Col. Thomas Fitz-Hugh, Jr., MC, Consultant in Medicine, Office of the Surgeon, Third Service Command.

(Right) Col. Alexander Marble, MC, Consultant in Medicine, Office of the Surgeons, Sixth and Eighth Service Commands.


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FIGURE 27.-Consultants in medicine, Service Commands.

(Left) Col. Frank D. Adams, MC, Consultant in Medicine, Office of the Surgeons, Fourth and Fifth Service Commands.

(Center) Col. Richard P. Stetson, MC, Consultant in Medicine, Office of the Surgeon, Fourth Service Command.

(Right) Col. John Minor, MC, Consultant in Medicine, Office of the Surgeon, Third Service Command.

(Left) Col. Johnson McGuire, MC, Consultant in Medicine, Office of the Surgeon, Fifth Service Command

(Center) Col. Roy H. Turner, MC, Consultant in Medicine, Office of the Surgeon, Third Service Command; Consultant in Medicine, Office of the Surgeon, USAFWESPAC; and Consultant in Medicine, Office of the Surgeon, USAFPAC.

(Right) Col. Irving S. Wright, MC, Consultant in Medicine, Office of the Surgeons, Sixth and Ninth Service Commands.


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commands requested consultants, despite the fact that early in the war no position vacancy existed for them in thie allotment of medical officers for service command headquarters. Consequently, the presence of a consultant used a position vacancy designed for other purposes and blocked promnotions.

    It should be pointed out that the success of the consultant system in the Zone of Interior during the early training phase of the war paved the way to a large extent for its adoption later within the communications zones and finally by the armies within the various theaters of operations. A conspicuous exception was the consultant system adopted quite early in ETOUSA (European Theater of Operations, U.S. Army). Under the guidance of Maj. Gen. Paul R. Hawley, Chief Surgeon, ETOUSA, and Col. William S. Middleton, MC, and Col. (later Brig. Gen.) Elliott C. Cutler, MC, Chief Consultants in Medicine and Surgery, ETOUSA, respectively, there developed consultant coverage that was ready for and kept pace with the rapidly expanding European Air and Ground Forces in World War II. The professional consultant system reached its fullest development and maximum efficiency in the European theater.

    The names of the medical consultants in the Zone of Interior and the service commands in which they served are listed in appendix A (p. 829).

    In the preparation of this chapter, full use has been made of the service command consultants' final reports which were prepared at the request of the Medical Consultants Division, OTSG (Office of the Surgeon General), at the termination of the fighting and just prior to the separation of the consultants from military service. All of the reports have been helpful, but special mention should be made of the report, Activities of the Medical Consultants in the United States, prepared by Col. Walter Bauer, MC, Consultant in Medicine, Eighth Service Command, from August 1942 to August 1945.

DUTIES OF MEDICAL CONSULTANTS

    The service commands varied greatly in size, from the relatively small First Service Command of the northeastern seaboard to the huge western Ninth Service Command (map 1). Because of the geographic area included in the more extensive commands, consultants found it almost impossible to visit even the larger hospitals with any frequency. Problems encountered in commands with large areas and populations and the means used for meeting these problems were discussed in the final report of Colonel Bauer. He summarized the scope of the activities of the service command consultants as the consultant program evolved in the different commands. Also, he commented on the jurisdictional conflict regarding medical administrative authority, which plagued The Surgeon General and the Air Surgeon and their offices during the war and which was brought into sharp focus by the medical consultants, whose chief concern was the improvement of the quality of medical


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MAP l.-Service Commands, Zone of Interior, during World War II.

care received in military hospitals.2  The following paragraphs summarize his observations and recommendations.

    The magnitude of the task to be performed by a service command consultant in a given service command depended on the wishes of the service command surgeon, the size of the area, the available transportation facilities, the number and type of installations, and the total troop strength. In one of the larger service commands, the surgeon desired that the consultant be responsible for the supervision of internal medicine, including all subspecialties except neuropsychiatry. He was to serve all fixed Medical Department installations within the geographic limits of the service command, including Army Air Force installations, induction stations, reception centers, replacement centers, internment camps, and, when necessary, Army-owned or Army-operated industrial plants. Even though the consultant worked rapidly, it was impossible for him to visit approximately 150 installations in a year's time. Experience soon demonstrated that, unless he could visit each installation at least every 2 months, he could not achieve maximum professional effectiveness. This assignment was in marked contrast to those of the smaller service commands, where it was possible to maintain the desired schedule with relative ease.

    In the event of another national emergency, every effort should be made to correct such gross discrepancies. One or more additional consultants should be provided in the table of organization (manning tables) of at least the larger service commands. Designation of an assistant by the

2 In fairness to Air Force hospital commanders and hospital staffs, it should he said that proximity to patients diminished the intensity of feeling which characterized higher echelons. If left to themselves at the operational level in the field, the service command medical consultants and the Air Force hospital commanders and staffs functioned together well with benefit to the patients and everyone else concerned.


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consultant, with the approval of the service command surgeon, would assure harmony. This arrangement would increase the frequency of hospital visits and provide for the continuous presence of a qualified professional consultant at headquarters.

    Since no provision was made for additional service command consultants, a substitute plan was developed by the Eighth Service Command in 1944. Each of the regional and general hospitals, with the approval of the Surgeon, Eighth Service Command, designated a competent internist, usually the chief of the medical service, to serve as consultant to its satellite stations. By having these regional consultants visit the smaller hospitals every 8 weeks, it was possible to provide better supervision of clinical activities, more intimate association with the parent institution, and more frequent consultations. Once this plan was in effect, the service command consultant was able to maintain the desired contact with those installations (general, regional, and large station hospitals) responsible for the care of most of the service command patients. His association with the medical officers of the satellite hospitals continued through the medium of educational exercises held at the time of his visits to the parent institution. At a later date, the more competent service command specialists in radiology, dermatology, neuropsychiatry, ophthalmology, and otology were also directed to visit the larger hospitals. These augmentations of the consultation service proved very effective and were adopted by several other service commands. The chief advantages were more frequent visits to all hospitals, greater exchange of professional experiences, and, most important of all, higher quality of medical service for every sick soldier regardless of his location.

    The consultants, having been instructed to visit all medical installations in their service commands, rightfully assumed that their relations with the Army Air Force hospitals were to be the same as with installations of the Army Service Forces. They were at the outset. However, in March 1944, the Commanding General, Army Air Forces, specifically requested that the service command consultants visit the Army Air Force installations only upon request and then for the sole purpose of teaching and holding clinics. This action marked the termination of the initial plan except in the Eighth Service Command, where the surgeon of that command insisted that the consultant continue as before or discontinue all contact with the Army Air Force installations. In a few of the other service commands, the visits were continued on a limited scale but only because medical officers assigned to the Army Air Force hospitals urgently requested that this profitable medical experience be continued. In retrospect, this action by the Army Air Forces appears very unwise, since no substitute for the service command consultant was provided until the closing months of the war and then only on a restricted scale. This and similar experiences at the ports of embarkation indicate the need for definitive statements of policy regarding the function of the consultant in the other installations under separate commands (fig. 28). The needed integration of all the medical services located in a service command cannot be achieved otherwise.


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FIGURE 28.-Typical scene at a port of embarkation. Livestock Pavillion Staging Area, San Francisco Port of Embarkation, Calif., 1942.

    Each consultant was free to adopt the methods of procedure that he deemed suitable to the needs of his own service command. Helpful suggestions were received from many sources, the most important being the service command surgeons; the Chief Consultant in Medicine, OTSG, and his staff; fellow consultants; and the commanding officers and staffs of many of the hospitals visited. The yearly conferences of the consultants afforded them excellent opportunity to discuss mutual problems.

    The scope of the consultants' activities as finally evolved included supervising the professional activities of the medical services and the allied specialties previously mentioned; advising the service command surgeon on all professional matters; maintaining close liaison with the chief consultant in medicine in the Surgeon General's Office; assigning medical officer personnel; fostering educational programs; coordinating medical consultant activities with those of the consultants in surgery, neuropsychiatry, and orthopedic surgery; consulting frequently with the other divisions of the medical branch; reviewing clinical records and autopsy protocols; performing the necessary editorial duties; aiding in the control of epidemics; and being available on request by the commanding officers of hospitals as consultants on unusual or complicated cases.

    Many of the consultants' fields of activity overlapped; the time devoted to each depended on its relative importance. Initially, the consultants were


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concerned primarily with the professional needs of the medical services in the service commands. In those service comniands where the augmented consultation system was introduced, these professional duties required only 75 percent of their time; the remainder was spent at headquarters.

Another appraisal of medical consultants' duties as they evolved with the passage of time is provided by Col. F. Dennette Adams, MC, Consultant in Medicine, Fourth Service Command, from September 1943 to December 1945. Colonel Adams observed in his final report that during the earlier months following the initiation of consultants' service in his command, the consultant's activities were limited almost exclusively to matters pertaining directly to the care of the patient. He was cimarged with the following duties:

    1. To advise the Surgeon, Fourth Service Command, concerning all matters relating to the diagnosis and medical treatment of disease and the professional operation of medical and laboratory services in all service command hospitals.

    2. To maintain liaison with the chief consultant in medicine in the Surgeon General's Office on matters of a professional nature and those pertaining to key personnel.

    3. To visit all service command hospitals, survey the medical and laboratory services and make recommendations to the chiefs of services and the commanding officer in each installation as well as to the service command surgeon, and prepare a report of each survey for channeling to The Surgeon General.

    4. To hold teaching rounds and clinics at installations visited.

    5. To serve as consultant for chiefs of medical service within the hospitals of the service command and advise them regarding professional problems.

    6. To evaluate professional qualifications of medical officers serving at each installation.

    7. To be available to act, on the request of the commanding officer of a hospital, as a consultant on any unusual or complicated case under his jurisdiction. (In some instances, this involved a personal visit to the hospital; in others, the chief of medical service or other qualified officer from a nearby general, regional, or station hospital was designated to act for the consultant.)

    As the elapsed, the consultant's duties were broadened to include the following:

    1. To survey professional qualifications of officers assigned to the medical and laboratory services in order to recommend proper professional classification and coding.

    2. To assist the personnel branch of the service command surgeon's office in the proper assignment of medical officers.

    3. To review all cases of death occurring in the service command to detect possible errors in diagnosis or treatment and to make recommendations aimed at preventing similar mistakes in the future.

    4. To review, edit, and approve or reject, prior to dispatch to The Surgeon General for final review and action, articles written by medical officers in the command and intended for publication in professional journals.


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    5. To prepare articles of timely professional interest for publication in the monthly Medical Bulletin of the Surgeon, Fourth Service Command.

    6. To encourage other officers in the command also to contribute appropriate articles to this bulletin.

    The service command consultants were not bureaucrats. Not more than one-third of their time, and usually less, was spent in headquarters. A summary of Colonel Adams' observations on medical consultant activities in the Fourth Service Command gives a detailed, intimate view of how one medical consultant carried out his mission.

    In general, the consultant spent 75 percent of his time in the field amid the remaining 25 percent at headquarters. Days at headquarters were devoted to administrative work, such as writing reports of his visits, familiarizing himself with current War Department directives, discussing policies with the service command surgeon so as to be qualified to interpret them properly to officers in the field, reviewing papers submitted for publication, and discussing with the Medical Personnel Branch, Headquarters, Fourth Service Command, changes of assignments to bring about better distribution of the more proficient officers and so encourage a higher level of medical care.

    The consultant usually spent from 10 to 20 days on each trip to the field, visiting from 3 to 6 installations, depending on their size. Such trips were alternated with periods of from a week to 10 days at headquarters. Until March 1944, Army Air Force hospitals were included in the itinerary. Subsequent to this time, because of changes in War Department policy, an Army medical consultant visited an Air Force hospital only at the commanding officer's specific request that the consultant come for the express purpose of consulting on all individual case or of participating in a clinic or in ward rounds. These requests were not common.

    It required from 4 to 6 days to accomplish a mission in a hospital with a large number of medical beds and from 1 to 3 days in a smaller hospital. Usually, rounds were held on every ward on the medical service or on at least one ward of each officer assigned to the service. The chief or assistant chief of service together with the section chief and ward officer concerned were expected to accompany the consultant. Other officers were always invited but never ordered to attend and, in most installations, rarely did so despite the fact that rounds were modeled after similar rounds held in civilian teaching hospitals. However, in a few installations, notably those in which the ward officers were young and appeared eager to learn, attendance was gratifying. Once in a ward, the consultant made it a point to see each patient. Word spread rapidly through every hospital that a consultant from headquarters was making ward visits. Patients who were not given some attention felt neglected, perhaps resentful. Time permitted detailed consideration of only the more difficult or serious problems, but each record was read and the soldier briefly questioned, often encouraged.

    In surveying a case, the consultant reviewed the history with great care, noting especially the length of the patient's stay in hospital, the adequacy of


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the history, progress notes, and details of treatmnent. Where indicated, a physical examination was performed. In a friendly way, the ward officer or section chief was questioned concerning his diagnosis and treatment, in an effort to contribute constructive teachiing as well as to gauge the officer's ability. Care was taken neither to embarrass any officer by a thoughtless remark nor to weaken the confidence of the patient in his physician. Free discussion without regard to rank of the medical officers participating was encouraged.

    An estimate of each officer's ability, industry, and judgment was always recorded in the official report and became the basis of a recommendation pertaining to MOS (military occupational speciality) number and letter designating proficiency in the specialty.

    A profitable opportunity for gauging the quality of professional work and judgment was afforded by attendance at meetings of the officers' disposition board, certificate of disability for discharge board, and other boards concerned with the final evaluation and disposition of patients. Here, in addition to estimating judgment and proficiency, the consultant often was able to help with decisions and interpret War Department disposition policies.

    It was planned to give at least one talk or clinic to the medical staff or the entire professional staff at each installation visited. In certain hospitals, the consultant was always requested to do so; in others, it was necessary for him to ask the commanding officer or chief of medical service to arrange a meeting. Interesting or problem cases discovered on the wards were presented and discussed, a talk on some timely subject was given, or a clinicopathologic exercise was conducted. In many instances, the officers appeared alert, interested, and anxious to learn; in others, apathy was the keynote; in still others, the staff seemed to regard attendance as just another chore. As would be expected, those medical officers most in need of instruction were the least likely to attend.

    The following deficiencies were frequently encountered during surveys of the medical services:

    1. Failure of the chief and assistant chief to make proper ward rounds sufficiently often to maintain familiarity with their cases. Sometimes this could be attributed to either lack of drive or lack of self-assurance. More often, however, especially in the larger installations, it was the direct result of the heavy load of administrative work. Where the hospital commanding officer was sympathetically interested in the actual care of the sick soldier and clearly recognized the need for careful clinical supervision by his chief of service, he made every effort to reduce this administrative load. If sufficient personnel were available, he provided the chief of service with one or more able Medical Administrative Corps assistants and capable enlisted personnel. Where the hospital commander placed primary emphasis upon administrative details, the chief of service was overburdened with annoying and time-consuming non-clinical tasks. In fact, it was not uncommon to encounter a commanding officer who habitually, several times a day, called his chief of service to his office to discuss minutiae that could have been covered in a routine daily conference.


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    In so doing, he interrupted rounds or otherwise hampered professional work. The consultant always made the effort to have Medical Administrative Corps assistants assigned to the chiefs of service and to dissuade commanding officers from calling upon the chiefs for such duties as Saturday inspections, investigations, and membership on administrative boards and councils. Shortage of personnel was the reason most often given by hospital commanders for failure to carry out such recommendations.

    2. Failure of ward officers and section chiefs to take adequate histories. When this was encountered, it sometimes reflected lack of interest but more often was due to lack of fundamental medical training and knowledge of symptomatology in relation to disease entities. Often, the history was a record merely of what the patient said; it showed no indication of an attempt to run down symptoms, to follow leads, or to unearth facts that might point toward the correct diagnosis. In urging for better histories, the consultant emphasized not only these points but especially the need for an account of the patient's performance and adjustments in civil and military life. Carefully taken, such performance histories often brought out emotional limitations responsible for the symptoms and were valuable in estimating the patient's suitability for future military duty.

    A social history was rarely taken on the medical service. Here was the cause of the backlog of neuropsychiatric consultations encountered in many hospitals. The neuropsychiatric specialist was forced to spend one or more hours taking the emotional and social history on each patient sent for consultation from other services.

    3. An excessive number of intersection consultations and the thoroughly established precedent of regarding each specialist's opinion as infallible. Once a so-called clearance had been obtained for any section, the decision was regarded as final. Personal consultations and discussion of cases at the bedside were infrequent. Too much emphasis was placed on written reports.

    4. Thoughtless requisitioning of unnecessary laboratory and X-ray studies. A complete blood count was ordered when white count, hemoglobin, and differential count would have been sufficient. Sedimentation rates often were a matter of routine, ordered without consideration of their diagnostic value. Gastric analyses were performed when by no stretch of imagination could they have been helpful. The unnecessary load on the laboratory resulted in hurried work. The same can be said of X-ray examinations, electrocardiograms, and other special procedures.

    5. Lack of attention to detail in prescribing treatment and failure to ascertain that treatment was given properly. This applied particularly to feeding problems and to administration of fluids, especially in patients treated with sulfonamides. Often, orders were written sketchily or only given verbally to the nurse. A sense of obligation to follow up and confirm was lacking.

    6. Too free use of sulfonamides. Particularly true in the earlier stages of the war, this became less noticeable as education and experience was accumulated. Coryza, mild sore throat, and fever of undetermined cause were treated with sulfonamides without due consideration of the potential dangers and


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limitations of these drugs. This was avoided in time case of penicillin by proper instruction prior to its release for general use.

    7. Tendency to label as a psychoneurotic any patient in whom routine examination failed to establish the existence of structural disease.

    8. Prolonged hospitalization of patients with minor ailments, especially neurocirculatory asthenia, functional gastric disorders, chronic headache of emotional origin, and other like disturbances. Psychoneurotics not only were made worse but many were actually created in hospitals. If promptly and properly handled at the start, a good share of them could have been saved for some useful military purpose.

    9. Failure to perform rectal examinations.

    10. Failure of the ward officer or his superiors to establish proper rapport with the patient, to encourage a close physician-patient relationship and to exhibit evidence of genuine interest. The most common complaint heard from soldiers was, "They ain't done nothing for me. They ain't told me nothing."

    The consultant continually emphasized these deficiencies on his rounds. They became somewhat less noticeable in the later months of his tour of duty.

PERSONNEL MANAGEMENT

    In World War II, after medical officers were commissioned, they were assigned to The Surgeon General's pool for redistribution to Army Ground and Service Forces and to the Air Forces as well until the independent procurement program of medical officers for the Air Forces came into being early in the war. The Surgeon General assigned officers (1) to the Army Ground Forces, where they were reassigned by the surgeon of the Ground Forces to mobile medical units and to combat units, or (2) to the Army Service Forces. Personnel were provided directly to those installations under the control of The Surgeon General, such as general hospitals in the Zone of Interior (excluding Walter Reed General Hospital, Washington, D.C., until after April 1943), the Army Medical Museum, the Army Medical Research Laboratories, the Army Medical Service School, and other Class II installations. The service commands were provided personnel for reassignment by the service command to station hospitals and other service command installations such as induction stations, reception centers, redistribution stations, and dispensaries.

    The extent to which service command consultants influenced or controlled the management of personnel responsible for the care of the sick was usually a measure of the consultants' effectiveness. The service command surgeons and personnel officers learned quickly that the medical consultants, constantly moving about the command visiting and working with hospital staffs, often for several days at a time, were the best informed officers in the command regarding professional personnel. In most instances, after the assignment of a consultant to a service command, there was no great delay before his counsel and advice were sought in personnel evaluations and assignments. Exceptions were few, conspicuous, and not tolerated in the later months of the war.


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    A discussion of a service command consultant's view on personnel problems based upon extensive experience and many conferences witim fellow consultants was provided by Colonel Bauer. The following paragraphs summarize his observations.

    The most difficult problem confronting the consultants upon their arrival in the service commands was that of personnel, so basically important to good medical practice. The personnel needs were never adequately filled, either numerically or professionally. The situation became more acute as the need for well-qualified officers in the various theaters of war increased. Many of the difficulties that did arise could have been avoided had the service command surgeons delegated their authority for personnel assignment to the consultants, once the latter were thoroughly acquainted with the medical officers and the needs of the individual installations. This method of procedure or some modification thereof was finally adopted by most of the service commands. The consultants then sought the most equitable distribution of medical officers on the basis of their qualifications, the total needs of the service commands, and the individual requirements of each hospital. An attempt was made to have the appropriate consultant interview every new medical officer before assignment in the service command, but this was not possible when the consultants were in the field. The consultant's appraisal of the intrinsic qualifications of a medical officer and decision as to the officer's correct MOS number was postponed until after personal contact on ward rounds. Proceeding otherwise resulted in too many injustices.

    The reassignment of medical officers, particularly chiefs of service, within the service command was always difficult because of the obstructive tactics employed by many of the commanding officers. Sometimes they opposed the transfer of favorite incompetent officers as much as the transfer of competent specialists. In such instances, it was the duty of the service command surgeon to intercede. Without such support, the consultants were unable to utilize the available personnel properly.

    The conception prevailed in some quarters in 1942 that every medical officer was capable of performing any type of professional service. Accordingly, newly assigned consultants often found highly trained specialists serving in assignments for which they were not qualified and men with inadequate training in positions of responsibility. Once correction of such malassignments had been achieved, the transfer of key personnel thereafter was not permitted-or should not have been-without the consent of the consultants. Serious disruptions of medical service would have resulted without this agreement, particularly when the transfer of strong chiefs of service was involved.

    It is also important that the consultants be permitted to maintain close liaison with the chief medical consultant in the Surgeon General's Office regarding needs for qualified specialists, whether undersupplied or, possibly, oversupplied. The help received from this source, though necessarily limited, was extremely valuable.

    The unequal distribution of medical personnel between Army Service


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Forces and Army Air Force hospitals was unfortunate and, while impossible to correct at the time, should not be allowed to occur again. To go from one hospital with 5 medical officers caring for 1,200 medical patients to another in the same area with 15 physicians and a total hospital census rarely exceeding 100 was disturbing. It was equally regrettable that so many well-trained specialists were concentrated in the small Army Air Force hospitals, where there was little need for such talent because well-staffed regional and general hospitals were within easy reach. The service command medical services would have been strengthened materially by these officers, could the officers have been transferred to these services. These specialists could have been replaced with well-trained general practitioners. More regular assignment of officers from numbered medical units, in training but without patients, to nearby service command hospitals would have brought similar, though relatively temporary, benefits.

    The type of medical personnel assigned to a hospital governed its professional success, unless it was hampered too greatly by the commanding officer. The presence of an able clinician possessing teaching and administrative abilities as chief of medicine materially influenced the professional development of the officers assigned to the medical service. Initially, many of the chiefs of service, not being of this caliber, had to be replaced.

    Professional development was enhanced on those medical services organized along the lines suggested by the Surgeon General's Office; namely, chief of service, assistant chief, chief of section, and ward surgeon. This arrangement permits the delegation of responsibility to a group of individuals each of whom is directly responsible to his immediate superior, and it allows for promotion on the basis of merit. If well organized, the arrangement also affords the chief of service sufficient time to supervise closely the clinical activities of his service. However, many chiefs of service did not function in this manner because of a heavily imposed or self-assumed administrative load. This was remedied in most instances by assigning Medical Administrative Corps officers and Medical Department enlisted men trained in administrative matters.

    U.S. Army medical officers represented a cross section of the Nation's medical profession. They varied greatly in their professional competence. Some of them lacked the qualities befitting true physicians, including interest in patients as human beings. In the Zone of Interior, many medical officers were reluctant to work more than 8 or 9 hours a day and desired to be free on Sunday. This lack of sense of duty was all too frequently reflected in their work. It was difficult to understand the willingness of many officers to entrust their more seriously ill patients to the officer of the day. However, some commanding officers and chiefs of service were successful in impressing upon their medical officers that in care for seriously ill patients there can be no such thing as duty hours.

    These and other observed deficiencies indicate the need for a short course of basic training at the Army Medical Service School followed by a period of from 3 to 6 months with troops in training before assignment to a hospital.


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    Without such experiences, medical officers have little conception of the physical and mental requirements of a soldier. With a properly conducted period of indoctrination, medical officers would come to appreciate that their most important duty in the Army is to keep the noneffective rate as low as possible. They would also gain a better understanding of the importance of preventive psycimiatry and the psychology of leadership in Army medicine.

    It is only fair to point out that many medical officers on duty in hospitals were unable to devote as much time to professional work as they desired because of assignments to bivouac areas, time spent accompanying troop trains and patients, overseeing ward property, and similar activities, with in addition, many admimmistrative duties. These difficulties were gradually overcome in some of the installations by assigning well-qualified Medical Department enlisted men for the duties mentioned, by making Medical Administrative Corps officers responsible for property, and by providing messenger service, adequate secretarial aid, and Dictaphones.

    The number of highly trained specialists was decidedly limited as was the number of general internists qualified as chiefs of service or section. As might be expected, the personnel records of educational training and postgraduate medical experience were not sure guides to medical proficiency. For instance, certain medical officers with a wide range of medical knowledge, some of whom had been qualified by an American specialty board, lacked conservative, sound clinical judgment or the necessary qualities of leadership. Conversely, other medical officers with little postgraduate training, who had maintained an active interest in scientific matters during years of general practice, were fully qualified to be chiefs of a medical service at a 250- or 500-bed station hospital. The better internists and specialists, when present, were the backbone of the medical organization and contributed as well to the training of physicians. Physicians of average training and ability formed the largest single group of medical officers. The majority of them made every effort to compensate for their lack in skill and training by diligence and willingness to learn. Much credit is due these officers who carried large clinical loads. There were others who, because of lack of training and ability, could not be trusted with the care of the sick without supervision. A small number of officers entered upon active duty with more rank, or shortly acquired it, than was consistent with their professional ability. They were a constant source of dissatisfaction to the consultants because these officers could not be utilized in positions commensurate with their rank. Though reclassification of such officers was frequently suggested, rarely was it effected.

    A shortage of officers was common, particularly in late 1944 and 1945. This shortage could have been alleviated to some extent by greater expedition and efficiency in allocation of the large number of medical officers in Medical Department replacement pools. Some of these officers remained unassigned for months.

    Some physicians came into the Army with great enthusiasm and a deep desire to serve, even at a sacrifice. Many others came in under stress of


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various kinds and were subsequently poorly prepared for the entirely new life. As time passed, many of them became discouraged or disgruntled because of their inability to adjust satisfactorily to Army life, failure to resolve other personal problems, malassigment, injustices in promotion, the rigidity and lack of understanding of certain hospital commanders, dissatisfaction with efficiency reports, time wasted in orientation courses that were not pertinent to professional activity, continued drilling and physical training after assignment to a hospital, and unnecessarily poor living quarters and mess facilities. The consultants were particularly impressed with the fact that, despite all these difficulties, groups of heterogeneous doctors gathered from the four corners of the United States were assimilated so readily that these doctors could function as coordinated staffs in a remarkably short period of time.

    This process of assimilation was most readily accomplished in the Air Force station hospitals because the staffs were smaller and composed of younger men who were approximately the same age and more nearly comparable to one another in their medical education, training, and thinking. The Air Force station hospitals had an additional advantage. The commanding officers were younger and more recently removed from professional work, with the result that most of them were as interested in the professional activities of their hospitals as in administrative matters. A commanding officer with these dual interests frequently made possible a more integrated and efficient institution.

    Medical officers assigned to airfield dispensaries and similar posts suffered from the effects of isolation. An active rotation system would have corrected this.

    The following paragraphs are a summary of comments on personnel by Col. Johnson McGuire, MC, Consultant in Medicine, Fifth Service Command, from 7 July 1944 to December 1945.

    The assignment of medical officer personnel within the Fifth Service Command was made by the service command surgeon through the service command personnel division. In practice, this authority was delegated to the assistant surgeon and constituted a large part of his duties. Until the medical consultant had been on duty for several months, there was relatively little opportunity to discuss assignments to specific hospitals when officers were offered to the Fifth Service Command by the Surgeon General's Office. This lack of discussion was due in part to the frequent visits of the medical consultant to the field and in part to the remarkable knowledge of the assistant surgeon of personnel problems in each hospital. The assistant surgeon therefore thought it unnecessary to discuss assignments with the medical consultant.

    After approximately 4 months, the assistant surgeon consulted with the medical consultant before making assignments of medical officers to key positions, and, by this time, the medical consultant was sufficiently familiar with the problems in each hospital to make specific recommendations, which were usually accepted.


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    With the permission of the Surgeon, Fifth Service Command, the medical consultant kept the Chief Consultant in Medicine, OTSG, constantly informed of the needs for replacement of key personnel within the Fifth Service Command. Such information was transmitted informally by personal letter. The cooperation of the chief consultant's office was outstanding, and, within relatively short periods of time, replacements were made available.

    The chiefs of service of the general hospitals of the Fifth Service Command had an MOS of A- or B-3139 without exception, and, during the period covered by this history, these officers were uniformly capable and efficient. Outstanding assistant chiefs of service were disappointingly few in number and difficult to obtain. Section chiefs, as would be anticipated, varied from superior to mediocre clinicians. The latter were replaced when better officers were made available.

    Ward officers were, in many instances, mediocre. Most of the young and healthy officers had been assigned overseas, leaving only middle-aged general practitioners with relatively little postgraduate training in internal medicine for assignment as ward officers in the Zone of Interior.

    The effect of the size of the service command and of the attitude of the surgeon toward his own role and toward that of his consultant on the type of personnel program which could be successful in a service command, as well as certain points of view of the consultant, were discussed in the report of Col. Alexander Marble, MC, who, after long service in the Pacific, was assigned as Consultant in Medicine, Sixth Service Command, from March 1945 to September 1945 and as Consultant in Medicine, Eighth Service Command, from September 1945 to December 1945. Colonel Marble reported, in essence, as follows:

    The matter of personnel was handled differently in the Sixth and in the Eighth Service Commands. In the Sixth Service Command, rather than having a group of officers whose sole duty was attending to matters of personnel, the service command surgeon acted largely as his own personnel officer, seeking the suggestions and advice of the consultants when indicated. His decisions were carried out through an officer of the general staff personnel divisions of headquarters. The latter had his office on another floor of the building and so was not an intimate part of the office force of the surgeon.

    The Surgeon, Sixth Service Command, had requested that, when medical officers were assigned to the Sixth Service Command, they not be sent directly to specific hospitals but that they first report to service command headquarters. Thus the service command surgeon together with the appropriate consultant had an opportunity to see and talk with the man, thereby making possible a better decision as to an appropriate assignment. It is possible that in a large service command this plan would not be feasible, but it worked very well in the smaller Sixth. Of course, those few officers who were sent by the Surgeon General's Office for definite assignments were given them, but, even in the case of these men, it was an advantage to have an opportunity to meet and talk with them before they reported to their duty stations.


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FIGURE 29.-Gardiner General Hospital, Chicago, Ill., one of the major medical installations in the Sixth Service Command.

    Throughout this consultant's service in the Sixth Service Command, there was a more or less constant plea by almost every installation for more personnel of every type (fig. 29). The lack of trained personnel was at times very real in some installations, but, by and large, there was an adequate number of officers to do the work. It is fair to say that most medical officers did not work any harder at their assignments in the Army than they had been accustomed to working in civilian practice. There were a few notable exceptions in certain specialties; for example, the pathologists in the larger hospitals were often overworked and badly in need of trained assistants, who could not be obtained because of the small number available. Some pathologists worked week after week until midnight in order to keep current with their work.

    Shifting of medical officers from one installation to another was not done thoughtlessly or carelessly. Due consideration was given to the effect of the transfer not only on the installation concerned but upon the officer and his family. At times, however, military necessity outweighed all other considerations.

CLINICAL PROBLEMS

    This is not the place for a detailed discussion of the clinical aspects of the diseases encountered, but, from material available in reports from several of the consultants, a general picture can be drawn of the clinical problems that engaged the interest of these consultants during their tours of duty.


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    Colonel Adams provides a broad view of the trends of disease as he observed them in the Fourth Service Command during the training period and, later, when patients invalided home from overseas began to arrive. Colonel Adams reported generally as follows.

    During 1942, 1943, and the early part of 1944, when training activities were at their height, hospital admissions for disease were largely due to (1) upper respiratory infections; (2) pneumonia, especially atypical pneumonia; (3) meningococcic infection; (4) diarrheal diseases occurring in epidemnics; (5) dermatologic disorders, especially dermatophytosis and other eruptions on the feet; (6) venereal disease; (7) asthma and other allergic disturbances; and (8) ill-defined symptoms for which no organic causes could be found and which were usually thought to be psychoneurotic. The last group included a large number of individuals designated "inadequate."

    Acute ripper respiratory diseases and the run of contagious diseases posed no particular problem, except for loss of time from training. The sulfonamides were prescribed much too freely in the upper respiratory cases, but, as medical officers became increasingly aware of the indications for and against their use, this practice diminished.

    Meningococcic infection first appeared in this command in epidemic form in December 1942 and for several months created a serious situation. The first epidemic began at Camp Sibert, Ala., in late December 1942; at about the same time, cases began to be reported from other camps. Immediately, a letter was sent by the service command surgeon to all post surgeons, inviting their attention to the need for watching closely for outbreaks of the disease, describing the signs and symptoms (especially the earliest), and outlining a plan of treatment. The medical consultant on his visits to each camp gave talks on this disease. This educational program is believed to have led to early diagnosis and more prompt and vigorous treatment, which may have contributed to a lower mortality rate. The following figures for this command were compiled: For December 1942 and January 1943, 317 cases with a immortality rate of 8.8 percent; and for February and March 1943, 761 cases with a immortality rate of 2.1 percent.3

    Cases of atypical pneumonia also appeared in large numbers. Here again, an educational campaign was waged. Little was understood about this disease. Most medical officers were not familiar with its manifestations. The officers were instructed regarding the clinical picture. Especially emphasized was the fact that the disease could exist in a severe form without physical signs, the diagnosis depending chiefly upon chest roentgenograms. As experience was gained, officers on the respiratory wards, especially in large station hospitals, became extremely proficient in recognizing this disease. At first, sulfonamides were too freely administered; the educational campaign reduced their unwise use. 

3 Thomas, H. M., Jr.: Meningococcic Meningitis and Septicemia; Report of Outbreak in Fourth Service Command During Winter and Spring of 1942-1943. J.A.M.A. 123: 264-272, 2 Oct. 1943.


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    Explosive outbreaks of diarrhea occurred in several organizations, usually those on bivouac, especially during the early periods of training. Investigation revealed that these epidemics most often were due to lack of recognition by line commanders of the necessity for rigid field sanitation. As officers and troops became more experienced, important outbreaks ceased.

    An allergy program, sponsored by Col. Sanford W. French, MC, Surgeon, Fourth Service Command, was well conceived and managed (fig. 30). Patients in the command suffering from any allergic disturbances received the best possible diagnostic and therapeutic care. However, if a soldier was transferred to another command or overseas, uniformity of therapy could not be guaranteed. Hence, the impracticability of Armywide application of the procedures standardized in this command limited the overall value of the program. Few soldiers with allergic disturbances were restored to full (general service) military duty, but many were enabled to render useful (limited) service when assigned to fixed installations.

    Admissions to general hospitals during the first 2 years in large part consisted of difficult diagnostic problems and cases requiring long-terms came or serious operative procedures. In June 1944, the large station hospitals were designated regional hospitals and were charged, in addition to previous assignments, with the care of such Zone of Interior patients as formerly would have been transferred to general hospitals. (This was done in order to free beds for the reception in the named general hospitals of patients from overseas.) Thus it became necessary to strengthen promptly the staffs of regional hospitals. This augmentation was rarely satisfactorily accomplished because of the shortage of specialists.

    Although designated for Zone of Interior patients, the regional hospitals also received a fairly large quota of patients with diseases that had been acquired overseas. These soldiers were in the United States as a result of rotation or, having been returned as patients, had been discharged from general hospitals to duty in this country. Malaria, amebiasis, allergic states, peptic ulcer, residuals of hepatitis, intractable dermatologic diseases, and psychosomatic disturbances were most commonly encountered in this group.

    As the load of patients from overseas increased, the following categories of illnesses were predominant in the general hospital medical wards: (1) Recurrent malaria; (2) acute or chronic hepatitis; (3) peptic ulcer; (4) allergic disorders, especially bronchial asthma; (5) trenchfoot; (6) amebiasis; (7) rheumatic fever, rheumatoid arthritis, and other forms of musculoskeletal disease; (8) psychosomatic complaints in soldiers who had been screened improperly and sent to medical services of hospitals in the Zone of Interior instead of to neuropsychiatric centers or convalescent hospitals; (9) skin diseases, especially atypical lichen planus and dermatitis in patients from the Pacific areas; and (10) various tropical disease, especially filariasis and schistosomiasis (Moore General Hospital, Swannanoa, N.C., only).

    The peptic ulcer cases were often difficult. Many soldiers were encountered in whom this diagnosis had been established in theaters of operations.


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FIGURE 30.-Allergy program, Fourth Service Command. A. Allergy clinic, Station Hospital, Fort McPherson, Ga., October 1942. B. and C. Preparing allergen solutions for diagnosis and desensitization, Fourth Service Command Medical Laboratory, Fort McPherson, Ga., October 1942.


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    On the soldiers' return to this country, perhaps because of relief from combat tension and treatment in oversea hospitals, they exhibited no clinical or roentgenologic evidence of ulcer. Most of them had mild gastric complaints, but it was impossible to determine how many of these complaints were the result of an unconscious desire to be relieved from military duty and how many the result of persistence of the disease. Chiefs of gastrointestinal sections had difficulty in deciding whether the patients actually ever had peptic ulcers and in evaluating their patients' current condition. Early in the war, many of these patients were sent to limited duty, but it soon was learned that they would not do well.

    The proper disposition of general hospital patients returned to the Zone of Interior from overseas presented a difficult problem. In the early stages, the emphasis was placed upon returning these patients to duty. However, it is doubtful if many were able to contribute effective service except when a real desire to remain in the Army existed. Later, there appeared a growing tendency to discharge oversea patients from the service.

    The following is a partial list of cases of unusual interest reported from the stations noted:

Cases

Station

Sarcoidosis

Battey General Hospital, Rome Ga.; Regional Hospital, Fort Benning, Ga.; Regional Hospital, Fort McClellan, Ala.; and others

Histoplasmosis

Foster General Hospital, Jackson, Miss; Reional Hospital, Fort Benning, Ga.; Regional Hospital, Fort Jackson, S.C.

Spontaneous rupture of spleen

Foster General Hospital, Jackson, Miss. 9during malaria therapy for neurosyphilis); and Regional Hospital, Fort Benning, Ga. (During attack of mononucleosis).

Leprosy

Stark General Hospital, Charleston, S.C.; and Regional Hospital, Camp Blanding, Fla.

Actinomycosis

Several hospitals

Coccidioidomycosis

Do.

Amebic abscess of liver

Do.

Endemic typhus fever

Several hospitals, chiefly in Southern Georgia and Alabama

Tuleremia

50 cases at Station Hospital, Camp Forrest, Tenn., during Tennessee maneuvers in 1942-43 (fig.31); from hospitals in Mississippi and elsewhere

Bacteroides funduliformis infection

Regional Hospital, Fort Benning, GA

coarctation of aorta

Do.

Heat stroke

Several hospitals, especially in southern training camps

Anculostoma brazilense ( creping eruption)

Regional Hospital, Camp Blanding, Fla.; Station Hospital, Camp Rucker, Ala; and southern camps

Poliomyelitis

Sharp outbreak of 17 cases with 3 deaths, in March and April 1945, Regional Hospital, Fort McClellan, Ala.



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FIGURE 31.-Patient brought to admission tent of 68th Medical Regiment at Nashville during Second U.S. Army Tennessee manuevers, 16 October 1942.

    Col. Henry M. Thomas, Jr., MC, Consultant in Medicine, Fourth Service Command, from August 1942 to August 1943, reported on clinical problems in military hospitals in 1942. His views are of special interest in relation to later developments in dermatology, venereal diseases, and neuropsychiatry. He commented, in general, as follows:

    1. Dermatology.-Dermatology should be a separate service; separate, that is, from venereal diseases, with which it was so often combined. There was a surprising dearth of well-trained dermatologists. In retrospect, it seems it would have been worthwhile to collect a few superior dermatologists and send them around to the various hospitals as instructors. Perhaps, schools of dermatology could have been established, but Army dermatology is rather stereotyped and does not cover a very wide field. A basic dermatologic training given to all officers on medical services would be valuable, particularly in tropical areas. The medical consultant always visited the dermatologic cases; however, he contributed notiming but encouragement and interest.

    2. Venereal diseases.-In some hospitals, syphilis and dermatology were treated on the medical service and gonorrhea on the surgical service; in others, syphilis and gonorrhea were both treated on the surgical service; and, in still other hospitals, syphilis and gonorrhea were both treated on the medical service. It is a matter of some importance that the responsibility for therapy should be uniform. In this consultant's opinion, syphilis is entirely a medical disease,


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and gonorrhea is a medical disease with a very rare surgical complication. It is true that a certain number of genitourinary surgeons specialize in the treatment of gonorrhea, while it is difficult to find any officers on the medical services who have had experience with treatment of gonorrhea. Furthermore, chiefs of medical services take very little interest in gonorrhea cases. These officers have learned about the disease in this war, and, from now on, gonorrhea will become a medical disease.

    3. Neuropsychiatry.-One of the most generally neglected phases of therapeutics in the leading medical schools of the country is so-called psychosomatic medicine. The Oslerian school treated these cases with a characteristic wave of the hand and pat on the back, went to the next patient with a heart murmur, and from there went to the pathology laboratory. The usual teacher of clinical medicine finds it difficult to crowd into the small number of hours the amount of learning essential to the fundamentals of diagnosis. When it comes to the time-consuming and somewhat subtle exposition of the patient as a whole and the part the psyche plays in symptomatology, the clinical teacher often feels himself at a disadvantage and avoids undertaking a complicated role. It was the medical consultant's experience that, by and large, the ward officers in the station hospitals in the Fourth Service Command had very little conception of the patients' worries and the psychologic aspects of the patients' treatment. This consultant, early in his Army experience, became interested in the functional aspects of duodenal ulcer cases and referred to this subject in discussions of the wider field of psychosomatic symptomatology.4 This, however, cannot be taught by Army consultants alone and actually is the responsibility of the medical school curriculum. In the Army, the consideration of the patient as a whole involves the morale of the patient as a soldier.

    The greatest help was obtained from Lt. Col. (later Brig. Gen.) William C. Menninger, MC, Consultant in Neuropsychiatry, Fourth Service Command, who frequently made rounds on the medical ward and discussed the many borderline psychiatric cases that abounded in all wards. A large percentage of medical patients have such problems, and the responsibility rests clearly on the chief and other members of the medical service. The neuropsychiatric consultant cannot see every patient, but he can function through the medical officers. During this war, the Medical Department went a long way in combining activities of the neuropsychiatric and medical services. The medical consultant was extremely interested in occupational therapy, both on the ward and in the workshop (fig. 32). Since there was no occupational therapy in most of the station hospitals, it became necessary to try to get the American Red Cross to provide this valuable service (fig. 33). Later, on visits with the neuropsychiatric consultant, it became a contest as to which consultant would get the most cooperation from the Red Cross department. Actually, the neuropsychiatric consultant could have kept two Red Cross departments busy at each hospital.

4 Thomas, H. M. Jr.: Peptic Ulcer in the Army. South, M.J. 36: 287-291, April 1943.


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FIGURE 32.- Occupational therapy at Madigan General Hospital, Tacoma, Wash. A. In wards. B. Workshop scene.


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FIGURE 33.-American Red Cross arts and crafts program, Station Hospital, Fort Hayes, Ohio, March 1944.

    Colonel Bauer, in a report on the weakness of the educational and training program of physicians in relation to Army psychiatry, the importance of proper psychiatric management in Army hospitals, and urgent problems concerning the proper and prompt disposition of patients, made the following observations.

    Neuropsychiatry remained under medicine in most of the Army hospitals, although a few of the consultants favored its being a separate service. Experience demonstrated that neither scheme necessarily provided successful management of medical patients with psychoneurotic and psychosomatic disorders. More important than operational arrangements are physicians who, because of their attitudes, skills, and mutual respect for one another's disciplines, are capable of functioning as members of a highly cooperative and coordinated team. Unfortunately, there were very few such diagnostic and therapeutic groups. If they had been more numerous, there would have been less disagreement concerning the location of patients, the physician responsible for therapy, and the relation of neuropsychiatry to medicine.

    Never has the need for physicians to recognize and manage psychoneurotic and psychosomatic complaints and disorders been more clearly demonstrated. It reflects the greatest deficiency in American medical education in recent years and also emphasizes the evils of specialization. Evidently, the effort to train physicians to recognize and treat physiologic and organic disorders


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has resulted in failure to stress the importance of personality functioning and psychopathology.

    The defects of such medical training were readily apparent in the service command hospitals. Too many patients were admitted; too much was done to them; they stayed too long; they were subjected to much indecision and received little or no psychotherapy, and their disabilities were either prolonged or increased. Under such conditions, the number of individuals salvaged for soldiering was disappointingly small. In many cases, treatment at the dispensary or outpatient level would have been more successful.

    These patients were essentially the same as their brothers in civilian life. The approach to them should have varied little. Carefully taken histories usually revealed the basic nature of the disorders. Well-trained medical officers who could handle their own anxiety and demonstrate friendliness, sympathy, and warmth to the soldiers as well as sincere desire to help had little difficulty in determining the patient's personality makeup, past performance, and relation to symptom formation. The failure of medical officers to function in this manner led to such labeling as "gold-brick," which resulted in increasing, unrelieved emotional tension and the precipitation of neuroticisms and psychoso in atic complaints.

    A prolonged period of observation and study of neurotic patients is not only wasteful of time and money but is also harmful to the patient, since the persistent effort of the physician to find an organic cause and failure to do so tends to aggravate the patient's belief that lie has an obscure malady. Furthermore, the inexperienced physician, overimpressed by a minor deviation from normal in some physical finding or laboratory test, adds to the patient's anxiety. Reliance on this method of procedure-diagnosis on the basis of exclusion-should be discouraged if not prohibited.

    Some of the difficulties that arose were attributable to administrative uncertainty and indecision as to the proper disposition of these patients. Under the pressure of an increasing manpower shortage, the administrative position changed from one of excluding them from the Army to one of retaining all but the most severe cases. With this change, however, there was no adequate system for assigning patients to suitable types of duties. During 1943, thousands of useful soldiers were discharged from the Army to their own detriment as well as to that of the service. As the regulations governing these discharges were tightened, the hospitals faced other difficulties. When these men were returned to duty, they found scant welcome in their organizations. The unit commanders found it easier to return the men to the hospitals than to find a place for them in the original unit or to follow the procedure necessary to have the men properly assigned elsewhere. Consequently, they were returned to the hospitals again and again by their commanders in an effort to get rid of these soldiers. This practice not only added greatly to the burden of the hospitals but also confused the medical officers and reacted disastrously on the soldiers. In no other instance in the Medical Department of the Army was there greater need for formulation and execution of a policy than in the


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management and disposition of soldiers with psychoneurotic and psychosomatic complaints.

LABORATORY ACTIVITIES

    The Laboratory Division, Preventive Medicine Service, OTSG, exercised supervision over medical laboratories in the Army. In the United States, elaborate service command laboratories supported those of the general and station hospitals, and the dispensaries. Laboratory personnel, equipment, and supply were administered separately from the clinical services of hospitals in spite of time fact that the laboratories operated in hospitals almost exclusively in support of the clinical services. Of course, important laboratory work was done for preventive medicine and public health, especially in the service command laboratories.

    In the best hospitals, there was the closest liaison between the medical service, the laboratory service, and the consultants in medicine. Wise clinicians and wise clinical pathologists saw to this. The interest and support of the professional consultants was important to the proper functioning of the hospital laboratories, since otherwise, in the opinion of many observers, they had limited supervision and advice from other sources. In many, if not most instances, the clinical laboratories would have functioned in professional vacuums had it not been for the consultants in medicine and the chiefs of medical services and sections.

    A critical appraisal of the utilization and operation of the laboratory facilities in a large service command was provided in Colonel Bauer's report. His views are summarized in the following paragraphs.

    A satisfactory laboratory service requires a director capable of coordinating its activities with those of the clinical services. It also requires properly trained personnel, suitable space, adequate equipment, and a workload adjusted to the size and ability of the laboratory staff. Directors who were competent pathologists and interested in clinical pathology and teaching contributed greatly to the intellectual atmosphere of hospitals. When such men were flanked by competent Sanitary Corps officers trained in biochemistry, immunology, and bacteriology, the clinicians were assured that the laboratory work would be carefully supervised and well executed. Unfortunately, such laboratory services were all too rare.

    The hospital laboratories were sufficiently well equipped eventually to perform practically all the examinations which are done in the better civilian hospitals. The maintenance of adequate technical staffs, however, was always difficult because the enlisted men were poorly trained and rapidly transferred. The resulting vacancies were of necessity filled by civilian technicians who were inadequately trained. Generally speaking, the bacteriology and immunology sections were the weakest.

    The abuses of laboratory services attributable to the clinicians were many and resulted in countless numbers of unnecessary determinations, which further impaired the efficiency of the work. This misuse of laboratories, common


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in civilian as well as military hospitals, was undoubtedly accentuated in the Army by the absence of the cost factor. Clinicians without firsthand knowledge of laboratory procedures were most frequently responsible for excessive requisitioning of laboratory studies. In some hospitals, the additive effect of all these factors was great enough almost to nullify t he laboratory's contribution to diagnosis and treatment.

    The consultants continuously impressed upon the medical officers the rational use of laboratory procedures as diagnostic aids and therapeutic guides. The consultants also urged the chief of the laboratory to meet with the chiefs of medicine and surgery immediately following the completion of each monthly report, in order to promote full discussion of matters pertaining to the efficient functioning of the laboratory. Supervision of the laboratories by the medical consultants was reasonably satisfactory when they had experience in such matters and could allot the necessary time. The assignment of an additional consultant in medicine, with suitable training, would have strengthened this objective of the consultant system, particularly in the larger service commands.

    In some hospitals, the laboratory was established as a separate service. This had the advantage of placing the director on an equal footing with the other chiefs of service and enabling him to perform his duties more easily and satisfactorily.

    The service command histopathology service, the Army Medical Center, and the Army Medical Museum discharged their responsibilities extremely well, considering the many duties these installations were called upon to perform. The work done by some of the service command laboratories did not justify their large staffs and annual expenses. Many of the directors failed in time particularly important duty of maintaining helpful contact with the staffs of the hospital laboratories. The function of the service command laboratories should be reexamined and redefined. They should be required to submit test specimens periodically to all service command hospitals. This arrangement would provide an additional check on the quality of laboratory work.

    Colonel Thomas, the first service command medical consultant to go on duty, reported on observations in the Fourth Service Command. The following paragraphs summarize his comments.

    There should be a laboratory consultant in each service command and theater. He would be one of those rarest of all medical officers, an excellent clinical laboratory man. By and large, the laboratory service was the worst in the hospital. There were not enough good, general, clinical laboratory men to go around nor nearly enough technicians. Later, this shortage was partially filled by Army schools for technicians (fig. 34), but this deficiency still reached into the theaters of operations, where it was even more noticeable.

    When the medical consultant to the Fourth Service Command found a laboratory problem, he, with the chief of the medical service and the ward officer involved, would go directly to the laboratory service. There a


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FIGURE 34.-Training volunteer as laboratory technician, Fourth Service Command Laboratory, Fort McPherson, Ga., 1944.

discussion would be undertaken on the indications for laboratory examinations, the results, the techniques, and other pertinent information. It was a very rare thing to find a medical ward officer who went directly to the laboratory with his problems. On the other hand, the laboratory almost always sent a rather poorly trained technician to the ward to handle specimens. The result was that many tests were unreliable, specimens were mishandled, and there was no close cooperation between the clinical laboratory and the ward. This problem was taken up regularly in each of the hospitals with the chief of the medical service, the chief of the laboratory service, and with the two of them together.

    It was discovered early in visits to hospitals that a great deal of useless routine laboratory work was being ordered for and performed by laboratories that were often already over-loaded. For instance, at Fort Jackson, S.C., it was found that some 300 complete blood counts were being requested on peak days. When this was brought to the attention of the surgeon of the service command, an order was immediately circulated forbidding routine laboratory work and directing that each test would be ordered according to its own merit. Surprisingly enough, this seemingly simple directive caused confusion and was interpreted by some medical officers to mean that no case should be thoroughly studied.

    The Fourth Service Command Laboratory, Fort McPherson, Ga., was a splendid service command laboratory (fig. 35). It was the habit of the


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FIGURE 35 -Section of Fourth Service Command Laboratory, Fort McPherson, Ga., February 1943.

medical consultant to send an account of the laboratory service at the various hospitals he had visited to the commanding officer of this laboratory. This service command laboratory sent test specimens to the various hospital laboratories for analysis. In this way, the reliability and accuracy of a laboratory in question could be checked. The local laboratories sent in specimens they had analyzed to be checked in the central laboratory. In addition, the service command laboratory gave refresher courses for technicians and for laboratory officers. This was very satisfactory. However, in addition to this, the need for a laboratory consultant was clearly evident. An assistant medical consultant should be appointed with duties confined to clinical laboratory work. This laboratory consultant should function in the professional consultants section in the office of the service command surgeon.

AUTOPSY PROTOCOLS

    It became an important function of service command medical consultants to review autopsy protocols in medical cases originating in the service command. This was a direct outgrowth of experience with the procedure in the Eighth Service Command, concerning which Colonel Banner commented substantially as follows.

    Beginning with the first hospital visited, the Eighth Service Command consultant reviewed copies of all autopsy protocols on file. The information gained was so pertinent to good medical care that the Surgeon, Eighth Service


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Command, soon issued a directive requesting that all autopsy protocols be forwarded to service command headquarters for review by the appropriate consultant. On the advice of Brig. Gen. Hugh J. Morgan, Chief Consultant in Medicine to The Surgeon General, this procedure was later adopted by the other service commands.

    Each of these autopsy protocols included a complete abstract of the clinical findings, clinical course, final clinical diagnosis, gross and microscopic pathologic descriptions, final pathologic diagnosis, and a paragraph summarizing the sequence of events that were thought to have led to death. Three mimeographed copies were forwarded to the service command headquarters, two for filing and one for review by time consultant. Others were distributed to the medical officers of the hospital, preferably at a clinical conference following receipt of the consultant's comments. The quality of the protocols, which varied greatly, furnished information regarding the ability, energy, and integrity of both pathologist and clinician. It was the consultant's duty to forward written comments pertaining to errors of omission and commission as well as to commend excellency of performance. This procedure proved extremely valuable to the consultant as well as to the hospital staff and served as a further check on the quality of care being rendered. It also had anticipatory value in that it was generally understood that the clinical record of any seriously ill patient might eventually be scrutinized in the surgeon's office. The most serious and frequent diagnostic and therapeutic errors disclosed by the protocols were often discussed by the consultants at subsequent visits.

POSTGRADUATE EDUCATIONAL AND TRAINING PROGRAMS

    From the outset, those responsible for the initiation and development of the consultant system believed that an active professional educational program would be the best stimulant to high standards of medical practice in the Army. The following is a general description of the medical education programs provided the Sixth and Ninth Service Commands under the direction of Col. Irving S. Wright, MC, medical consultant to each of these commands at different times.

    It appeared early to the medical consultant that continued medical education and training were vital to the maintenance of superior medical care, especially if the war was to be a long one. There were many methods, most of which were tried by the consultant in either the Sixth or Ninth Service Commands. They were not equally successful and some that were successful in one hospital failed in another. The following techniques were utilized:

    Ward rounds by the consultant.-Visits to wards by the consultant appeared to be a very useful form of medical education and training. It was the consultant's policy in hospital visits to spend between 80 and 90 percent of his time on the wards examining patients with members of the staff.


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The objective usually was not only the solution of the problem of a particular patient but also the use of that patient's problem as a stimulus for consideration of both scientific and administrative principles.

    Field trips.-Visits to the field installations, made with civilian consultants in medicine who were outstanding teachers, were also beneficial to all concerned. These visits probably constituted the highest form of medical teaching and were popular with and greatly appreciated by the hospital staffs.

    Unfortunately, the number of medical officers benefited during any one trip with a civilian consultant was small. Nevertheless, the employment of the civilian consultants in this fashion was important, for it introduced new attitudes and fresh points of view from medical schools and civilian hospitals.

    Wartime graduate medical meetings.-The principle of wartime graduate medical meetings was sound. There existed factors that militated against success in some of the service commands. Certain requisites were essential, as follows:

    1.A consultant who believed in the program and was willing to work for it.

    2. One or more civilians who believed in the program and who were dynamic and self-sacrificing enough to activate it on the civilian side.

    3.A sufficient number of medical schools or outstanding hospitals to provide men of high professional caliber to act as speakers for the programs. For example, the small Sixth Service Command with its many medical schools and hospitals was an ideal command for this type of teaching, whereas the Pacific Northwest in the Ninth Service Command never achieved a satisfactory program.

    After some experimentation in areas where the program was feasible, one meeting every 2 to 4 weeks was arranged. The speakers arrived in adequate time to permit bedside teaching through ward rounds and consultations. Papers for the formal program were usually brief, and an opportunity was provided for discussion and questions from the floor. The wartime graduate medical meetings in the Sixth Service Command were available to all of the personnel in the service command hospitals once or twice each month.

    Conferences of chiefs of services.-It was helpful for the chiefs of the medical services of service command hospitals to come together at regular intervals for the exchange of ideas and experiences and for the consideration of recent advances in the fields of medicine that were of practical importance. This type of meeting was not sufficiently used. Some service commands managed to achieve one conference during the entire war. Such a conference should be held at least once a year. The program of a conference in the Ninth Service Command is included in this volume as appendix D (p. 841).

    Clinicopathologic conferences.-Material for clinicopathologic conferences was made available through the courtesy of the Massachusetts General Hospital at Boston, Mass., and the New York Postgraduate Medical School of Columbia University, New York City. Arrangements were made in the Sixth and Ninth Service Commands for the protocols to arrive at regular intervals at each large hospital.


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    The success of such conferences depends upon certain factors. The chief of the laboratory service must be a competent pathologist who enjoys teaching and understands the technique for presenting the material. Since it was noticeable that in hospitals where the staff was predominantly surgical the conferences were not very popular, it would seem that members of the medical services appreciate this type of teaching to a greater degree.

    Probably the most important type of pathologic conference is the autopsy. Unfortunately, attendance was not required in some hospitals, although this consultant consistently recommended that it be made mandatory.

    Temporary duty assignments for training.-A very important means of comparing experiences and gathering information was the detailing of certain officers to temporary duty in other hospitals where they could learn certain techniques or observe special procedures. For example, when the consultant found that the use of the classification of rheumatic fever was quite different in two of the rheumatic fever centers-namely, Torney General Hospital, Palm Springs, Calif., and Birmingham General Hospital, Van Nuys, Calif.- he arranged for the chief of the medical service at Birmingham to visit Torney and later for the chief of the medical service at Torney to visit Birmingham. They studied patients and went over charts together and were able to resolve differences in the use of the classification.

    Editorial duties.-The consultant reviewed many papers prepared by medical officers. This was a pleasant task, which seemed worthwhile and especially helpful to young, inexperienced authors. Numerous papers severely criticized in their original form either have reappeared later, much better because of further thought and revision, or have been included in the authors' souvenirs of war experiences where they rightfully belong.

    In summary, then although there would probably be some obstacles to continued medical education and many nonreceptive medical officers, such education is unquestionably fundamental to the maintenance of proper medical thought and practice in any hospital system during times of peace or war. The programs described in these paragraphs were not entirely successful in every detail in the two service commands considered in this report, but they did appear to have been helpful to the majority of officers on the medical services of hospitals in these commands.

    The postgraduate educational program developed in the Eighth Service Command was most carefully planned and executed. A summary of Colonel Bauer's report follows.

    It is generally conceded that the strength of any institution for the care of the sick is directly related to educational facilities which exist therein. However, it was not until the establishment of the consultant system that the educational possibilities of Army hospitals received proper emphasis.

    The consultants soon recognized that fostering a strong educational program was the best method of improving the medical services. They further agreed that bringing to the hospital a system of postgraduate education would benefit the largest number of medical officers.


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    The consultants' ward rounds and clinics served as educational exercises and stimulated better professional performance. However, as visits were too infrequent to have the desired continuing effect, the chiefs of service were urged to establish strong educational programs. These usually included weekly medical staff meetings, clinicopathologic conferences, clinical X-ray conferences, and biweekly hospital staff meetings. In addition, some of the medical services established journal clubs for reviewing the current medical literature. The smaller station hospitals conducted educational programs on a smaller scale.

    The staff meetings were often time basic educational activity. Generally speaking, they were well conducted. The cases selected for presentation were well chosen and the available pertinent literature thoroughly reviewed. A few of the abler and more energetic chiefs of service preferred ward conferences from 2 to 3 times a week, attended by the entire medical staffs. These exercises, if properly conducted, encouraged free discussion, furthered professional thought, and served to unify diagnostic and therapeutic procedures.

    The clinical X-ray conferences were very successful when well conducted, as evidenced by the large weekly audiences. When the participation by both the clinician and the radiologist was active, such conferences were extremely informative and contributed greatly to the intellectual atmosphere of the hospital.

    The general hospital staff meetings varied greatly both in quality and purpose. In many of the installations, the major services-surgery, medicine, neuropsychiatry, and radiology-were responsible for one meeting each month. These meetings were usually devoted to a formal presentation of some topic of general interest. In some hospitals, the meetings were held only rarely or not at all because of the lack of cooperation between the medical and surgical services. Thus was most unfortunate because such meetings, if well organized, aided materially in unifying the purpose of the hospital staff.

    The other educational opportunities afforded medical officers were the wartime graduate medical meetings sponsored by the American College of Physicians, service command conferences for chiefs of service and their staffs, special postgraduate and refresher courses in civilian and Army hospitals, temporary duty assignments, and an intern program.

    The first of these was very successful in several of the smaller service commands having many medical schools and energetic, enthusiastic regional chairmen; for example, the Sixth Service Command. Lack of success in other service commands was attributable to failure to have the regional area correspond geographically with that of the service command, the long distance between the Army hospitals and the medical centers, the lack of dynamic, self-sacrificing regional chairmen, and the absence of sufficient medical schools and outstanding hospitals to provide properly qualified teachers. Effective wartime graduate medical meetings required the utmost cooperation between the regional chairman and the service command surgeon and his consultant. Without this cooperation, the meetings were not sufficiently well integrated to meet the needs.


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    A model program should furnish one or more civilian consultants to each service command hospital at least once a month. The participants should remain for at least 1 day, spending the greater part of their time on the wards with the medical officers. If talks are permitted, they should be confined to appropriate topics and be sufficiently brief to allow ample time for discussion and questions from the floor. The aim of these wartime graduate medical meetings was sound.

    During the first 2 years of the war, many medical officers were sent to various specialized schools operated either by the Army or for the Army in civilian hospitals and medical schools. The benefits derived from these courses depended upon the individuals assigned, their ability, diligence, and interest in the subject. Too often, poorly qualified and indifferent officers were indiscriminately ordered to these schools in order to fill the required quota. Therefore, in many cases, neither the individual nor the Army profited from the experience.

    The refresher courses meld at some of the service command hospitals varied greatly in their accomplishments. Many of the courses were too ambitious considering the teaching staff that was available. Those courses of a more limited scope were the most successful and the only type that should be permitted.

    Assignment of medical officers temporarily to service command hospitals in order to acquire needed techniques and other information proved to be a very helpful means of strengthening certain hospital staffs.

    Intern teaching programs were established in order to provide additional instruction for recently graduated physicians entering the service. These young officers were assigned as assistants to tine best qualified ward officers. They accompanied the chiefs of service on their rounds and received 1 hour or more of didactic instruction each day. The majority of these young physicians were enthusiastic, energetic, receptive to instruction, and helpful in the operation of the wards to which they were allocated.

    During this emergency, the space, fixtures, and equipment apportioned for libraries were often inadequate. In some hospitals, the libraries were so dissipated by informal loans to service and section chiefs as to be of little value to other staff members. In the institutions where they were readily accessible, attractively furnished, and well managed, the libraries played important roles. The number of current medical journals received by the larger hospitals represented an excellent cross section of the better periodicals. However, the quota of books originally supplied was inadequate both numerically and qualitatively. This inadequacy was dune largely to unnecessary duplication, such as from 6 to 8 volumes of Christopher's Textbook of Surgery, Cecil's Textbook of Medicine, Dorlammd's Medical Dictionary, Useful Drugs, and other books to a lesser degree. Later, the libraries were supplemented by additional books and purchases from specifically allotted funds. In addition, books and periodicals were loaned by the Army Medical Library, medical


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schools, and societies, whose generous cooperation enhanced the education of medical officers.

    The educational program in the Eighth Service Command was more comprehensive than that of other commands because the surgeon and the consultants obtained a substantial yearly grant from the Rockefeller Foundation. These additional funds made possible better libraries, the distribution of clinicopathologic conference case material, and the active participation of visiting professors in the teaching program.

    Considerable time was devoted to the selection of the volumes needed to provide each hospital in the Eighth Service Command with a library sufficiently complete to furnish definitive information concerning all medical and surgical diseases. The books were then purchased and distributed. This undertaking not only profited the hospital staff but also served to demonstrate that small civilian hospitals could have reasonably comprehensive libraries without spending large sums of money.

    The use of case teaching by means of chinicopathologic conferences, first introduced in the Eighth Service Command through the grant-in-aid from the Rockefeller Foundation, was very well received. The numerous requests for this material finally led the foundation to make it available to all service commands. Selected case reports of the type published in the New England Journal of Medicine were obtained from the Massachusetts General Hospital for these conferences. Two such case reports were distributed to each service command installation each week. The hospital staffs were urged to conduct these conferences in much the same manner as is done at the Massachusetts General Hospital. The success of the conferences depended in large part on the ability of the hospital pathologist to teach and to invite discussion. Participation in these conferences by the staff members necessitated reading the medical literature and keeping in touch with the newest developments in medicine and surgery. In addition, the conferences served to maintain interest in those diseases not encountered frequently in Army hospitals.

    Case records pertaining to the major psychoses, psychoneuroses, psychosomatic disorders, and neurologic diseases were distributed to all hospitals. These were used in much the same manner as the clinicopathologic caseteaching material. They were well received and stimulated interest in neuropsychiatric disorders.

    Another and extremely important feature of the educational program in the Eighth Service Command was the provision for the active participation of eminent teachers. The annual budget was sufficient to permit nationally known internists, surgeons, neuropsychiatrists, orthopedic surgeons, and, for a time, radiologists to visit the service command hospitals. Once such specialist accompanied the corresponding consultant on his monthly tour of hospitals. Each visitor spent 2 or 3 weeks in the service command, depending upon the length of leave granted by his medical school. The foundation grant paid his traveling expenses and provided him with a modest honorarium. The invited


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guest joined the service command consultant in making ward rounds, holding clinics, and in roundtable discussions. Formal lectures were not featured with any regularity because of the desire to have the visiting physician demonstrate, by actual performance, good medical practice.

    Initially, the consultants and their visiting specialists visited all types of service command installations. With the institution of the regional consultant system, visits were confined to the regional, general, and large station hospitals. The continued participation of the staffs of the satellite stations in such exercises was made possible by having the commanding officer of the parent or host institution invite the staff members to attend. This they did with great regularity Not infrequently, the staff members requested aid in the solution of some of their more recent therapeutic and diagnostic problems, and occasionally they presented cases While at the parent hospital, the consultant and his visitor were available for consultation to the satellite installations.

    Seeing the visiting professors intimately and in action had a most stimulating effect upon the medical officers They appreciated brushing shoulders with these leaders and eminent authorities of the profession, submitting cases to them, and having the benefit of their experiences and opinions. The give and take of the ensuing discussions provided the medical officers with professional experiences of great and lasting value rarely to be had in private practice.

    An unexpected result of these educational programs was their effect on the visiting professors. The two impressions most frequently discussed by the civilian consultants are worthy of recording. First, the consultants were of the opinion that, concerning diagnostic facilities and technical equipment, military medicine was at a very commendable level. Second, they were agreed that most of the graduates of American medical schools had not been taught sufficient psychiatry to enable these graduates to practice comprehensive medicine. Several of the distinguished consultants returned to their medical schools determined to make changes in teaching methods. One wrote that his tour of military hospitals had opened his eyes to the role of psychosomatic medicine and convinced him of the importance of teaching the fundamental principles of psychiatry not only in the department of psychiatry but in every division of the medical school.

    Many, especially commanding officers of hospitals, argued that the institution of educational exercises of the type just described would interfere seriously with the discharge of the medical officers' routine duties. Experience soon demonstrated that the beneficial effects more than compensated for the time required The most important direct result of the educational programs was better medical care for sick soldiers. In addition, the programs furnished needed instruction for medical officers who came directly to the service after long periods of practice, and these programs continued instruction for the more recent medical school graduates.

    If the Army Medical Corps is to provide the best possible medical care, it must fulfill certain educational obligations. In the of war, this obligation will necessitate greater discrimination in the use of the affiliated hospital staff


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members,5 the Army's greatest source of clinical teachers. The assignment of most of these officers to key hospital positions and the establishment of systematic rotation of ward surgeons will provide excellent opportunities for the development of physicians.

ADEQUACY OF MEDICAL CARE IN ARMY HOSPITALS

    This subject is one of prime importance to the historian. The discussion that follows represents thoughtful, thoroughly objective treatment of the subject. It is a summary of an appraisal written by Colonel Bauer, a service command consultant whose knowledge and experience rendered him exceptionally qualified for the task.

    The medical care provided sick soldiers in Army hospitals was, in most instances, superior to that previously received in civilian life. This care was made possible through the organization and supervision of clinical activities, the unification of diagnostic and therapeutic procedures, better placement of medical officers, and continued education. Nevertheless, unnecessary fatalities did occur.

    In criticizing Army medical care, it is important to stress that many of the deficiencies reflected more upon the undergraduate arid graduate training of physicians than upon military medicine. Physicians often did not adjust well as members of disciplined teams, nor did they always accept unusual assignments graciously. The majority of offices, however, executed their responsibilities to the best of their ability despite handicaps such as new surroundings, unaccustomed administrative procedures, and unfamiliar professional duties.

    Deviations from the basic principles of good medical practice were frequently observed in the form of poor doctor-patient relationships, unnecessary hospitalization, inadequate histories, absence of personality evaluation, incomplete physical examination, delayed clinical evaluation, institution of therapy before establishing a diagnosis, paucity of progress notes, inadequate treatment, and indecision in diagnosis, therapy, and disposition. These shortcomings were consciously or unconsciously compensated for by superfluous laboratory tests, radiologic examinations, consultations, clearances, and treatment. Such practices often bespoke either inadequate medical training or a feeling of insecurity on the part of medical officers and constituted some of the ictrogenic factors to which soldiers were exposed. Such factors further increased an already staggering neuropsychiatric rate.

    Full documentation of other breaches and deficiencies would not justify the time and space required. It is sufficient to cite a few examples regularly observed, such as limited knowledge of communicable diseases; meager understanding of the principles of chemotherapy; unwarranted reliance on laboratory procedures; and lack of clinical judgment concerning the varied manifestations

5 Experienced teachers in medical units formed by a sponsoring medical school or hospital.


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of rheumatic fever, infectious hepatitis, diphtheria, infectious mononucleosis, malaria, and diseases incurred in tropical regions.

    The adequacy of medical care depended upon the professional qualifications, attitude, and performance of the chief of service and his fellow officers and also on their relationship to one another. It was demonstrated repeatedly that even with personnel of average ability a capable chief of service elevated medical care above the level of mediocrity by constantly striving for improved diagnoses, therapy, and disposition. In order to achieve this, he had to avoid being saddled with a heavy administrative load. Good leadership not only promoted better performance but also invited a more critical attitude and a free expression of opinion on all professional matters by medical officers, irrespective of rank. This atmosphere improved rather than diminished esprit de corps.

CLINICAL RESEARCH

    At the outbreak of the war, the policymakers of the Medical Department of the Army were not favorably disposed to clinical research in Army installations. These administrators were preoccupied with the many and important problems involved in planning for supplies, hospitals, personnel procurement and management, and operations for the huge and steadily expanding Army; and, at the same time, they were concerned with the efficient operation of the Medical Department in relation to pressing current problems. Not only did clinical research fail to receive encouragement at this time, but attempts to carry out original studies were actively discouraged.

    In time, this attitude changed. The influence of the consultants was of the greatest importance in bringing this about. They understood the Army's need for additional knowledge in order better to support the combat training program in the Zone of Interior and, later, the combat strength of troops in the line. This responsibility made research a very practical matter for the Medical Department. Many questions had to be answered. What disposition to make of patients with hepatitis? What treatment to employ for malaria? How to prevent and treat properly cold injury? How to prevent and treat meat exhaustion? These and innumerable other questions could be answered only after study, and often the studies could be made only with troops. As time passed, the attitude of the Medical Department in the Zone of Interior changed from one of active resistance to clinical research to one of passive acquiescence and, rarely, to one of wholehearted acceptance.

    Only in isolated instances, however, was it possible to obtain the necessary priorities in material, transportation, and especially personnel. if priorities could be obtained at one echelon of command, it was common experience to have them denied at another. Nevertheless, clinical research developed in a modest way in certain places. In some of the hospitals designated for the care of special disorders and, less frequently, elsewhere, research actually flourished toward the end of the war.


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    The following comments regarding clinical research in three service commands are based on observations of the medical consultants who served in these commands and who often initiated and supervised studies. A summary of Colonel Thomas' experience in the Fourth Service Command follows:

    There were several clinical research projects in some of the hospitals. Some officers turned out a great many papers; a few of them were quite good. Whenever the medical consultant saw an interesting and unusual case or a well-studied group of cases, he encouraged the chief of medical service and ward officer to prepare a report for publication. The Fourth Service Command Laboratory was interested in various studies including dysentery and meningococcic infection.

    The influenza commission was established at Fort Bragg, N.C., where primary atypical pneumonia was studied. Members of the staff of that commission contributed to the program of a conference held in the service command and distributed information concerning their work. The large epidemic of meningococcic infections presented an opportunity for careful clinical and therapy studies. At Fort Bragg, Lt. Col. (later Col.) Worth B. Daniels, MC, studied an outbreak of a rare disease, which inc called pretibial fever. On the whole, the medical personnel in the hospitals in the Fourth Service Command were not trained for clinical research. There were a number of cardiologists who collected rare forms of cardiac arrhythmia, and the gastroenterologists made valuable contributions in the study of peptic ulcers. The work on the use of prophylactic sulfonamides in aborting a meningococcic epidemic was of great value, and the studies along this line performed by the Fourth Service Command Laboratory personnel were outstanding.

    A summary of a report by Colonel Adams, also concerning the Fourth Service Command, is presented in the following paragraphs.

    The following studies and investigations were made in this command:

Location                                             Study

Battey General Hospital, Rome,         1. Clinical studies on acute pericarditis. Ga.
                                                         2.Comparison of vaccine products and Brucellergen intradermal tests in brucellosis.

Finney General Hospital, Thomas-     1.Malaria therapy in neurosyphilis.

ville, Ga.                                            2.Penicillin therapy in neurosyphilis.
                                                         3.Spinal-fluid Wasserman reaction during the course of and subsequent to malaria treatment of neurosyphilis.                                                                   4.Studies on penicillin concentration in spinal fluid.
                                                         5.Value of Thio-Bismol (sodium bismuth thioglycollate) in quartan malaria.
                                                         6.Value of gastric analysis in the diagnosis of duodenal ulcer.
                                                         7.Survey of bronchial asthma in soldiers
                                                         8.Studies in histamine-stimulated fractional gastric analysis.
                                                         9.Statistical study of 200 cases of arthritis.  


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Location                                             Study

Foster General Hospital, Jackson,      1.Clinical studies on rheumatic fever and rheumatic

Miss.                                                   heart disease.
                                                         2.Value of salicylate therapy in rheumatic fever.
                                                         3.Effect of various adjuvants (such as sodium bicarbonate, ammonium chloride, and aluminum hydroxide gel) on                                                                 blood salicylate levels.
                                                         4.Penicillin therapy in chronic bronchial asthma.
                                                         5.Clinical study of asthmatics returned from overseas.

Kennedy General Hospital, Mem-      1.Evaluation of certain drugs is the treatment and control of malaria

phis Tenn.                                          
                                                          2.Studies on palmar sweating.
                                                          3.Clinical study of asthmatics returned from overseas.

Lawson General Hospital, Atlanta,      1.Comparative value of liver-function tests in hepatitis.

Ga                                                      2.Gastroscopic studies in acute hepatitis.
                                                          3.Electrocardiographic studies in various forms ofheart disease.
                                                          4.Effect of amputation of the extremities on the electrocardiogram
                                                          5.Evaluation of penicillin in treatment of skin disease.

Moore General Hospital, Swannanoa, 1.Comparative evaluation of different drugs in treatment and suppression of malaria

N.C.                                                   
                                                          2.Clinical studies on filariasis.
                                                          3.Comparative evaluation of different drugs in treatment of schistosomiasis.
                                                          4.Evaluation of certain antigens in the diagnosis of schistosomiasis .
                                                          5.Comparative evaluation of different drugs and dosage in the treatment of kala-azar
                                                          6. Clinical studies on hookworm infections.
                                                          7.
Clinical studies of various forms of treatment inatypical lichen planus and cezematoid dermatitis.
                                                          8.Histopathology of atypical lichen planus.
                                                          9 Relationship of Atabrine (quinacrine hydrochloride) administration to atypical lichen plants   
                                                         10.Clinical studies of dermatologic and faucial diphtheria.
                                                         11.Study of metabolism of antimony by use of radioactive tartar emetic (in conjunction with the U.S. Public Health                                                                 Service, Department of Zoology, National Institutes of Health).

Oliver General Hospital, Augusta,      1.Combined penicillin-heparin therapy in subacute bacterial endocarditis

Ga.                                                     
                                                         2.Evaluation of various forms of treatment in atypical lichen planus.
                                                         3.Recurrence rate of malaria treated without specificdrugs. Diagnosis of Strongyloides stercoralis infestation by                                                               duodenal drainage.
                                                         4.Statistical studies of the incidence and types of asthma in the Army.


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Location                                             Study

Oliver General Hospital, Augusta,      5. Evaluation of Anthiomaline (antimony sodium thiomalate malate) in granulma inguinale

GA                                                     
                                                         6.Evaluation of intrathoracic penicillin treatment of empyema.

Regional Hospital, Camp Blanding,    1.Studies on heat stroke.

Fla.                                                   2.Loeffler's syndrome in eases of Ancylostoma braziliense (creeping eruption).

Regional Hospital, Fort Benning,        1.Evaluation of immune globulin in the prevention of mumps orchitis

Ga.                                                     
                                                         2.Gastroscopic studies in infectious hepatitis.
                                                         3.Evaluation of antistreptolysin titer in differential diagnosis of rheumatic fever.
                                                         4.Evaluation of sulfonamide drugs in the prophylaxis of gonorrhea.
                                                         5.Studies to determine the optimum dosage of penicillin in acute gonorrhea

Station Hospital, Camp McCain,       1.Evaluation of sulfonamide drugs in the prophylaxis of meningococcic

Miss.                                                   infection (in cooperation with the Fourth Service Command Laboratory).

Station Hospital, Camp Wheeler, Ga.1.Evaluation of sulfadiazin prophylaxis in the control of respiratory diseases and meningococcic infection.

Thayer General Hospital, Nashville,   1.Malaria therapy in neurosyphilis.

Tenn.                                                2. Penicillin therapy in neurosvphilis.
                                                        3.Effect on propylene glycol aerosol in barracks on the incidence of respiratory infection.

United States Army General Hospi-  1.Studies on trenchfoot, including biopsy material,

tal, Camp Butner, N.C.                        fluorescein studies of circulation, and mycologic studies of skin complications.
                                                        2.Value in hepatitis of the coagulation band, the Watson quantitative urobilinogen, and the quantitative methylene                                                                 blue tests.

Welch Convalescent Hospital, Day-  1.Studies on antiamebic drugs in diarrheal patients admitted by transfer with the diagnosis of

tona Beach, Fla.                                    functional gastrointestinal disease.

Regional Hospital, Fort Bragg, N.C.  1.Clinical and laboratory studies on pretibial fever.
                                                         2.Clinical, laboratory, and epidemiologic studies on an outbreak of bacillary dysentery (in conjunction with the                                                                      Fourth Service Command Laboratory).
                                                         3.Intensive arsenotherapy of syphilis.
                                                         4.Penicillin therapy of syphilis.
                                                         5.Evaluation of Frei antigen.
                                                         6.Therapeutic value of penicillin-beeswax-peanut oil mixture in various infections, including gonorrhea,early                                                                      syphilis, tonsillitis, pneumonia, and others.
                                                         7.A comparative study of penicillin and sulfadiazine in the treatment of pneumococcic pneumonia.
                                                         8.Studies to determine the optimum dosage of penicillin in acute gonorrhea.

Regional Hospital, Fort McClellan,    1.Use of estrin in the prevention of mumps orchitis.

Ala.


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Location                                             Study 

Regional Hospital, Fort Jackson,        1.Evaluation of sulfonamide drugs in the prophylaxis of meningococcic infection (in cooperation with the

S.C.                                                     Fourth Service Command Laboratory).

Station Hospital, Camp Forrest,         1.Clinical study of an epidemic of tularemia.

Tenn.

    An extensive study of methods for prevention and treatment of dermatophytosis was conducted at Fort Benning, Ga., from August 1942 through December 1945 by the Division of War Research of Columbia University, under contract with the Committee on Medical Research of the Office of Scientific Research and Development. The project was directed by Dr. J. Gardner Hopkins, Professor of Dermatology, College of Physicians and Surgeons, Columbia University. He was assisted by four trained mycologists and several technicians. Office and laboratory space were first provided at the regional (then station) hospital; later a barracks building was allocated by the post surgeon for a laboratory and clinic. Troops for surveys and testing of prophylactic measures were made available from various infantry regiments and other organizations on the post. Treatment clinics were held in two of the post dispensaries. In July 1945, the scope of the project was extended to include a study of penicillin therapy in all types of skin infection, including those secondary to dermatophytosis. A special ward in the regional hospital was allocated for these cases, and a trained Medical Corps dermatologist was placed in charge of the clinical work.

    The following problems were investigated: (1) Incidence of fungus infection in infantry troops; (2) types of fungi and bacteria concerned in these infections; (3) effectiveness of prophylactic measures, including footbaths, powders, ointments, and special types of shoes in preventing dermatophytosis; (4) evaluation of new fungicides, including a number of antibiotics, in the laboratory; (5) evaluation of new fungicides in treatment of mycotic infections; (6) evaluation of antiseptics and the sulfonamides in treatment of secondary infections; and (7) effectiveness of penicillin in pyodermas and time frequency of sensitization resulting from its use.6 As a result of these studies, a new fungicidal ointment containing undecylenic acid was added to the supply tables. Methods for treatment of dermatophytosis and secondary infections were published in the Army Medical Bulletin. Close cooperation existed between time post surgeon, the hospital staff, and Dr. Hopkins and his group. The latter freely gave their services in consulting with the hospital staff on difficult dermatologic cases.

    The Commission on Acute Respiratory Diseases, 1 of the 10 commissions activated by the Army Service Forces Board for the Investigation and Control of Influenza and Other Epidemic Diseases in the Army, reported to Fort Bragg on 19 October 1942. Its general objectives were: (1) To maintain continuous

6 A detailed discussion of these investigations appears in Medical Department, United States Army. Preventive Medicine in World War II. Volume V. Communicable Diseases Transmitted Through Contact Or By Unknown Means, chapter VII. [In press.]


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observations of respiratory diseases as they occurred at Fort Bragg and to investigate their epidemiologic, etiologic, serologic, clinical, and prophylactic aspects; (2) to maintain a constant watch for the occurrence of influenza and to study any outbreaks of this disease; (3) to carry on studies of primary atypical pneumonia, with particular emphasis on its etiology; and (4) to conduct field investigations as directed by The Surgeon General.

    This commission had its special laboratory in the regional hospital and had access to all clinical material. Its investigations were carried on with the full cooperation of the hospital staff. The members of the commission were most helpful to this hospital as well as to other installations in the command in performing special laboratory tests and in freely giving their expert clinical advice whenever called upon.

    A summary is presented of an informative statement about research in the Fifth Service Command. The statement was included in a report by Colonel McGuire. The experiences at the Wakeman General Hospital, Camp Atterbury, Columbus, Ind., illustrate some of the not infrequent obstacles to well-planned investigations.

    There were two major efforts to carry on well-planned investigations within the Fifth Service Command. One was a study of physiologic alterations in the circulation consequent to arteriovenous fistulas. This investigation was planned by Lt. Col. (later Col.) Daniel C. Elkin, MC, Chief, Surgical Service, Ashford General Hospital, White Sulphur Springs, W. Va.; a group of clinicians who were members of or selected by the National Research Council; representatives of the Surgeon General's Office; and the Fifth Service Command consultants in surgery and medicine. The study was conducted at Ashford General Hospital.7 A civilian clinical investigator, Dr. Eugene A. Stead, Jr., trained in the technique of measurements of circulatory physiology, was placed in charge of this project. Technicians and the necessary apparatus were brought to Ashford, where an extraordinarily large number of patients with arteriovenous fistulas were being prepared for surgical treatment. In a careful and thorough manner, alterations in blood volume and cardiac output and other changes in cardiovascular physiology before and after operation were investigated. Measurement of peripheral blood flow distal to fistulas was planned but abandoned following V-J Day.

    The second investigation was a careful study of the nutritional status of the paraplegic patients at Wakeman General Hospital.8 This study was planned by the nutritional consultant, the chief of the surgical service, and the medical and surgical consultants of the Fifth Service Command. The project was first formally presented to The Surgeon General in May 1945 but was returned with the comment that the patients to be studied were definitely surgical

7 Elkin, Daniel C.: Arterial Aneurysms and Arteriovenous Fistulas Circulatory Effects of Arteriovenous Fistulas. In Medical Department, United States Army. Surgery in World War II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955, pp. 181-205.

8 Medical Department, United States Army. Surgery in World War II. Neurosurgery, Volume II. Washington: U.S. Government Printing Office, 1959, p. 151.


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and therefore the project should be carried on under thee direction of the surgical consultant and the chief of surgery at Wakeman General Hospital. The project was then resubmitted in accordance with this suggestion, and formal approval was received under date of 11 July. In the interim, the conditions under which the project had been originally conceived were markedly altered. The cessation of hostilities in Europe diminished the flow of paraplegics to the hospital, reducing the supply of the more acutely ill patients. Personnel shortages made it difficult for the hospital to organize and properly staff a special ward for the care of the patients under observation. The construction and equipment of a laboratory for the considerable volume of analytical work required was deferred by the increasing emphasis on the enlargement of the reception-station and separation-center facilities which were located at Camp Atterbury, for it was through the camp administrative channels that approval of such construction had to pass. Such was the status of the project when V-J Day arrived. Shortly thereafter, it was recommended that the project be abandoned, and, with the concurrence of the service command headquarters, The Surgeon General gave authority to discontinue it in October 1945.

    Col. Thomas Fitz-Hugh, Jr., MC, Consultant in Medicine, Third Service Command, from May 1944 to January 1945, provided the following comment on clinical research.

    One of the highlights of this war has been the output of excellent clinical research publications by many medical officers. A great deal of valuable material has been accumulated under difficult and trying circumstances. The medical consultant is dutybound to encourage and aid such endeavors. By the same token, it is his duty to be critical of poorly organized, repetitious, and non-contributing publications.

RECONDITIONING

    The delay in the development of a reconditioning program by the Army Medical Department was principally due to indifference in the Surgeon General's Office to a need which had been recognized by medical officers in the field installations. Stimulation from the field, and especially from the splendid Air Force program instituted by Col. Howard A. Rusk, MC, eventually led to reconditioning in Army installations. The need for such a program was evident from the single fact that medical officers in hospitals were ordered to retain their convalescent patients in hospitals until they could be returned to their units in full-duty status.

    The interest of the service command medical consultants in the reconditioning units which ultimately came into being varied greatly. The consultants were almost to a man extremely busy and preoccupied with important matters for which they were directly responsible. Once a separate program for reconditioning became established, the medical consultants usually considered themselves relieved of responsibility in the matter.

    Col. George P. Denny, MC, Consultant in Medicine, First Service Command, from January 1944 to December 1945, commented in his final report


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on the reconditioning program for that command. The following paragraphs summarize his observations.

    The usual reconditioning program at general and station hospitals for class I, II, III, and IV patients was in operation at the time of this consultant's assignment to the service command. This was set up and operated in accordance with Circular Letter No. 168, dated 21 September 1943, OTSG, U.S. Army. In March 1944, the medical consultant attended a meeting for reconditioning consultants of all service commands at Schick General Hospital, Clinton, Iowa.

U.S. Army Medical Center at Camp Edwards

    In April 1944, a reconditioning center was set up at Fort Devens, Mass., and patients in classes I and II were sent there from all hospitals in the First Service Command. This center was a part of Lovell General Hospital, Ayers, Mass., and, because of the complexity of the program, the difficulty of obtaining machinery and materials, and the work necessary to adapt the barracks buildings available, the program got under way slowly. About the time things were working well, the whole activity was uprooted and moved to Camp Edwards, Mass., where in January 1945, it became a part of the U.S. Army Medical Center at Camp Edwards. This center was designed to take care of 6,000 men with the idea of freeing hospital beds for patients evacuated from overseas. Beds were quickly filled to capacity by class I and II patients, and many more patients were carried on furlough.

    The original, primary object of reconditioning was to return as many men to duty as possible and to fit the remainder for return to civilian life. As the program progressed, it was found that only a small percentage could be returned to duty of any type, and the center became a vast waiting room of men who knew they were on their way out of the Army and who did not take kindly to the various moral, mental, and physical methods of improving their condition. This impression was derived from personnel observation and talks with the officers concerned. The ideal of reconditioning was worthy and high but so complex and diffused that it appeared to choke itself.

    At first, there was a tendency on the part of hospitals to transfer patients who could not by any stretch of the imagination be benefited and who should have been discharged at the hospital of origin. This procedure was gradually corrected, but reconditioning remained in part a dumping ground used by hospitals needing to free beds for anticipated new patients. Many men were sent directly to the reconditioning center from debarkation hospitals, some with either no records or very scanty ones and requiring examinations that could only be accomplished in the general hospital or by consultations. Finally, a consultation service and X-ray and clinical laboratories were established within the reconditioning unit, and, although medical officers in various specialties from the general hospital were still called upon, the hospital load was greatly lightened.


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    There were not more than two companies of medical patients (exclusive of neuropsychiatric patients). The usual medical census was only about 300 from a total of 6,000 in the center. Chronic skin disease represented about 50 percent of this group. Other common conditions were the residuals of acute infectious hepatitis, recurrent malaria, and the usual gamut of indefinite gastrointestinal complaints without definite organic disease. Little could be done for the dermatoses, but the gastrointestinal and malaria patients usually were returned to limited duty. Rehabilitation of patients with the residuals of hepatitis had been given special attention in 1942 and 1943 with little or no success, and the same was found true at the Camp Edwards center in 1945. No special diets were available, time assumption being-and rightly so-that if a man were well enough to be reconditioned, he should be able to eat at a general mess. It became common practice to dispose of these men by providing them 90-day furloughs with the hope of sufficient improvement at home to permit their ultimate return to duty-a fairly slim hope, as it turned out.

    Each company had a medical officer in charge who saw all of his patients every day, if he could catch them between classes; and medical consultants from the professional service visited the companies routinely and on request of the officer in charge. If a man became sick, he was sent to the dispensary by the company medical officer where one of three things was done: (1) He was given appropriate treatment and returned to barracks, (2) He was referred to the U.S. Army General Hospital, Camp Edwards, Falmouth, Mass., for study and treatment, or (3) he was referred to the convalescent hospital professional-service consulting staff for their opinion and advice. The professional consulting service usually determined the type of disposition to be made.

    Viewed from a realistic point of view, the convalescent and reconditioning hospital was essential for the freeing of hospital beds for patients evacuated from overseas, but its complex and unwieldy system of reeducation hardly merited the vast effort and expense put into it.

    Colonel Bauer also had extensive experience with problems of convalescence and rehabilitation in service command hospitals. A summary of his comments on reconditioning follows.

    In December 1942, one of the largest service commands, without the consent of higher authority, established detachments at three posts. Their purpose was the physical reconditioning of convalescent patients and the physical and mental rehabilitation of selected soldiers with neuropsychiatric complaints, to the end of saving training days and reducing the number of soldiers receiving certificates of disability for discharge. These detachments, located some distance from the hospitals, were independently operated under the direction of the post commanders and surgeons. If these three detachments achieved their aims, it was planned to establish similar units at all posts. Although their value was demonstrated in approximately 3 months, higher authority ordered that they be discontinued. Some months later, in September 1943, the previously mentioned Circular Letter No. 168 directed


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the establishment of reconditioning units at all larger service command hospitals. These units were maintained for the duration of the war (fig. 36).

    The program held promise of contributing to the military knowledge of the care of convalescent patients, for the good of both the Army and the soldiers. It was obvious from the outset that the program's success would depend upon a sound plan, executed with intelligent enthusiasm by the service command surgeons, the post surgeons, and the personnel in immediate charge of each unit. Failure to develop a satisfactory program more rapidly was due to many causes. There was insufficient coordination and direction from higher command, and a lack of understanding of the principles mind purposes of reconditioning by hospital commanders and clinicians alike and, save for noted exceptions, no real, enthusiastic desire to do the job. Initially, with no extra personnel allotment, there was a shortage, particularly of trained individuals. However, this was corrected by creating a table of organization and by assigning a nucleus of trained men. Reconditioning units with intelligent, well-trained personnel accomplished a great deal. When such personnel was lacking, reconditioning became something to be tolerated. Where units operated in this atmosphere, lip service was usually given in the form of mimeographed schedules issued weekly showing exactly what patients in the four different classes were supposed to be doing hour by hour, day by day. Close scrutiny of such units frequently revealed many omissions and deviations from the printed schedule.

    Although it is not directly related to the problem under discussion, attention should be directed to the problem of conditioning or hardening new troops. Many admissions to hospitals were necessary because of failure to adjust the physical training program in the Army to the material at hand. Usually, no difference was made in what was required physically of the college athlete or farm boy as contrasted with the clerk or bank teller. Lame backs, sore feet, and general physical exhaustion were often causes of hospital admissions and the basis for the activation of underlying neuroses.

DIETETICS

    During the war years, no problem relative to procurement of food supplies for the Army hospitals in the Zone of Interior was experienced, nor was there rationing for U.S. soldiers in these hospitals. The only problems in the Zone of Interior were those having to do with the preparation and serving of the abundant rations which were always available (fig. 37). The hospital soda fountains and candy counters made their usual inroads upon the balanced diets provided by hospital dietitians. The medical consultants, with other Army officers in similar positions, showed the traditional concern about the quality and quantity of food available for the soldiers for whom they were responsible, but actually the only real problem in the service command was to get the soldiers to eat the good food provided them. Poor hospital messes existed in service command hospitals but not for long. Dietetics in Army


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FIGURE 36. -Reconditioning at Percy Jones General Hospital, Battle Creek, Mich. A. Calisthenics in wards at Reconditioning Unit, Fort Custer, Mich. B. Mass calisthenics outdoors for patients at Reconditioning Unit, Fort Custer, Mich.


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FIGURE 36.-Continued. C. Water therapy in pool. D. Carefully supervised activities in gymnasium.


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FIGURE 37.- Food service at Madigan General Hospital, Tacoma, Wash. A. Messhall. B. Kitchen.


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FIGURE 37 -Continued. C. Serving line with steam tables and huge automatic toaster (center  rear).

hospitals, exclusive of the special diets prescribed in certain diseases (such as diabetes, gout, nephritis, hepatitis, and acute infections) was of little concern to the medical consultants.

    The TM (War Department Technica1 Manual) 8-500, Hospital Diets, dated March 1945, was prepared in large part under the supervision of Col. Garfield G. Duncan, MC', who was on temporary duty in the Medical Consultants Division, OTSG.

MEDICAL SUPPLIES

    Fortunately, medical supplies in abundant quantity were practically always available promptly to Army medical installations in the United States (fig.38). Such shortages as were encountered were usually because of faulty implementation of the Army system of requisitioning, faulty interpretation of the function of a given hospital, and, therefore, faulty distribution of the supplies appropriate and available to that hospital. The procurement or distribution of medical supplies for general and station hospitals in the United States was never a problem, and the consultants had little occasion to deal with supply problems, except when acting as personal representative of a hospital commander to the service command supply officer or vice versa.


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FIGURE 38.-Well-stocked pharmacy at Percy Jones General Hospital, Battle Creek, Mich 

  This role was a common one for the professional consultants, not only with relation to supplies but also in relation to many other matters, for they visited and actually were familiar with the medical units functioning within the boundaries of the service command in a way that was unique and, to a degree, rarely approached by any other headquarters officer.

NURSING CARE

    Interesting comments on nursing in the service commands were submitted in the consultants' final reports. Col. John Minor, MC, Consultant in Medicine, Third Service Command, wrote approximately as follows:

    Nursing in the service command hospitals was a very minor concern of the medical consultant. Medical officers, even in command positions in large hospitals, have minimal jurisdiction over nursing problems. In fact, except for inquiries as to the adequacy of care in case of sick patients or in supervision of special wards, the medical consultant had practically no contact with nursing problems.

    Also concerning the Third Service Command, Colonel Fitz-Hugh noted that the chief problem in regard to nursing care which he encountered was occasional numerical inadequacy. However, this shortage was not serious. In general, the nursing care was excellent.

    Col. Edgar van Nuys Allen, MC, Consultant in Medicine, Seventh Service Command, from August 1942 to December 1945, reported in general that


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FIGURE 39.-Senior cadet nurses in training

nursing care was usually adequate except when there was a numerical shortage of nurses. Experience indicated that wardmen could be trained to discharge many nursing duties in a satisfactory manner. In general, nurses served in a supervisory capacity, except in the case of seriously ill patients.

    Colonel Marble reported on nursing in the Sixth Service Command. The following paragraphs summarize his comments.

    The inauguration of the system of cadet nurses put into operation a plan which apparently worked excellently. For all practical purposes, a nurse who had had 2 years' training or its equivalent in an accelerated program in a civilian hospital was as capable as one who had spent the full 3 years and was fully qualified to do her share of the nursing work in an Army hospital. The fact that she was obliged to stay only 6 months and the fact that the majority of cadet nurses chose not to remain in the Army was offset by the fact that when the 6 months' term of duty for one group of nurses was up, that of another group began. Although this consultant does not claim to know much about the Cadet Nurse Corps and the actual results achieved, in his opinion, the idea is an excellent one, which in another emergency should certainly be used in order to provide a sufficient number of nurses for the Zone of Interior (fig. 39).

    Until the time of the establishment of the Cadet Nurse Corps, it was an almost universal complaint that there were not enough nurses in any of the hospitals. This was more or less true, but the whole situation was confused by various administrative precedents. In some hospitals, what seemed to be an unwarranted number of nurses were kept at administrative work in the office of the principal chief nurse. It was thought by some that the nurses could have been of more help doing professional work on the wards. A constant source of aggravation was the continual shifting of nurses from one ward or one section


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of the hospital to another. Upon inquiry, it was always stated that the shifting of nurses was necessary because of two reasons: (1) An unbroken rule that at regular intervals every nurse must take her turn at night duty, and (2) the number of nurses actually available for duty from day to day was constantly changing as the result of leave, illness, days or afternoons off, and transfers in and out of the installation. Whatever the cause, the shifting of nurses when they had just become used to a given ward and trained in a specialized technique was a decided nuisance and resulted in a poorer quality of care for patients.

    One complaint made by nursing supervisors was that in the average Army hospital there were not enough real nursing problems to challenge the capabilities of the nurses. As a consequence, over a period of time the nurses became less alert and less interested professionally. It is true that in the average Army hospital there are fewer patients who are acutely ill and who need specialized nursing care than are found in the average civilian hospital. The consequence often was that the nurse in charge of the ward spent most of her time doing clerical and administrative work. It will be interesting to observe what effect this practice has had upon the performance of these nurses on their return to civilian life.

COORDINATION WITH OTHER CONSULTANTS

    The medical, surgical, orthopedic, and psychiatric consultants assigned to a service command had much in common. Their ultimate aims as medical officers were identical. They worked in the same administrative setting, employed the same channels of communication, often occupied adjoining offices in service command headquarters, and shared transportation on field trips. It is not likely that any other officers of the headquarters group possessed as much personal knowledge of the general medical activities of the command as did the consultants. The relationship between the consultants themselves and between them and the service command surgeon was often intimate, to the great advantage of all concerned. The following summary of comments by Colonel Adams, of the Fourth Service Command, provides a picture of how the medical, surgical, psychiatric, and orthopedic consultants coordinated activities among themselves, with the officers of other headquarters divisions and services, and with their chief, the service command surgeon.

    The consultants representing the four major specialties-medicine, neuropsychiatry, surgery, and orthopedic surgery-coordinated their efforts closely and worked in perfect harmony. Friction was nonexistent. Whenever possible, two or more of them made trips together, reviewed their sections of the hospital separately, and compared notes in the evenings. As a general rule, because of the inevitable interruption of work, hospital commanders regarded it as undesirable to have visits from more than three consultants at any one time; most preferred not more than two. By mutual agreement, whenever one consultant observed a situation that needed correction within the sphere of another's activities, he always reported it to his confrere. Such problems


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or deficiencies otherwise might have escaped attention because of infrequent visits to a particular installation.

    When two or more consultants visited an installation simultaneously, they sometimes conducted joint clinics or teaching rounds or together studied problem cases. It was hoped that such demonstrations with the free discussions that always occurred in the conferences would serve to promote similar interservice joint consultations with free discussion and to discourage sole reliance upon formal, written opinions.

    Again, in the consultants' relationship with the officers of the other divisions and services in the surgeon's office, friendliness and close cooperation were the rule. It was the policy of the Surgeon, Fourth Service Command, that members of his staff returning from the field should report directly to the appropriate officer any observed deficiencies that fell within the scope of other divisions or branches. For example, if unsanitary conditions in a camp, a mess, or elsewhere were encountered, the chief of preventive medicine branch was notified. The discovery of any minor epidemics or threats of epidemics were similarly reported. Shortage of supplies or some special need, as for an instrument, for example, was referred to the chief of supply section. This system of direct reporting led to the more prompt correction of unsatisfactory situations.

    A close and friendly relationship existed between the consultants and the officers in the Medical Personnel Branch, Military Personnel Division, Headquarters, Fourth Service Command. In spite of this, the consultants were often unable to advise the personnel officer regarding the assignment of medical officers as effectively as was desirable. The necessity for quick action and the established policies of the Military Personnel Division made it impossible for the medical personnel officers consistently to obtain the advice of the consultants when the latter were away from headquarters. A more generous use of telephone would have resulted in more effective distribution of the better trained officers within the command.

SERVICE COMMAND INSTALLATIONS OTHER THAN STATION AND GENERAL HOSPITALS

    The relationship of the medical consultant to nonhospital medical operations within his service command depended in large part upon the attitude of the service command surgeon toward these installations and toward his consultant and the interest displayed by the consultant. Thus, in the Third Service Command, Colonel Minor made no visits to induction centers, reception centers, replacement centers, dispensaries, or outpatient clinics. He pointed out in his report many weaknesses with regard to professional care and professional personnel management that could have been avoided or rectified by cooperative action of the service command surgeon, the surgeon of the ground forces, and the post surgeon.


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    The following detailed comment upon the subject as it affects all service commands is based upon a report from Colonel Bauer, whose extra-hospital interests and activities were lively and who speaks from a fund of experience and knowledge of the consultant system in the service commands. The discussion includes the effects of improved ambulatory medical care of the soldier in training camps upon the noneffective rate and the effect of proper professional personnel management upon the morale of Medical Department officers.

    The service command surgeons' policy affecting the relationship of the consultants to various service command installations governed the consultants' activities in the installations. Some service command surgeons considered the supervision of the care of the sick time consultants' sole function. Others regarded the consultants as their professional representatives and directed them to aid in the coordination of all medical activities of the service command. The latter policy is a most desirable one, but it cannot be realized until the requisite authority is delegated to The Surgeon General and the service command surgeons. When this is granted, it will be possible for them, with the aid of their professional consultants, to establish the proper type of integration of the Medical Department's activities at all Army levels. Such action will not only strengthen the Medical Department but also will really contribute to military planning, training, and operation. If such a scheme is ever effected, additional service command consultants will be needed to supervise and integrate properly the activities of the installations which are considered in the following paragraphs.

    Induction stations. - In a few of the service commands, the consultants visited the induction stations frequently. The deficiencies most often observed were inadequate and poorly arranged quarters, workloads too large for the doctors to handle efficiently, insufficient social service investigation and psychologic examination, and a paucity of good neuropsychiatrists, competent radiologists, and qualified specialists to serve as consultants. The medical officers lacked the authority necessary for the proper execution of their duties. The most common infringement was dictation by line officers as to the number of rejectees permitted in a given period. Many certificates of disability for discharge, pensions, lost training days, and much hospitalization were directly attributable to poor screening at the induction stations.

    Reception centers. - Many of the induction station errors could have been unearthed at the reception centers if rescreening had been allowed. However, separation from the service or checking the work of induction stations at this level was either discouraged or prevented. Neither sufficient time nor personnel was allowed for the proper classification and assignment of the men received. These important decisions were made on the basis of quota demands and the inductees desire rather than on qualifications and aptitudes (fig. 40). In future mobilizations, reception centers should be charged with a greater responsibility in the classification and assignment of inductees. Detailed reports pertaining to improved selection and job assignment, based on excellent studies, are available.


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FIGURE 40.- Data for personnel and classification records being obtained from newly inducted soldiers at a reception center

    For a time, the treatment of venereal diseases at reception centers was not satisfactory. This was due to a lack of the necessary facilities.

    Replacement training centers.- The establishment of psychiatric consultation services in the replacement training centers was of immense value and represented a real advance in the medical program of the Army. The better psychiatrists demonstrated most impressively the role of educational, preventive, and treatment methods in the assignment and training of soldiers. The line officers were cooperative and appreciated the help received. The efficiency of these psychiatric consultation services was impaired at times because of lack of clinical psychologists, social service workers, interviewers, and stenographic and clerical assistants.

    Camp dispensary and outpatient services. - During the training period, the sick soldier was first seen in a company, regimental, or camp dispensary (fig. 41). In retrospect, it is apparent that failure to organize and integrate the medical facilities at each camp made it impossible to provide adequate ambulatory medical care. There is little to be gained from a lengthy exposition of the evils of isolated dispensaries, furnishing only crude medicine in most instances; crowded hospital outpatient departments, where the harassed medical officers could only guess as to the cause of symptoms; and abuse of the hospital receiving office function, where proper selection was not permitted,


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FIGURE 41.-New Picker portable X-ray equipment being put to use in the outpatient service, Camp Rucker, Ala., July 1942.

and, as a result too many admissions were allowed and unnecessary hospitalization, with its attendant evils, was encouraged. The institution of an ideal camp medical service requires that the post surgeon be delegated full responsibility for the health of all soldiers on the post.

    The first essential for an adequate camp medical program is a strong dispensary service. The assistant chief of the station hospital medical service, who also serves as chief of the camp dispensary service, should therefore be an energetic, well-trained internist with a working knowledge of or interest in psychiatry. Once the proper organization is effected, supervision of the dispensary would not require more than 50 percent of the chief's time. On visiting the dispensary not less than every second day, he should demonstrate by example that adherence to the basic principles of good medical practice accomplishes the desired goal.

    Unfortunately, the Army failed to stress that the dispensary surgeon is the key person in effecting the lowest possible noneffective rate. Dispensary surgeons must realize their importance to the Army, be vested with the necessary authority, have protection against undue pressure by command to hurry with sick calls, receive support and supervision of their clinical activities, be included in the professional and social activities of the hospitals, and share in a just rotation system. In many instances in World War II, these conditions


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were not met, and this explains the development of many bitter, disillusioned, ineffective medical officers, who did more harm than good.

    Because of assignment practices and notions concerning the prestige and the relative importance of work done, there was a regrettable and erroneous overevaluation of the hospital staff positions. This misinterpretation merits special attention by responsible leaders in the Army Medical Corps, since a good dispensary physician is much more valuable than a hospital ward officer. The scope of tine physician's activities is much wider and demands infinitely more enterprise, social skill, arid emotional and administrative adaptability, for he is physician to a large group of men and the logical source of advice on all matters pertaining to health and morale. Due to his position and special vantage point, he can do much to help line officers fulfill their obligations as leaders. There is literally nothing in the soldiers' lives which may not be of concern to command and hence to the dispensary surgeon who should be a sensitive observer and an accurate transmitter of information to responsible officers.

    The dispensary service is the most strategic location for the management of psychosomatic complaints. Therefore it is important that the dispensary surgeons appreciate that most of the soldiers seen on sick call are suffering either from relatively minor illnesses or from concern over personal health and welfare. The majority of these patients can and should be treated on an ambulatory basis. On the on hand, if these individuals are returned from the dispensary level without adequate examination, treatment, and reassurance, they will continue to worry about their health, will lose confidence in the Medical Corps and become less effective in their assignments. On the other hand, if they are unnecessarily referred to the consultation clinic or needlessly hospitalized, they are very apt to assume that the dispensary surgeon is in doubt or that their symptoms indicate the presence of serious disease. Such practices increase the neuropsychiatric casualty rate and loss of training days as well as make it evident to soldiers that disability is an asset. Most of them ask such questions as: "What have I got?" "Will it get worse?" "Can I take a 20-mile mike?" Some semblance of an examination at this time and an explanation as to the cause of the symptoms, assurance, and simple psychotherapy frequently are all that are needed. Fulfilling these requisites keeps at a minimum the all too common gripes: "He thinks I imagine it." "He called me a 'gold-brick' ('screw-ball,' 'eight-ball')." "All I ever get at the dispensary is the brush-off."

    The dispensary surgeon's multitudinous and important duties prevent him from personally undertaking detailed diagnostic studies. Therefore, he must have access to a strong hospital outpatient clinic and good camp and hospital psychiatric services. If the consultations are to be of maximum benefit to the soldier, the dispensary surgeon must maintain good liaison with the people who provide them in the outpatient clinic and should inform them regarding the soldier in his Army environment. Such consultation privilege must be used with discrimination. It is extremely important that


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the responsibility for the patient remain principally with the dispensary surgeon and that all personal problems be referred back to the dispensary surgeon and the scene of conflict, usually the soldier's platoon, company, battalion, or regiment. In order to avoid unnecessary hospilitization, there must be adequate facilities for soldiers treated on quarters status. Dispensaries, properly designated barracks, or the convalescent annexes can be used for thus purpose. Reconditioning should be made available for ambulatory dispensary patients if quarters status is not desirable or permitted.

    Station hospital outpatient clinics, when properly organized and directed, were of great value to the dispensary surgeon. In these clinics, soldiers were furnished with good professional care, and unnecessary hospitalization was prevented. The effectiveness of the outpatient service in station hospitals was one of the best indexes of the quality of medical care rendered by these hospitals. In the future, the importance of good outpatient clinics should be stressed.

    The functioning of the camp dispensary service and hospital outpatient clinic in the manner described necessitates their inclusion in a complete camp medical service. This facilitates the rotation of all camp medical officers, except for key personnel, through the dispensary service for a period of not more than 4 months. This type of duty would acquaint the majority of medical officers with the importance of good ambulatory care in maintaining the lowest possible noneffective rate. Regular rotation of medical officers removes the onus of discrimination and punishment, so frequently associated with indeterminate assignments to the dispensary service; encourages better performance of duty; and permits greater professional development.

    The number of officers assigned to a dispensary will depend upon the number of soldiers served. If two are required, selection and assignment should be so effected that the ranking officer is the more competent physician.

    A camp medical service so organized affords maximum performance and effectiveness of its medical facilities, provides proper preventive medicine, and gives all medical officers a greater sense of responsibility with keener appreciation of the many camp medical problems. In addition, it makes possible better qualified, more efficient, and happier medical officers.

    Ports of embarkation. - The medical activities at ports of embarkation should have been more closely integrated with those of the service commands. This cannot be accomplished until the former are under the jurisdiction of the service command surgeons. Though the hospitals always welcomed them, there was too much division of authority to enable the consultants to be of maximum aid to the port surgeons in the solution of many problems that arose.

    Separation centers. - The process of separation mirrored the induction examination with all its handicaps (fig. 42). It was readily apparent that most


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FIGURE 42.-Separation Center, Fort Dix, N.J., October 1944. A. A step in medical processing. B. Lost to the Army, discharged soldiers on their way home.


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FIGURE 43.-Geared for mass evacuation of patients in transit, ambulances from debarkation hospital awaiting docking of hospital ship, Charleston Port of Embarkation S.C., January 1944.

separation centers would have functioned better if measures similar to those recommended under induction stations had been instituted.

    Other service command installations which may be of interest to the medical consultant are discussed in the following paragraphs.

    Hospital centers for special diseases. - The establishment and operation of these centers have been discussed on pages 33-39.

    Debarkation hospitals. - This designation was given hospitals used for the reception of patients transported from overseas by water and air. These hospitals were generally administered well, but it must be said that the compulsion to evacuate patients to hospitals located inland, in order to have empty beds available, often made difficult proper triage and treatment of patients in transit (fig. 43). The lack of judgment with regard to this matter was on occasions incredible. Transportation and evacuation seemed to become the end and not the means-the empty hospital bed the goal and not a facility - for providing necessary treatment for the sick and injured. This unsatisfactory situation was clear to medical consultants, and they often fought the tendency to impersonal decisions, group management, and the premature movement of oversea patients in the evacuation chain to their ultimate hospital destinations in the United States.


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CONSULTANTS' EVALUATION OF THE CONSULTANT SYSTEM

    Summaries of evaluations of the consultant system, its weaknesses and strengths, its failures and accomplishments, as formulated by a representative sample of the opinions of the medical consultants to the service commands are herewith presented. Their statements were prepared soon after V-J Day. They were formulated in a spirit of thoughtful, constructive criticism by individuals of great competence and of complete loyalty to the United States Army and its Medical Department and also to the highest ideals of medicine.

    First, are presented the views as generally expressed by Colonel Adams, medical consultant to the Fourth Service Command from September 1943 to December 1945. His comments are summarized, as follows:

    It is believed that the consultant system as set up in the service commands contributed definitely to the welfare of the patients. In anticipation of this report, a questionnaire was sent to the chiefs of medicine of every hospital in this command. With one exception, the replies indicated that the consultants' visits were helpful mind stimulating but too infrequent.

    The following is a summary of Colonel Adams' criticisms of the consultant system as it operated during World War II:

    1. In a large service command, such as the Fourth, one consultant in each major branch was not enough. Each consultant should be able to visit an installation at least once from every 3 to 4 months instead of from every 8 to 12 months. This arrangement could be accomplished by assigning assistant consultants, who could be responsible for bedside visits and personnel evaluations in a specified group of hospitals. Then, the service command consultant, using the information provided by his assistant, could cover the command more rapidly and frequently, concentrate on trouble spots, and devote more time to teaching, personnel assignments, and general supervision.

    2. The suggested plan of having the chief of service in each large hospital visit nearby smaller stations was not practicable. The chief of service in any large installation usually has more duties than he can discharge adequately. To send him away for several days each month to visit other stations would result in increasing the backlog of his own work.

    3. To execute his mission properly, the consultant should have a grade commensurate with his duties and with his relative importance as an officer of the Medical Department of the Army.

    Next, a summary of the opinion of Colonel Denny, medical consultant to the First Service Command from January 1944 to December 1945, is presented:

    The uses and possibilities of the service command consultant can be illustrated by a visit to the northern bases in Newfoundland, Labrador, Iceland, and Greenland made by the First Service Command consultants at the request of the Eastern Defense Command. Most of the medical officers in these isolated stations had been on such duty from 2 to 3 years without a


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visit from a medical officer who was primarily interested in the clinical work being done. The hospitals were small and not active when visited in May 1945 and probably not much was accomplished professionally by the visit, but the interest and gratitude of the medical officers was, in many instances, almost pathetic. Physical and professional isolation lowers medical interest and general morale. Visits by consultants much earlier in the war would have been of real value to these medical officers, almost all of whom were well-trained and conscientious men who by reason of their isolation had come to feel that no one in higher authority took any interest in their professional work. Given sufficient authority consultants might well have been able to rotate such officers before dry rot set in.

    Colonel Fitz-Hugh, medical consultant to the Third Service Command from May to December 1944, expressed primarily the following views in his evaluation:

    1. The medical consultant system as it operated during World War II was fundamentally sound and necessary. Some of the difficulties and problems inherent in it were no doubt unavoidable; some could be corrected.

    2. The autonomy of the service command and the necessity of going through channels at times impaired the relationship of the service command consultant to the chief consultant in the Surgeon General's Office. Higher authority in the service command at times resented direct communication between the service command consultant and the chief consultant in the Surgeon General's Office. If possible, this conflict should be resolved.

    3. The autonomy of the service command also made it difficult for an overall adjustment of key personnel needs. The office of the chief consultant in the Surgeon General's Office is the only qualified central authority possessing the necessary knowledge of personnel qualifications and institutional needs. Therefore, in the future, the authority and power of the central authority should be increased.

    4. The service command consultants' concern with professional personnel should be more effectively implemented. The consultants should, through the office of the chief consultant in the Surgeon General's Office, be given more real authority over assignment, transfer, and reassignment of professional personnel. If this authority is considered unwise, then the consultants should be instructed to keep out of personnel problems and to confine themselves to the task of trying to improve the personnel of each installation as they find it.

    5. The selection of consultants in the recent war was generally well done. In the opinion of this consultant, the service command consultants should always be men who are fully qualified and have proven themselves adequate as consultants and teachers in civilian life. The outstanding qualities of General Morgan were no doubt responsible for much of the best that came out of the consultant system in this war. All consultants should not only be good enough to rank as full colonels but should have this rank. If an inflation of grade occurs in the next war, then the consultants' grade should also be comparably inflated.


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    6. Finally, the Medical Corps of the Army, in general, was undergraded and promotions were too slow and too few. Improvement in this important aspect of military service would result in much better morale.

    Colonel Minor, medical consultant to the Third Service Command from December 1944 to December 1945, summarized his opinion of the consultant system, generally, as follows:

    The medical consultant service was an important addition to the Medical Department and served very well the functions for which it was planned. These functions were (1) to assist in establishing and maintaining professional staffs as well qualified and as stable as possible in hospitals and other installations; (2) to oversee the general picture of medical professional care in the command medical installations, to keep tine staffs informed of recent advances, and to bring the practice of medicine to as high a level as possible; and (3) to furnish consultation of professional and often personal nature for the medical officers, develop educational programs, stimulate special study projects, and minister in these important ways to the total professional morale of the medical officers.

    A corollary to these functions was, of course, the maintaining of close relationship with the surgeon, by making suggestions and preparing directives about professional matters for his signature. An additional function was the correlation of activities with the surgical and neuropsychiatric consultants.

    The consultant functioned to a very large degree on a personal basis because duties of the position, while of evident importance, were not officially integrated into the preexisting planning for the Medical Department. The consultant's activity, therefore, and his ability to accomplish his objectives depended first on his relationship to the surgeon and the amount of confidence and respect he earned from his direct superior and, secondly, on the same factors in the commanding officers and the key professional officers of the hospitals with whom Inc worked. In other words, it was necessary for the consultant to sell himself as a useful and competent individual with something to offer before he could function effectively, there being no recognized or official status for his job. As a result, success in accomplishing his mission was largely dependent on developing such relationships.

    It was Colonel Minor's opinion that the quality and amount of interest taken by the service command surgeon in the professional matters that were the prime concern of the medical consultants was a determining factor in the effectiveness of the consultant system. The consultant was clearly responsible to the service command (through the surgeon) and had only an associated relationship with the Surgeon General's Office. All administrative power was placed in the hands of the service command headquarters; that is, in the hands of the commanding general. It was therefore necessary to sell one's wares to the commanding general directly, when possible, or indirectly through the surgeon or other officers. In this command, the policy of complete control of all installations on a post by the commanding officer of the post raised many serious difficulties in the allocation and shifting of medical personnel. All the


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methods that could be used by the consultants to bring about needed changes sometimes failed to overcome the opposition or passive resistance of the commander of a post, who might be an infantry officer with mo knowledge and little interest in the real medical problems at hand. Similar difficulty was occasionally encountered with medical officers commanding hospitals, but in large part these officers were cooperative. A point of view not infrequently encountered was that one medical officer was the same as another, and this without regard to special professional training or ability. This viewpoint might be called the "doctrine of the body." However, as time passed, there developed realization among even the most reactionary medical officers that special men were required for special jobs.

    The most effective portion of Colonel Minor's work was visiting the hospitals in the service commands. It was necessary at the start to make clear that these visits were not inspections in the usual Army sense. When the professional staff realized that tine consultant was interested primarily in good work, in the advancement of competent men and their proper assignment, and also sincerely interested in their personal problems, little opposition or resentment was encountered. The more time spent in visiting, the more effective was the consultant. With rare exceptions, the consultant was made welcome and was able to establish satisfactory liaison with the various officers, administrative and professional, who operated the post.

    The promotion of educational activities and the holding of formal and informal discussions with members of the staffs to consider professional problems of importance furnished an opportunity for free interchange of ideas, which was mutually beneficial.

    Ward rounds were of great importance from three standpoints: (1) They afforded the best opportunity for the consultant to evaluate and to know the officers on a service; (2) they provided an overall view of the management of patients and of diseases, as for example, diabetes, rheumatic fever, hepatitis, syphilis, gonorrhea, arthritis, pleurisy, and others; and (3) they made possible a review of problem cases by the consultant, which was an interesting and instructive exercise and often contributed directly to improved management of the case at hand.

    In the preparation of reports of visits, an effort was made to give a general picture of the operation of the hospital from a professional angle; to evaluate with fairness and frankness the various officers; to describe important professional problems and the methods by which they were handled; to make recommendations as to the proper classification of officers by MOS numbers; and to recommend promotions when deserved.

    The relationship of the medical consultant to the Surgeon General's Office was as close as was permitted by the organization described. It was, of necessity, largely on a personal basis, as the Surgeon General's Office was unable to implement its plans with regard to personnel or method without the consent of the service command. In the case of the Third Service Command, nearness to the Surgeon General's Office and the warm personal relationship


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existing between the officers there and all the service command consultants made possible the solution of many personnel problems. Also, questions of policy and procedure were readily ironed out by means of this direct, personal contact.

    The medical consultant service in the Third Service Command earned its way and proved itself a most valuable addition to the organization of the Medical Department. In the long view and from the standpoint of promotion of the best in medicine, it can only be called an essential element to the proper functioning of the Medical Department. In spite of frustrations, difficulties in administration, and the reliance on personal relationships to achieve ends that could be attained only in that way under the existing system, the medical consultant plan achieved important success and was of great benefit to tine practice of medicine in the command and to the development and proper use of professional personnel.

    Colonel Marble, medical consultant to the Sixth Service Command from March to September 1945 made, generally, the following observations:

    1. There is no doubt that the consultant system is worthwhile. It is imperative, particularly during times of expansion of the Army, that medical officers with the necessary professional qualifications be assigned to service command headquarters to advise the service command surgeon on professional matters and, by visits to medical installations throughout the command and by other contacts with medical officers, to promote and maintain high standards of professional care.

    2. It is desirable that the position of the consultant in the service command headquarters and throughout the service command be clarified so that administrative difficulties may be avoided and the carrying out of professional policies expedited.

    3. Some plan should be worked out whereby free and informal contact by the consultant with higher authority (Medical Consultants Division, OTSG) and medical officers throughout the service command may be possible on purely professional matters, without arousing concern that administrative channels have been bypassed.

    4. One of the greatest fields of usefulness of the consultant is in his advice to the service command surgeon and the headquarters personnel officer regarding the proper placement of medical officers. By his personal professional contacts, the consultant after a period of time comes to know the professional qualifications of medical officers and the professional needs of various installations in the service command better than any other officer on the staff.

    5. The next greatest field of service of the consultant lies in the teaching and professional encouragement of medical officers by frequent and prolonged visits to hospitals and other medical installations.

    Colonel McGuire, medical consultant to the Fifth Service Command from July 1944 to December 1945 summarized his endeavors, in general, as follows:

    1. To be of assistance to the service command surgeon and the chief


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consultant in medicine in the Surgeon General's Office by keeping both constantly informed of professional and personnel problems on the medical services of the general and station hospitals.

    2. To be of assistance to the chiefs of the medical and laboratory services of service command hospitals by: (1) Presenting their personnel problems to the attention of the service command surgeon; (2) conducting teaching ward rounds and attempting to stimulate the section chiefs and ward officers to carry on their professional duties at the highest possible level; (3) stimulating clinical research; (4) encouraging scientific meetings of high quality; (5) recommending transfer of mediocre medical officers; (6) recommending changes to improve physical location and administrative procedures of medical libraries; and (7) obtaining clarification of confusing administrative procedures for chiefs of medical service from the service command surgeon and the Surgeon General's Office.

    Colonel McGuire stated further that, if the consultant system should be needed in the future, a clearer definition of the consultant's responsibility to the service command surgeon as compared with his responsibility to the chief consultant in medicine in the Surgeon General's Office, would be of value. In the Fifth Service Command, no problem arose, since there was perfect cooperation between the service command surgeon, the chief medical consultant, and the service command consultant. However, it may be difficult to serve two masters, and, unless the consultant's fundamental responsibility be more precisely defined, it is clear that on occasion his position will be ambiguous.

    To prevent misinterpretation of the function of a professional consultant and to avoid being regarded as an inspector, the professional aspects of the consultant's function should be emphasized and the administrative aspects minimized. However, since the best available personnel are essential to the maintenance of the highest professional standards, it was the opinion of this medical consultant that assignment of key personnel to the medical services of hospitals should be made only on the recommendation of the service command consultant.

    Finally, in a summary and critique prepared in 1945, Colonel Bauer, medical consultant to the Eighth Service Command from August 1942 to August 1945, presented the views expressed in the following paragraphs.

    Regardless of the accomplishments or shortcomings of individual consultants, there can be little doubt that the consultant system has favorably influenced the medical service of the Army and therefore should be included in its permanent organization. It has served particularly to focus attention on the primary importance of the professional aspect of military medicine.

    The problem now [1945] is not so much the future of the consultant system as what to do about the future medical service of the Army. The high standards of professional care attained in this war must be maintained and advanced. The way must be opened for capable and ambitious young officers to progress in their profession. Postgraduate opportunities must be made available to a


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sufficient number of officers of the Medical Corps to furnish the Army a group of qualified specialists in the various branches. These men should receive recognition in the form of rank and pay commensurate with their eminence in their profession and the weight of the duties that they will be required to perform.

    The benefits of the experience gained by the group of men who have acted in the capacity of consultants in the service commands during this war should not be lost to the Army. Through this experience, they have acquired an insight into the practical workings of the Army Medical Corps. This, joined with their professional knowledge in various special fields, fits them for the task of evaluating the future needs of the medical service of the Army.

    Colonel Bauer made the following recommendations: 9

    1. That the Medical Department be represented on the Army staff at the departmental level instead of being relegated to a subordinate position such as was the case in the Services of Supply and Army Service Forces reorganizations during World War II. This representation of the Medical Department at the highest level will provide better opportunity for the integration of medical activities throughout the Army and restore to the Medical Department more prestige and autonomy. It is hoped that the changes in staff organization at all levels implicit in this recognition of the responsibility of tine Medical Department will permit it to make a greater contribution to all military planning, training, and operations.

    2. That the Medical Department formally recognize different career patterns for medical officers who are primarily interested in staff and command functions from those who are primarily interested in the professional practice of medicine or in research and provide appropriate training, assignments, and rewards to each group.

    3. That the consultant system, as evolved during the present conflict, be retained and extended.

 9 The original recommendations made by Dr. Bauer were revised in a letter from Dr. Bauer to Col. J. B. Coates, Jr., MC, Director, The Historical Unit, U.S. Army Medical Service, 9 Nov. 1956, and a letter from Col. Coates to Dr. Bauer. 19 Nov. 1956.