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Chapter III

Activities of Medical Consultants

CHAPTER III

Mediterranean (Formerly North African) Theater of Operations
Perrin H. Long, M.D.

FUNCTION AND DUTIES OF A MEDICAL CONSULTANT IN AN OVERSEA THEATER OF OPERATIONS

The advent of World War II found the Medical Department of the U.S Army without a professional consultant group in either medicine or surgery. From the middle of 1940 until shortly after the entry of the United States into the war, an attempt was made to overcome this deficiency by the establishment. of liaison, in strictly professional matters, between the various newly created advisory committees of the Division of Medical Sciences, National Research Council, and the Professional Service Division, Office of the Surgeon General. Between the end of World War I and 1925, when the Professional Service Division was formally established, the activities normally carried out by such a division had been performed by various professional offices or divisions of the Office of the Surgeon General.

Even after the Professional Service Division was set up in 1925, its scope had been limited and its functions poorly defined. It had been concerned chiefly with routine administrative matters, and its influence as a positive force in developing and guiding the professional aspects of medicine and surgery in the Army had been negligible.

As a consequence, when consulting services were established in World War II in the Office of the Surgeon General and in the service commands and the theaters of operations, a certain amount of education was necessary on both sides. Command and staff officers of the Medical Corps of the Regular Army, whose work, in the emergency, was necessarily chiefly administrative, had to learn the functions and the potential value of consultants in the maintenance of professional standards. For their part, the consultants, most of whom had been commissioned from civilian life, had to learn the complexities of their position in the Army and the extreme importance of what might be termed the administrative background of military medicine.

It was not until both the consultants and the Regu]ar Army medical officers had learned--usually by trial and error--to define and comprehend their individual and joint responsibilities that the consultant system achieved real efficiency. Much time and effort would have been saved in World War II if a consultant group had been maintained in the Office of the Surgeon General between the two World Wars. It would also have been helpful if, before any consultants had been appointed, the nature of their duties had been clearly


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established in an official publication. For those who were fortunate enough to see it--and many were not--the first official notice of the consultant's functions was contained in TM (War Department Technical Manual) 12-406, Officer Classification, Commissioned and Warrant, dated 30 October 1943. In this manual, under MOS (Military Occupational Specialty) 3117, the duties of a consultant are summed up in the following paragraph:

Renders special professional advice to various headquarters concerning the medical service within the command. Visits various medical installations and advises the staff of their medical services as to methods of diagnosis, treatment, and operations, with special reference to professional improvements and new developments; conducts clinical-pathological conferences on unusual cases; reviews professional aspects of work of medical services; develops methods for training junior medical officers; advises superior officer concerning professional policy on matters pertaining to the practice of internal medicine within the command; transmits professional information and suggestions between subordinate installations and higher echelons.

In the North African and Mediterranean theaters, the medical section, which was a component of AFHQ (Allied Force Headquarters) was always maintained at the theater level. This gave the Surgeon direct access to the theater commander, the chief of staff, and the chiefs of the general and special staff sections; and it facilitated the Surgeon's entrance into all subordinate commands in the theater. The consultants division of the Medical Section, AFHQ, was enabled to coordinate the professional aspects of medicine and surgery in the various echelons of the command more easily than would have been possible had the medical section been placed at the level of the communications zone or the services of supply. As a result of this system, advice on all technical subjects emanated from the highest level in the theater; the various consultants rarely experienced any difficulty in entering subordinate echelons such as the field army, the air forces, or the communications zone; and coordination and correlation of technical subjects between these commands were made relatively easy.

The need for consultants in the professional fields of medicine and surgery was amply demonstrated during World War II. The establishment of a consultants division in the medical sections in oversea theaters of operations freed the Surgeon and his staff officers from perplexities arising in the practice of medicine and surgery and provided the Surgeon with expert advice concerning the care of the sick and wounded. It also provided him with a channel for ascertaining, and putting to the best use, the professional talents of non-Regular Army medical officers. At their peak employment, these officers composed approximately 98 percent of the Medical Corps of the Army.

Professional Functions

Advisory functions. - The functions and duties of a medical consultant are many and varied and in practice are much broader than outlined in TM 12-406.In the first place, the consultant should always remember that he is in an advisory capacity, and that, unless he is directed to do so by the theater


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Surgeon, he will be at fault if he descends to operational levels. His prime duty is to keep the Surgeon constantly and accurately informed of the standards of professional care obtaining in the care of the sick. This service cannot be rendered by sitting at a desk in headquarters. The consultant must spend at least two-thirds of his time in the field, observing and studying medical care at all levels, from the aid stations through the general hospitals. He should be familiar with the tactical and other conditions that affect the diagnosis and treatment of disease and govern the evacuation and disposition of patients in all echelons of the comnmand. To accomplish this mission, the consultant must have easy access to all medical installations, and he should be regarded as a friend and advisor to the Surgeon and medical officers of all commands. It should be well understood that the consultant's main interest is improvement in the care of the sick, in order that patients may be returned promptly to duty. The consultant should never assume the functions of, or be regarded as, an inspector.

Administration of professional personnel. - The second important function of the medical consultant is to advise the Surgeon upon personnel changes that may be necessary to insure a high level of professional efficiency. The Surgeon, as a rule, has not had the training, nor has he had the time, to evaluate medical personnel. He must have confidence in the recommendations made by his medical consultant and should do his utmost to support them even though, at times, reluctant commanding officers have to be brought into line. Otherwise, it would be best for the consultant to ask to be relieved of his duties, so essential is this function to his usefulness. For his part, the medical consultant must have accurate knowledge of the professional capabilities of all medical officers directly concerned with the care of the sick. He should have understanding, as well, of officers' personalities and reactions to their environment. An individual may do better work if shifted from a particular situation to one to which he is better adapted. Again, a family problem may lower efficiency and can sometimes be solved or ameliorated by judicious recommendation of leave, rotation, temporary duty, compassionate leave, and other devices. The consultant in medicine should interest himself in the welfare of the medical officers, general duty, MOS 3100, because these are the forgotten men of the Medical Corps, and it is from this group that many of the ward officers on the medical services will ultimately be derived. Finally, it is the duty of the consultant in medicine to direct the Surgeon's attention to meritorious or outstanding services rendered by medical officers.

Professional education. - The consultant in medicine should be the leader in initiating and guiding professional educational programs for the medical officers under his advisory supervision. Through the medium of clearly written circular letters from the Office of the Surgeon, he should keep them constantly advised concerning medical experience within the command and concerning new developments in scientific and clinical medicine in the Zone of Interior. He should see that medical officers receive all the textbooks and


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medical journals to which they are entitled, and if he thinks additional publications would broaden their intellectual horizons, he should make the necessary recommendations to the Surgeon. When conditions permit, the consultant should assist in establishing a medical periodical, in which local experiences in the prevention, diagnosis, clinical course, treatment, and other aspects of disease are recorded, for circulation to all medical officers within the command. It is his duty to initiate staff conferences, clinicopathological and X-ray conferences, journal clubs, and other educational programs within hospital installations. He should recommend and assist in the formation of medical societies in the lower echelons and should see that medical meetings are held in which medical officers from all echelons of the command participate. The consultant in medicine, being generally himself a teacher in civilian life, should always revert to this capacity when making ward rounds in any medical installations. He should plan and initiate a program through which medical officers assigned to field service or nonprofessional duties could be rotated to hospital assignments, in order to prevent the professional deterioration that frequently follows too long an absence from professional duties.

Medical research. - Research, having for its aim the better understanding of medical problems and the more efficient care of the sick within the command, should be fostered by the medical consultant. He should not be discouraged if his first efforts in this direction are rebuffed by administrative or commanding officers with the reminder "there is a war on" and the assertion "there is no time for research." In reply, the consultant should outline the problem clearly and show how, with the resources available within the command, knowledge might be obtained that would benefit the health of the command and save manpower. He should encourage and assist medical officers who have initiated research problems on their own. He should critically correlate and coordinate the various problems in order that the work may progress in an efficient manner. When results are obtained, he should see to it that they are made available to the command and also to the Office of the Surgeon General for wider dissemination. In promoting research within a command, the consultant in medicine should endeavor to secure for it adequate personnel, supplies and equipment. Finally, if the problem appears to warrant extramural aid, he should recommend to the Surgeon that investigators selected by The Surgeon General be sent into the command.

Care of prisoners of war. - The medical care of prisoners of war should be carefully supervised by the consultant in medicine. It is his duty to report to the Surgeon upon the expected needs for professional services in prisoner-of-war compounds and to recommend what should be done to insure an adequate level of medical service among prisoners of war. He should visit such installations and should supervise and advise upon care of the enemy sick. If the latter are under the care of their own medical officers, he should inform these officers of the prevailing theater policies on the treatment of disease and should instruct them in the use of U.S. Army medical supplies. At all times, the consultant in medicine should be on the lookout for violations of the Geneva,


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conventions in respect to protected enemy personnel, and, if such are noted, he should make strong recommendations to the Surgeon in respect to their correction.

Liaison and Staff Functions

Hospitalization and evacuation. - It is sometimes assumed that the consultant in medicine has little or nothing to contribute to the operational side of the Medical Department. On the contrary, he can offer valuable aid in estimating bed needs, based upon his knowledge of the prevalence of and average duration of hospitalization for current diseases. His opinion is also of value in respect to the ability of any given medical installation to handle overloads of patients. His advice on the triage of sick patients and their assignment to suitable medical installations will be useful to every operations officer. It should be the consultant's function to recommend to the Surgeon the creation of special centers to facilitate and improve treatment. He should also recommend to the Surgeon a plan for time evacuation and disposition of the sick that will meet existing needs and one that will insure uniformity in procedure throughout the command. In the course of actual tactical operations, the consultant in medicine can frequently be of aid to the task force surgeon, by recommending holding policies for the sick. Often through his efforts and influence, a considerable saving in manpower can be effected.

Medical laboratories. - Although laboratory services are under the direction of the preventive medicine service, the consultant in medicine should be cognizant of the functioning of laboratories in all of the medical installations under his supervision. He should carefully check the diagnostic methods being used and the accuracy of the results obtained. If he believes a laboratory service could be improved, he should communicate his views to the preventive medicine officer in the medical section of the headquarters and request the necessary action. The consultant should also ascertain time extent to which the ward officers on medical services rely upon laboratory tests, rather than upon clinical ability in making a diagnosis. If he thinks an excessive amount of laboratory work is being requested, he should recommend proper corrective measures to the chief of the medical service.

Medical supply. - Problems of medical supplies should rarely be the concern of a medical consultant in the U.S. Army. To be sure, local shortages may develop, but these often can be corrected by dropping a friendly word to the officers in charge of medical supplies. The consultant's greatest concern should be the requests made by medical officers for nonstandard supplies, which they have been accustomed to using in civilian practice. It is his duty to instruct medical officers in the use of those preparations found on the Armed Forces supply table. He should constantly keep abreast of all therapeutic advances and make appropriate recommendations to keep the supply table up to date. In addition, he should make all recommendations concerning the acquisition of nonstandard items that are deemed necessary for the proper prosecution of clinical investigations.


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Interpersonal relations with the headquarters staff - The consultant in medicine should not let himself become the headquarters staff or generals' doctor. He should refrain from giving medical advice or attention to his fellow staff officers unless requested to do so by the Surgeon or by the chief of medicine of the general dispensary at his headquarters. First, if he practices medicine at headquarters, he will find it next to impossible not to discuss questions involving medical policy with members of other staffs; such discussions should be left to the Surgeon or his designated representatives. Secondly, his proper work will be constantly interrupted, and his trips away from headquarters curtailed. It should be the policy of the consultant in medicine to refer, politely and in a helpful manner, all questions relating to medical treatment of staff officers to those whose duty it is to practice medicine at a headquarters.

Staff work. - The consultant in medicine should become versed in staff work as rapidly as possible. He should never forget that he functions in an advisory capacity. He should learn the proper channels for communication, should avoid going out of channels, and refrain from any activities that might create the impression he is going over the head of the Surgeon. Staff work is not too difficult if one remembers that every paper should be coordinated with all interested parties within and without the office of the surgeon of the headquarters before it is passed on by the Surgeon. It is also less difficult if one remembers that, as a principle, established channels are the most effective. A properly coordinated staff paper is rarely turned down, if only because it has been agreed to by all concerned before it is presented. The consultant in medicine should be in constant communication with the other consultants, the preventive medicine officer, the supply officer, the personnel officer, and, for that matter, with all other members of his section. Close liaison with other consultants is especially desirable because in matters of broad professional policy a united front is generally irresistible. If the consultant in medicine is functioning in an allied force, he should coordinate his professional work with his opposite allied number and should take every opportunity to visit the medical installations of the ally. At the same time, he should make certain that similar privileges are extended to his allied colleague.

Visits in the field. - When the consultant in medicine is visiting any medical installation, he should visit an appropriate cross section of the patients on the medical service in company with the chief of the medical service. During such visits, he should check on the prevalence of various diseases, diagnostic methods, therapeutic measures, the condition of patients, and the policies in force regarding disposition of patients. It is here, too, that he can do his best teaching--at the bedside of the patient.

The consultant in medicine should remember to observe military courtesy each time he visits a subordinate echelon. After reporting to the office of the surgeon of the unit he is visiting, the consultant should call upon the commanding officer of the echelon or his designated representative and explain in general lay terms the purpose of his visit. This procedure should be repeated


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FIGURE 44.-Col. Perrin H. Long, MC, Chief Consultant in Medicine, Medical Section, AFHQ, MTOUSA (formerly NATOUSA).

when the medical consultant leaves the command. Common courtesy demands that he inform the commanding officer of the observations and conclusions made during the tour. When medical installations are visited, the commanding officer or his representative should be seen first and the purpose of the visit should be explained. At the termination of his visit, the medical consultant should discuss with the commanding officer those points, both good and bad, that have been noted. This permits the commanding officer to take such corrective action as may be necessary. It obviates filling out long reports, since no further action need be taken, unless the commanding officer is either unwilling or unable to act upon the recommendations of the consultant. Finally, it is important to remember that the consultant in medicine should allow other consultants, the chiefs of medicine, and the officers working on the medical services a considerable degree of latitude in the performance of their duties, provided they stay within the bounds of the established principles of the practice of medicine. It is only by doing so that the spirit of mutual esteem, which is so necessary for the maintenance of high standards of medical service, can be preserved.

Assignment and Arrival

On 20 November 1942, the Deputy Surgeon, AFHQ, informed Lt. Col. (later Col.) Perrin H. Long, MC, who at that time was the Scientific Liaison


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Officer, Office of the Chief Surgeon, ETOUSA (European Theater of Operations, U.S. Army), that he had put in a request to the Chief Surgeon, ETOUSA, for the services of Colonel Long as consultant in medicine (fig. 44) for the American branch of the Medical Section, AFHQ. This request was refused by the Chief Surgeon, ETOUSA, but on 14 December 1942 the following radiogram was received: "C in C directs that Perrin Long Lt. Col., MC, ETOSOS be relieved from present assignment and dispatched by first available transportation and assigned to AFHQ." His new assignment was directed by a letter order dated 17 December 1942, and passage was secured for him in convoy K.M.S., 5, sailing from Glasgow, 26 December 1942, and arriving in Algiers on 3 January 1943. Reporting to AFHQ and being assigned to the medical section, by the authority contained in paragraph 5, Special Orders No. 3, AFHQ, 3 January 1943, he immediately assumed his duties as consultant in medicine.

ORGANIZATION

Allied Force Headquarters was the combined Allied command for all operations in the North African theater and the later Mediterranean theater (map 2) 1 NATOUSA (North African Theater of Operations, U.S. Army) and MTOUSA (Mediterranean Theater of Operations, U.S. Army) staff sections supervised strictly U.S. Army operations within the theater. Operational and tactical control remained with AFHQ. This control was exercised through various task forces, British Army Groups, the Seventh U.S. Army and later the Fifth U.S. Army in Italy.

At its inception as a functioning unit within the theater, the Medical Section, AFHQ, was a completely integrated special staff section because, in the early days (until June 1944), British and American interests were interlocking as regards both tactics and logistics. An officer of the British Army Medical Service (not the Royal Army Medical Corps) was Director of Medical Services and Chief Surgeon, AFHQ. The Deputy Surgeon, AFHQ, was a U.S. Army medical officer. Within the Medical Section, AFHQ, British and American components were divided into a British branch and an American branch. The American branch was allotted five officer spaces, three in the grade of colonel and two in the grade of lieutenant colonel. When the consultant in medicine arrived at AFHQ, on 3 January 1943, this branch consisted of the Deputy Surgeon, AFHQ, and executive, dental, and preventive medicine officers. The consultant in medicine made the fifth officer. In addition, Brig. Gen. (later Maj. Gen.) Albert W. Kenner was assigned to AFHQ as medical inspector, a position from which he reported directly to General

1 When the Allied forces invaded North Africa on 8 November 1942, the region was, insofar as strictly U.S. elements were concerned, a part of the European theater. NATOUSA. was established on 4 February 1943 and included northwestern Africa, Italy, and portions of the Mediterranean Sea. The theater was renamed MTOUSA on 1 November 1944 and expanded to include all of the Mediterranean Sea, Greece, and the Balkan nations. On 20 November 1944, however, base sections in southern France were assigned to the European theater. Early in 1945, MTOUSA was further diminished by assigning its African territory to the Africa-Middle East theater, On 1 October 1945, AFHQ was formally separated from MTO USA and, for all practical purposes, ceased to function.


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MAP 2. - Campaigns in North African and Mediterranean Theaters of Operation 1942-45.


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Dwight D. Eisenhower, Commander-in-Chief, Allied Expeditionary Force, without reference to the Director of Medical Services (Chief Surgeon) and the Deputy Surgeon, AFHQ.

Most of the important problems facing the Medical Section, AFHQ, were settled by conferences and committees with representatives of the British and American branches meeting jointly and bringing in recommendations to the Director of Medical Services. The American consultant in medicine, from the earliest period of his assignment to the Medical Section, AFHQ, maintained a constant liaison with his opposite number, the consulting physician in the British branch, Brigadier Edward R. Boland, O.B.E. Throughout the war, the recommendations on professional practices that were made to the Surgeon, NATOUSA, were the joint and coordinated effort of the British consulting physician and the American consultant in medicine.

Later, as the participation and responsibilities of the French increased in the war, representatives from the office of the surgeon of the French Army in North Africa joined in these conferences and committee meetings. Following the invasion of Sicily, the line of demarcation in respect to tactics, logistics, and administration between the two components of the AFHQ began to take form, and, from that time until the war ended, the actions taken by the two branches of the Medical Section, AFHQ, tended to become more unilateral. Hence, with the exception of certain problems involving the control of diseases (such as malaria), joint action resulting from the decisions of Anglo-American committees became increasingly less common.

The Medical Section, NATOUSA, came into existence in February 1943. It was not until sometime later that a table of organization (chart 1) for this section was approved. The Consultants Division, Medical Section, NATOUSA, was purposely restricted to five officers, one each for surgery, medicine, orthopedic surgery, neuropsychiatry, and chemical warfare medicine. The reason for restricting consultant spaces to five officers was based on experience gained in certain other theaters which tended to show that the need for consultants in other medical and surgical specialties, although definitely existent, was not always great enough to require the full-time services of a specialist. Moreover, it was known that a considerable number of affiliated general hospital units were to arrive in the theater, and specialists from these units could be used as consultants on a temporary duty status in the Office of the Surgeon, NATOUSA, for such periods of time as were considered necessary. In the North African, and later the Mediterranean theaters, this approach proved to be sound. Such medical specialties as dermatology, neurology, tuberculosis, and others were adequately supervised in this way without tying up valuable personnel during the periods of relative inactivity common to all theaters. An added advantage was the fresh and enthusiastic outlook of the special consultants, unjaded by periods of inactivity and the petty annoyances of normal administrative routine. No provision was made in the table of organization for a chief of professional services, because it was thought likely that the addition of such an officer would increase administrative detail without


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CHART 1.- Organization of Medical Section, North African Theater of Operations (American Medical Component of AFHQ), August 1943

serving any useful purpose. For the best functioning of the division, it was thought that each of time five consultants should have direct access to the Surgeon of the theater.

Officers assigned to the medical sections of NATOUSA and later MTOUSA also were assigned to AFHQ. These officers served in dual capacities. When dealing solely with problems concerning time operations of U.S. Army forces in the theater, they would act in their staff capacity as members of the medical section of NATOUSA or MTOUSA, but when planning, operations, or policy matters required joint action with the British, their staff actions would be carried out as members of the Medical Section, AFHQ.

Initially, an organization entitled "the Service of Supply" existed in NATOUSA, but this organization dealt solely with supplies and had no other service or administrative functions. Later, in February 1944 when the name of Service of Supply was changed to the Communications Zone, it was given true administrative, service, and operational functions over the various base sections, and at that time the American special staff sections at the Allied Force, NATOUSA-MTOUSA level became, in theory, advisory and planning sections with no operational functions.2 This resulted in the organization of large general and special staff sections at Communications Zone headquarters, which, at least insofar as the medical section at the theater headquarters level

2 The organization of such an intermediate headquarters between theater headquarters and the base sections was necessary to coordinate activities of widely separated base sections in providing logistical support for the opening of a new front in southern France. - J. B. C., Jr.


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CHART 2. - Organization of Medical Section, Mediterranean Theater of Operations (American Medical Component of AFHQ), April 1943

was concerned, caused a considerable amount of administrative and operational confusion in problems involving the ground and air forces, and the Communications Zone. NATOUSA was renamed, effective 1 November 1944, MTOUSA, and within the month 3 its medical section assumed the functions of the former medical section of the Communications Zone in addition to its theater functions. This reorganization restored to the theater surgeon all the responsibilities he had previously, before February 1944, and added an important new function in the form of a complex supply activity (chart 2). The medical section acting at theater and allied headquarters was now responsible for all medical functions of theaterwide scope.

In late 1944, all the officers then assigned to the Medical Section, MTOUSA were reassigned to AFHQ.

CONSULTANT ACTIVITIES IN VARIOUS TYPES OF MEDICAL INSTALLATIONS

In time of war, and especially in a newly established, active, oversea theater of operations, a medical officer is likely to have many tasks in addition to his assigned duties, and the U.S. Consultant in Medicine, AFHQ, was no

3 The extensive communications zone organization in southern France, consisting of Southern Line of Communications, Continental Advance, and Delta Base Sections, was made a part of ETOUSA. With the loss of this area and the area commands, the Medical Section, Headquarters, MTOUSA, again assumed direct operational control over medical matters in the original base sections that had constituted NATOUSA before preparation began for the invasion of southern France. - J. B. C.. Jr.


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exception to this rule. Initially, he was the representative of the Deputy Surgeon in all conferences and committees having to do with professional services of all types, and, because of the illness and the subsequent transfer of the preventive medicine officer to the Service of Supply headquarters, he assumed the functions of the officer in charge of venereal disease control for 2 months, those of the preventive medicine officer for 7 months, and those of the theater nutrition officer for 18 months. Summaries of the problems with which he dealt in these other capacities can be found in other volumes of this history.

In the North African and Mediterranean theaters, the function of the consultant in medicine was purely that of an advisor to the Surgeon, except in those rare instances in which, by command, he was placed on an operational or at a command level. His prime duty was to keep the Surgeon constantly and correctly informed of the standards of professional care that were being exercised in the treatment of the sick. In addition, the consultant represented the Surgeon in matters pertaining to the care of the sick, he advised the surgeons of lower echelons in respect to medical problems within their jurisdiction; he prepared circular letters upon the diagnosis, treatment, and disposition of medical patients and prepared other educational matter for medical officers; he supervised the activities of the consultants in neuropsychiatry and chemical warfare medicine; he advised the Surgeon on problems of professional personnel in the Medical Corps; he attempted to stimulate clinical research; he interpreted the policies of the Surgeon to members of the medical staff of the various hospitals in the theater; he considered himself the guardian of all medical officers, general duty, MOS 3100; and he prepared that section of the monthly ETMD (Essential Technical Medical Data) report that dealt with medicine. These duties were accomplished by constantly observing professional work in medical installations and by trying to maintain a continuous contact with medical officers throughout the theater. Because of the shifting nature of operations in the North African and Mediterranean theaters, with the resultant rapid buildups and as rapid deflations of tactical units and base sections, it was not considered expedient to have subsidiary consultants in medicine, except for the Fifth U.S. Army. A consultant was recommended, but not accepted by the surgeon of that command until the closing days of the war in Italy. As a result of this general policy, the theater consultant in medicine was away from his headquarters on tours of visits during 67 percent of the time in 1943, 74 percent in 1944, and 69 percent in the first half of 1945. It was only by being in the field that it was possible for him to fulfill his duties to the Surgeon.

Initially, the activities of Colonel Long, Consultant in Medicine, AFHQ, were limited by the uncertainties surrounding the actual position and powers of the American branch of the Medical Section, AFHQ. This section had been established primarily as a planning and advisory section; the operations of the Medical Department in the theater were to be carried out at the level of the base sections, task forces, and air force. By December 1942, however, it had


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MAP 3.- Base Sections, North African Theater of Operations, July 1944.


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become clear that the Medical Section, AFHQ, because of its position at the theater level, would have to assume the additional function of coordinating the medical activities of its subordinate echelons. As this naturally meant that the American branch had to enter the field of operations, which the original plan had not envisaged, certain administrative difficulties arose between that section and the medical sections of the lower echelons of command.

This situation created, in turn, certain difficulties for the consultant in medicine. Surgeons of some base sections (map 3) accepted him at once. Considerable education was necessary before the surgeons of other sections fully accepted him or made real use of him. Generally speaking, a period of about 6 months elapsed before the surgeons in the theater understood the duties of the consultant in medicine well enough to permit him to function properly in his assigned mission. It is only fair to add that it also took the consultant in medicine a certain period of time to learn how to function effectively within the framework of the Army in an active theater of operations.

The activities of the consultant in medicine in the North African and Mediterranean theaters were practically always limited to those of an advisory nature because operational and technical command duties were sharply limited, within the medical branch, to the Surgeon and his executive officer. The consultant advised the Surgeon, NATOUSA, and the surgeons of subordinate commands concerning the problems discussed under the various headings that follow.

PERSONNEL MANAGEMENT

One of the most important duties of both medical and surgical consultants was evaluation of medical personnel. Hospital staffs were frequently found professionally unbalanced. Some of them, particularly the affiliated units, had a surplus of talent. Others had been constituted without due regard for their special functions and the ability of their professional staffs to carry them out.

It was the practice of the consultant in medicine to review the professional attainments of medical officers assigned to the medical services of all hospitals as soon as possible after their arrival in the theater. This was done (1) by studying the questionnaires which all medical officers were required to fill out and (2) by interviewing them individually as soon as opportunity permitted.

Assignment and Reassignment of Medical Officers

If glaring errors of assignment had been made in a unit, recommendations for reassignment or transfer were made to the commanding officer immediately. Otherwise, recommendations were withheld until the consultant in medicine had been able to review the professional work of the officers in question after the unit was in operation. Then, if deficiencies were noted, appropriate recommendations were made.


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It was sometimes difficult to convince commanding officers of the need for these changes, particularly if the changes involved transferring officers of superior ability to build up weaker units. In the North African theater, the general hospitals were all affiliated units and were therefore rich sources of medical and surgical talent. Officers with such qualifications were seldom relinquished willingly, even when the new assignments might mean promotions and positions of greater responsibility for them.

At the other extreme, although the functions of the consultant in medicine included the making of recommendations for transfers, these changes were sometimes initiated without reference to his opinions and recommendations.

One difficulty which arose in the first days of action in the North African theater was not entirely settled until Api'il 1944. Because of certain command policies in effect within the theater at this time, it was not possible for representatives of the theater Surgeon to interview replacements and unassigned personnel until their completed questionnaires had been received at headquarters. This policy meant that medical officers sometimes remained in replacememmt pools for a month or more before assignment, a waste of medical manpower which the circumstances of the theater did not warrant.

In a number of instances in 1943, Medical Corps personnel entered the theater and were assigned by G-1, NATOUSA, without reference to the Office of the Theater Surgeon. This difficulty, like the one just described, was not satisfactorily settled until April 1944.

Replacements

In March 1944, a further complication was added when the Communications Zone command took over the personnel services in the base sections in addition to its already existing supply function. Thus, an intermediate echelon was created between AFHQ and base section levels, and, although the Surgeon, Communications Zone was always cooperative in respect to the recommendations of the consultant in medicine, this meant that every contemplated change in Medical Corps personnel that affected base section units had to be coordinated with still another echelon of command. Then too, at this time, because of a shortage of replacements for medical officers in combat units, it was decided that all medical officers in base section units who were under 35 years of age and physically fit were to be made available to the Fifth and Seventh U.S. Armies as needed. The responsibility for making these officers available was given to the Personnel Division, Medical Section, Communications Zone, which was presided over by a nonmedical officer of the Medical Department, who again had had little or no training in personnel problems. This really made things difficult, and this officer had to be watched constantly, because to him a captain in the Medical Corps was a captain, and hence, regardless of whether he had had specialized training or not, was material of which battalion surgeons were made. When chiefs of services or assistant chiefs of services (many of whom were diplomates of American Specialty


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Boards) were recommended for transfer to combat units by time personnel section in the Office of the Surgeon, Headquarters, Commnunjcations Zone, it was only the vigilance of the consultants that prevented serious dislocation on certain services in general and station hospitals.

In the Fifth U.S. Army, the chief of the personnel section in the Surgeon's Office was a nonmedical officer until after the surrender in Italy, and the philosophy of that office dictated that Medical Corps replacements, no matter how highly qualified they might be professionally, should serve 6 months with combat troops before they could be assigned to hospital units within the Fifth U.S. Army. The extreme example of this type of thinking occurred in the winter of 1944-45, when an officer who was a member of the American Board of Ophthalmology was assigned to a general service combat engineer unit at a the when there was a real need for well-trained ophthalmologists in the evacuation hospitals within Fifth U.S. Army.

In July 1944, Maj. Gen. Morrison C. Stayer, Surgeon, NATOUSA, having surveyed the situation, took the steps necessary to establish central control in his office of the initial assignment of Medical Corps personnel within the base sections and, to a certain degree, within the Fifth U.S. Army. To make this plan effective, he first arranged that all replacements and unassigned medical officers should be concentrated in a replacement depot close to theater headquarters and that his office should be notified by telephone on the day any medical officers arrived at that depot. Then, through the personnel section of his office, arrangements were immediately made for interviews with the newly arrived medical officers. When the professional attainments of these officers had been ascertained, they were promptly assigned by NATOUSA, and later by MTOUSA orders, to existing vacancies in medical installations in the base sections, or they were sent to the Fifth U.S. Army with recommendations respecting the type of duty they could best. perform. In effect, with this system placing the initial assignnment of these officers in the hands of the consultant staff, there was mnore chance of their being properly placed on the basis of their professional abilities, and the time they had to remain in the replacement depot was cut from weeks to a matter of a very few days. It might also be added that, following the institution of this system of personnel placement, complaints arising from alleged improper assignments were practically eliminated.

Redeployment

After V-E Day, the Commanding General, MTOUSA, directed that redeployment to the Zone of Interior and the Asiatic-Pacific areas of Medical Corps personnel assigned to hospital units be the responsibility of the Surgeon, MTOUSA. The Surgeon, in turn, delegated it to the consultant staff in his office.

These officers laid down the policy that the seventeen 500-bed station hospitals, the three 400-bed evacuation hospitals, the three field hospitals, and the two general dispensaries that had to be redeployed by MTOUSA would be


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staffed with medical officers (1) who possessed the proper MOS; (2) who had demonstrated their ability to fill their new assignments; (3) whose adjusted service ratings were below 85 points; and (4) whose ages, whenever possible, were below 40 years. It was also decided that every opportunity would be given for promotion this meant that assignments were not made in grade but in one grade below that which was called for in the tables of organization.

Although the theater was short of medical officers-in May 1945, it was operating on a basis of 4.6 medical officers per 1,000 men-it was possible to complete redeployment upon the basis of the criteria just outlined.

Classification and Promotion

One of the outstanding advances in the proper management of Medical Corps officers resulted from War Department Circular No. 232, dated 10 June 1944, which created the graded MOS numbers. As the result of his long service in the North African and Mediterranean theaters, Colonel Long was well aware of the professional qualifications of the majority of medical officers who belonged to field army or base section units. In anticipation of the responsibility for grading medical officers, he had, late in 1944 and early in 1945, interviewed chiefs of medical services of hospitals in the base sections and in the Fifth U.S. Army, as well as the majority of battalion medical officers in the Fifth U.S. Army, for the purpose of reviewing once again the professional attainments of medical officers in MTOUSA. In the actual grading, the status of each medical officer in the theater was reviewed before an MOS was assigned. The consultant in medicine was assisted in this task by Col. Donald S. King, MC, and Col. Marion H. Barker, MC, each of whom had a wide acquaintance with medical officers in the theater. It is a pleasure to be able to state that the Office of the Surgeon received only one request for a change in MOS. In this instance, the purported error had resulted from an improperly filled out questionnaire. There can be little doubt that the possession of an accurate MOS contributed more than any other factor to the proper assignment of individuals during the redeployment period.

In the Mediterranean theater, as in other theaters, the promotion of medical officers was always a problem. The number of vacancies was limited, and the number of medical officers who deserved promotion on the basis of their qualifications and performance was many times the spaces available. It is to the credit of the officers who entered the service from civilian life that, in spite of disappointments and actual injustices in this regard, they did not let them affect the excellence of their work, particularly when, as inevitably happened, less qualified officers sometimes received the promotions which they felt belonged to them or for which they had been recommended. The question of promotions was a problem which the consultant in medicine was never able to solve.


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FIGURE 45.- Open storage of medical supplies, Naples, Italy.

MEDICAL SUPPLIES

The U.S. consultant in medicine in the North African and Mediterranean theaters was much more fortunate than his British colleague, in that he rarely had to be concerned with problems of medical supplies. Aside from certain unavoidable local shortages, medical supplies (fig. 45) were always abundant, and the supply officers in the theater were most cooperative in obtaining nonstandard items that were deemed desirable for the treatment of patients or for the pursuit of research.

DISEASES OF MEDICAL INTEREST

The problems that arose in the North African and Mediterranean theaters in respect to the management of various diseases will be discussed sequentially.

Neuropsychiatric Casualties

Early in February 1943, the problem of the treatment and disposition of neuropsychiatric battle and nonbattle casualties became pressing. Since December 1942, casualties of this type had been entering British medical installations from the 18th Regimental Combat Team (U.S.), Commando and


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FIGURE 46 - British hospital ship (in foreground) Algiers, North Africa.

Ranger units. When the II Corps was committed in southern Tunisia neuropsychiatric patients began to flow into the evacuation and the surgical hospitals assigned to that Corps. Since these hospitals did not have psychiatrists on their staffs, the neuropsychiatric patients were treated on the medical wards. Because medical ward officers lacked knowledge and interest in the management of such patients, the rate of return to duty in the corps area was very low, and most of the patients were evacuated by air to the 95th General Hospital (British) in Algiers or to American hospitals in the Oran area. By the first week in February, the 95th General Hospital (British) was crowded with more than 70 U.S. neuropsychiatric casualties. This group constituted a great additional load upon the already overworked psychiatrist in that institution, and, as this British general hospital did not possess the authority for the final review and disposition of American neuropsychiatric patients, they were steadily accumulating, despite the fact that American casualties were still being evacuated to the United Kingdom in British hospital ships (fig. 46).

At the request of the Director of Medical Services, AFHQ, the consultant in medicine reviewed the situation at the 95th General Hospital (British) and made two recommendations. The first was that a medical disposition board consisting of 2 British and 1 American medical officer be created and be empowered to pass upon the status of American neuropsychiatric patients, while the second dealt with the possibility of attaching an American psychiatrist to the 95th General Hospital (British) for temporary duty. The first recommen-


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dation was immediately put into force by the Director of Medical Services, who created a special disposition board of which Maj. (later Col.) Roy R. Grinker, MC, the psychiatrist of the 12th Air Force, was the American member. This board immediately began to function, and it provided a needed mechanism for the disposition of neuropsychiatric patients coming to the rear in the British and American lines of evacuation. Because of a shortage in personnel, it was not possible to attach an Anmerican psychiatrist to the 95th General Hospital at that time.

On 12 February 1943, Colonel Long flew down to southern Tunisia at the direction of the Surgeon, NATOUSA, to investigate and make recommendations concerning the treatment and disposition of neuropsychiatric casualties in forward areas. The situation in the forward areas was very interesting. Neuropsychiatric casualties were being treated, without segregation, on the medical wards of the surgical and evacuation hospitals by inexperienced internists. The result was that more gross hysterical and conversion manifestations were developing than were ever noted before or subsequently in forward areas. Hysterical blindness, deafness, aphonia, and gross tics were common and were developing even in individuals who had entered the hospitals with but minor anxiety states. Treatment of these patients was neither individualized nor standardized, and there was ample evidence that the neuropsychiatric disturbances were spreading, in the manner of an infection, to other patients in the medical wards of the hospitals. After spending 6 days in observing the management of these patients and collecting data in respect to them, the consultant in medicine returned to AFHQ and rendered the following report to the Surgeon, on 21 February 1943:

1.This report is based on data obtained from the Medical staff of II Corps, and from interviews with medical officers of the 9th and 77th Evacuation Hospitals.

2.The problem of psychotic, psychoneurotic and anxiety states in the personnel of the A.U.S. in NATOUSA is a real one, and is becoming more acute as relatively new and untried troops are placed on combat duty. Experience in this theater, which is derived from reports of the Center Task Force and II Corps show that when troops are in battle for the first time, a considerable number of psychiatric casualties may be expected. The curve of such casualties is a sharp one which will fall rapidly as troops become acclimated to combat conditions with the exception that a secondary rise in the curve will be noted when troops are kept under battle conditions for long periods of time, as has already happened in this theater (6th Commandos, Inniskilling Fusiliers, etc.).

3. For the sake of convenience, psychiatric conditions can be roughly classified as follows:

a. Psychotic States. Unfortunately, a number of individuals with histories of previous treatment in mental hospitals have been inducted into the Army. These men are having recurrences of their psychoses. The only problem in respect to such individuals is that the nature of their psychosis be promptly recognized by the Medical Officer and the proper disposition made of them. At the present moment, many of these patients are being sent to U.K. This is not desirable because one theater of operations should not throw such a burden upon another. Whenever it is possible, psychotic patients should be sent directly to the U.S.A.      

b. Psycho-Neurotic States. The individuals who fall into this classification are those who generally have past histories which show that they were unstable in civilian life. They are the ones of whom it is frequently said, "The Army will make a man out of him."


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Unfortunately, the Army has its difficulties in such an endeavor, and has instead, a problem child on its hands. These individuals are especially hard to handle as members of combat units and, in desperation, unit commanders resort to all sorts of subterfuges to get them sent "down the line" with diagnoses of "shell shock," "gastric ulcer," etc. Upon reclassification, a fair number of these individuals will he able to perform some type of base sector duties. However, a certain group will be complete misfits in whatever unit they are placed, and because of their inaptitude or other characteristics should be sent home to be discharged under the provisions of Section VIII [Inaptitude and Undesirable Traits of Character, AR 615-360], if this section is operative in this theater.      

c. Anxiety States. Personnel suffering from these physiological and psychological disturbances should be the special concern of the Army, because with proper treatment many of them can be promptly rehabilitated for combat duty, and the majority of the remainder will perform well in the Base Sections. Individuals who are suffering from anxiety states rarely give histories of previous difficulties. The factors which produce these states are multiple. Among them are exhaustion, lack of food, equipment or munitions, poor leadership, and extremely difficult, immediate personal tactical situations. Suddenly, when these factors become operative, something happens to an otherwise balanced intellect, and an acute anxiety state is produced. Unfortunately, at the present time, the inception of these disturbances is frequently not being recognized by unit commanders or medical officers and the symptoms progress to become full blown. Then patients are frequently evacuated with a diagnosis of "shell shock" on their Emergency Medical Tag. These patients all read their Emergency Medical Tags sooner or later, and when they see the diagnosis of "shell shock" they have something that they know of, and a fixation of the psychological component of their illness frequently results. Much can be done for this group if the nature of their disturbance is understood and recognized, and the proper treatment is instituted and carried out in forward areas.

d. Exhaustion States. These disturbances are primarily physiological in nature, but are frequently misdiagnosed by forward medical officers, and hence, personnel are sent down the line of evacuation improperly labeled as "shell shock," anxiety state, or psychoneurosis. Individuals suffering from exhaustion, in practically every instance, can be treated in the far forward areas and returned to their units within a very short time.

4. Treatment of Anxiety and Exhaustion States. At the present time the treatment of these psychological and physiological disturbances in forward areas, frankly is not very good. The reason for this is that many of the Medical Officers who deal with these men really do not understand the nature of the disturbances. Sedation to the point of light anesthesia is considered by many psychiatrists to be the basis for the treatment of anxiety states, and it is not being used. None of the patients are arriving at the surgical or evacuation hospitals completely "knocked out," but instead, they are being given, for example,1˝ grains of phenobarbital, 15 grains of sodium bromide or, what is worse, morphine. Hence, with an evacuation line which is long (12 to 15 hours), plenty of time in which a fixed neurosis can develop is being allowed to elapse. The ideal place for the treatment of these patients is in the evacuation hospitals, but there again,  owing to the lack of a trained psychiatrist in such installations, the true nature of these disturbances is frequently missed, and imuproper therapy is instituted. There can be no qumestion but that the addition of a trained psychiatrist to those hospitals would not only be welcome, but also would pay large dividends in facilitating the proper sorting of psychiatric casualties and the proper treatment of anxiety and exhaustion states. As conditions exist at present, psychiatric casualties are spread over the medical wards of the evacuation hospitals, and there is evidence that they are acting as foci of infection for thespread of neuroses to other patients. This is an unhealthy situation.

5. Availability of Psychiatrists in NATOUSA. According to Major Grinker there is a dearth of trained psychiatrists in this theater. Two are in the 12th Air Force. The 12th and 21st General Hospitals have trained psychiatrists. However, the senior psychiatrist


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in the 21st General Hospital has been transferred to the 64th General Hospital. In addition to these men, there are said to be three other psychiatrists in NATOUSA.

6. It is therefore recommended on the basis of the situation as it now exists that:

a. A directive be issued stating that the term "shell shock" shall not be used as a diagnosis and that the term "anxiety state" be the sole diagnosis permitted on Emergency Medical Tag or Field Medical Record of patients who are suffering from the physiological and psychological disturbances described in paragraphs 3c of this report.

b. A psychiatrist be attached to each evacuation hospital, in order that proper sorting and treatment of psychiatric casualties can be carried out and proper instruction can be given to medical officers in battalion aid and clearing stations in the initial handling of these casualties.     

c. Psychiatric casualties be segregated from other patients.
         d. Sodium Amytal, for intravenous use in sterile 7 ˝ grain ampules, be provided for clearing stations.

   e. Five additional trained psychiatrists be assigned to this theater.

The Surgeon, NATOUSA, accepted all of these recommendations. The Surgeon, II Corps, on being queried stated that he would be glad to have psychiatrists in his evacuation hospitals, and Maj. (later Lt. Col.) Louis L. Tureen, MC, and Capt. (later Lt. Col.) Frederick R. Hanson, MC, were assigned to II Corps, with understanding that Captain Hanson would work in the forward areas. This stipulation was made because of the latter's familiarity with actual battle conditions, which he had gained in the course of commando raids and in the landing at Dieppe. On 22 March 1943, Circular Letter No. 4, entitled "Psychotic and Neurotic Patients, Their Management and Disposition," was issued by the Office of the Surgeon, Headquarters, NATOUSA. Before the appearance of this circular letter, supplies of Sodium Amytal (amobarbital sodium) had been made available in all forward areas. Thus, the policy was initiated of treating neuropsychiatric casuahities as far forward as possible. The wisdom of this policy was demonstrated during the battles for Maknassy and El Guettar (fig. 47), in the course of which Captain Hanson returned more than 70 percent of 494 neuropsychiatric casualties to combat after 48 hours of treatment, and Major Tureen rapidly rehabilitated the majority of the remainder for duty in the base section.

At the beginning of the battle for northern Tunisia the consultant in medicine held a conference with the four psychiatrists in the II Corps (two new 400-bed evacuation hospitals having been assigned to the II Corps). As a result of the conference, the II Corps commander, Maj. Gen. (later General) Omar N. Bradley, issued, on 26 April 1943, the following directive on the handling of psychiatric casualties:

    1. Evacuation Policy. - Psychiatric cases should be evacuated, treated and disposed of as rapidly as possible. The following evacuation policies will prevail for such casualties in hospitals in II Corps:

a. 11th Evacuation - 3 days

        b. 15th Evacuation - 3 days

        c. 48th Surgical - 3 days

        d. 9th Evacuation - 7 days


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FIGURE 47.-Battle of El Guettar. Foxholes and slit trenches south of El Guettar, Tunisia, North Africa, 23 March 1943.


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FIGURE 48.-Admission of "exhaustion" casualties to clearing stations.

2. Selection of Cases.

        a. If any or all corps hospitals are acting as clearing stations, the psychiatrist shall be on duty in the receiving room, sorting and labeling psychiatric casualties and seeing that further sedation is given.

        b. The following types of psychiatric disorders will he immediately evacuated to E.B.S. [Eastern Base Section:

        (1) Moderate and severe hysteria.

(2) Patients with a past history of nervous disorders.

(3) All psychogenic repeaters.

(4) All psychoneurotic disorders such as neuro-circulatory asthenia, gastrointestinal disorders, sustained ties, etc.

(5) All psychoses.

3. All psychiatric or psychogenic disturbances will he diagnosed as exhaustion in the battalion and, collecting, or clearing stations (fig. 48). The definitive diagnosis will be made in the evacuation hospitals.

4.Treatment.

a. The treatment of all psychiatric casualties in corps area will be under the direction and supervision of the psychiatrist (fig. 49) assigned or attached to the hospital.

b. In general, all psychiatric cases will be segregated for treatment.

c. Insofar as it is possible, patients will be kept under sedation from battalion aid stations to evacuation hospitals.


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FIGURE 49.-Treatment of neuropsychiatric casualty under supervision of psychiatrist.

        d. Specific Therapy. - Battalion aid or collecting stations for all psychogenic or psychiatric patients.

    (1) By mouth - Initial dose: Sodium Amytal 6 grains, or phenobarbital 4 grains, or Nembutal 4 1/2 grains.

    (2) Subsequent dosage should be adjusted to keep patients drowsy. Do not give more than 12 grains of Sodium Amytal, or 6 grains of phenobarbital per 24-hour period in the line of evacuation.

    (3) Morphine or codeine will not be given to neuropsychiatric patients.

5. Disposition. - Psychiatric and psychogenic cases should be disposed of as promptly as possible and their disposition will be in the hands of the psychiatrist. They will be sent direct to duty when possible, if not, to the replacement pool with a statement that they must be returned to duty as promptly as possible.

It may be noted that in this directive the term "exhaustion" was introduced for the first time. Of the possible diagnostic terms discussed this word was chosen because it was thought to convey the least implication of a neuropsychiatric disturbance, and probably it came closest to describing the way the patients really felt.

In the campaign in northern Tunisia, the results obtained again were excellent as approximately 70 percent of neuropsychiatric casualties were returned to combat duty within the time periods defined in the directive. One of the prime objectives of treatment in the North African theater was to reduce the period of hospitalization to the minimum consistent with the rational care of the patient. When a neuropsychiatric patient was released from the hospital an attempt was made to assign him to duty as promptly as possible. In the more severe cases, under this system, not all traces of anxiety were lost by the time the patients were assigned new duties in the base sections. It was noted


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FIGURE 50.-Brig. Gen. Frederick A. Blessé, Theater Surgeon.

by the consultant in medicine during time spring of 1943 that on many occasions reclassified neuropsychiatric casualties were given duties that frequently, often promptly, resulted in their exposure to enemy air raids. These raids produced a return of the acute symptoms of anxiety in these men, which necessitated further hospitalization. In an effort to define more carefully the types of duty to which reclassified neuropsychiatric casualties should be assigned in the base sections, Colonel Long made the following recommendations to Brig. Gen. Frederick A. Blessé (fig. 50), the Surgeon, NATOUSA, on 1 May 1943:

1. Experience is showing that certain types of neuropsychiatric casualties cannot be returned to combat duty because they quickly deteriorate and have to be evacuated to the rear.

2. Many such casualties when properly reclassified and placed on duty in quiet areas such as the ABS or MBS [Atlantic Base Section or Mediterranean Base Section] are able to fulfill their duties in a satisfactory manner. The use of rehabilitated neuropsychiatric casualties in the quiet base section also obviates the need for a certain number of replacements for such areas.

3. If, however, such rehabilitated casualties are placed in areas such as Algiers, etc., which are subjected to bombing and hence AA fire, many will revert to their neuropsychiatric state after the first bombing. It is therefore plain that such areas are not to be used for the placement of rehabilitated neuropsychiatric casualties.

4. It is therefore recommended that a statement covering the types of and places for duty be prepared and signed by station and general hospital psychiatrists for all rehabilitated neuropsychiatric casualties and that their statements he forwarded to reclassification boards with the request that they be acted upon accordingly. If this plan is carried out more useful work will be gotten out of such individuals and the chance of them repeating their neuropsychiatric syndrome will be greatly lessened.

These recommendations were accepted by the Surgeon, and from that time a conscious attempt was made to assign reclassified neuropsychiatric casualties to duties in quiet areas. Also, during the Tunisian campaign, Captain


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FIGURE 51.-Reghaia swamp, Algiers area, North Africa, 1943.

Hanson made a brilliant record in the return of neuropsychiatric patients to combat duty and in the organization of the psychiatric facilities in the II Corps. Because of this, the consultant in medicine recommended to the Surgeon, NATOUSA, that Captain Hanson be designated as consultant in neuro-psychiatry for the North African theater. This suggestion was carried out by the Surgeon early in June 1944, and subsequently the consultant in medicine acted solely in an advisory capacity insofar as neuropsychiatric problems were concerned.

Malaria

It became evident to the consultant in medicine shortly after his arrival in North Africa that, because of the frequency and severity of malaria in that area (fig. 51), special efforts would have to be made to indoctrinate American medical officers in the need for prompt survey, control (fig. 52), diagnosis, and treatment. In Circular Letter No. 6, entitled ''Treatment of Malaria,'' which was issued on 10 April 1943 by the Office of the Surgeon, Headquarters, NATOUSA, the importance of early recognition and treatment (fig. 53), was stressed, and it was recommended that the quinine-Atabrine-Plasmochin or the Atabrine-Plasmochin scheme of therapy be employed. The dosage system recommended was that advised in Circular Letter No. 135, 21 October 1943, Office of the Surgeon General. These methods of treatment were used during


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FIGURE 52.-Malaria control, Algiers area, North Africa, 1943, A. Italian prisoners of war working on minor clearing and canalization. B. Completed minor canalization for malaria control on stream on Barbe farm.


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FIGURE 53.-Making blood smear drawing for early recognition of malaria, Algiers area, North Africa, 1943.

the summer of 1943 with the following average periods of hospitalization 15 days, aestivo-autumnal malaria; 17.6 days, benign tertian malaria; and 20 days, clinical malaria.

In August, 1943, Colonel Long began to doubt the necessity for the use of Plasmochin (pamaquine naphthoate) in the treatment of malaria in U.S. Army troops in the North African theater. His reasons for this point of view were summed up in the following report, which was made to General Blessé on 2 September 1943:

Plasmochin has very little plasmodicidal effect upon malarial parasites except in the gametocyte stage.

It is the opinion of experienced malariologists in NATOUSA that, as a result of eliminating routine Plasmochin therapy in U.S. troops, adult gametocyte carriers will not increase the present rate of mosquito infection from troop sources.

The reported reduction in malaria relapses in primary cases by use of Plasmochin therapy has not been confirmed.

As Plasmochin is more toxic than Atabrine or quinine and of limited therapeutic value, it should be used only in selected relapsing patients who possess a heavy gametocyte concentration in their blood and who cannot be adequately protected from anophehine mosquitoes. It is recommended that the plan outlined in Circular Letter No. 6, Office of the Surgeon, Hq. NATOUSA, Paragraph 3a(1) for the treatment of uncomplicated malaria be abandoned.

In addition, it was thought that the time required for the hospitalization of malaria patients would be decreased if the use of Plasmochin was discontinued. At the same time, it was recommended that, if Atabrine (quinacrine


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hydrochloride) alone was used for the treatment of malaria, the dosage schedule should be changed to 0.2 gm., three times daily, until the temperature was normal, then 0.1 grn., three times daily, after meals for 5 days. This revision was motivated by the desire to build up the concentration of Atabrine in the tissues early in the disease and then, when the infection was known to be under control, to maintain an effective level of time drug over a period of days. The quinine-Atabrine method of treatment was left unchanged, as were also the directions for the parenteral use of quinine or Atabrine in severe forms of malaria. These recommendations were accepted and were published on 3 September 1943 in Circular Letter No. 32, Office of the Surgeon, Headquarters, NATOUSA. On the day after this circular letter was published, reports were received from the National Research Council indicating that Atabrine was as effective, if not more so, in the therapy of malaria than quinine (a conclusion also arrived at in NATOUSA), and giving detailed information concerning the pharmacology of Atabrine. On the basis of these reports and of information received from the Office of the Surgeon General, in addition to theater experience, it was decided to abandon the routine use of quinine and to recommend that Atabrine be used as the drug of choice in the treatment of malaria. This was done in section II, Circular Letter No. 34, issued on 14 September 1943 by the Office of the Surgeon, Headquarters, NATOUSA. In this circular letter, the pharmacology of Atabrine was discussed, and a dosage schedule of 0.2 gm. of Atabrine every 6 hours for 5 doses, followed by 0.1 gm. three times a day after meals for 6 days, was recommended for the treatnment of malaria. This method of therapy, which resulted in a reduction in hospitalization required for malaria to an average of 11 days for all cases, was maintained as the method of choice for treating malaria throughout the life of the theater, except that a temporary modification was made in respect to the treatment of relapsing malaria in February 1944.

At this time, a considerable number of patients were being seen with three, four, or more relapses of benign tertian malaria. After consultation with the theater preventive medicine officer and the malariologist, the following suggestions for the treatment and disposition of patients ill with relapsing malaria were published in section III, Circular Letter No. 10, 15 February 1944, Office of the Surgeon, Headquarters, NATOUSA:

Relapsing Malaria

1. Experience has shown that despite various treatment regimes malaria is a disease prone to relapse, especially when the infection is caused entirely or in part by Plasmodium vivax. This letter deals with treatment of relapses and disposition of malaria patients to the Zone of the Interior.

2. First and second relapses of malaria should be treated like a primary attack, using the system of therapy outlined in Section II, par. a (1), Circular Letter, No. 34, Office of the Surgeon, Hq. NATOUSA, dated 14 September 1943.

3. Third and subsequent relapses should be treated with quinine according to the following 10-day regime:

a. Quinine sulfate 1.0 gram (15 grains) by mouth three times daily after meals for the first three days.


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b. Quinine sulfate 0.32 gram (5 grains) by mouth three times daily after meals for the next seven days.

4. The use of adrenalin followed by Atabrine or quinine (so-called Ascoli method) is not recommended because its value has not been demonstrated.

5. Every method of adjuvant therapy should be employed as indicated to restore the physical condition of malaria patients. Of special value are:

a. High caloric, high meat protein diets.

b. Multivitamin pills or capsules.

c. Transfusion when patient is very anemic.

d. Ferrous sulfate in appropriate doses.

6. It is not logical to set up absolute criteria for disposition to the Zone of Interior of personnel who have had one or more attacks of malaria. Some patients are ill better physical condition after several relapses than other patients after a primary attack. Patients who develop chronic malarial cachexia, persistent splenomegaly, or recalcitrant anemia should be considered as subjects for evacuation to the Zone of the Interior.

It is to be noted that in this circular letter time use of epinephrine in the treatment of malaria was not recommended-a move to counteract the influence of the teachings of Ascoli-and that a policy for the disposition of patients ill with relapsing malaria was established. That part of Circular Letter No. 10 that dealt with the use of quinine in the treatment of relapsing malaria was rescinded in paragraph 4e, Circular Letter No. 41, 29 July 1944, Office of the Surgeon, Headquarters, NATOUSA, after it became apparent that therapy with quinine did not alter the rate of relapse in malaria. In Circular Letter No. 41, the importance of the physical rehabilitation of malarial patients was again stressed, and a directive that all patients convalescent from relapsing malaria should receive 0.1 gm. of Atabrine daily, for 7 days a week, regardless of whether they were in a "safe" or "dangerous" area, was issued. No other changes in policy for the treatment or disposition of cases of malaria were made until after the surrender of the enemy in Italy in May 1944, when it was recommended verbally by the Surgeon, MTOUSA, that patients suffering from frequently relapsing malaria should be sent to the Zone of Interior.

Dysentery

The threat of dysentery-both bacillary and amebic-seemed great in the early part of 1943. As a result of the recommendations made by Colonel Long, Circular Letter No. 9 was issued on 6 April 1943 by the Office of the Surgeon, Headquarters, NATOUSA. Diagnosis and treatment were discussed

in this directive. The highpoints of this circular letter were the recommendations that sulfaguanidine was the drug of choice for the treatment of bacillary dysentery and that the course of emetine hydrochloride to be used in the therapy of amebic dysentery should be of 10 days' duration, rather than the customary 6 days. This latter recommendation was made upon the advice of the British consulting physician, who had had an extensive experience in the treatment of amebic dysentery in soldiers in Egypt. It is believed that the wisdom of this advice was borne out by the experience of the theater.


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In September 1943, in paragraph VIIb of Circular Letter No. 34, the more extensive use of sulfadiazine for the treatment of bacillary dysentery was advocated, and, in paragraph IIl.a(1) of Circular Letter No. 24, 15 April 1944, Office of time Surgeon, Headquarters, NATOUSA, it was stated that for time treatment of bacillary dysentery "sulfadiazine is the drug of choice with sulfaguanidine and sulfathiazole following in the order named." This recommendation was made because, under the conditions existing in the theater, it had been found that sulfadiazine was an effective, practical drug. Time inference that it was therapeutically superior to sulfaguanidine in the treatment of bacillary dysentery could not be drawn, as both appeared to be equally effective, but sulfadiazine was easier to administer to patients because of the smaller doses and less frequent dosage periods required for its use.

In the spring of 1944, during the offensive from the Hitler to the Gothic Line, the hospitals in Italy were very busy, and it became common practice to discharge from hospitals patients suffering from amebiasis, with instructions to take a second course of carbasone while on a duty status. As a consequence, the second course of carbasone frequently was not completed, and relapses often occurred. in paragraph 3 of Circular Letter No. 41, 29 July 1944, Office of the Surgeon, Headquarters, NATOLTSA, this practice was condemned, and instructions were given that all patients suffering from amebic dysentery should remain hospitalized until their treatment had been completed. It is unfortunate that a true evaluation of the effects of the recommended therapy for amebic dysentery in the North African and Mediterranean theaters could not be made because adequate diagnostic criteria for the disease could not be formulated, and relapses frequently could not be distinguished from possible reinfections. Curiously enough, probably because of good sanitation, amebic infection was never a real problem in NATOUSA or MTOUSA.

Poliomyelitis

In the summer and fall of 1943, 1944, and 1945, the question arose concerning the treatment and disposition of patients suffering from acute anterior poliomyelitis. The policy in respect to the treatment of such patients, based upon the recommendations made by the Conference on Poliomyelitis of the National Research Council-which did not recommend the Kenny Treatment -was laid down in Circular Letter No. 42, 1 November 1943, Office of the Surgeon, Headquarters, NATOUSA. Standard Drinker respirators were not requisitioned by the theater, because these could be borrowed from the British, and patients with paralysis that persisted after the acute phase of the disease were evacuated to the United States.

Infectious Hepatitis

The epidemic of infectious hepatitis, which began in August 1943 and mounted rapidly to its peak in November of that year, caught the North


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African theater in a state of intellectual and physical unreadiness. All medical officers were familiar with a disease called catarrhal jaundice, which in their clinical experience had been essentially a mild disease occurring, without sequelae, in children and young adults. It was difficult for them to comprehend what was happening-and this was true of others who did not witness the epidemic-when, within 4 months, more than 14,000 cases of hepatitis were admitted to hospitals. They sought aid from their textbooks, from their elders, and from their consultant in medicine, to little avail, because this was something new in the experience of most medical officers. To be sure, a number of them had witnessed numerous cases of jaundice following vaccination against yellow fever in 1942, but this naturally occurring disease appeared to be different. Also, none of the medical officers, with possibly two exceptions in the theater, had followed their cases of hepatitis in 1942, with the numerous correlations that are so necessary if the clinical picture of a disease is to be obtained. Thus, the fall of 1943 can be considered as a period in which medical officers began to learn about infectious hepatitis at the bedside.

It was also a difficult period for the patients, because with the successful assault on Italy, many hospitals moved from North Africa to Italy, where it took time to set up these installations, with the result that there was a constant pressure upon medical officers to return patients to duty in order that beds might be made available for additional sick and wounded flowing into the base from the Army Air Forces and the Fifth U.S. Army. At the same time, the B ration had become badly unbalanced owing to the substitutions and eliminations always made in that ration during periods of stress. The total situation was difficult-medical officers were dealing with a disease about which little was known, hospitals beds were at a premium, and the hospital ration was unbalanced. In the course of a tour of inspection of hospitals in PBS (Peninsular Base Section) and the Fifth U.S. Army made in December 1943, Colonel Long noted that marked variations existed in the therapy, period of hospitalization, and disposition of patients ill with hepatitis. There was no unanimity of opinion among medical officers concerning the management of the disease, and it appeared that unless action was initiated, a chance to make a fundamental contribution in respect to management would be lost. The Surgeon, Peninsular Base Section, requested the assistance of the consultant in medicine with this problem. The latter recommended that, as soon as the l2th General Hospital arrived in Naples, Colonel Barker be given the task of assembling pertinent information concerning the diagnosis, treatment, and disposition of patients suffering from infectious hepatitis. This recommendation was made because it was known that Colonel Barker had studied the hepatitis that followed vaccination against yellow fever in 1942 at Camp Custer, Mich. Colonel Barker began his work early in 1944 and obtained enough information to permit the consultant in medicine to make


177

the following report to the Surgeon, Peninsular Base Section, on 1 March 1944:

          *             *            *            *             *             *            *

2. Within the past few weeks, recurrences of hepatitis with and without jaundice, which are marked by anorexia, dyspepsia, fatigue, or enlarged, painful or tender liver, have become increasingly frequent. These recurrent manifestations of hepatitis are very similar to those noted in the course of the epidemic of hepatitis which followed inoculation with certain lots of yellow fever vaccine. To date, however, the severe instances of the disease marked by a rapidly progressing cirrhosis of the liver with ascites have been rare. Thus, it has become clear that in the present outbreak of hepatitis, the sequelae which marked the jaundice following the yellow fever inoculation are being repeated.

3. It is impossible to state exactly how much of a role insufficient hospitalization and convalescent care play in the production of the recurrences or relapses of hepatitis because adequate data upon this point are not available. However, evidence is accumulating which shows that many cases of hepatitis appear to be discharged from hospitals, convalescent sections, and even from personnel centers before the disease is completely arrested and as a result of these premature dispositions, recurrences or relapses of the disease are occurring.

4. If experience repeats itself, recurring waves of hepatitis with and without jaundice may be expected in this theater until troop dispersal is effected after the cessation of hostilities. It is therefore necessary to enunciate as promptly as possible, those criteria which will enable medical officers to dispose of cases of hepatitis as efficiently as possible in order that a maximum of fit individuals be returned to duty. However, absolute criteria for making efficient dispositions are still in the experimental stage and a final answer awaits the accumulation of experimental data. However, certain observations have been made which are helpful in determining the physical status of patients who have been ill with hepatitis. These are:

a. Freedom from clinical jaundice with an icterus index which is within normal limits.

b. The absence of signs of anorexia, dyspepsia, or food intolerance when the patient is placed upon the expeditionary force 'B' ration.

   c. Lack of fatigue at the end of the day, and the absence of any liver enlargement, pain, or tenderness late in the afternoon after the patient has been up all day. The enlargement must be determined with the patient in the upright position, and the tenderness can best be elicited by a light quick blow with the doubled fist applied just below the costal margin in the right anterior axillary line.

  d. Work and exercise tolerance must be adequate and not produce jaundice, dyspepsia, liver enlargement, pain or tenderness. This is best determined by putting patients convalescing from hepatitis through a graduated series of exercises followed immediately after each exercise or work period by careful observation for the appearance of jaundice, anorexia, dyspepsia, undue fatigue, or enlarged, painful, or tender livers.

5. Patients suffering from hepatitis with or without jaundice who show a persistence of jaundice, anorexia and dyspepsia, undue fatigue or enlarged, painful or tender livers should be evacuated from field, station, and convalescent hospitals to general hospitals for further observation, treatment and disposition. All such cases and all recurrent or relapsing cases of hepatitis should be carefully observed according to the suggested schedule as outlined above, and if jaundice or dyspepsia persists or work and exercise tolerance tests do not show a progressive improvement, and the liver continues to become large, painful or tender, then such patients should he carefully considered by the medical disposition boards of general hospitals as candidates for evacuation to the Zone of the Interior.

6. In order to facilitate the efficient handling of patients suffering from hepatitis, the following recommendations are made to The Surgeon, Peninsular Base Section:

a. That a Surgeon's Circular upon the subject of hepatitis, compiled by Lieutenant Colonel Marion Barker and the Consultant in Medicine NATOUSA, be issued immediately to all medical officers in PBS.


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FIGURE 54.-23d General Hospital situated between Bagnoli and Naples, Italy

b. That Major Richard Capps be placed on temporary duty with the authority to visit all hospital installations in PBS for the purpose of educating medical officers on medical services of the hospitals in procedures which are of proven value in assisting medical officers to arrive at correct decisions concerning the disposition of patients suffering from hepatitis.   

c. That every facility be given Lieutenant Colonel Barker in the prosecution of his investigation upon accurate functional tests for the diagnosis, evaluation and disposition of patients suffering from hepatitis and in order to hasten his investigations, that fifty (50) beds be allotted for new cases of suspected or actual hepatitis in the 225th Station hospital, while all recurrences or relapses and protracted instances of jaundice, dyspepsia, or enlarged painful or tender livers (hepatitis) will be routed to the 21st, 23d (fig. 54), or 45th General Hospitals after Monday, the 6th of March, 1944. This last could be made effective by a memorandum to commanding officers of PBS hospitals at The Surgeon's conference on March 6th.

The recommendations contained in this report were accepted by the Surgeon, Peninsular Base Section, with minor modifications, such as the suggestion that the proposed circular letter be issued by time Surgeon, NATOUSA, and that all investigative work be carried out in the 182d Station Hospital, in which 100 beds were allotted for the study. Thus, in March 1944, a concentrated attack on the disease was initiated under the general supervision of Colonel Barker, who was assisted by Lt. Col. Ross L. Gauld, MC, and Lt. Col. Harold H. Golz, MC, Maj. (later Lt. Col.) Richard B. Capps, MC, and, as the program developed, by many other medical officers in the theater. On 28 March 1944, Circular Letter No. 19, subject: Infectious Hepatitis, was issued by the Office of the Surgeon, Headquarters, NATOUSA.

Circular Letter No. 19 was rescinded by Circular Letter No. 37, which was issued on 8 July 1944 from the Office of the Surgeon, Headquarters,


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NATOUSA. This circular letter brought up to date the available information in respect to infectious hepatitis and stressed the therapeutic effects of a high-protein, low-fat, high-carbohydrate diet. Circular Letter No. 37 drew severe criticism from certain officers of the Medical Consultants Division, Office of the Surgeon General, because of their disbelief in the existence of certain of the clinical types of the disease that had been described, their disagreement with the diagnostic criteria that had been established their dislike of the method of treatment that had been prescribed, and finally their fear that the regime employed in the treatment of these patients would produce psychoneurotics. That these criticisms were unjustified was demonstrated by the record of the theater in respect to the diagnosis, treatment, and disposition of patients with infectious hepatitis.

In the fall and early winter of 1944, hepatitis again became epidemic in MTOUSA. This time, the air force and base section troops came off almost unscathed, and the bulk of the cases were reported from the infantry units of the Fifth U.S. Army. This outbreak provided another excellent opportunity for time study of the disease. Important contributions were made by medical officers in respect to the value of the various tests of liver function in early diagnosis; the importance of using the high-protein, how-fat, high-carbohydrate diet was confirmed; the necessity of using the exercise-tolerance test for establishing cure was reaffirmed; and important pathological studies were made by Maj. Thomas N. Horan, MC, Lt. Col. Tracy B. Mallory, MC, and Capt. Leslie S. Jolliffe, MC. These investigators utilized the peritoneoscope for obtaining biopsies of the liver in various stages of the disease. It can be said without hesitation that the management of cases of hepatitis during the fall and winter of 1944-45 was infinitely superior to that of the previous winter. The total experience of the theater regarding the diagnosis, treatment, and disposition of patients ill with infectious hepatitis was summed up in Circular Letter No. 21, issued on 20 June 1945, by the Office of the Surgeon, Headquarters, MTOUSA, subject: Infectious Hepatitis.

Diphtheria

Although diphtheria never became epidemic in the theater, it always caused concern because of the relative unfamiliarity of most U.S. practitioners with the disease in young adults and because deaths from diphtheria were always tragic and avoidable. Circular Letter No. 37, issued on 2 October 1943, by the Office of the Surgeon, Headquarters, NATOUSA, stressed the importance of the early diagnosis and treatment of diphtheria. In this letter, the use of large doses (from 50,000 to 250,000 units) of antitoxin was recommended, and the necessity for keeping soldiers ill with diphtheria in bed for considerable periods of time (from 2 to 4 weeks or more) was indicated. These injunctions were based upon realization that the definitive treatment of the disease in soldiers would probably occur at a later period than in civilian patients. With the apparent demonstration within the theater that therapy with penicillin


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FIGURE 55.-Winter in Italy, 1943


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FIGURE 56.- Trenchfoot, Fifth U.S. Army, 1943.

was of some value in eliminating Cornebacterium diphtheriae from the throats of carriers, the therapeutic use of this antibiotic in conjunction with large doses of antitoxin was recommended in section II, Circular Letter No. 51, dated 19 October 1944, Office of the Surgeon, Headquarters, NATOUSA. Although attempts were made to assess the value of the combined therapy, it was impossible to arrive at any definite conclusion.

Trenchfoot

In the late fall and winter of 1943 (fig. 55), conditions of climate and terrain were such in the area opposite the Hitler Line, to the north of the Volturno River, that about 6,000 cases of trenchfoot occurred in the Fifth U.S. Army (fig. 56). For reasons unknown, the disease was considered a surgical rather than a medical emergency, and the advice of the consultant in medicine was not asked until February 1944. At that time, the Surgeon, Peninsular Base Section, was confronted with the problem of what to do with several thousand individuals who had had trenchfoot of varying degrees of severity. Unwisely, an attempt had been made to send some of these men back to combat duty, but, as the same conditions that had produced the injury prevailed, relapses of trenchfoot occurred. In a report made to the Surgeon, Peninsular Base Section, on 2 March 1944, the consultant in medicine gave the following advice, which was accepted:

The solution of the problem is relatively simple. With the return of the feet apparently to a normal condition these men should be sent to personnel centers where they should be

4 A detailed discussion of the serious losses which occurred from cold injury among U.S. Army personnel in World War II appears in Medical Department, United States Army. Cold Injury, Ground Type. Washington: U.S. Government Printing Office. 1958.


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organized immediately into separate battalions and then a gradual process of conditioning for combat should be instituted. The only care which must be taken in this program is that it be gradual, that during the next six weeks these men must not be exposed to freezing or near freezing weather under conditions in which their feet will be damp or wet, and their feet must be kept dry and warm. It might be advisable to have two medical officers, one experienced in the treatment of "Trench Foot" and one in orthopedic surgery attached to these battalions during the training period. It would seem quite certain that if this program could be activated immediately, a considerable group of experienced veterans would be ready for combat by 15th of April, 1944.

During the late spring and early summer of 1944, certain incapacitating late sequelae of trenchfoot were noted, and, in Circular Letter No. 41, 29 July 1944, Office of the Surgeon, Headquarters, NATOUSA, it was recommended that patients showing the following signs should either be placed on limited duties or be evacuated to the Zone of Interior:

          *             *            *            *             *             *            *

    (1) Pain and swelling of the feet after walking short distances.

    (2) Loss of cornified epithelium on the soles, resulting in tender "tissue paper" skin which is very prone to blister.

    (3) Hyperhidrosis with vasomotor changes.

    (4) High rate of epidermophyton infection.

   (5) Atrophy of the subcutaneous [tissues] and muscles of the feet which results in an acute breakdown of the transverse and longitudinal arches and which at times is so marked that shoes of smaller size may be required.

Early in the fall of 1944, a conference was held with the Surgeon, Peninsular Base Section, the theater consultant in surgery, and certain interested medical officers upon the subject of trenchfoot. The recommendations made by this group, after being coordinated with the Surgeon, Fifth U.S. Army, were incorporated in Circular Letter No. 2, issued on 2 January 1945, by the Office of the Surgeon, Headquarters, MTOUSA. They read as follows:

          *             *            *            * *          *             *

4. The management of "trench foot" in the first echelon:

a. Unless actual gangrene or a superimposed clinical infection requiring immediate surgical care is found, all patients suffering from "trench foot" should be sent to the medical services of first echelon hospital units. [Evacuation and Field Hospitals].

          *             *            * *          *             *             *

5.The management of "trench foot" in the second echelon:

    a. Patients suffering from "trench foot" sufficiently severe to require evacuation to the second echelon usually should be treated in general hospitals. Patients will be admitted to the surgical service in the second echelon hospitals upon presence of gangrene or infection for which surgical treatment is necessary. Otherwise, they will be sent to the medical service of these hospitals.

          *             *            *            *             *             *            *

6.The proper disposition of patients suffering from "trench foot" should be a matter of primary concern to the disposition boards in station and general hospitals of the second echelon. It must be remembered that while it is the primary duty of the Medical Department to maintain [conserve] manpower, patients sent back to general or limited assignments must be able to perform the duties recommended by the Medical Corps. It is of little value to send back a man who will promptly become a physical liability to a service or combat unit. Hence, the case


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of each patient must be strictly individualized by disposition boards, and the type of duty recommended be based upon the known fact that a patient who has suffered from "trench foot" is very susceptible to cold and wet and may be unable to march or stand for periods of time without producing a return of symptoms. Therefore, the following broad criteria are suggested for the disposition of these patients:

    a. General Duty. The patient must he able to pass an exercise tolerance test similar to that outlined for hepatitis in Circular Letter Number 37, Office of the Surgeon, Headquarters NATOUSA, dated 8 July 1944. The skin of the feet should be normal, free from lesions or loss of subcutaneous tissue, and anesthesia, paresthesia or marked hyperhidrosis should not be present.

b. Limited Assignment. The patient should be able to stand a two mile walk or two hours on guard duty. The skin of the feet should be normal, free from infections or loss of subcutaneous tissue, and anesthesia, paresthesia or hyperhidrosis should not be present. In recommending the patient for limited assignment it should be stressed that he should be kept away from the cold and wet.      

c. Patients not falling into the two categories mentioned above, should be considered individually as possible candidates for evacuation to the Zone of the Interior.

Fortunately, owing to the provision of more suitable footwear and to the static nature of the tactical situation in the northern Apennines during the winter of 1944-45, trenchfoot was not the problem that it had been the previous winter.

Sandfly Fever

A minor, though real problem encountered by Colonel Long during 1943-44 was the hesitancy of medical officers in making the diagnosis of sandfly fever. In the summer of 1943, this disease was prevalent in Tunisia and Sicily and, later, on the Salerno beachhead. Despite the fact that the clinical picture was clear cut, the diagnosis of sandfly fever was made in only a small fraction of a percent of the total cases, with the result that FUO (fever of undetermined origin) was reported to a degree entirely out of proportion to its actual occurrence. This situation resulted from an unfamiliarity with the disease, from lack of a diagnostic test for it, and from intellectual laziness on the part of medical officers. Despite an intensive education campaign carried out in 1943-44, it may be said that it was not until the summer of 1945 that the reporting of sandfly fever became satisfactory.

Tuberculosis

Late in 1943, the 46th General Hospital, Mediterranean Base Section, the 6th General Hospital, Atlantic Base Section, the 24th General Hospital, Eastern Base Section, and later, early in 1944, the l7th General Hospital, Peninsular Base Section and the 26th General Hospital, Adriatic Base Section, were designated as centers for the diagnosis, reception, treatment, and disposition of patients suffering from tuberculosis. This plan of hospitalization was originally recommended because Colonel Long believed, on the basis of his observations in station and general hospitals, that the diagnosis, treatment, and disposition of tuberculosis patients was not being very well managed because of a lack of knowledge of the disease and lack of interest, once the


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diagnosis had been made, on the part of most medical officers. During the latter part of 1943, these centers, especially the one in the Mediterranean Base Section, functioned well, but owing to a lack of understanding on the part of medical officers in other hospitals of the fundamental purposes of these centers, they did not reach high standards of efficiency until the following memorandum dealing with their function was published, at first locally in the Peninsular Base Section, June 1944, and later in Circular Letter No. 41, Office of the Surgeon, NATOUSA, 29 July 1944:


          *        *          *            *            *             *             *

a. All patients suffering from active tuberculosis will be sent from other hospitals to the general hospitals which have been designated as "tuberculosis reception centers" as soon as the diagnosis of active tuberculosis is made. The "tuberculosis reception centers" will manage and dispose of all patients suffering from active tuberculosis.          

b. All patients in whom the activity of a recent or old tuberculosis is a matter of doubt will be sent to a "tuberculosis reception center" for an evaluation of their status, and if follow-up checks are desirable, patients with doubtful lesions will be returned to a "tuberculosis reception center" after the advised interval, for the necessary diagnostic tests. The "tuberculosis reception centers" will maintain in their patient record file, adequate records of patients in whom the diagnosis of tuberculosis is doubtful, and will preserve all X-ray films of such patients until the case is closed. These records will be made available to other "tuberculosis reception centers" upon request.

c. It will be the responsibility of the commanding officers of the "tuberculosis reception centers" to notify the medical officer of any organization, in which an "open case" of tuberculosis is discovered, of the existence of such a case, and it will then be the responsibility of the unit medical officer to initiate promptly such studies as are considered necessary for the detection of pulmonary tuberculosis in intimate contacts of the patient.      

d. Patients suffering from active tuberculosis or in whom there is a question of activity which will necessitate follow-up studies, will he evacuated promptly from all medical installations to the nearest "tuberculosis reception centers." In order to facilitate the routing of such patients, the hospital destination of the patient will be prominently noted upon MD Form 52d.

Following the publication of this circular letter, the triage of patients suffering from tuberculosis to the "tuberculosis centers" became excellent, and with it the care and disposition of the patients markedly improved.

Dermatological Conditions

By the fall of 1943, it became evident to the consultant in medicine that an improvement could be made in the methods used for the management of patients with diseases of the skin. After considering various measures to accomplish this end, he communicated his views to the Surgeon, NATOUSA, in the following letter dated 13 November 1943:

1. Dermatological conditions (excluding syphilis) are not being properly treated in NATOUSA. This is especially true of eczema and fungus infections of the hands and feet.

2. There are few qualified dermatologists in NATOUSA.

3. Two excellently trained dermatologists are upon the staff of the 46th General Hospital while one well trained and one fairly well trained dermatologist are upon the staff of the 64th General Hospital.

4. When the opportunity offers itself shortly, an appraisal will be made of the dermatologists in the General Hospital PBS.


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FIGURE 57.-64th General Hospital, Leghorn, Italy, 1945.

5. It is recommended that the 46th General Hospital MBS and the 64th General Hospital (fig. 57) EBS he designated as dermatological centers and that the facilities of these hospitals he made available for consultation, diagnosis and treatment of skin diseases within their respective Base Sections.

These recommendations were accepted. Early in 1944, a third dermatologic center was opened in the 45th General Hospital in Naples. It can be said without hesitation that the establishment of these centers created a renewed interest in dermatologic problems and that a definite improvement was effected throughout the theater in the treatment of diseases of the skin.

PENICILLIN

The medical use of penicillin in the North African theater began in the late summer of 1943. At that time, because the supply of the agent was limited, its use was restricted to cases in which sulfonamide therapy fell short of expectations. During the fall of 1943, the supply became more abundant, and, upon the recommendation of Colonel Long, most of the penicillin that was available for medical purposes was devoted to the treatment of gonorrhea which had proved resistant to therapy with the sulfonamides. By the end of the winter of 1944, enough penicillin was available in the theater to permit a more general use of this antibiotic. The full treatment of all cases of gonorrhea


186

and syphilis with penicillin was initiated on 1 August 1944. It was the policy in the North African theater to follow the instructions received from the Office of the Surgeon General concerning the medical uses of penicillin. As a result, there was little experimentation with the product, and it is felt that penicillin was both effectively and economically used in the theater.

DISPOSITION OF PATIENTS TO ZONE OF INTERIOR

The opening of the Italian campaign and the subsequent activation of the Peninsular Base Section with its numerous general hospitals created a problem in the disposition of patients to the Zone of Interior, which had not existed to any degree when the general hospitals were situated in North Africa. During the late fall and winter of 1943-44, many patients had to be evacuated to North Africa from Italy in order that a reasonable status of vacant beds might be maintained for army contingency that might arise. This meant that many patients, recommended by the medical disposition boards of general hospitals in Italy, were sent to hospitals in North Africa (fig. 58) to await evacuation to the Zone of Interior. In December 1943, complaints were heard from the general hospitals in Italy that many such patients, being reviewed by the medical boards of the general hospitals in North Africa, were being returned to a general service category. As a result, these men were then returned to their units in Italy, where, within short periods of time, they frequently had a return to their original disease and were rehospitalized, thereby necessitating a complete clinical review of the case with the attendant paperwork and other necessary processing. By the first of 1944, the situation reached a point where the medical services of the general hospitals in Italy and in North Africa began to question each other's professional qualifications.

At the direction of the Surgeon, the consultant in medicine made a thorough study of this problem and came to the conclusion that the root of the evil lay in a misunderstanding on the part of the general hospitals in North Africa of the environmental conditions existing in forward army, air force, and base areas. Upon the recommendation of the consultant in medicine, the Surgeon, NATOUSA, issued instructions in Circular Letter No. 21, dated 3 April 1944, concerning the disposition of patients from medical services. These instructions were based upon the natural history of certain diseases as observed in the theater and upon an appraisal of environmental factors that might influence the course of certain diseases. In formulating this policy, special consideration was given to establishing stringent criteria for the medical disposition of key commissioned personnel and Medical Corps officers. The important points of policy established were as follows:

1. The following memorandum is based upon experience gained in this Theater and is to be used as a guide by medical officers in formulating the disposition of certain patients from field, evacuation and station hospitals to general hospitals and from the latter to the Zone of the Interior. This memorandum is to be used as a guide and not as a directive and should be so interpreted by medical disposition boards of general hospitals, especially when such boards are dealing with the disposition of medical officers or other key commissioned


187

personnel. It is of paramount importance that the manpower needs of the theater be safeguarded, but at the same time it is incumbent upon medical disposition boards to make a careful estimate of each patient's potential effectiveness, in order that effective manpower may be maintained at the highest level, and multiple admissions to hospital, resulting from recurrent or chronic disease be reduced to a minimum.

2. A study of the natural history of disease in NATOUSA has demonstrated that under the conditions which exist in this theater, the occurrence of the following disease entities in patients may be construed as relative indications that such individuals should be considered as candidates for limited service assignments (if medical officers or key commissioned personnel), or for evacuation to the Zone of the Interior. When the indications for evacuation out of the theater are considered absolute, such a statement will be made

a. The existence of the following disease entities may be considered as an indication that the patient should be evacuated to the United States.

    (1) Virus diseases.

        (a) Anterior poliomyelitis with persistent paralysis. (b) Encephalitis lethargica (von Economo's disease). (c) Equine encephalomyelitis.

     (2) Bacterial diseases.

     (a) Diphtheria with a complicating persistent (6 weeks) paralysis, or any definite cardiac involvement. Care should be exercised to see that patients in the latter group are not evacuated until they are entirely free from clinical signs of cardiac involvement and essentially free from electrocardiographic changes. (h) Typhoid fever complicated by multiple relapses or by perforation of the ileum, generally requires a prolonged period of convalescence and such patients should be evacuated as soon as their conditions permits. (c) Recurrent undulant fever. (dl) Active pulmonary or other types of active tuberculosis. (e) Mycotic infections such as actinomycosis, blastomycosis, streptothricosis or sporothricosis,

(3) Protozoan infections.

         (a) Malaria with chronic cachexia, resistant anemia, blackwater fever, repeated attacks of the cerebral type, or with repeated attacks of the disease and a permanently enlarged spleen. (b) Recurrent amoebic infection which is resistant to therapy or which has produced a chronic colitis.

(4) Diseases of doubtful origin.

    (a) Acute or chronic rheumatic fever. (b)Disseminated lupus erythematosus. (c) Sarcoid.      

(5) Diseases due to allergy.
            (a) Asthma which is persistent, resistant to therapy, or to changes of environment, or which due to frequency of attack renders the diseased individual ineffective.

    (b) Recurrent, treatment-resistant, disabling angioneurotic edema.

(6) Diseases due to chemical agents.

    (a) Chronic lead poisoning with encephalopathy or hypertension and vascular changes. (b) Proven, persistent damage to the hematopoietic system produced by chemical agents.

(7) Diseases due to physical agents.

    (a) True sunstroke (not heat exhaustion). (h) Frost bite with gangrene resulting in incapacitating amputations.

(8) Diseases of metabolism.

    (a) Diabetes in enlisted personnel. (h) Proven gout. (c) Diabetes insipidus.

(9) Diseases of the digestive system.

    (a) Proven peptic ulcer in enlisted personnel. (b) Proven cases of mucus or spastic colitis. (c) Regional ileitis. (d) Recurrent intestinal diverticulitis. (e) Proven chronic pancreatitis. (f) Cirrhosis of the liver. (g) Chronic persistent, infectious hepatitis. (h) Relapsing or recurrent infectious hepatitis, with or without jaundice, which relapses or recurs despite adequate periods of convalescence and reconditioning.


188

FIGURE 58.-Air evacuation from Italy to North Africa.


189

FIGURE 58.- Continued


190

(10) Diseases of the respiratory system.

    (a) Chronic, persistent bronchitis associated with physical signs and X-ray changes. (b) Clinical, radiographically proven, moderate or severe bronchiectasis. (c) Subacute or chronic lung abscess.      

(11) Diseases of the kidney.

    (a) Paroxysmal hemoglobinuria. (b) Acute or chronic glomerular or interstitial nephritis. (c) Nephrosis. (d) Proven pyelonephritis. (e) Pyo- or hydronephrosis with decreased function in the other kidney.

(12) Diseases of blood-forming organs.

    (a) Treatment resistant secondary anemias. (b) Pernicious anemia in enlisted personnel. (c) Leukemia or lymphosarcoma. (d) Hodgkin's disease. (e) Idiopathic thrombocytopenic purpura with enlarged spleen. (f) Hemolytic icterus. (g) Hemophilia. (h) Banti's disease.

(13) Diseases of the circulatory system.

    (a) Chronic valvular heart disease except those instances in which the lesions are minimal and there is no history of recent rheumatic attacks. (b) Syphilitic valvular disease or aneurysm. (c) Subacute bacterial endocarditis. (d) Proven, chronic, myocardial disease with signs of functional failure. (e) Proven essential hypertension in enlisted personnel. (f) Thrombo-angiitis obliterans. (g) Proven coronary occlusion or insufficiency. (h) Angina pectoris in enlisted personnel.

(14) Diseases of the ductless glands.

    (a) Exophthalmic goitre. (b) Addison's disease. (c) Proven hypo- or hyper-parathyroidism.

(15) Diseases of the joints.

    (a) Recurrent persistent or crippling rheumatoid arthritis. (b) Still's disease. (c) Ankylosing spondylitis. (d) Degenerative arthritis in which symptoms and signs persist or in which repeated clinical attacks occur.

(16) Neoplastic disease.

    (a) Malignant neoplastic disease with the exception of minor superficial lesions for which treatment is available in the Theater.

(17) Neuropsychiatric disease.

    (a) All instances of progressive incapacitating neurological disease. (b) Epilepsy with grand mal attacks. (c) Psychoses. (d) Severe or frequently recurring psychoneuroses.

(18)Dermatological disease.           

(a) Chronic incapacitating treatment-resistant or frequently recurrent dermatological diseases which are productive of prolonged hospitalization.
        b. The existence of the following disease entities in medical officers or in key commissioned personnel may be considered as an indication that officer patients can be reclassified to a limited service status and retained within the theater.

(1) Disease of metabolism.

    (a) Diabetes mellitus which is mild and for which adequate dietary and treatment facilities are available.

(2) Diseases of the digestive system.

    (a) Uncomplicated peptic ulcer for which an adequate dietary regime can be provided.

(3) Diseases of the blood-forming organs.

         (a) Pernicious anemia in medical officers.

(4) Diseases of the circulatory system.

    (a) Proven essential hypertension without symptoms or signs of renal or cardiac failure in medical officers. (b) Mild angina pectoris.


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Following the publication of this circular letter, the problems concerning the disposition of patients were markedly reduced and were rarely the cause of disputes between hospitals.

LABORATORY SERVICES

During the first 7 months of his service in the North African theater, Colonel Long supervised the activities of hospital laboratories (figs. 59 and 60) by virtue of the fact that he was also acting as time preventive medicine officer. Following the establishment of the Preventive Medicine Service in the Office of the Surgeon, Headquarters, NATOUSA, the control of the laboratories passed to this service. This separation made for immediate difficulties because endless coordination at all levels was needed in order to have the laboratories function in their proper relation to the clinics, it must be remembered that clinical laboratory work, like roentgenology, is primarily an adjunct to diagnosis and therapy and hence should be subordinated to the various clinics in the hospital. This is the policy in effect in all university clinics and in the better class of civilian hospitals. When such a system is used intelligently, it tends to decrease the amount of laboratory work required for patient care, which, on the other hand, increases when the direction of laboratories is in hands other than those responsible for the care of the patient. It was the considered opinion of Colonel Long that the system of organization which placed the supervision of laboratories under preventive medicine was archaic and that the supervision of laboratories belonged to the Medical Consultants Division.

PROBLEMS OF EVACUATION AND HOSPITALIZATION

Principles of evacuation and hospitalization in the Mediterranean theater were finally crystallized, but only after a long process of evolution. Part of the difficulty arose from the fact that both evacuation and hospitalization had dual aspects. These aspects were largely administrative or operational problems, it is true; but it is equally true that both had basic clinical components which could not be ignored. At times, some officers in charge of evacuation in certain base sections did not understand this fact. This was particularly true during the first 18 months of the life of the theater when some sick and wounded were moved about in frantic haste.

In spite of his realization of the importance of logistic and other considerations, the consultant in medicine could not lose sight of the fact that, when casualties passed through a number of hospitals, breaks in the even tenor of medical care occurred, and therapy was interrupted. From a sound professional viewpoint, the best interests of neither the Army nor patient would have been served if the consultant in medicine had not continuously interested himself in such matters and struggled to keep medical care at respectable levels. Continuity of treatment was of prime importance in the care of the sick or wounded patient.


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FIGURE 59.-Hospital laboratory activities. A. Bacteriology. B. Histopathology.


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FIGURE 60.- Mobile laboratory, Florence area, Italy, 1945.

MEDICAL CARE OF PRISONERS OF WAR

Before the battle for northern Tunisia in May 1943, Colonel Long was requested to submit to the Surgeon, NATOUSA, his views upon the provision of medical care for prisoners of war (fig. 61). This request was answered in two memorandums; the first, dated 18 March 1943, covered the prevention of disease in prisoners of war, while the second, dated 19 March 1943, detailed in broad outline professional services for prisoners of war.

The text of the 18 March memorandum follows:

Subject: Prevention of Disease in Prisoners of War

1.The coming battle of Tunisia will throw a heavy strain upon existing medical and sanitary facilities in the AUS [Army of the United States], NATOUSA, because in addition to the medical cases of enemy sick and wounded, the AUS will be charged with the prevention of disease among captured enemy troops. This burden will fall mainly upon the AUS because present plans call for the evacuation of prisoners of war along American lines of communications.

2. Every effort must be made to prevent the outbreak of epidemic disease among the anticipated prisoners of war not only because of the humane aspects of the problem, but also because of the dangers to our own forces which would be created by such outbreaks.

3. At the present time G-2 [intelligence] has very little information concerning the


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FIGURE 61.-German and Italian prisoners of war, North Africa, 1943.

status of immunization procedures carried out in enemy troops. Current information from nonmilitary sources would lead one to believe that the following procedures are in effect:
                                                            German Italian

Typhoid Inoculations              +          +

Tetanus      "                                       0           +

Typhus       "                                +           ?

Smallpox      "                                +           +

Accurate information upon this point should be obtained at once through the interrogation of prisoners and by asking for information upon this point from Cairo.

4. There are three main health problems which will concern prisoners of war: typhus, malaria and dysentery.

a. Typhus. According to available nonmilitary information at least a portion of the German army is inoculated with Weigl's vaccine (typhus). The exact protective action of this vaccine is unknown under field conditions but it is likely that the German vaccine is at least as protective as the Cox vaccine used by the American Army. The status of the Italian army in respect to typhus vaccination is unknown. Excerpts from diaries of captured Italian soldiers as published in the weekly G-2 reports speak of the lousiness of the Italian troops. It is to be assumed that there will also be a considerable degree of lousiness in German prisoners. Every effort must be made to combat this situation by delousing procedures (fig. 62), because if typhus breaks out in prisoners of war, it will not only throw an added and unwanted burden upon our hospitals, but due to quarantine regulations, the movement of the prisoners toward base camps in the L.O.C. lines of communication) and the Z.I. (Zone of Interior) will be greatly hampered. To prevent such an occurrence, delousing and bath units, both British and American, should be mobilized in the forward units and prisoners of war should be deloused before they are concentrated in large prisons


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FIGURE 62.- Delousing of prisoners of war.

pens. To accomplish this, immediate plans should be made in consultation with the Engineer Corps, Quartermaster Corps and the Provost Marshal, to cope with the lousiness of prisoners of war. In addition to delousing, adequate stocks of lice powder should be available in the forward area.
     b. Malaria. The concentrations of prisoners in exposed areas, without the benefits of mosquito nets amid other physical methods of malarial control will result in many cases of malaria if rigid prophylaxis of the disease is not carried out in prisoners of war. This should be done by the administration of Atabrine 0.2 gram, on Monday and Thursday nights after the evening meals from the 22nd of April until the 30th of November. The responsibility for the enforcement of this scheme should be placed on the shoulders of the various enemy noncommissioned officers who will have certain responsibilities for the enforcement of discipline in their respective prison pens. Inasmuch as there is no knowledge concerning the enemy stocks of Atabrine in Tunisia and because of the possibility that existing stocks might be destroyed as a result of action on our own part,or that of the enemy, plans for the prophylaxis of malaria among prisoners of war should envisage that the AUS will supply the Atabrine needed to carry out this procedure.

c. Dysentery. Due to the necessarily exposed conditions of prison camps, the lack of sanitary facilities, and the impossibility of screening cook shacks and mess halls, it is likely that dysentery will be a problem among prisoners of war. To offset this threat, a most rigid and severe sanitary discipline must be enforced in all prison camps in respect to the disposal of human excreta and every effort must be made to remove fly breeding sources from the environs of all prison camps to a distance of at least one and one-half miles. Even if such measures are enforced it is likely that a considerable amount of dysentery will occur and that sulfaguanidine in large quantities will be needed for the treatment of this disease.


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Provisions should be made immediately for increasing the supplies of sulfaguanidine in NATOUSA and for maintaining such supplies at a high level. As far as it is known, very little if any sulfaguanidine is produced in Germany or Italy, hence captured supplies will probably be negligible.

The text of the 19 March memorandum follows:

Subject: Professional Services for Prisoners of War

1. The anticipated number of prisoners of war as laid down in recent G-3 [operations] reports will throw a heavy strain upon the medical personnel and facilities of the AUS in NATOUSA. In order to lighten this burden every effort should be made to initiate preventive measures and to coordinate medical services for prisoners of war.

2. A primary consideration must be that of personnel, and to this end, it is suggested that medical officers be detailed to each secondary forward concentration area to initiate and supervise sanitary and preventive procedures and to look after the health of prisoners. As this will be a dispensary type of medical practice, such supplies as are needed should be made up and allotted to each concentration area in advance. In order to relieve the strain upon AUS medical personnel the services of captured medical officers should be utilized at the earliest possible moment in the medical care of prisoners of war. To facilitate this, plans should he made with the Provost Marshal to the end that enemy medical officers and medical corps men should be routed as soon as possible to concentration areas and that this should be done with a minimum of delay and red tape. In the Middle East, the British have utilized the services of enemy medical officers within 24 hours after their capture.

3. The aim of the medical service should he to cut down the average period of hospitalization required for the treatment of a given disease to a minimum which is consistent with good medical practice. In the instance of infectious diseases which require hospitalization and for which there exist specific therapies, it is well known that the sooner the patient comes under adequate treatment, the more promptly is a cure accomplished and hence the shorter is the period required for hospilization. It is likely that acute infections will account for the majority of requests for the hospitalization of prisoners and in order that their stay in the hospital will not he prolonged, arrangements must be made for the prompt and rapid evacuation of prisoners of war to medical installations for the definitive treatment of infectious diseases. This will require a plan which will cover the evacuation of enemy patients from forward areas, through the L.O.C. and in the MBS [Mediterranean Base Section] and ABS [Atlantic Base Section] along the routes and in the base section hospitals, where prison ward facilities should be designated for the reception of these patients.

Upon receipt of the memorandums, the Surgeon, NATOUSA, had them circulated to the interested staff sections. By some accident of fate, instead of their being returned to the surgeon's office, they were buried in the records section of the Adjutant General's Office, AFHQ, and no action was taken upon the recommendations made in them. By May 1943, the battle for northern Tunisia was well under way, and prisoners of war (fig. 63) began to stream in by the thousands. At that time, it was found that, through agreements made at a general staff level, the care of prisoners of war taken in northern Tunisia would become the initial responsibility of the British. After being processed, the majority of German and Italian prisoners would then be turned over to the U.S. troops at points near Constantine for transportation to compounds in the Mediterranean and Atlantic Base Sections. The British were therefore responsible for the initial steps to be taken in the prevention of disease in prisoners of war and for the segregation and division of protected personnel.

In the course of a tour of inspection made by the consultant in medicine


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FIGURE 63.- Prisoners of war, Tunisia, 1943.

during the closing days of the campaign in northern Tunisia, it was noted that the recommended measures for the prevention of disease among prisoners of war were being disregarded by both of the capturing powers and that little use was being made of enemy medical officers for the care of their own nationals. The following memorandum was prepared for the Surgeon's signature and was sent to the Provost Marshal General, NATOUSA, on 17 May 1943:

1. Insofar as it is possible prisoner of war medical officers and corpsmen should he used to assist in the prevention of disease and the care of the sick and wounded in prison compounds.

a. In order to assure an adequate supply of such medical personnel it is therefore recommended that enough of such protected personnel he retained in this theater until the prisoners of war are all evacuated.

2. Prisoners of war should immediately receive a stimulating dose of 0.5 cc. of T.A.B. typhoid vaccine upon entering American prison compounds.

3. Prisoners of war should be placed upon suppressive Atabrine therapy as outlined in paragraph 2, NATOUSA Circular No. 38, dated 20 March 1943, and it is strongly recommended that this suppressive therapy be continued for one month after they reach their final destination in USA.

4. Additional medical supplies required should be requisitioned from the Base concerned.

By the first week in June 1943, prisoners of war were arriving by the thousands (fig. 64) in the Mediterranean and Atlantic Base Sections, and, although the bare outlines of compounds had been erected, little else had been prepared for their arrival. None of the recommendations as to immunization had been effected, suppressive therapy with Atabrine was being carried out by fits and


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FIGURE 64.- U.S. Army trucks loaded with German prisoners arriving at a prisoner-of-war camp, near Mateur, Tunisia, 10 May 1943.

starts, and the sanitation within the compounds was generally poor. As a result, malaria and dysentery were rife, and, because of the slowness with which enemy medical personnel was being obtained from the British, American hospitals had to look after the prisoner-of-war sick. The following report upon these conditions was made early in June to time Surgeon, NATOUSA:

Diarrhea and Dysentery in Prisoners of War

A considerable amount of dysentery is occurring in prisoners of war in the forward areas.

Prisoners of war are being sent to American areas in very unsanitary convoys.

This results in dysentery developing among prisoners on their way to, and after they arrive in American controlled prison camps.

  Because of the unsanitary conditions which prevail, a line of potentially infected material is being created along the railroad line from Constantine to Casablanca. This is evidenced by the following statement taken from Lt. Paul Goetze, ASN 53, 1/44 Flak regiment, German Army:

"On May 31 this officer and 39 other officer prisoners were placed in a barrel car at Constantine. The food provided for them for their trip was adequate, but no water was furnished them and they got none until the second day of their trip. On the first day out 4 officer prisoners developed dysentery and on the next day two more came down with the same disease. Because there were no latrine facilities (not even a flimsy can) in the car they had to defecate in their bread bags, which they then threw out of the railway car. On the second day of the trip, the train stopped and all were allowed to go to the latrine." This prisoner was taken off the train at St. Barbe at 11:30 A.M. on June 3, 1943, because he was suffering from acute dysentery and was placed in the 16th Evacuation Hospital.


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The fact that prisoners are corning down the line with dysentery constitutes a grave health menace to American troops because the infected feces will constitute sources of infection all along the way. Immediate steps should he taken to eliminate unsanitary conditions along the convoy line. Latrines should be built at proper intervals and should be policed daily. It is said that latrines have been contemplated but that little has been done about them, because no service will take the responsibility for looking after them.

The consultant in medicine conferred with the British consulting physician, and the agreed that the consulting physician would do all in his power to bring about an improvement in the care of prisoners of war before they were turned over to the Americans and would try to expedite the movement of prisoner-of-war hospitals and the needed medical personnel from the British to the American areas. After a further conference by these two officers with the officer in charge of prisoners of war in the office of the Provost Marshal General, NATOUSA, the following informal memorandum was sent to the Provost Marshal General, on 11 June 1943:

1. Enemy medical personnel should be segregated until classified and recommendations are made as to their disposal by The Surgeon, NATOUSA. This scheme will provide adequate medical personnel for the POW camps and will permit us to keep the needed specialists in the theater. This has been agreed to informally.

2. The P.M.G. plans for medical care of POW on ships returning to US or UK is considered adequate from a professional point of view.

3. Those cadres of prisoners of war which will remain in the theater for any length of time should receive the various immunizations prescribed in Army Regulations and modified as to subsequent doses in NATOUSA.

   4. Every effort should be made to maintain camp sanitation. Flies must be kept down to avert outbreaks of dysentery. Fly-swatting squads should be on duty daily in all compounds in the kitchens and around latrines. Kitchens should be screened.

5. Every effort should he made to expedite the shipment of the captured hospitals, their equipment and personnel, to the POW camps in order to relieve American medical personnel.

6. The Consulting Physician (Br) and the Consultant in Medicine (A) will he glad to render any aid within their province on the professional service aspects.

Unfortunately for all concerned, a sweeping reorganization of the office of the Provost Marshal General took place at about the time this memorandum was submitted, causing further delays in carrying out the suggested changes.

At the opening of the campaign in Sicily, the preparations for the reception and processing of prisoners of war in the Eastern Base Section were still primitive, as was indicated by the following report made by the consultant in medicine to the Surgeon, NATOUSA, on 25 August 1943:

      *          *          *          *          *          *          *

6. POW Medical Service and Sanitation. One would have imagined that the P.M. [Provost Marshal], EBS [Eastern Base Section] had never been previously informed that an offensive operation was contemplated and that prisoners would he taken. (The P.M., EBS, complained that he had had little help from NATOUSA.) When the first prisoners arrived, the stockades were half completed, latrine pits not dug, latrine boxes not flyproofed, kitchen facilities and waste disposal were primitive, water and rations were short, delousing facilities were lacking, medical supplies were short, one medical officer was in the area, and a battalion of the 135th Infantry had to be used to guard prisoners because but a handful of the P.M. representatives were available. The POW (especially the Italians) arrived ex-


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hausted and ill with dysentery and malaria. Scabies was frequent and venereal diseases were not uncommon. They were herded off the LST's (on which water was frequently short), lined up in the hot sun, and then marched along the main roads to the POW compound. (The result was always an important traffic block.) En route many fell out from heat exhaustion or from other causes. On one occasion a large group of POW burst through their road guards like a bunch of wild animals and practically threw themselves into a badly contaminated well, so great was their thirst. Such conditions were undoubtedly responsible for the lighting up of chronic malarial infections in the prisoners, with the result that they took up hospital beds in the Bizerte-Mateur area which otherwise would have been available for use by American patients. The one medical officer in the compound did a sterling job without much assistance. He selected POW medical officers and corpsmen as his aides, and soon had a smooth running dispensary which took care of many of the medical needs of the prisoners.

As the organization and planning in respect to time care of prisoners of war became more mature, an improvement was noted in the manner in which they were handled, as is evidenced by the following paragraph taken from a report made to the Surgeon, NATOUSA, on 29 September 1943:

1. The following report is based upon data available in the WD MD Forms 86ab for prisoners of war. To obtain information upon the morbidity resulting from certain diseases, the records of the 56th Station Hospital, 16th Evacuation Hospital, 21st General Hospital, 78th Station Hospital, and the 80th Station Hospital were studied. These hospitals were selected because the bulk of the sick prisoners of war who were hospitalized between June 15th and September 15th, entered these hospitals.

a. Morbidity. In the discussion of morbidity the hospitals will be grouped as follows: (1) 56th Station Hospital, 16th Evacuation Hospital, and 21st General Hospital. (2) 78th Station Hospital and 80th Station Hospital. This grouping has been adopted because the prisoners entering the hospitals listed in the first group were Germans and Italians taken primarily in the Tunisian campaign, while those in the second group were primarily Italian prisoners taken during the first phase of the Sicilian campaign.         

b. Deaths. All deaths recorded upon the MD Form 86ab for prisoners have been grouped as to cause.

2. Morbidity.

    a. 56th Station Hospital. In the period from June 11 to August 13, 1943, the total admissions into this hospital for certain infectious diseases were as follows: (1) Diphtheria-15 cases. (2) Primary atypical pneumonia-11 cases. (3) Tuberculosis-9 cases. (4) Dysentery-532 cases. (5) Typhoid fever-1 case. (6) Malaria-432 cases. (7) Jaundice-28 cases. (8) Smallpox-2 cases. (9) Typhus-1 case.
            b. 16th Evacuation Hospital. From June 18th until August 8th, 1943, the following prisoner-of-war patients were received: (1) Diphtheria-5 cases. (2) Primary atypical pneumonia-5 cases. (3) Tuberculosis-3 cases. (4) Dysentery-194 cases. (5) Typhoid-1case. (6) Malaria-310 cases. (7) F.U.O.-28 cases. (8) Jaundice-8 cases.        

c. 21st General Hospital. From June 18th until September 11th, 1943, the following prisoner-of-war patients were received: (1) Tuberculosis-8 cases. (2) Dysentery-48 cases. (3) Typhoid fever-8 cases. (4) Malaria-157 cases. (5) Jaundice-8 cases. (6) F.U.O.-8 cases.

d. 78th Station Hospital. From July 17 until September 2S, 1943, the following prisoner-of-war patients were received: (1) Primary atypical pneumonia -12 cases. (2) Tuberculosis-16 cases. (3) Dysentery-43 cases. (4) Typhoid-4 cases. (5) Malaria-587 cases. (6) F.U.O.-225 cases. (7) Jaundice-12 cases.


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e. 80th Station Hospital. From July 24 until September 25, 1943, the following prisoner-of-war patients were received: (1) Primary atypical pneumonia -10-cases. (2) Tuberculosis-6 cases. (3) Dysentery-20 cases. (4) Typhoid fever-7 cases. (5) Malaria-609 cases. (6) F.U.O-150 cases. (7) Jaundice-16 cases.      

f. Total number of patients in each disease category received by the above mentioned hospitals during the stated periods.

   (1)Diphtheria-12 cases

    (2)Primary atypical pneumonia-38 cases

    (3) Tuberculosis-42 cases

   (4) Dysentery-827 cases

   (5) Typhoid fever-21 cases

   (6) Malaria-2095 cases         

(7) F.U.O.-411 cases
`           (8) Jaundice-115 cases<>     

   (9) Smalpox-2 cases

   (10) Typhus-1 case (Another case was reported in an Italian prisoner of war by the 23d Hospital)       

g. Discussion of observed disease morbidity in prisoners of war. The high initial occurrence of dysentery in patients on admission to the 56th Station Hospital and 16th Evacuation Hospital (ABS [Atlantic Base Section] and MBS [Mediterranean Base Section]), reflects the unsanitary conditions which prevailed along the route and in PO\V compounds which were not ready to receive the influx of over 200,000 prisoners which were taken at the end of the Tunisian campaign. It is to be noted that as sanitation improved, admissions for dysentery fell. It is interesting to observe that on the contrary in the 78th Station Hospital and 80th Station Hospital (EBS) [Eastern Base Section], the admissions for dysentery were low. This was probably due to a short evacuation route and a relatively well sanitated POW compound in EBS. The admissions for malaria follow a trend which is quite comparable to those noted for American troops so it can be assumed that the patients entering the 56th Station Hospital and 16th Evacuation Hospital at least in part, contracted their disease either in POW compounds or en route to them across North Africa. The patients ill with malaria entering the 78th Station Hospital and 80th Station Hospital during July and the first week in August obviously contracted their disease in Sicily. However, it seems quite probable (and this thesis is supported by a shift from 10 vivax infections to 1 falciparum infection, to 3 vivax infections to 1 falciparum infection in prisoners of war in EBS) that many of the cases of malaria developing after the first week of August were the result of infections incurred in North Africa. The high percentage of F.U.O. noted in the EBS resulted from the non-recognition of sandfly fever, the treatment of true malaria before blood films could be taken, and from inadequate laboratory work due in turn to the influx of febrile patients. On some days as high as 150 or 200 blood films were examined in a single station hospital laboratory. Jaundice has been increasing in the prisoners of war, but not out of proportion to the increase of this disease noted in our own troops. There have been 42 instances of tuberculosis recognized. There are probably more unrecognized cases among the prisoners. It is interesting that 38 instances of primary atypical pneumonia have been noted. The occurrence of 21 cases of typhoid fever is indicative of crowding, imperfect sanitation and incomplete vaccination. As steps have been taken through command channels to re-vaccinate fully all prisoners of war against typhoid fever, a lessened incidence of this disease should be observed in the future. Twenty-one cases of diphtheria occurring in a period of the year in which the incidence of diphtheria is minimal probably reflects crowding, the non-recognition of early cases of the disease and a normal or slightly high carrier rate. It is interesting to note that 15 of these cases were received in the 56th Station Hospital in ABS and occurred in prisoners taken in the Tunisian Campaign. Two cases of smallpox and two of typhus have been recorded in prisoners.


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3. Deaths. The following causes of death have been recorded. These data are fairly but not completely accurate because deaths among prisoners of war occurring in other than the stated hospitals are not listed. Those occurring in POW camps are included.

        Cause  -    Deaths

        Malaria  -  24

        W.I.A  -   12

        Hypertension -  1

        Brain Abscess -  2

Dermatitis exfoliativa (arsenical) - 1

        Acute Nephritis - 1

Typhoid Fever   - 3

Acute Amoebic Colitis -  1

Acute Ulcerative Colitis - 1

Acute Infectious Hepatitis -  1

Carcinoma - 1

Dehydration and Exhaustion  -  2

      Coronary Thrombosis -  4

   Dead on arrival (?)  -  1

   Respiratory paralysis  -  1

   Tuberculosis  -   2

   Suicide -  1

   Killed by guards  -   8

   Diphtheria  -  2

  Pneumonia  -  3

   Accidental  -   1

   Ruptured Appendix  -  1

A survey of these deaths shows one striking thing; namely, that the case fatality rate from malaria in prisoners of war far outstrips that observed in American troops. An example of this is that of 2095 admissions to prisoner-of-war hospitals for malaria, 16 or 0.77 percent died. When one considers the conditions of concentration, surveillance, supervision, etc., under which the prisoners were kept, this is a high case fatality rate. The two deaths listed as "dehydration and exhaustion" were undoubtedly due to imperfect handling of POW personnel while in transit. The deaths from diphtheria are tragic.

4. Summary. The record of the prevention and treatment of disease among prisoners is fair. Two great causes of morbidity (malaria and dysentery) could have been markedly reduced if adequate preparations for the reception and care of prisoners of war had been made. The following figures (which are based upon average periods of hospitalization noted for American patients) show the number of hospital-bed days taken up by prisoners of war who were suffering from diseases for which preventive measures are well established.          

a. Malaria - 31, 425 days

    b.Dysentery -  4, 135 days

    c. Typhoid fever - 745 days

    Total   36, 305 days

5. Consolidated figures received from the Surgeon MBS, show that 77 cases of typhoid fever in POW have been admitted to POW hospitals #129 and #130 since July 4th.

In the winter of 1943-44, the German prisoner-of-war hospital was moved from its former location to Prisoner of War Camp No. 131, and following this move the personnel of the hospital lost their "protected" status and were treated by the local compound commander as ordinary prisoners of war. This violation of the Geneva Convention was noted by the consultant in


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medicine, in the course of an inspection of the hospital, and was made the subject of the following report to the Surgeon, NATOUSA, dated 17 May 1944:

1. When the original German POW Hospital was set up near Ste. Barbe, the German medical officers and corpsmen were given the full status of "Protected Personnel" and were allowed recreational facilities outside of the prison compound after working hours. There was at least one violation of this status and the offending German medical officer reverted to a POW status.

2. In December 1943, this PO\V Hospital was moved from Ste. Barbe to its present location within a compound in PW Camp #131, and since that the German medical officers and corpsmen have not been permitted to leave the stockade which in part is guarded by Italian Carbinieri.

3. In the course of an inspection of the professional services of this hospital made upon May 10, 1944, Dr. Meyer, the German Surgeon of the hospital, stated that the restrictions placed upon his medical officers and corpsmen represented a violation of the "Protected Personnel'' clause of the Geneva Convention of 1929, and that as a result of this violation, he does not feel that he can ask his officers and corpsmen to behave as "protected personnel" when actually in one respect, they are being treated as ordinary prisoners of war.

4. From time to time, the repatriation of wounded and sick German PO\V takes place from this hospital and it can he assumed that when such prisoners come under enemy authority, they are questioned regarding the "Protected Personnel" status of medical corps personnel in the POW Hospital, and that retaliatory measures will he taken against American Medical Corps [Department] personnel, now held by the enemy, if the ''Protected Personnel'' status of the German medical officers and corpsmen is questionable.

5. It is therefore recommended that the necessary steps be taken to insure to the fullest extent the "Protected Personnel'' status of German medical corps personnel now in our hands.

Action was immediately taken by the Surgeon, MTOUSA, with the result that the Provost Marshal, Mediterranean Base Section, restored in part the ''protected" status of the medical department personnel of the German hospital.

From the summer of 1944 until the capitulation in Italy, German medical department personnel received privileges that were pretty much in accord with the Geneva conventions, and the sick and wounded prisoners of war received adequate treatment. At the time of the capitulation in Italy, many thousands of sick and wounded Germans and hundreds of German medical department personnel (fig. 65) fell into the hands of the U.S. Army. The decision was immediately taken to utilize all captured German medical installations to their fullest extent. Two large German hospital centers at Bolzano and Cortina had been taken over, and the capacity of these centers was increased by the addition of isolated hospitals that had been captured. Colonel Long made an extensive study of these hospitals in May and June 1945 and reported to the Surgeon, MTOUSA, on 11 June 1945, as follows:

1. This study is based upon practices observed in German General and Camp Hospitals in the Merano and Cortina and Chide areas and upon interviews and discussions which were held with Col. Matisse, the chief consultant in medicine of the German Army Group in Italy, Lt. Col. Professor Horster. (Wurzburg) Chefarzt of the German hospital in the Palace Hotel, Merano, Lt. Col. Professor Schopper, (Leipsic) Consultant in Pathology to the Army Group, Major Assistant Artz Veith, (Freiburg) Pathologist in the Pathological Laboratory, Merano group of hospitals, Lt. Col. Professor Marks, (Munster) Consultant in Medicine to the 10th German Army, Lt. Col. Professor Bock. (Wurzburg) Consultant in Medicine


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FIGURE 65.- German medical officers, under command of Maj. Henry M. Carney, MC, U.S. Army, in hospital of U.S. prisoner-of-war stockade, Scandicci area, Italy, March 1945.

to the 14th German Army, Lt. Col. Schreiber, Chefartz of the German General Hospital in the Savoia in Cortina, Col. General Menardus, Surgeon of the German Army Group in Italy, Major Peters, Chief Malariologist, German Army Group in Italy, and numerous Stabsartzen in the German hospitals which were visited. It is believed that they represent a true cross section of medical practices in German General Hospitals in Italy. In every instance, the German medical officers who were interviewed or with whom the Consultant in Medicine went ward-rounds, were entirely cooperative, were polite, gave out information freely, and were not arrogant. This experience is to be contrasted with that reported by the Consultant in Surgery, who found the German surgeons arrogant. Perhaps this observation means that in the German army, as in other armies which the Consultant in Medicine has had the opportunity to observe, the physicians of necessity are meek and lowly.

2. The medical practices in these German general hospitals were, by and large, very good. The records of all patients who were observed were well kept, neat and complete. The German system of charting the complete course of the patient upon temperature charts from his time of entry into a hospital installation, made it very easy to follow the course of disease in any given patient. The laboratory work in general was adequate and while certain of the laboratory tests which are commonly used in American hospitals were not in evidence, due either to a lack of materials or to unfamiliarity with the tests, those which were being utilized were being used intelligently. Therapeutic practices were somewhat similar to those in the American Army, with the exceptions that more nonspecific protein fever therapy was being used and there was a tendency to employ parenteral products frequently, when from the American point of view, peroral therapy would have sufficed. The medical ward officers in these general hospitals seemed to be adequately trained in the art of history taking, physical examination and the proper utilization of the laboratory tests which were available. The Consultant in Medicine was struck by the fact that the average period of hospitalization and convalescence for practically every disease observed in these German hospitals was considerably longer than that in American military hospitals in


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MTOUSA. This means that the average noneffective days' rate per patient was higher in the German army. It also appeared that the criteria used for the discharge of medical patients to a civilian status from the German army were less severe than those in force in the U.S. Army.

3. In general, the bulk of the patients seen, except at Chide, were true general hospital types of patients, and in American hospitals would have been classified as "C" for evacuation to the Zone of the Interior. This same classification would have been given these patients by the German medical officers, had not their "Zone of the Interior" disappeared during April and May. Hence the eventual disposition of many of the patients will be a problem unless some arrangement can be made for their return to Germany and their discharge from the German army.

4. The following diseases were especially observed:
        a. Field or War Nephritis. This disease was quite a problem in the German army in Italy during the winter of 1944-45 and a great problem every winter in Russia. Lt. Col. Professor Marks states that at one time, when he was medical consultant in a hospital center in Germany, he had 3000 cases of Field Nephritis under his supervision. At the time this visit was made it was estimated that there were about 500 patients ill with Field Nephritis in the two hospital centers. The following are points of interest concerning this disease.

    (1) Etiology. There is one school of thought in Germany which believes that field nephritis is a virus disease; however, Lt. Col. Professor Marks states that Volhard and others in Germany consider the disease to have the same etiological basis as does the type of hemorrhagic glomerular nephritis seen in civilian life. In surveying the histories of and talking to about 40 patients with this disease, a story of a recently antecedent nasopharyngitis (hemolytic streptococcal infection) was rare and the onset of the disease was ordinarily insidious in nature. The German medical officers considered that sudden chilling or wetting played an important role as a precipitating etiological factor in field nephritis. The average time from the appearance of symptoms and signs to first hospital entry was 10 days.          

(2) Facial and ankle edema were the most common presenting signs. headache was uncommon. In a few instances a grossly bloody urine was noted as the first sign.

    (3) On entry into the hospital, the common signs were facial and ankle edema, hypertension and a urine which showed from 1 to 2 plus albumin with many hyaline and granular casts and red blood cells. Clinical evidence of cardiac enlargement and uremia were rare. In many instances the NPN was normal and rarely was it highly elevated. Lt. Cols. Professor Marks and Horster both stated that abnormalities of the fundi were rare.          

(4) The clinical course of the disease in the patients whose records were examined was quite constant. In most instances the edema disappeared quite promptly and the blood pressure returned to normal within a few days. If the NPN was elevated it also returned to within normal limits within a few days. From this point on, the course of the disease had to be judged primarily from laboratory tests. The albumin slowly disappeared but there was a persistence of microscopic hematuria for weeks and months, and the dilution-concentration tests showed definite abnormalities over long periods of time. These two examinations were the ones which were depended upon most and a normal urinary sediment from repeated fresh morning specimens and normal dilution-concentration tests were used as criteria in determining the cure.

    (5) The prognosis for recovery in the great mass of patients was said by the German medical officers to be good. However, it was their practice to recommend for discharge from the army all patients whose urinary sediments and dilution-concentration tests were abnormal at the end of six months' observation. None of the medical officers had had an opportunity to observe the eventual course of patients returned to civilian life. Relatively few patients had died in the acute or subacute stage of this disease while in army hospitals.          

(6) The treatment consisted of absolute bed rest, a modified Karrel diet for the first three days, this then followed by fruit and fruit juices for 5 days, and then the patient was placed on a low protein (20 to 40 grams of protein) salt-free diet. Bed rest was


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absolute for about one month and quite well maintained for three months. Lt. Col. Professor Marks also used the "Hunger and Durst" regime for three-day intervals about once [a month] in all of his patients. Lt. Col. Professor Horster did not use the "Hunger and Durst" regime. Both observers added salt in gradually increasing amounts to the diets of these patients before they were permitted to be up freely, and it was generally 3 or 4 months before the patients were placed on the normal hospital diet.          

(7) Comment. It can be said with certainty that the type of kidney disturbance which has just been described did not occur in any appreciable amount in the American troops who were in contact with time Germans in the northern Apennines during the winter of 1944-45. No explanation for this difference can be offered.
        b. Infectious Hepatitis. This disease was first noted in epidemic form in the Afrika Corps in the winter of 1941-42. Later it became epidemic German units in Russia and there was a high incidence of the disease in the German forces in Italy during time fall of i943. In the fall of 1944, while the incidence of the disease was increased, it did not reach epidemic proportions. This, the Germans attributed to the development of a herd immunity throughout their army. The Germans were certain that the disease was caused by a virus, but believed that it was spread by droplet infection. They had no idea that the virus was present in the stool of hepatitis patients.

    (1) Diagnosis was made generally after jaundice appeared. The only liver function test employed was the Taka-Arata test.          

(2) The sheet anchor employed by time Germans in the treatment of hepatitis was absolute bed rest for 4 or more weeks. The diet used was of the conventional, old fashioned, high-carbohydrate, low-fat type. The average period of hospitalization was eight weeks. Relapses have been uncommon since the prolonged hospitalization program has been in effect, but were very common initially in the Afrika Corps when patients with hepatitis were either kept on duty or were released from hospital when their jaundice had disappeared. The intensive hospitalization program began about the middle of 1942 and has been strictly adhered to since.

    (3) The Germans have conducted fairly thorough studies of the pathology of hepatitis by means of "liver-punch" biopsies. Their findings are in line with those made in this theater.       

c. "Trench Fever," Volhynia Fever. There were hundreds of cases of this louse-borne disease among troops in the Mediterranean area in the winters of 1943-44, 1944-45. It reached epidemic proportions in German troops in Russia.

d. Atypical Primary Pneumonia. The German medical officers insisted that this disease was unknown (unrecognized?) in Germany prior to 1939. The first appearance of this disease in the German army occurred in Greece in 1941, at which time it was considered a "new" disease. Following the publication of abstracts of American papers upon this disease in German, the true nature of the "Grecian" disease was recognized. Since that time it has appeared sporadically in the German army. It is the opinion of the consultant in medicine that there has been much more atypical pneumonia in the German army, but because routine roentgenograms of the chest were not made (only sparingly so) the disease was frequently missed. At one hospital in which X-ray films of the chest were made frequently, an approximately normal admissions rate for this disease was noted.       

e. "Trench Foot." As the Germans said, a word for this condition does not exist in the German language. Plenty of true frostbite was seen in the Russian Campaign but all German medical officers stated that they had not seen "Trench Foot" in German soldiers in MTOUSA during the winters of 1943-44 and 1944-45. In fact some of them said that they had traveled many miles to observe American prisoners of war who were suffering from "Trench Foot." They attributed this absence of "Trench Foot" to:

  (1) Excellent foot hygiene and discipline.

    (2) The easily removable high leather German field boot.

    (3) The four pairs of thick but loosely woven all-wool high stockings provided to German forward troops in winter.


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f. Peptic Ulcer. Many patients suffering from peptic ulcer were seen. All had been confirmed by roentgenograms and all were being treated by low residue diet without alkalies. The average period of treatment was 4 weeks. Patients with initial severe symptoms, with gastroenterostomies or with partial resections of the stomach were discharged to the particular "Magen" battalion which represented their part of Germany. There they were given light duties and low residue diets based upon the accustomed diet of their part of Germany.       

g. Diphtheria. The Germans have been experiencing an increased incidence of diphtheria during the past year. A fair amount of diphtheritic paralysis has followed this disease. It is the opinion of the medical consultant that low initial doses of antitoxin (10-20,000 units) were responsible for this increased incidence of paralysis.

  h. Amoebic Disease. Stool-carrier studies conducted in German troops in Italy during the fall of 1944 showed an incidence of 14 percent cyst carriers. Amoebic dysentery is not uncommon and has been treated with emetine and Yatrin with good results. Amoebic hepatitis and amoebic abscess have not been very common.       

i. Streptococcal and typhoid-paratyphoid infections occurred in the German Army in Italy somewhat more frequently than in the American army. The treatment of these diseases was similar to that used in the American army.

  5. General Comments       

a. German rations for the staff and patients in hospitals in the Cortina area were available for about ten days more at the time of this inspection The Consultant in Medicine was informed by the commanding officer of the 379th Collecting Company that at the end of that period, the patients in German hospitals would receive the American hospital ration, while the Medical Department staff will receive type "C" rations. If this is correct, then title III, chapter 2, article II, Treaty Series No. 846 which was proclaimed by the President of the United States, 4 August 1932, is being violated, because it is distinctly stated "The food ration of prisoners of war shall be equal in quantity and quality to that of troops in base camps." It is being argued that inasmuch as Germany did not observe time Geneva Convention, we do not have to treat their prisoners of war in accordance with the Convention. Such reasoning is specious and it should always be remembered that "two wrongs do not make a right."

b. It is the opinion of the Consultant in Medicine that our aim should be to utilize every method to get the German sick well, or if they are suffering from known chronic disease to give then a certificate of discharge for disability as soon as such a course is feasible. To this end it is therefore recommended:          

(1) That our treatment directives be sent to all German hospital installations with instructions that they be translated into German and be used as the basis for treatment.           
            (2) That penicillin be made immediately available for the treatment of acute and chronic gonorrhea, acute syphilis and such other diseases in which the use of this antibiotic has been shown to be timesaving in the cure of disease. The present methods used by the German Medical Corps for treating gonorrhea have produced resistance to sulfonamide therapy with the result that time-consuming methods (intermittent fever therapy, prostatic massage, irrigation, etc.) are being used in the treatment of chronic infections and patients are being discharged before a bacteriological cure has been affected. It would seem important to use penicillin in these patients because eventually a certain number of them will return to the area being occupied by the American Army in Austria or Germany, and there will become foci of infection in the civilian population.

c. It is recommended that Colonel General Menardus be sent to Germany and be discharged from the German army at the earliest possible moment. His presence in the Cortina-Merano area is unnecessary and somewhat confusing.

In summary, it may be said that during 1943 and early 1944, the consultant in medicine frequently encountered serious problems in carrying out the


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FIGURE 66.-German prisoners of war, Italy, 1945

duties specifically given to him by a verbal order of Maj. Gen. Everett Hughes, Deputy Theater Commander, NATOUSA.

General Hughes had stated unequivocally, "I want prison camps, both disciplinary and POW, run in a strict but humane fashion." At tunes, the level of care in prisoner-of-war camps was excellent and in full accord with these orders (fig. 66). At other times, it was considerably less good, chiefly because of thoughtless administrative practices in lower echelons. The solution of the problem was strict adherence to the Geneva Convention dealing with the treatment of prisoners of war, and the consultant in medicine, whenever inefficiencies were detected, made it his business to see that those in charge of these men fully understood their responsibilities toward them.

NUTRITION

In the course of a tour of inspection of British military hospitals made 13 to 20 January 1943, the consultant in medicine heard his first complaints concerning the monotony and unpalatability of the C ration. At the same time, complaints from American units attached to British units were heard in respect to the monotony and lack of bulk of the compote ration. However, during this tour, clinical evidence of vitamin deficiencies was not noted in


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American soldiers, and the January 1943 sanitary reports did not mention vitamin deficiencies and contained few complaints about rations. The sanitary reports arriving in February and thereafter however, increasingly mentioned various inadequacies noted in the rations. These complaints were especially frequent from the Army Air Force units, which, operating in forward areas where conditions were often difficult logistically, were compelled to exist for considerable periods of time upon emergency or unbalanced rations.

It was not until the II Corps was visited in northern Tunisia, in April and May 1943, that there were bitter reports about the rations, and vitamin deficiencies were noted. Battalion surgeons reported that their men had been fed C rations for such long periods of time that they had ceased to eat them and that the continued use of these rations produced nausea, vomiting, and diarrhea. These surgeons stated also that their men were undernourished. The consultant in medicine checked upon these reports by observing and interviewing men of the 3d Battalion, 39th Infantry, and patients in the evacuation hospitals. He found himself in agreement with the battalion surgeons. During this same period, he also observed patients suffering from deficiencies of vitamin A, thiamine, riboflavin, nicotinic acid, and ascorbic acid in the evacuation hospitals of the II Corps.

The extent of undernutrition observed in the II Corps prompted the consultant in medicine, on 1 May 1943, to recommend to the Surgeon, NATOUSA, that a board of officers be appointed to ascertain the facts and make recommendations concerning the diet of combat troops in this theater. The consultant's recommendation for the appointment of a board was accepted by the Surgeon and was forwarded in the form of a memorandum to the deputy theater commander on 15 May 1943. After being circulated by the Chief of Staff to G-4 (logistics (supply)) and the quartermaster sections, where it was received favorably, the memorandum was submitted to the Deputy Theater Commander who returned it to the Surgeon, with the suggestion that the difficulty lay in the misuse of the C ration rather than the ration itself. The Surgeon then again recommended that a board of officers be appointed, but the Deputy Theater Commander negated this suggestion.

The 2-month period that elapsed between the end of the campaign in northern Tunisia and the opening of the Sicilian campaign was one of great activity along the whole North African coast and especially in the Eastern Base Section. Troops were being trained (fig. 67) for amphibious operations in this period, and their diet varied from C to fully balanced B rations. Supplies of all types were being poured into the Eastern Base Section, and there, inevitably, the B ration became unbalanced. Caloric estimates, prepared by the 56th Evacuation Hospital, demonstrated that during June, July, August, and September 1943, the average caloric value of the B ration, as issued in the Eastern Base Section, was in the neighborhood of 2,500 calories per day.

Four of the six divisions entering the Sicilian campaign had been, relatively or completely, inactive as far as combat was concerned, but the other two divisions had seen extensive service during the Tunisian campaign, during which, toward


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FIGURE 67.-Amphibious training.

the end, patients with clinical nutritive deficiencies had been received in hospitals of the II Corps from both divisions.

During the initial stages of the Sicilian invasions, the majority of the troops subsisted upon C and K rations (fig. 68), but, as the campaign progressed, 5-in-1


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FIGURE 68.-U.S. Army Field Ration K and British Ration.

and modified B rations made their appearance. This was especially true of those divisions that took the western half of the island because, in addition to rations issued to them, variety and nutritive value were increased by the capture of a certain amount of frozen beef and German field rations (fig. 69), as well as by local purchase. The troops in the II Corps which were progressing towards the northeast were not so well off, because tactical conditions were such that C and K rations frequently had to be issued, especially to combat infantry units. However, owing to the shortness of the campaign and to the fact that troop reliefs were made, local foraging was permitted, and the 5-in-1 and modified B rations were provided early, it seems likely that the nutritive status of the combat many during the Sicilian campaign was better than in any previous, or any subsequent campaign in 1943. However, at this point, that part of WD Circular No. 208, 1943 that dealt with percentage reduction of the authorized allowances for field rations based upon unit strength, was activated by section III of NATOUSA Circular No. 164, dated 29 August 1943. This move resulted in penalizing members of large units at the expense of small units and did not fulfill its anticipated purpose of saving food. In fact, the evidence at hand showed that it contributed further to the general state of undernutrition then existing in NATOUSA.

Again, following the Sicilian campaign, a period of intensive training took place, but, as B rations were used largely during this period and many of the troop units were well rested and well fed, one can conclude that the opening of the Italian campaign was made with troops in a fairly good state of nutrition. The term "fairly" is used advisedly, in view of the fact that the expeditionary-force B ration was a deficient ration, as was shown by the quartermaster board


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FIGURE 69.-Medical Department soldiers of 10th Infantry Division (Mt.) preparing to sample German meat and hard tack, Italy, February 1945.

project. However, as the Italian campaign evolved, the nutritive status of divisional troops, especially the infantry progressively deteriorated. This was because of (1) the longtime employment of troops in combat, (2) tactical situations that made C or K rations the sole rations feasible for use, (3) the unbalancing of the B ration as evidenced by 50 percent substitutions or eliminations on certain days, and (4) the use of a summer type B ration, which had not been changed to meet the energy requirements of continuous hard fighting and cold weather.

Thus, by the end of November 1943, while the nutritive status of Peninsular Base Section troops and service troops in armies, corps, and divisions was constantly improving, that of the combat infantry troops was progressively deteriorating. During the end of November and in December, a survey of nutrition in NATOUSA was made by Col. Paul E. Howe, SnC, Chief, Nutrition Section, Office of the Surgeon General, and Colonel Long. Gross evidence of nutritional deficiencies was observed in the course of this tour and the following recommendations were made: (1) That the percentage reduction in rations as provided for section III, NATOUSA Circular No. 164, dated 29 August 1943, be eliminated; (2) that that part of section I, par. 3, NATOUSA Circular No. 122, dated 27 June 1943, forbidding the drawing of excess rations, be eliminated; (3) that the pertinent parts of WD Circular No. 208, paragraphs 16b and c dealing with increased issues, be made effective immediately in


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FIGURE 70.-Fresh bread from 110th Quartermaster Bakery Company, Italy, January 1945.

NATOUSA; (4) that combat and other troops, who, owing to the prolonged use (3 or more days) of C, K or other nutritionally deficient rations be subjected to nutritional rehabilitation until the estimated caloric loss has been restored; (5) that monthly reports be rendered by army and base section commanders on elimination and improper substitutions within the B ration; (6) that menus be provided and that issue sheets, indicating the proper amounts of food to be drawn, be issued to all organizations drawing rations; and (7) that multivitamin capsules or tablets be issued automatically to all troops subsisting for 3 or more days upon C or K rations. These recommendations were under consideration at the end of the year. Recommendations (1) and (2) were accepted officially, and (4) was being carried out unofficially in the Fifth U.S. Army and in the hospitals of NATOUSA. Time B ration was improved markedly during the last 2 weeks of December by the addition of frozen meat, poultry, bread (fig. 70), and fresh butter.

Late in May 1943, a conference group was appointed, under the chairmanship of Brigadier R. M. Hinde, O.B.E., to consider establishing an interallied common ration scale. The possibility of evolving a common ration had been contemplated for some time, and, following approval of the deputy theater commander, the chief administrative officer (British), AFHQ, had nominated this committee with the consultant in medicine as one of the two American members. The function of the committee was to consider the matter from all angles and to surmount any difficulties that might prevent the proposed scale from being put into operation.


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Several sessions were held beginning 13 June 1943. At the first meeting, it was pointed out that a common ration scale would save duplication of depots as well as shipping tonnage and food supplies, both in the United States and in the United Kingdom. Further discussions made clear that the existing British scale lacked variety and many issues were too low in quantity. Brigadier Hinde called upon the medical member of the committee to submit schedules of the calories, vitamins, minerals, variety of foodstuffs, and similar items that would constitute an adequate common ration scale. This was done after a series of joint conferences and was accepted with a few minor modifications by the committee at a meeting on 8 July 1943. The proposed scale was referred to the Quartermaster Section and by it to Headquarters, Service of Supply. The latter office added a few minor changes, and in addition, suggested that a 10-day cycle and issue chart be prepared and that the ration be fed to test groups of individuals from both armies before being formally adopted. These suggestions were agreed upon by the committee on 29 July 1943. Nothing has been heard of the interallied common ration scale since that date.

Although the rations for combat troops became temporarily unbalanced during periods of intense fighting in 1944-45, situations such as existed in 1943 were rarely encountered. The nutrition of all in the theater was at a relatively high level, especially during the stabilization of combat in the high Apennines during the winter of 1944-45. The breakout into the Po Valley, with the subsequent drive towards the Alps, was so rapid and through country so relatively well supplied with food that the nutrition of the force was never a serious problem.

RECONDITIONING

The problems associated with the physical rehabilitation of sick and wounded soldiers became apparent in the late spring of 1943, when patients convalescent from various diseases and from wounds were being discharged directly to the replacement depots. It was found that many of them, although convalescent and in need of no further medical attention, were in such a poor physical state that they could not undertake the training programs then in force in the replacement depots. Accordingly, the Surgeon, NATOUSA, requested the advice of the consultants in surgery and medicine in respect to the physical rehabilitation of convalescent patients. At the direction of the consultants, Maj. (later Lt. Col.) James H. Townsend, MC, 6th General Hospital, and Capt. Lewis T Stoneburner, III, MC, 45th General Hospital, were detailed to make a study of all convalescent and rehabilitation facilities existing in the theater. After a study of the problem in the 2d Convalescent Hospital, the Palm Beach Convalescent Camp, the 1st Replacement Depot, in numerous station and general hospitals, and in the 8th and 10th British Convalescent Depots, these officers made the following recommendations on 30 August 1943, which were favorably endorsed by the consultants in surgery and medicine and approved by the Surgeon, NATOUSA.


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      *          *          *          *          *          *          *

3. Conclusions.       

a. It is believed that theme is a clearly demonstrated need for some type of installation in this theater for the rehabilitation of men who have completed their treatment in general hospitals and station hospitals acting as general hospitals, who by virtue of their long periods of hospitalization and absence from their units, are in need of physical reconditioning and mental reorientation before undertaking the training program of replacement centers.

b. It is believed that this can be most effectively accomplished with an organization under the administration of line officers with the assistance of a suitable medical detachment and continuous liaison with the medical department.       

c. An installation organized as a separate training battalion with a slightly augmented medical detachment is believed to be well suited to this purpose. It could be an independent installation, or attached to a replacement center.

d. The outline of the organization and operational program of such an installation are appended. They do not differ materially from what is already in operation at the Combat Conditioning Battalion of the 2d Convalescent Hospital, and at Palm Beach.

4.Recommendations.       

  a. That in each geographical center of hospitalization in this theater a rehabilitation center be established to recondition men discharged from hospitals who are to be returned to combat duty.
        b. That such installations should be organized under line administration with a suitable medical detachment.

c. That professional liaison be established between hospitals, rehabilitation centers and replacement centers to insure optimum results in the functioning of the whole program.

The policy laid down in these recommendations, namely, that it was not the mission of the Medical Department to train men for combat or other army duties, was accepted by the Surgeon, NATOUSA, who, however, took no specific action upon the report of Major Townsend and Captain Stoneburner. Early in 1944, reconditioning units, whose sole purpose was to rehabilitate patients to the point where they could undergo the type of training required in the combat. reconditioning companies and in the training sections of the replacement depots, were established in most station and general hospitals (figs. 71 and 72) in the theater. The efficiency of these units varied with the enthusiasm and interest of the noncommissioned and commissioned officers who were in charge of them. However, with the development of exercise tolerance as a test for cure in patients convalescent from hepatitis in 1944, the physical reconditioning program was given a boost, and it functioned in a satisfactory manner during the remainder of the life of the theater.

PROFESSIONAL EDUCATION

From the beginning of his duties as consultant in medicine in the North African theater, Colonel Long attempted to stimulate and plan the graduate education of medical officers, believing that a program of graduate education would materially assist in the maintenance of reasonable standards of medical practice within the theater. It has been noted earlier in this chapter that medical officers of service and tactical units were isolated from medical thought. In a report made to the Surgeon, NATOUSA (Deputy Surgeon, AFHQ) on 25 January 1943, the consultant in medicine made two recommendations.


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FIGURE 71.-Occupational therapy, 21st General Hospital, Italy, 1944.

First, every effort should be made to improve the professional standards of unit medical officers by conferences, short courses, lectures, meetings (fig. 73), and similar methods. Such programs could be carried out when divisions and units were in rest areas. The consultant staff, Medical Section, NATOUSA (AFHQ), and the staff of general, stations, and evacuation hospitals could be used as instructors. Second, all circulars, directives, and other mediums dealing with the professional aspects of patient care that might originate from the Medical Section, NATOUSA (AFHQ), should be prepared in such quantities that a copy of each might be placed in the hands of each unit medical officer.

Hospital Programs

During his first tour of all American hospitals in NATOUSA, completed in March 1943, the consultant in medicine had noted that, although the general caliber of professional work upon the medical services was excellent, the libraries in certain hospitals were not very accessible or complete, and, in some hospitals the holding of medical conferences or staff meetings had been abandoned. Upon his recommendation, Circular Letter No. 2, dated 18 March 1943, Office of the Surgeon, Headquarters, NATOUSA, was distributed to the commanding officers of all field, evacuation, station, convalescent, and general hospitals. It read as follows:

1. The Surgeon, NATOUSA, has been impressed with the high standards of professional service which exists in the army hospitals in NATOUSA, and he desires that every effort


217

FIGURE 72.-Reconditioning, 21st General Hospital, Italy, 1944.

be made to maintain or even increase the levels of professional practice. To this end it is suggested:        

a. That hospital libraries be placed in a position where they are easily available to all members of the hospital staff and that the Office of the Surgeon, NATOUSA, be notified immediately of any deficiencies noted in medical books and journals.

  b. That medical officers be encouraged to study the clinical course of interesting groups of patients with the viewpoint of collecting adequate data upon which medical and surgical reports may be based. It is suggested that completed papers be submitted to the Surgeon's Office, NATOUSA, for editing and forwarding to The Surgeon General.        

c. That weekly clinical or clinical pathological conferences be held by the staffs of all hospitals in NATOUSA.

   d. That when the opportunity arises members of one hospital staff will visit neighboring hospitals for the purpose of observing professional practices.

As a result of this letter, deficiencies in time libraries of hospitals were corrected, weekly medical meetings were instituted as a regular procedure in all hospitals, and papers dealing with disease in the North African theater began to be sent in for publication. Thus was initiated a continuous program of practical medical education, which lasted throughout the life of the theater.

Meetings and Societies

With the grouping and concentration of hospitals in certain areas such as Oran, Bizerte, Naples, Leghorn, and in time Fifth U.S. Army area, it was


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FIGURE 73.-Weekly meeting of Fifth U.S. Army medical officers at 38th Evacuation Hospital, February 1944.

only natural to expect medical officers to organize medical societies. As a result of such activities the Mediterranean, Eastern and Peninsular base medical societies were organized, and these flourished as long as the base sections existed. A particularly interesting organization was the Fifth U.S. Army medical society, which held its weekly meetings in the opera house of the palace of Caserta in the winter of 1943-44. The success of these parent organizations led to the formation of specialist groups such as the Peninsular Base Section neuropsychiatric association, which was active through 1944.

Hospital sponsored meetings and societies. - The large general medical societies served a very useful purpose because the topics presented were of a practical and timely nature, and the sessions of these societies provided a common meeting ground for medical officers in the various areas. The success of these meetings led individual hospitals to sponsor medical meetings; those of the 26th General Hospital at Bari, Italy, and the 8th Evacuation Hospital when it was located near Raticosa, are worthy of comment. The 26th General Hospital functioned as the general hospital for the Fifteenth Air Force from January 1944 until June 1945, and, because of its central location within that air force, was accessible to squadron surgeons. Hence, its medical meetings were well attended and served a very useful purpose in keeping the medical officers of the Fifteenth Air Force au courant with the latest developments in medicine. The 8th Evacuation Hospital (fig. 74) conducted a series of afternoon and evening meetings for medical officers of field units that were near the Florence-Bologna road during the first 4 months


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FIGURE 74.-8th Evacuation hospital, Italy, January 1945.

of 1945. At times, the program was presented by the personnel of the 8th Evacuation Hospital; at other times, guest speakers were present. The meetings were so organized that an afternoon program of 2 hours' duration was followed by the opportunity to take a hot shower, followed by cocktails and dinner, and in the evening another scientific program was presented. Thus, the needs of both mind and body were met. The attendance at these meetings was always large.

Interallied meetings. - During the life of the North African and Mediterranean theaters there were several large meetings that were interallied in scope. The first of these, organized under the aegis of the Surgeon, Mediterranean Base Section, was held in Oran, Algeria, on 6 November 1943. Owing to the geographical location of Oran, the meeting was largely attended by American and French medical officers, and papers were presented by officers of both nationalities upon subjects of current interest. An attractive feature of this meeting (fig. 75) was a series of exhibits dealing with the work of optical units, malaria survey and control units, certain aspects of medical supplies, the treatment of fractures, and other interesting subjects.

The second large medical meeting was the Interallied Medical Congress, which was held in Algiers, Algeria, 21-24 February 1944. Membership in this congress was open to medical officers of the Allied nations and to French civilian physicians in North Africa. Unfortunately, owing to the transpor-


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FIGURE 75.-Brig. Gen. Frederick A. Blessé and U.S. Army and Navy medical officers examine models of Tobruk splints at medical conference in Oran, North Africa, November 1943.

tation situation and the problem of billeting, American and British participation in this congress had to be limited to medical officers who were then resident in North Africa. Despite this limitation, the congress was well attended - over a thousand members registered - and the subjects of typhus, venereal diseases, malaria, dysentery, neuropsychiatric conditions, and military surgery received special attention.

The third large medical meeting was sponsored by the 26th General Hospital and was held in Bari, Italy, on 4 November 1944. The program was designed to be of current interest, and among the speakers were both British and American medical officers. Transportation to and from this meeting was mainly aerial, made possible through the cooperation of the Fifteenth Air Force and the Air Transport Command. Several hundred medical officers attended this meeting.

The fourth large meeting was organized by the 300th General Hospital in Naples and was held on 26 and 27 January 1945. The program was presented largely by the staff of the hospital, although certain papers were presented by British and other American medical officers. A feature of this meeting was the fact that most of the more than six hundred American and British medical


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officers who attended were billeted in the hosptal. They were transported to and from Naples by air.

The fifth and last large meeting was the conference of Army physicians, which met in Rome from 29 January to 3 February 1945. It was organized by Brigadier Boland, the British consulting physician of AFHQ. The membership was made up primarily of the officers in charge of medical divisions and time medical specialists of British, Canadian, South African, New Zealand, Indian, and Polish general hospitals and casualty clearing stations, but more than fifty chiefs of the medical services of American hospitals in the theater were invited to attend. In addition, the consulting physicians from the Middle East Force, East African Command, Persia and Iraq Force, South Africa, New Zealand Corps, Canadian Corps, and the consultant in medicine and the Surgeon, MTOUSA, were in attendance. Thus, a wide variety of opinion was represented, and the sessions in which malaria, diphtheria, infectious hepatitis, trenchfoot, amebiasis, penetrating wounds of the chest, neuropsychiatric problems, and the medical uses of penicillin were covered, were well attended, and the subjects were freely discussed. Ample time was taken out during the conference to permit visits to places of interest in Rome, an audience was granted the members of the conference by the Pope, and the delegates were invited to a wide variety of social functions. It was considered one of the most successful meetings held in the North African and Mediterranean theaters.

Rotation of Medical Officers

The problem of continuing the graduate education of field service medical officers attracted the attention of the consultant in medicine within the month after he arrived in North Africa, when he noted the paucity of opportunity for these officers to do anything resembling the practice of medicine as they had known it. It was almost impossible, because of the varying tactical situations, to place these officers in hospitals for periods of temporary duty. In May 1943, at the suggestion of the consultant in chemical warfare medicine, a flexible plan for rotating medical officers from service and combat units to hospitals was devised. The plan envisaged the replacement of all medical officers, after varying periods of combat duty, by general duty medical officers from army hospitals within the theater. This plan, which was never enumerated as official policy, had as its purpose the professional rehabilitation of medical officers who had long been removed from the practice of medicine. Initially, minor opposition was presented by commanders of the field units and the hospitals concerned, because both groups of commanders disliked giving up trained and known medical officers for unknown ones, but, when the plan began to function and its merits were understood, this opposition quickly disappeared. As a result of this program, more than three hundred service and combat unit medical officers were rotated from the field to hospital services during the existence of the North African and Mediterranean theaters.


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Plans for Postarmistice Training

On 30 August 1944, the consultant in medicine initiated an action by sending to the theater surgeon a memorandum, subject: Proposed Staff Memorandum of a Plan for the Postarmistice Professional Rehabilitation in North African Theater of Operations, United States Army of Field Service and Administrative Medical Officers in Internal Medicine, which read as follows:

1. There are many medical officers in NATOUSA who have not had adequate contact with the practice of medicine for extended periods of time. This is especially true of field and administrative service medical officers, many of whom have been out of the practice of medicine, as it is commonly understood, for from 2 to 3 years. The experience of this theater indicates that medical officers who have been in the field or administrative services for a year or more require from 3 to 6 months training before they can be fully trusted with the care of patients upon the wards of station or general hospitals. To date no plan for training which will rehabilitate these medical officers in the art of taking care of patients, has been put forth either by the War Department or civilian agencies at home. It is believed that if the following plan could be made effective in NATOUSA immediately in the postarmistice period, that the morale of medical officers would be maintained and that this theater would be performing a definite service, not only to the civilian population bitt also to the Army as well.

  2. Plan for the professional rehabilitation of medical officers in NATOUSA.       

a. Post graduate training must be carried out upon a temporary duty basis, with the student medical officers assuming definite ward responsibilities in the hospitals to which they may be attached.

b. The period of training should be 6 weeks in duration and the program can be carried out in all General and the 7th, 23d, 182d, and 225th Station hospitals.        

c. The primary aim of the rehabilitation program should be to refresh medical officers in the techniques of history taking, physical examination, the value of laboratory diagnostic procedures and the advances which have been made in medicine since 1940. This can best be accomplished by giving the student medical officers direct responsibility (under competent supervision) for the management of ward patients, by formal teaching ward rounds, lectures upon special subjects, X-ray conferences, clinical pathological conferences and journal clubs. The training program should concern itself primarily with general internal medicine, but special emphasis should he placed upon the newer aspects of the diagnosis and treatment of venereal diseases, modern concepts of dietary regimes, and a thorough review of indication for use and the practical application of penicillin, etc.

   d. The modus operandi could be as follows: There are approximately 100 ward medical officers in the general and station hospitals which have been listed, and there are roughly 675 field service medical officers in NATOUSA. Obviously, it is impossible to estimate how many of these officers will desire training in internal medicine. It is suggested, therefore, that upon the signing of the armistice a paragraph outlining the scope of the program be published in a NATOUSA Circular and that application for training he filed through command channels. Priority on training would be given to those officers who have been longest in field or administrative medical positions, irrespective of whether such service was in the United States or overseas. It is the consensus of opinion that from 45 to 50 medical ward officers (and as the surgical service will be light, surgical ward officers would also be available) could be placed on 6 weeks temporary duty with field units as replacements for the trainees. Additional candidates for the program, for whom replacements would not he necessary could be obtained from the administrative services. Is it estimated that from 75 to 100 medical officers could be rehabilitated at a time under such a system.      

e. In order to assure the smooth functioning of this program it would be necessary to have a "school director" attached to the Office of the Surgeon, NATOUSA. His duties


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would be to select candidates and to supervise and coordinate the proposed program. This officer should be attached to the Office of the Surgeon, NATOUSA, when the armistice seems imminent, in order that the program may be started as soon as the tactical situation in the theater becomes stabilized.

This memorandum was thoroughly discussed with the Surgeon, MTOUSA, and upon his recommendation, it was decided to suspend action upon this plan until it appeared that the enemy was about to surrender.

Early in March 1945, the end of hostilities in the Mediterranean theater seemed imminent, and a committee, under the chairmanship of Col. Edward

D. Churchill, MC, was formed to make plans for graduate education in the postsurrender period. This group held its first meeting on 15 April 1945, and the following recommendations were made to the Surgeon, NATOUSA.

  a. A director of Professional School Service should be appointed to the staff of the Surgeon, MTOUSA, and implemented with clerical aid.
        b Authorization of courses as official War Department school courses should be sucured.     

c. When the program has been formulated, a circular letter or bulletin describing the program should be distributed to every medical officer in the theater.

   d. General hospitals and the 7th Station Hospital should be requested to submit plans for a basic course in accord with the following general policies:         

(1) Medical officers attached to a general hospital for a basic course are to be regarded as students and will not he used for army other function except in an emergency.

  (2) A basic course of 6 weeks duration will he designed so that a student may enter at any time and, when essential, depart at any time.         

(3) General hospitals will plan for 20-25 students each at a time; the 7th Station Hospital will plan for 7 students.

  (4) Supplemental professional teaching personnel will be supplied, when available, by the director of Professional School Service. The mobile hospitals will be a source of personnel for this purpose.         

(5) The course will include: clinical pathology, general medicine, general surgery, preventive medicine, and neuropsychiatry.

  (6) Ward rounds in general medicine or general surgery will he conducted by a senior officer. In addition, there will be clinics, clinicopathologic conferences, X-ray conferences, didactic lectures, round-table discussions and journal club meetings.      

e. The director of Professional School Service shall also arrange elective courses, usually of 2 weeks' duration, in the following: Field course in preventive medicine, (malaria control, typhus, enteric diseases, venereal disease). In general, these should follow completion of the basic course.

The Surgeon, MTO1IJSA, accepted the recommendations of the committee, and shortly afterwards, Lt. Col. Joseph O. Weilbaecher, Jr., MC, of the 64th General Hospital was placed on temporary duty in the Office of the Surgeon, MTOUSA, as director of professional school service. Colonel Weilbaecher immediately made a detailed study of the problem of setting up the desired courses in the general hospitals of the theater, and, at the completion of his study, He submitted a comprehensive plan for instruction over a 6-week period. This plan was accepted by the Surgeon, MTOUSA, shortly after the surrender of the enemy in Italy, but it could not be put into effect immediately because of the redeployment program. After the completion of the redeployment program early in July, it was found that the staffs of certain hospitals had been so


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disrupted as to make them unavailable for teaching purposes, and in the end, it was found necessary to shift from the rather formal course that had been planned, to on-the-job training in the 33d General Hospital, Leghorn, Italy, 64th General Hospital, Ardenza, Italy, and the 300th General Hospital. Undoubtedly, some benefit was derived by the medical officers who received training in these hospitals, but the experience of the Mediterranean theater definitely showed the difficulty of organizing and carrying out postgraduate training at such a time, and it appeared that completely satisfactory programs for medical education could not be devised during periods of redeployment.

RESEARCH PROBLEMS

It became evident to the consultant in medicine early in 1943 that practical and, possibly, some fundamental contributions to medical knowledge might be made in an oversea theater of operations, if the investigative spirit that lay dormant in many medical officers was stimulated. In the course of his first tour of inspection of hospitals, interesting problems were noted in respect to the etiology of diarrhea, the significance of chronic dyspepsia in the Army, the treatment of gonorrhea, the treatment of anxiety states, and the description of exotic diseases, and medical officers were asked to send papers on these subjects to The Surgeon General.

Malaria. - The initiation of the policy of universal Atabrine therapy for the suppression of malaria in the Allied Forces offered excellent opportunities for the study of the toxicology and pharmacology of the drug, and in a report to the Surgeon, NATOUSA, dated 17 May 1943, recommendations were made regarding the possibility of making such studies.

1. The next six months are going to offer unrivaled opportunities for the study of the effects of Atabrine therapy in respect to its actual effect in suppressing malaria, the conditions under which "breakthroughs" occur, the value of the drug in respect to the various types of malarial parasites and the effect of terminal concentrations of the drug on the subsequent development of malaria. In addition, the use of quinine could be studied from the same point of view.

2. This same period will offer the same opportunity for studying new methods of malarial therapeusis.

3. To date all of our ideas in respect to the suppressive and therapeutic aspects of Atabrine or quinine therapy have been based upon empirical observations and there is good reason to believe that with the techniques for determining the concentrations of Atabrine and quinine in the tissues and body fluids which have been developed within the last year, notable contributions might be made from NATOUSA upon the suppression and therapy of malaria. This will also benefit our troops.

4. Physical equipment such as laboratory space, benches, etc., are readily available and unused in French civilian institutions in Algiers.

5. It has been the policy of the Surgeon General's Office to investigate special disease situations within and without the United States by civilians who are designated as consultants to the Secretary of War.      

a. The investigations of the Board for the Control of Influenza and other epidemic diseases.

    (1) Under army auspices but with civilian personnel a large laboratory has been set up at Fort Bragg.


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        (2) The civilian members of the various commissions have conducted extensive investigations under army auspices in the field in the United States.       

b. Two members of the Virus Commission have been dispatched to Cairo to study sand fly fever and jaundice from the point of view of the causative organisms.

c. The army has sent special investigators outside the continental United States to study certain special problems since December 7, 1941. An example of this is the inspection of wounded made by Drs. I. S. Ravdin and P. H. Long at Pearl Harbor in 1941.

6. Therefore, inasmuch as the problem is pressing and of great importance and the following recommendation involves no question of War Department policy or precedent, it is strongly recommended:       

a. That the theater commander urgently request that the services of Dr. James Shannon, Professor of Pharmacology, New York University, one junior assistant and four technical assistants, be made available immediately in this theater of operations and that permission be given to permit them to bring those laboratory instruments and reagents, necessary for them to accomplish their mission. Dr. Shannon is the individual who developed the methods for the quantitative determination of both quinine and Atabrine in body tissues and fluids.

b. If this recommendation meets with your approval the following radio to the War Department, attention Surgeon General, is suggested: "Unrivaled opportunities will exist in NATOUSA during the next seven months for the scientific study of suppressive and therapeutic activities of quinine and Atabrine from the pharmacological and toxicological points of view. Special experimental studies upon this problem can he arranged easily with French civilian medical authorities. Laboratory space is available. Information gained from these studies will be most valuable in its application to the personnel of this theater. It is urgently requested that Dr. James Shannon of New York University, one designated associate, and four technicians be sent immediately under a civilian status to NATOUSA to study these problems. Such technical laboratory instruments and reagents needed for their mission should be brought with them. Because of the urgency of these problems priority of transportation is requested."

The Surgeon accepted these recommendations and communicated informally with the Chief, Preventive Medicine Service, Office of the Surgeon General, concerning the possibility of carrying out such studies in the North African theater. Unfortunately, the reply to this communication was misaddressed and did not arrive until September, when it was too late to do anything about such studies.

Dysentery. - In late spring of 1943, a major outbreak of flyborne bacillary dysentery occurred in the North African theater. Careful studies upon the types of micro-organism responsible for this outbreak were made in the Second Medical Laboratory in Casablanca, French Morocco, the 151st and 69th Station Hospitals in Oran, Algeria, and the 73d Station Hospital at Constantine, Algeria, with the result that not only was the etiology of the diarrhea in North Africa clarified but also hitherto unrecognized species of the Shigella family were described. These studies were especially helpful in counteracting the French point of view that bacillary dysentery was uncommon in North Africa.

The arrival of the l5th Medical General Laboratory (fig.76) in the fall of 1943 accelerated the tempo of investigation in the theater because such a unit could function as the clearinghouse for research activities and specifically because the stimulating presence of Major Mallory was felt by all. The


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FIGURE 76.-15th Medical General Laboratory, Italy, 1945.

laboratory was established in Naples early in 1944 and from that time on served very usefully as the center of research activities within the theater.

Early in 1944, the Surgeon, NATOUSA, created a board of officers to evaluate proposals for the investigation of various problems and to stimulate research in the theater. The members of this board were the medical inspector, the consultant in surgery, the commanding officer of the 15th Medical General Laboratory, the consultant in medicine, and the preventive medicine officer. It was the opinion of the consultant in medicine that although the Medical Research Advisory Board served a useful purpose in screening certain suggestions for research and in bringing the weight of its authority to bear when necessary to accomplish certain things, it rarely fulfilled its mission of stimulating research. Certain of the individual members did, but certainly not the board as such

During 1944-45, certain examples of investigation involving laboratory studies were as follows:

Hepatitis. - Studies on infectious hepatitis were instituted on a large scale under the direction of Colonel Barker, early in 1944, and were continued until July 1945. These investigations included comprehensive investigations on the etiology, epidemiology, pathology, clinical course, prognosis, and treatment of this disease.


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Atabrine. - In the summer of 1944, an extensive study was made by Capt. (later Maj.) John C. Ransmeier, MC, of the 300th General Hospital, on the relation of the concentration of Atabrine in the blood to alleged breakthroughs in the course of the use of Atabrine for the suppression of malaria.

Liver function. - During 1944-45, numerous medical officers studied the value of various tests of liver function, not only in patients ill with infectious hepatitis, but also in those with malaria, syphilis, tonsillitis, primary atypical pneumonia, bacillary dysentery, and in normal individuals.

Trenchfoot. - Studies were carried out in the winter of 1944-45 upon the capillary beds and upon temperature variations in the skin of individuals suffering from trenchfoot.

Other studies. - In addition to these investigations, many excellent clinical papers were written dealing with malaria, dysentery, boutonneuse fever, sandfly fever, arthritis, rheumatic fever, primary atypical pneumonia, leishmaniasis, and other diseases, and the treatment of gonorrhea and syphilis with penicillin, in the North African and Mediterranean theaters.

EDITORIAL DUTIES

Every effort was made by the consultant in medicine to provide the physicians in MTOUSA with the latest information concerning advances being made in medicine. In this attempt, it was found that the reports received from the National Research Council and the Committee on Medical Research, Office of Scientific Research and Development, were especially useful because they were valuable sources of restricted information upon such subjects as malaria, dysentery, insecticides, and penicillin. These reports were frequently reprinted in circular letters within the theater and were greatly appreciated by all medical officers. The WD technical bulletins, medical, were also valuable sources of information, but, unfortunately, in the Mediterranean theater, these bulletins frequently did not arrive until after the need for the advice contained in them had passed.

In 1943, it became evident that a means other than circular letters for disseminating information of current value to medical officers was greatly needed in the North African Theater of Operations. After considerable thought and discussion, in which Col. Earle G. Standlee, MC, Deputy Surgeon, NATOUSA, was the leader, it was decided to produce a monthly medical journal, the Medical Bulletin of The North African Theater of Operations. An editorial board consisting of the chiefs of the various divisions and sections in the surgeon's office, and under the chairmanship of the Surgeon, NATOUSA, was established. Capt. Carl D. Clarke, SnC, was appointed managing editor. The success of this publication (the title of which was changed on 1 December 1944 to the Medical Bulletin of the Mediterranean Theater of Operations was instantaneous, and there can be but little doubt. that it was a leading educational stimulus, as copies reached every medical officer in the theater.


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In July 1944, following conferences with various chiefs of medical services, the consultant in medicine decided to recommend to the Surgeon, NATOUSA, that comprehensive monographs covering diseases of importance in the theater be prepared by individual medical officers, or boards of medical officers, in order that the collected opinion of medical officers concerning these diseases might be recorded. In a memorandum to the Surgeon, NATOUSA, dated 9 September 1944, subject: Clinical Description of Disease in Respect to Management, Disposition and Prognosis in NATOUSA, the following recommendation was made:

It is recommended that comprehensive reports on the problems concerned with the management, disposition and prognosis of the following diseases in NATOUSA be prepared by the following medical officers. It is furthermore recommended that immediately after the armistice is signed or before that occurrence if necessary, these medical officers be placed on D.S. [detached service] in order that they may collect the necessary data on various disease entities and assemble it without being disturbed by administrative or clinical duty.

This recommendation received favorable consideration from the Surgeon, NATOUSA, and, at his suggestion it was decided that two reports would be made in each instance. A preliminary report, which would be prepared in the fall of 1944, and a final report, which would be written after the war ended in Italy. This decision was activated by the following letter, signed by the Deputy Surgeon, NATOUSA, dated 16 October 1944.

Subject: The Detailing of Medical Officers to Assist in the Preparation of Clinical Monographs on disease Problems in NATOUSA.

To: Surgeon, Peninsular Base Section, APO 782 (Thru: Surgeon, COMZONE, NATOUSA, APO 750)

1. It is desired that clinical monographs be prepared on the major disease problems with which this theater has been concerned. The objective is to have considered, authoritative statements in respect to these various problems available before the termination of medical activities in NATOUSA.

2. The purpose of these monographs is to describe accurately the diagnostic methods employed, clinical course, treatment and the results thereof, and the disposition of patients ill with certain diseases in NATOUSA. Special attention should be paid to the problems faced in dealing with these diseases under the military conditions which have existed in the Theater since one aim of these reports is to differentiate clearly those factors influencing the management of disease in an active theater from those operative under garrison or civilian conditions.

3. To facilitate this undertaking, it is requested that the designated medical officers compile and edit time available data upon specified diseases. These medical officers will receive the fullest cooperation in their endeavors, and furnished facilities such as secretarial aid, etc., necessary in the preparation of reports.

4. In the instance of certain diseases, two or more officers from different hospitals, will constitute a board to collaborate upon the reports in order that a broad critical analysis may be obtained. They will confer whenever necessary with each other or with medical officers in the Theater upon their particular problems. The senior officer will act as chairman of the board. Direct communication between members of the group or any other medical officer who possesses pertinent data is authorized.

5. As far as is possible, the reports should be based upon factual data and not upon impressions. To this end, all necessary records will be made available to the authors of


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the various monographs. Use should be made of the pertinent laboratory data accumulated by the 15th Medical General Laboratory and 2d Medical Laboratory. Due credit will be given for the contributions of these laboratories.

6. When more than one officer is concerned in the preparation of a report, the individual experiences of each officer will be recorded first, and the final report will represent the consensus of opinion of the board. This will naturally require a certain amount of professional give-and-take

7. Travel orders will be issued for such inspection of records, conferences, etc., as is necessary in the opinion of the authors, for the completion of their assigned missions.

8. It is desired that these monographs be completed within 60 days after designation of the responsible officers, and one original and four carbon copies forwarded through technical channels to the Surgeon, NATOUSA. These reports will be classified "Restricted."

9. Diseases and authors,

a. Common respiratory diseases.

    Primary atypical pneumonia.

    Streptococcal sore throats.

    Lt. Col. D. W. Myers, 0-437966, 7th Station Hospital

    Major E. D. Matthews, 0-436735, 24th General Hospital      

b. Common diarrheas.

    Bacillary dysentery.

    Major H. W. Hurewitz, 0-1700449, 73d Station Hospital         

c. Malaria.

    Major P. B. Bleecker, 0-355049, 225th Station Hospital

    Major F. S. Perkin, 0-470551, 17th General Hospital

    Major H. H. Golz, 0-318515, 182d Station Hospital         

d. Infectious hepatitis.

    Lt. Col. M. H. Barker, 0-409083, l2th General Hospital

    Major R. B. Capps, 0-386360, 12th General Hospital

    Major F. W. Allen, 0-257301, 15th Medical General Laboratory         

e. Tuberculosis.

    Lt. Col. D. S. King, 0-413283, 6th General Hospital

    Capt. G. T. McKean, 0-428031, l7th General Hospital         

f. Dermatological conditions.

        Major C. B. Kennedy, 0-40377 1, 64th General Hospital

    Major R. N. J. Buchanan, 0-404505, 300th General Hospital

    Major R. C. Manson, 0-330183, 45th General Hospital

    Major R.. E. Imhoff, 0-479552, 61st Station Hospital          

g. Arthritis and rheumatic fever.

    Major C. L. Short, 0-178366, 6th General Hospital

    Major E. F. F. Bland, 0-397996, 6th General Hospital         

h. Peptic ulcer.

    Major N. F. Fradkin, 0-430698, 33d General Hospital

    Major D. P. Head, 0-230608, 26th General Hospital

    Major C. J. W. Wilson, 0-445327, 24th General Hospital         

i. Infections polyneuritis.

    Major J. W. Johnson, Jr., 0-468994, 300th General Hospital         

j. Allergic diseases.

    Major H. H. Golz, 0-318515, 182d Station Hospital

    Capt. A. C. Kahisch, 0-1695328, 182d Station Hospital         

k. Sandfly fever.

    Lt. Col. William A. Reilly, 59th Evacuation Hospital

    Major Roberto F. Escamilla, 59th Evacuation Hospital

    Col. Perrin H. Long, Medical Section, A.F.H.Q.


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    l. Venereal disease.

    Capt. R. L. Gettman, 0-1693729, 23d General Hospital         

m. Leishmaniasis.

    Major Alfred Kranes, 6th General Hospital.

For the Surgeon:

E. Standlee

Colonel, M. C.,

Deputy Surgeon

The initial monographs were forwarded to the Chief Consultant in Medicine, Medical Consultants Division, Office of the Surgeon General, in February 1945, for suggestion and criticism and were then rewritten and brought up to date after the surrender of the enemy in Italy. This was done in compliance with the directive contained in the letter of the Surgeon, MTOUSA, dated 7 February 1945, subject: Clinical Monographs on Disease Problems in

MTOUSA.

MEDICAL INTELLIGENCE

Early in 1943, when faced with the problem of the medical care of prisoners of war, Colonel Long realized that there was practically no source of medical intelligence in the theater. With this in mind, he made the following report to the Surgeon, NATOUSA

1. There is available in NATOUSA very little information regarding enemy immunization programs, medical field service, medical practices and medical supplies. The possession of such information would be of value in the planning of future operations and in the medical care of prisoners of war. It is also conceivable that information or drugs might be picked which would aid the AUS in improving certain aspects of medical practice.

2. It is therefore suggested that an intelligent trained young medical officer be attached immediately to the G-2 Section, II Corps, and that he be instructed:

a. To interview prisoners of war in order to obtain medical information from them.

b. To inspect, photograph and describe captured enemy medical installations.

c. To inspect, describe and photograph enemy medical equipment and supplies.

d. To report the existence, general type of, and location of captured enemy medical supplies.

e. To send samples of new instruments, drugs. etc., promptly to The Surgeon, NATOUSA.

  f. To file reports of his findings with G-2, NATOUSA.

The Surgeon, NATOUSA, did not take these recommendations very seriously and did nothing about them. When this became evident, the consultant in medicine made arrangements with the Documents Branch, G-2 Section, AFHQ, to have sent to him all the captured enemy documents that related to any field of medicine. This arrangement worked out fairly successfully, and some useful information concerning the incidence of typhus and tetanus, the prophylaxis of malaria and immunization against disease was obtained. However, it was always felt that much more valuable material could have been obtained if a properly trained medical service officer had been placed in charge of medical intelligence.