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Chapter V

Activities of Medical Consultants

CHAPTER V

Southwest Pacific Area

Henry M. Thomas, Jr., M.D.

Part I. Administrative Considerations

    The medical history of the SWPA (Southwest Pacific Area) and the part played in it by the medical consultants must be viewed in the light of conditions as they existed in this area. These conditions included warfare in the tropical jungle; ainphibious island hopping; stupendous engineering feats by which jungle was cleared and a whole series of isolated bases built, complete with airstrips, roads, docks, and supply dumps; and the conduct of a war 7,000 miles from the United States, with relatively little manpower and relatively little materiel of any kind.

    The best of planning could not have prepared for the unique developments in Australia, New Guinea, and the Philippine Islands. No one could have foreseen that hospital personnel would have to build their own hospitals, sometimes even clearing the jungle, grading and draining the area, and installing plumbing and electricity. No one could have anticipated that shipping and air transportation would be so scarce and over such great distances that equipment which was usually considered essential, as well as key personnel, would sometimes be left behind to make room for ammunition and minimum food allowances. No one could have planned for the evacuation of casualties with even minor wounds 500 to 1,000 miles by water or air. No one could have anticipated that there would be a constant struggle to provide enough hospital beds for patients who constituted what proved to be a low sick and wounded rate. Yet all of these things came to pass, and as a result attention was focused, first of all, upon the procurement of basic essentials.

ORGANIZATION OF THE MEDICAL DEPARTMENT

    The medical organization in the SWPA, which eventually grew to considerable size, began as USAFIA (U.S. Army Forces in Australia), with only a few officers. Early in 1942, Col. (later Brig. Gen.) Percy J. Carroll, MC., who was on duty in the Philippines when the war began in December 1941, collected a group of patients just before the fall of Manila and evacuated them on the small U.S.A.H.S. Mactan (fig. 158). When he arrived in Australia, he was made responsible, as ranking medical officer in the area, for Medical Department activities of USAFIA.

    On 28 February 1942, the 4th General Hospital and a number of casual medical officers arrived and set up in Melbourne, Australia. In April, the 1st and 10th Evacuation Hospitals landed, together with several small station


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FIGURE 158.-U.S.A.H.S. Mactan upon her return to Manila, Philippine Islands, June 1945.

hospitals. In early June, a miumber of other station hospitals landed in Melbourne, on the U.S.S. West Point, which also brought three affiliated hospitals. These were the 1,000-bed 105th General Hospital, the 500-bed 118th General Hospital, and the 500-bed 42d General Hospital. From this time, until more than a year later, only a few casual Medical Corps officers and a few nonaffiliated station hospitals were sent to SWPA. It is small wonder that, during the early days, it seemed to many medical officers in this area that they had been left to struggle along as best as they could, since they had relatively little help in the form of either materiel or personnel.

    During 1943 and 1944, certain peculiarities of the command organization in SWPA, which succeeded USAFIA on 18 April 1942, explained certain medical difficulties in this area, including the limitation of the consultants activities.

The Commander in Chief of the Allied Forces, SWPA, Gen. Douglas MacArthur, had as his staff the personnel assigned to General Headquarters. Under General Headquarters (chart 4) were the United States and Australian Forces. On the U.S. side, directly under General Headquarters, were the U.S. Navy and USAFFE (U.S. Army Forces in the Far East). On the next level under USAFFE were the following components:

    1. Ground Forces, consisting mainly of the Sixth U.S. Army. This army, with its predecessor commands, the Alamo Force (United States) and the New Guinea Force (Australian), did all the land fighting in New Guinea. The Eighth U.S. Army was organized in the course of the New Guinea campaign:


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CHART 4. - Simplified organization chart, SWPA, 1942-45

it saw major action in the southern Philippines but played a smaller role than the Sixth U.S. Army on both Leyte and Luzon. Both the Sixth and Eighth U.S. Armies had been assigned roles in the invasion of Japan.

    2. The Fifth Air Force, later the Far East Air Forces.

    3. USASOS (U.S. Army, Services of Supply).

    When Col. (later Brig. Gen.) George W. Rice, MC, arrived in Australia and became Surgeon on the staff at General Headquarters, SWPA, his position was entirely advisory, and he had no office personnel. There was no actual theater surgeon, although the Chief Surgeon, USASOS, ostensibly filled the position. All operational activity was centered in his office, but there was little if any collaboration between it and the Office of the Surgeon at General Headquarters, SWPA.

    USAFFE, which was intermediate between these two headquarters, was a small headquarters in which the surgeon s office consisted only of one lieutenant colonel and one or two secretaries. This headquarters coordinated the activities of the various forces but did not initiate polices.

    Minor changes in this organizational structure were introduced from time to time, but it was not until the end of the war, when the Surgeon s Office in Headquarters, USAFPAC (U.S. Army Forces, Pacific) was placed on the General Headquarters level and was given a sizable table of organization, that the theater surgeon s office achieved a position from which it could function effectively.


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    During the period of reorganization in the Pacific in the spring of 1945, General Headquarters, SWPA, and USAFFE were combined to form Allied Forces Pacific, and SWPA was changed to U.S. Army Forces, Western Pacific.

Professional Services Division

    In February 1943, Col. Maurice C. Pincoffs, MC, Commanding Officer, 42d General Hospital (fig. 159), was moved to the Office of the Chief Surgeon, Headquarters, USAFFE, to serve as Chief, Professional Services. By this time, Colonel Carroll had been transferred from his position as Chief Surgeon, TJSASOS, to the position of Chief Surgeon, USAFFE, where he was to remain until his return to the Services of Supply Headquarters in September 1943.

    Colonel Pincoffs, by both backgrounid and experience, was admirably suited for his new position. In World War I, he had served with troops in an aid station and had been awarded the Distinguished Service Cross for bravery. Between the World Wars, his position as professor of medicine at the University of Maryland Medical School, Baltimore, Md., had given him heavy teaching and administrative responsibilities. When World War II began, he organized a 1,000-bed general hospital, recruited from the staff of the University of Maryland. When it became apparent that a unit of such size would have a long wait for oversea duty, he persuaded The Surgeon General to divide it into two 500-bed hospitals and to send them overseas promptly. His training was rounded off by firsthand experience with the problems of his own hospital after it arrived in Australia, where he had some contact with casualties returning from New Guinea.

    Almost overnight, Colonel Pincoffs became director of all phases of professional medical operations in the Office of the Chief Surgeon, Headquarters, USAFFE. He performed many of the duties of consultant in medicine until the arrival of Col. Henry M. Thomas, Jr., MC (fig. 159), in October 1943. Colonel Pincoffs represented the Chief Surgeon on all professional matters, particularly those that required cooperation with other headquarters or other branches of USASOS. With Col. Howard F. Smith, U.S. Public Health Service, he also represented the Chief Surgeon on the Combined Advisory Committee on Tropical Medicine, Hygiene, and Sanitation. This committee, which was attached to General Headquarters, SWPA, and reported directly to General MacArthur (chart 4), was composed of representatives of the armies, navies, and air forces of the United States and Australian commands. Its chairman was Brigadier N. Hamilton Fairley of the Royal Australian Army Medical Corps, an international authority on tropical disease.

    Colonel Pincoffs edited technical bulletins. He reviewed all reports, including those from various research projects. He handled arrangements for the United States of America Typhus Commission (p. 526). He directed the policies and activities of the Preventive Medicine Section, which consisted of a single health officer, with almost no army experience, a situation which could not be corrected because of lack of contact with the Office of the Surgeon General. Colonel Pincoffs also advised with the surgical and neuropsychiatric


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FIGURE 159.- Consultants in medicine, Southwest Pacific.


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consultants; reports from the Dental, Veterinary, and Nursing Sections passed over his desk.

    Colonel Pincoffs continued to perform these responsible and onerous duties in Headquarters, USAFFE, until June 1945 except for the period between 1 October 1943 and 21 January 1944, when he served in the same capacity in Headquarters, USASOS.

    In the early days, when SWPA was in the formative stage, it was both necessary and practical for this widespread diversity of duties to be handled by one person. As time passed and complex problems began to develop in rapid succession, each duty grew larger, and bottlenecks developed and persisted. There was no one to rearrange duties and delegate authority, for the Chief Surgeon, the Deputy Surgeon, and the Executive Officer were all fully occupied with necessary planning and operations in their office.

    In January 1944, when Brig. Gen. (later Maj. Gen.) Guy B. Denit (fig. 160) was appointed Chief Surgeon, USASOS, and also designated Chief Surgeon, USAFFE, it had seemed that a step was being taken toward coordination of the various units of the theater medical service. Only in the Office of the Chief Surgeon, Headquarters, USASOS, however, was there adequate personnel for operational functions, and the general status of the medical service therefore remained substantially unchanged.

    In January 1944, when Colonel Pincoffs returned to USAFFE, the various consultants were instructed to report directly to the Chief Surgeon, USASOS (fig. 161). This change in organization, which was designed to give the consultants greater scope in their activities, did not materially alter their duty functioning, but it added so greatly to the Chief Surgeon s routine duties that the consultants, with the rest of the office staff, were placed under the direction of the Deputy Surgeon. His duties left him no time for professional matters, and the situation was as unsatisfactory as it had been before General Denit s appointment.

Growth of the Consultant System

    From time to time in the early days of the war in the Pacific, Colonel Carroll transferred officers from hospital units to duty in his office at USASOS or used them to form base surgeon s staffs when bases were formed throughout Australia and later in New Guinea.

    In June 1942, Lt. Col. (later Col.) William B. Parsons, MC, and Lt. Col. (later Col.) Samuel A. Challman, MC, were sent from the United States and assigned to USASOS, Colonel Parsons as consultant in surgery and Colonel Chailman as consultant in neuropsychiatry.

    A month later the young, inexperienced captain in the Medical Reserve Corps who had been sent from Washington, D.C., to act as consultant in medicine, USASOS, was replaced by Lt. Col. (later Col.) Joseph M. Hayman, Jr., MC, Chief, Medical Service, 4th General Hospital, who acted in this position until 11 October 1943. On that date, Colonel Thomas, formerly consultant in medicine, Fourth Service Command, reported to General Headquarters,


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FIGURE 160.- Brig. Gen. Guy B. Denit

SWPA, and was assigned to the Office of the Chief Surgeon, Headquarters, USASOS, as consultant in medicine.

    When Colonel Thomas assumed his duties as consultant in medicine, SWPA, in October 1943, he had been greatly assisted by the 2 days spent with Colonel Hayman, who had been serving as consultant in medicine and who had recently returned from a useful tour of instruction in hospitals in Australia and New Guinea. His explanation of the overall situation in the area proved extremely helpful.

    When, therefore, Colonel Thomas requested and was granted a replacement during the reorganization of the area in the spring of 1945, rather than embark on a new and possibly lengthy undertaking, he performed the same service for Col. Roy H. Turner, MC, the newly appointed consultant in medicine. Colonel Thomas remained for 5 weeks in the Chief Surgeon s (General Denit s) Office while Colonel Turner visited several bases and became acquainted with office procedures and personnel. During this period, the Chief Surgeon, the Sixth U.S. Army surgeon, and several consultants attended a conference in Washington on medical problems in the Pacific.

    Colonel Thomas arrived in San Francisco, Calif., on 21 September 1945.

    Assistant consultants. - When the consultant service finally began to function with some degree of adequacy, it was immediately apparent that one of the most useful functions performed by consultants was the visits they were making to hospitals operating in remote bases in New Guinea. These visits served for both instruction and morale building. When Colonel Thomas


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FIGURE 161.- Consultants at medical section, Headquarters, USASOS. Extreme left, Col. Maurice C. Pincoffs, MC. Facing camera, Maj. John Ambler, MC, to left of post, Lt. Col. Eugene Eppinger, MC, to right of post.

returned from his first visit to forward areas in New Guinea, he recommended an increase in consultation service, by the appointment of two clinicians of superior ability to serve as assistant medical consultants on temporary duty, who would spend most of their time visiting medical installations in forward areas. This plan was approved and was also adopted by the surgical consultant service. It proved increasingly useful as the fighting moved farther along in New Guinea and more and more bases were turned over to USASOS by various task forces.

    On 4 January 1944, Colonel Hayman and Lt. Col. (later Col.) Eugene C. Eppinger, MC, were flown to New Guinea, each to serve as medical consultant for two bases. Late in 1944, these officers were replaced by Maj. (later Lt. Col.) Myles P. Baker, MC, from the l05th General Hospital, and Maj. (later Lt. Coi.) Frederick T. Billings, Jr., MC, (fig. 194, p. 548) from the l18th General Hospital. Major Baker was later Chief, Medical Service, 54th General Hospital, and Major Billings, Chief, Medical Section, 118th General Hospital. Their work as assistant medical consultants was of great value to them in their subsequent assignments as well as to the units which they visited.

    The bases in New Guinea were under a command known as Intermediate Section. The Surgeon, Col. Raymond O. Dart, MC, a Regular Army pathologist, who had been in command of the 105th General Hospital, was extremely helpful to all professional consultants, and his cooperation greatly aided them in performing their duties.


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    Consultant system, Sixth and Eighth U.S. Armies. - In the SWPA, because of the command organization (p. 475), the Chief Surgeon, USASOS, was on the level of the Surgeons of the Sixth U.S. Army and the Air Forces. Each new task force was largely staffed by the Sixth U.S. Army, accompanied by Navy groups and the Fifth Air Force. Each task force functioned directly under General Headquarters, SWPA, without control from USAFFE or USASOS.

    This arrangement made for innumerable difficulties and effectively prevented the consultants from having any contact with the army surgeons. All reports, requisitions, and requests from the Surgeon, Sixth U.S. Army, went directly to General Headquarters. There was no routine communication between what was supposed to be the theater surgeon s office (Chief Surgeon, USASOS) and the surgeon of the combat troops (Surgeon, Sixth U.S. Army). The theater consultants activities were therefore strictly confirmed to units under USASOS control unless specific requests for assistance were received from the Surgeon, Sixth U.S. Army.

    On the surface, it would seem that these difficulties could readily have been resolved if the appropriate officer from the Office of the Chief Surgeon, Headquarters, USASOS, had visited forward headquarters (Sixth U.S. Army) with instructions to cooperate in every way possible with respect to the medical needs of the combat troops. If General Denit s trip to New Guinea had not been cut short by a severe attack of dengue, which required his return to Australia for convalescence, it is quite possible that the situation, which had developed before he was assigned to SWPA, would have been altered.

    By July 1943, when the need for a medical consultant in the Sixth U.S. Army had become apparent, Col. (later Brig. Gen.) William A. Hagins, MC, assigned to this position Lt. Col. (later Col.) Garfield G. Duncan, MC, Chief of Medicine, 52d Evacuation Hospital, an affiliated unit then assigned to the Sixth U.S. Army. Colonel Duncan was later decorated with the Legion of Merit by the Sixth U.S. Army commander, particularly for his field demonstration of the efficacy of Atabrine dihydrochloride (quinacrine hydrochloride) in suppressing malaria and for his educational and supervisory activities concerning its use in combat troops.

    When the Eighth U.S. Army was forming, while it was still a skeleton organization, Lt. Col. (later Col.) Worth B. Daniels, MC, was sent from the Zone of Interior to serve as medical consultant to the Army Surgeon. By virtue of his background in internal medicine and his accomplishments as Chief, Medical Service, Station Hospital, Fort Bragg, N.C., he was unusually well fitted professionally for consultant duties in a combat army. The closest and most profitable kind of cooperation grew up between him and Colonel Thomas as the result of numerous conferences and long discussions.

    In January 1945, when vacancies for medical consultants existed in both the Sixth and the Eighth U.S. Army, Col. Bruce P. Webster, MC, and Colonel Eppinger were requested for this purpose. Colonel Eppinger at that time was assigned to the Office of the Chief Surgeon, Headquarters, USASOS, as assistant


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to the Chief, Professional Service, and both he and Colonel Webster were declared indispensable by the Chief Surgeon. After a lapse of several months, two excellent young lieutenant colonels were assigned from the Zone of Interior on the recommendation of Brig. Gen. Hugh J. Morgan, Chief Consultant in Medicine to The Surgeon General.

FUNCTIONS OF THE MEDICAL CONSULTANT

    Before discussing the functions of consultants in the SWPA, it might be well to mention briefly the plight in which the Medical Corps found itself in the early days of the war, when it was obliged to care for the health, both on and off the battlefield, of some 10 million citizens who had been suddenly culled away from their civilian pursuits and made into soldiers. With very little help from line officers, who had all that they could do in their own fields, the Medical Corps of the Regular Army found itself directing the military training and functioning of the civilian physicians who had entered the service and who were to provide most of the specialized care which soldiers required.

    These civilian physicians, by virtue of their professional status, had been accustomed to giving orders, not taking them. They did not take kindly to discipline. They disliked redtape. They were usually oblivious, because of their training, to everything but the welfare of the sick and wounded. Many of them were slow to learn that wars are not won by sick and wounded. The business of keeping fighting soldiers in condition to fight was a new point of view for them. They comprehended only vaguely the morale-building value of preventive and supportive medical service. They had suddenly been transported into an exacting new environment, in which they were required to perform uniformly as well as efficiently. Left to themselves, many of them would never have learned how to find the sick and wounded, how to transport and house and feed them, and what to do with them after their medical treatment had been completed. In short, they had no idea how much they did not know or what they had to learn about military organization.

    For their part, the Regular Army medical officers were faced with serious problems. It was these officers who, often without firsthand experience, had to command hospitals, a position which even the best of the affiliated units often had difficulty in filling satisfactorily from their own personnel.

    Under the circumstances, misunderstandings were inevitable, and unlimited patience, tact, and effort were needed to resolve them. Consultants could have served profitably on the staffs of command surgeons, filling the important professional gap between the surgeon of the command and newly inducted medical officers. It is unfortunate that all consultants were not appointed earlier and that their functions were not more clearly understood.

    The consultants themselves, however, were in a rather difficult position. They had not had any previous experience in their duties, and they had no experience in overall military organization and operation. There was no position for them in the table of organization, and the Chief Surgeon, USASOS,


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acting as theater surgeon, was allowed only about a third of the officer personnel he needed in his office. He therefore gave the consultants assigned to it many and various duties. They were given various routine duties, including checking disposition board proceedings for physical disability examinations for candidates. The surgical consultant was given the task of organizing the writing of the medical history, a task which was later taken over by a lieutenant in the Medical Administrative Corps sent from Washington. Until after the visit in May 1943 of Brig. Gen. Charles C. Hillman, Chief, Professional Services, Office of the Surgeon General, the consultants could not leave the office to visit hospitals.

    There was constant pressure from higher headquarters to limit the table of organization. To comply with this pressure, the consultants were placed on the rosters of various hospital units in which position vacancies existed and were brought into the Office of the Chief Surgeon, Headquarters, USASOS, on temporary duty. This was not a desirable arrangement, for a number of reasons. It eliminated chances for promotion of medical officers in the hospitals to which the consultants were assigned. Because they were not on the headquarters table of organization, the consultants were not adequately provided with office space or secretarial service. As a result, each consultant functioned individually. When, after General Hillman s visit, the consultant was given some freedom of movement, he spent part of his time traveling around the area to obtain information and give instruction and part at headquarters, where, almost singlehandedly, he prepared reports and recommendations and attempted to accomplish  completed staff action. Often on his return he found on his desk for such action the very reports which he had himself made during his tour.

    In January 1945, in an informal report, Colonel Thomas outlined his impressions of the function of a consultant in medicine, based upon his own 15-month experience in this position, as follows:

    Improvement in the care of the patient and the conduct of the hospital can be attained by the consultant s precept and example, by his supervision, by his explanation of the principles laid down in the technical memorandums circulated by headquarters, by discussions of the medical literature, by the awakening of interest in the study and treatment of disease, and by the proper handling of the soldier patient so as to improve his morale and prevent the condition known as hospitalitis.

    The chance to discuss their observations and ideas with more experienced medical men is welcomed with real enthusiasm by the few well-trained clinicians in small hospitals. For less well trained medical officers, the opportunity to widen their knowledge is of the utmost importance in their present and future careers in the practice of medicine.

    The work of the whole service in a hospital is raised to the level of efficiency of the individual chief of service when he realized that an important part of his duties is careful bedside supervision, in order to provide for good case histories, thorough physical examinations, appropriate laboratory tests, suitable therapeutic measures, and, finally, prompt and correct disposition of patients. Worthwhile clinical experience then can be obtained by all members of the service.

    Colonel Thomas commented, at the end of this report, that, at present, most chiefs of medical services were well-trained men, whose only lacks were


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experience in teaching and in running a service. These timings they could learn. In the few instances in which chiefs of service had insufficient professional training, adequate replacements could be provided.

    Redistribution of medical officer personnel. - On the whole, well-trained professional personnel were scarce in SWPA and were chiefly concentrated in the group of general hospitals affiliated with medical schools (Harvard, Johns Hopkins, University of Maryland, College of Medical Evangelists). Each of these hospitals had among its personnel highly qualified surgeons and internists who were fully competent to perform as chiefs of services but who were assigned as chiefs of sections or, in some instances, as ward officers. In addition, occasional station and evacuation hospitals had among their personnel several officers competent to serve as chiefs of services. In contrast to this plethora of skilled and well-trained medical officers, many station and evacuation hospitals were completely lacking in competent surgeons and physicians.

    In September and October 1944, Colonel Eppinger, who was then serving as assistant consultant in medicine, Headquarters, was directed by the Chief Surgeon, USASOS, in collaboration with other consultants, to make a survey of existing assignments and to make recommendations for reassignment of medical officers throughout the theater. The objective of the survey and redistribution of personnel was to strengthen the weak units without weakening the strong.

    In November 1944, on orders from the Chief Surgeon, USASOS, more than 100 medical officers were transferred to new assignments. The reactions to these transfers were varied. Many officers were given opportunities to assume positions commensurate with their abilities and were put in line for promotions. Others were loath to be separated from their units. Still others, unfortunately, became displaced persons, losing both their positions and their seniority.

    By 1945, the affiliated units had been so reduced in key personnel that some of them had difficulty in functioning efficiently. On the other hand, the excellent performance of the reconstituted units during the remaining fighting in New Guinea and the campaigns in the Philippines justified the drastic reshuffling of officers.

    Upon the completion of this survey, Colonel Eppinger visited all the New Guinea bases, advising with the disposition boards of the hospitals and responding to requests to function as medical consultant.

Summary and Analysis

    In retrospect, the following points impress one as explaining many of the professional difficulties encountered by consultants in the SWPA in the performance of their duties:

    1. The type of warfare necessary in the jungle and the long water or air travel between bases introduced unusual problems of organization, construction, hospitalization, evacuation, and supply.


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    2. General Headquarters, SWPA, did not concern itself to any great extent with medical problems.

    3. There was no authoritative surgeon at the theater level, and command organization led to indirect and conflicting relations between the medical branches of USASOS and the Sixth and Eighth U.S. Armies and the Fifth and Thirteenth Air Forces.

    4. In the Office of the Chief Surgeon, Headquarters, USASOS, most professional problems were directed by a single officer, a state of affairs which persisted even after the theater had grown large.

    5. Medical officers in the area during its formative days were inexperienced in administrative duties.

    6. The functions of consultants as a group were poorly understood by all concerned. Regular Army medical officers were inclined to think of them chiefly as inspectors, and they were usually treated as such by the commanding officers of the units that were visited. The professional staff were more inclined to consider them as professional consultants, as in civilian life, and to accept them as instructors and advisers. Instruction and advice were frequently needed by the chiefs of service in respect to supervision of the professional activities of their officers, personnel problems, and supply problems.

    An additional difficulty was that the consultants in the various specialties arrived in the SWPA at different times, with different concepts of their own and each other s functions. The administrative difficulties under which they labored and the wide areas that separated them during most of their duties delayed their learning to function cooperatively, and there was no one to give them the assistance they needed. Owing to lack of definition, their efforts at cooperation with various sections of the Chief Surgeon s Office were often ineffectual.

    7. The SWPA, not without reason, came to believe that medical care had to be provided in an area in which neither materiel nor personnel would be adequate until Germany had been defeated. General Morgan visited the theater in the very early days of the war, but he had so much ground to cover that he was unable to clarify many of the problems which then existed. A second visit from him at a later date would have been very useful. When the Consultant in Surgery, Office of the Surgeon General, visited the SWPA in 1944, the circumstances of his visit prevented his spending much time on these matters. There were other occasional visitors, but they did not stay long enough to find out why the policies and procedures they criticized were being employed, and their visits were too short to be really helpful.

    In spite of these difficulties and serious handicaps, however, the Medical Department in SWPA performed courageously and to good effect.

ACTIVITIES OF THE MEDICAL CONSULTANT

    Colonel Thomas first week at Headquarters, USASOS, after his appointment in October 1943, left him with a somewhat confused picture of the war in


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SWPA. Brisbane, a pleasant, middle-sized Australian city, had a climate not unlike Baltimore, Md. Most of the ranking officers, in addition to General MacArthur, were billeted at the single modern hotel, Lennon s. The two general hospitals nearby had a few interesting cases, but their personnel were rather bored by nothing but routine duties, far from the combat zone, and were inclined to be critical of evacuation policies, especially those for neuropsychiatric patients.

    All headquarters were then located in Brisbane except those of the Sixth U.S. Army, which had moved to Goodenough Island. One was depressed by the feeling of isolation from Washington and the Army in the rest of the world, and by the indirect relationship between the Office of the Chief Surgeon, Headquarters, USASOS, and the medical services of the fighting forces. It was stated that since General Hillman s visit to the area in May 1943, the consultants had been allowed more freedom of movement, but it was still evident that their functions and possible usefulness were not well understood.

    First tour of New Guinea hospitals. - When Colonel Thomas was about to set out on his first tour of New Guinea hospitals, the problem of transportation was simplified by the arrival of the team from the United States of America Typhus Commission, which had been sent out to study tsutsugamushi fever (scrub typhus) and was about to be flown to its station at Dobodura, New Guinea. After a long wait at the airstrip near Brisbane, in the early morning darkness, the C-47 took off with its passengers in strapless bucket seats. At Townsville, Australia, 700 miles north, the plane stopped briefly for fuel, and then flew straight across the Coral Sea to land, after another 700 miles, at Port Moresby, New Guinea. That night, the group was billeted in the dormitory of a small officers club, and on the following morning, the scrub typhus team, headed by Dr. Francis G. Blake and Dr. Kenneth F. Maxcy, took off to fly through the gap of the Owen Stanley Range to Dobodura.

    By this time, Port Moresby and Milne Bay had become staging areas and transportation terminals. The war had moved on past Buna and Dobodura up toward the Markham Valley and around the coast toward Finschhafen. It was at about this time that Bases D, A, and B (Port Moresby, Milne Bay, and Oro Bay) were designated as Intermediate Section, USASOS, and provided with a small headquarters.

    The surgical consultant, Colonel Parsons, who was just finishing a trip in New Guinea, went out of his way to assist the new medical consultant on his first tour. He accompanied him to Milne Bay and introduced him to the Surgeon, Base A, and to several of the local hospital commanders. This was cooperation of a positive nature, which was most helpful at an important time of adjustment to a new and strange environment.

    As Colonel Thomas visited the station hospitals in New Guinea (fig. 162) and talked to the various medical officers in them, he found that disease problems fell into a pattern quite different from the pattern which had been anticipated. When a Japanese force of some 11,000 troops had crossed the Owen Stanley Range, over the Kokoda Trail, in August and September 1942, and had come


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FIGURE 162.-117th Station Hospital, Port Moresby, New Guinea, October 1943.

within 32 miles of Port Moresby, it was stopped at Ioribaiwa by three adverse forces, (1) valiant Australian troops assisted by U.S. forces, (2) semistarvation, and (3) disease. The two diseases which were known to have wrought havoc in Japanese troops, and which also affected U.S. troops in the area, were malaria and dysentery.1

    Work at headquarters. - On his return to Brisbane, Colonel Thomas prepared memorandums on a number of subjects, including common mistakes in the suppression and treatment of malaria; the diagnosis and treatment of scrub typhus; the problems of psychoneurosis as they concerned medical and line officers; and fungus infections of the feet. A reply was also prepared to a request from the Office of the Surgeon General for information on filariasis in the Southwest Pacific. All of this material was submitted to the Chief, Professional Services, USASOS.

    Colonel Thomas, during his stay at headquarters in Brisbane, visited the 14th General Hospital in Melbourne, the 118th General Hospital in Sydney, Australia, the l05th General Hospital in Gatton, Australia, and two station hospitals. By special arrangement with Colonel Duncan, he also visited the Sixth U.S. Army Reconditioning Center at Rockhampton, Australia (fig.163).

 1  As a matter of convenience, descriptions of all diseases observed by Colonel Thomas in his tours of hospitals are concentrated in part II of this chapter.


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FIGURE 163.-5th Station Hospital, one of medical facilities at Rockhampton, Australia, May 1944.

    On 4 January 1944, with two temporary duty consultants, he left Brisbane for a second round of visits to New Guinea hospitals.

    Second tour of New Guinea hospitals. - In January 1944, the base at Milne Bay (Base A) was visited, and local medical installations were inspected in the company of Colonel Eppinger. Short visits were paid to the 227th Station hospital, the 268th Station Hospital, the l24th Station Hospital (fig. 164), and the l25th Station Hospital.

    Three recent sudden outbreaks of diarrhea in three separate units, each numbering from 50 to 75 cases, were under investigation by the base area surgeon. Shigella flexneri had been recovered in the first outbreak, and bacteriologic studies of the other outbreaks were in progress. No break in sanitary techniques had been discovered, and no water or food could be incriminated. The medical consultant was asked to suggest further studies which might be indicated.

    Conferences were held with the Surgeon, Base A, who expressed his appreciation for the help being given by the consultants to the various hospitals, as well as to his office through the information gained on their previous visits. He had already realized the weakness in the professional training of some of the hospital units.

    Tour in Leyte.- After Leyte was turned over to the Eighth U.S. Army and to ASCOM (Army Service Command), Colonel Thomas was relieved of tem-


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FIGURE 164.-124th Station Hospital, Milne Bay, New Guinea, May 1944.

porary duty with the Sixth U.S. Army and spent the first 3½ months of 1945 in Base K (Tacloban, Leyte) (fig. 165), working with general and station hospitals and with the Base K surgeon on professional problems. He had been greatly pleased when space was provided for him to accompany the staff of the Surgeon, Sixth U.S. Army, and the attack force sailing from Leyte Gulf to Luzon on 6 January 1945, but orders arrived the day before embarkation transferring him back to USASOS and ordering him for the present to remain at Leyte. This, in fact, was proper, since 90 percent of a medical consultant s activities concern the care of the sick who require hospitalization and are of no immediate concern to a combat army. The other 10 percent concern observations which might be valuable in some future military operation or might be used for the information of the theater surgeon s office in planning to take over a base when the army turns it over. The surgical consultant takes an active part in the early care of the wounded. The neuropsychiatric consultant is much more effective after the smoke of battle has cleared away.

    Many problems were studied. Trained laboratory officers and technicians were badly needed by all hospitals. Several Drinker respirators were installed at the l26th General Hospital, and active cases of poliomyelitis were treated there. Assistance was given to Col. Alvin J. Tillman, MC, Chief, Medical Service, of this hospital in preparing a condensed outline of treatment of infestation with varying combinations of intestinal parasites. Copies of this


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FIGURE 165.-Office of the Surgeon, Base K, Dulag, Leyte, Philippine Islands, December 1944.

outline were distributed to the hospitals in Base K and, later, to hospitals in Bases X (Manila) and M (San Fabian, Luzon).

    Amebiasis was observed in all hospitals, and particularly fruitful work on this condition was done at the 133d, 44th, and 118th General Hospitals (p. 539). Infectious hepatitis was frequent in all hospitals, and the patients were, of necessity, transferred during the active stage of the disease to the 2d Convalescent Hospital, Leyte, or evacuated to rear bases. There were a few relapses, but most of the patients did surprisingly well under the rather rapid treatment that the exigencies of war imposed.

    Tour in Manila. - When the Chief Surgeon s Office moved to Luzon, on 12 April 1945, the consultants followed Manila was a pile of dust and debris. The destruction of large parts of the city, the U.S. bombardment, and Japanese demolition in their retreat completely wiped out the distribution of water and electricity and, of course, destroyed all sanitation. The victors found themselves in possession of a public health situation best compared to a volcano filled with dynamite. The danger of ravaging outbreaks of cholera and all manner of dysenteric diseases was enormous, and local public health agencies had been either destroyed or demoralized.

    This problem was the responsibility of Colonel Pincoff s, who had been assigned as director of public health in Luzon, and his successful management of this unplanned-for emergency is a story of great importance. He brought with him the consultant in dermatology, Maj. (later Lt. Col.) John V. Ambler,


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MC, who also functioned as venereal disease control officer after the incumbent officer, Lt. Col. (later Col.) Ivy A. Pelzman, had been evacuated for dermatitis.

    Due credit must be given to the Army Air Forces for cooperation in repeated dusting of the entire city and its environs with DDT (fig. 166), which kept the fly population well controlled and prevented spread of disease. In the disorganized filth of Manila, however, an unprecedented increase in venereal disease was inevitable. Soon several station hospitals were filled with patients requiring specialized treatment. Dr. Joseph E. Moore was sent out to observe the situation and offer advice. The whole problem rightfully belonged to the Preventive Medicine Section, but this office was inadequately staffed, with a single officer of little experience, and liaison and communication with the Office of the Surgeon General were poor.

    Hospitals were established in Manila in buildings which had been left standing, one of them the grandstand of the Manila Jockey Club (fig. 167). Except for two field hospitals, all the units sent to Manila were relatively new in the theater; some had arrived directly from the United States.

    Colonel Eppinger, with 20 officers recruited from 10 different hospitals and about 35 nurses, had arrived in Manila to care for the internees of Santo Tomas shortly after their liberation (fig. 168). When this mission was completed, he returned to the Chief Surgeon s Office and soon thereafter departed for the Zone of Interior, where he was assigned to duty in the Medical Consultants Division, Office of the Surgeon General. Colonel Thomas requested that an assistant consultant be assigned to serve as executive officer of the consultant section at Headquarters, USASOS, in Manila. The request was approved, and the difficult position was ably filled by Maj. (later Lt. Col.) Wilson M. Wing, MC.

    Routine duties kept Colonel Thomas in his office at Headquarters,USASOS, a large part of the time. One of these duties was a review of the MOS (Military Occupational Specialty) classification of every medical service officer, an arduous task, since it had to be performed all at one time. A comprehensive chart of the officer personnel of the medical services of all the hospitals was completed and was taken to the Office of the Surgeon General by the Chief Surgeon in July 1944. It showed graphically the extreme weakness in the area of B-3139 officers, who were the better trained internists.

    Hospitals in New Guinea were closing and moving to the Philippine Islands and the new general hospitals arriving in the area were poorly staffed and inexperienced. Colonel Baker, Chief of Medical Service, 54th General Hospital, was again placed on temporary duty as assistant medical consultant. He performed an essential service visiting the hospitals in and around Manila and also made one visit to northern Luzon. Teams were established to brief the newly arrived general hospitals on administrative and professional matters.

    A preliminary plan for the creation of an Army school of tropical medicine in Manila had been submitted to the Chief Surgeon, USASOS, by the medical consultant, who had been assisted in formulating the detailed plans by Lt. Col. Charles A. Armbrust, MC. The purpose of the school was to emphasize the


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FIGURE 166.-DDT dusting of Manila by C-47 aircraft, April 1945.

teaching of the clinical and laboratory aspects of tropical medicine, as well as the preventive aspects, and it was hoped that it might become a permanent fixture in the peacetime Army Medical Department.

    Plans for the school were approved, and the opening date was set for 12 December 1945, but V-J Day came before the opening day, and the plans were dropped.

    Billets.- The consultants were itinerants. They left their footlockers at Lennon s Hotel, USASOS Headquarters in Brisbane, and traveled only with two musette bags. When they were found to be away a large part of the time, they soon lost these accommodations, particularly since on paper they were assigned to some distant general hospital and were at Headquarters, USASOS, only on so-called temporary duty. in the field, they had a variety of accommodations, sometimes in the commanding officer s tent, sometimes with other medical officers (fig. 169). Mosquitoes made it necessary to sleep inside of nets. The large field rats called bandicoots often prowled through the tents at night. Mud or dust was the rule.

HOSPITALS AND MEDICAL SERVICE

    In general, hospitals in the theater retained their authorized bed capacity, expanding and contracting according to needs of the moment. In a few instances, in the fall of 1944, evacuation and large station hospitals were expanded to general hospitals; the changes were made before the consultants


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FIGURE 167. -49th General Hospital at the Jockey Club, Manila, Philippine Islands, April 1945

and officers in the Professional Service Division, Office of the Chief Surgeon, Headquarters, USASOS, were informed of them.

New Guinea - After visiting the 54th General Hospital, Colonel Thomas submitted an informal report to the Chief Surgeon, USASOS, on 25 November 1944, containing the following (summarized) information:

    The 54th General Hospital now has a census of 2,100 patients-700 medical, 170 neuropsychiatric, and 1,230 surgical. In all probability, this census will increase to between 2,500 and 3,000.

    The table of organization provides for 44 medical officers for the professional services. At present, 4 officers are assigned to the neuropsychiatric service; 1 or 2 more will be necessary. This leaves 40 officers for the medical and surgical services-23 surgical and 17 medical. The medical service would them consist of 21 to 30 wards, with 1 chief of service, 1 assistant chief of service and 15 ward officers. Such a service could function by using abbreviated clinical histories, a minimum of laboratory tests, rapid group boarding methods, and supervision of only the seriously ill patients by the chief, with weekly or fortnightly circulation through the wards. When all personnel are well trained and capable of that most difficult clinical procedure consisting of a rapid short clinical history and physical examination and an intelligent reduction of laboratory tests to the bare essentials, then a service such as this can provide good medical care.


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FIGURE 168. - Santo Tomas University, Manila, Philippine Islands, February 1945

    The surgical service was visited by the surgical consultant, who would render a separate report. Many of the more than 1,200 patients on this service were severely wounded or needed surgery. The chief of service was the only highly trained surgeon on the service, and only a few of the medical officers assigned to it were capable of serving as satisfactory assistants to him. A partial solution to this difficulty had been found in the utilization of the services of officers staging in the base. At one hospital, officers from three ship platoons were lending valuable assistance. At another, officers from a single ship platoon were reporting irregularly, and their services were not satisfactory. At this hospital, officers reporting for duty at two new evacuation hospitals which were staging were also helping out.

    In the past, the busiest period experienced by hospitals was immediately after they were opened. The jump from a census of 0 to one of 2,000 patients in the course of a few weeks represented a huge volume of work. Later, as the war moves forward and the base stabilizes, the hospital remains busy but returns to a more normal existence.

    It is of the utmost importance that hospital staffs be augmented in the early days of operation, when the casualty load is excessive, and that the augmentation be accomnplished by design rather than by chance. If units are not available in the base from which temporary duty personnel can be drawn, then the necessary officers can be temporarily attached from units in other bases in which the load is lighter or in which units are staging.


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FIGURE 169.-Lt. Col. Homer K. Nicoll, MC, Commanding Officer, 13th General Hospital, standing beside his quarters, Finschhafen, New Guinea, June 1944.

    The need to help these hospitals with additional personnel is simply to enable them to perform their professional duties satisfactorily, not to spare them hard work. They are all willing to work to exhaustion when the need arises, but after a certain time the caliber of their work suffers. It is hoped that teams of surgical and medical officers can be attached to hospitals opening in new areas, to augment their staffs for the first 2 months after they start admitting patients.

    The Chief Surgeon, USASOS, approved the reinforcement of hospitals in periods of overloading and transmitted his approval to the Surgeon, Intermediate Section, for consideration. No action was necessary, as the war moved on and these hospitals did not become overcrowded.

    Leyte. - Letters written to General Denit in December 1944 and early January 1945 by Colonel Thomas, when he was attached to the Sixth U.S. Army on temporary duty and served as acting medical consultant to the Sixth U.S. Army, indicated, as he expressed it,  how the pieces were gradually falling into place. The letters contained, among other items, the following (summarized) comments on the hospital situation.

    Early in December, the Sixth U.S. Army was almost ready to relinquish its responsibilities to the Eighth U.S. Army and to ASCOM or USASOS. Two evacuation hospitals, the 36th and 58th, the field hospitals, and the collecting and clearing companies would then come under the Eighth U.S. Army. At


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the same time, general hospitals, station hospitals, the 27th Medical Laboratory, and the responsibility for evacuation of patients from Eighth U.S. Army hospitals would come under Base K (Leyte).

    Clearing the area, sawing down trees, building roads, drainage, and putting up buildings, including plumbing and lighting, would have to be accomplished without benefit of heavy equipment and with only irregular native labor to help. Vehicles were being taken from the hospitals for the motor pools. The 133d General Hospital, for instance, came in four LST s, borrowed hinge trailers, and moved all their equipment into a slightly cleared area. They were ordered to take patients in 3 days and did so. On the other hand, the 44th General Hospital came in with pup tents and K-rations. The 118th General Hospital came in with tenting, basic mess equipment, a jeep and water trailer, and one truck, and all their equipment was in the harbor for want of transportation from the docks to their area. All of these difficulties developed because engineering problems were several times as great as had been anticipated, and there were no engineers for hospitals. Even if the hospitals had had their own medical engineers, Colonel Thomas added ruefully, they would probably have been taken away from them, on the ground that those who had were being obliged to give to those who had not.

    Three general hospitals, the 44th, the 133d, and the 118th, landed on the beaches at Leyte during a heavy Japanese air raid on D-plus-27-day. Negotiations for a favorable building site had been carried on with maps before the landings, but these arrangements had to be countermanded under the pressure of battle needs. The 118th and 133d General Hospitals were located near the main road running along the eastern edge of the island, and the 44th was placed near three small airstrips formerly used by the Japanese, and intended for reconstruction for use by U.S. planes. Actually, these airstrips, which were suitable for the light, small Japanese planes, turned out to be on soft earth which defied and finally, after weeks of frantic work, defeated the engineers.2 Meanwhile the Japanese dropped paratroopers into this area, and the 44th General Hospital found itself defending, from rapidly dug trenches, part of the frontline perimeter. By bad luck, these trenches were dug in an area which was heavily impregnated with hookworm (Ancylostoma) larvae and Endamoeba histolytica left from a recently evacuated native village. The ensuing epidemic of acute hookworm infestation will be described later.

    In the same letter, Colonel Thomas reported that the Sixth U.S. Army had conducted several dispensaries for native civilians as well as two civilian hospitals, one beyond the headquarters and the other in an old schoolhouse (fig. 170) near the 36th Evacuation Hospital. They were staffed by personnel of the 250-bed station hospitals, with a census of about 120 patients each, which were supposed to be absorbed by the 133d General Hospital. Personnel of the PICAU (Philippine Island Civil Affairs Unit) had no idea how medical care was to be supplied to the Filipinos or how to decide who was to hospitalize

2 This delay resulted in 10 days without any air defense after the Navy with its flattops had been ordered away.


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FIGURE 170. -98th Evacuation Hospital, Leyte, Philippine Islands, caring for Philippine civilians. A. Entrance. B. Ward scene.


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them (fig. 171). It was understood that six Filipino physicians were working in the area, but obviously they were not enough to take over.

    The 44th and 118th General Hospitals, it was reported later, were getting their equipment slowly. The 124th Station Hospital was helping the 36th Evacuation Hospita1. The 133d General Hospital was building while at the same time housing 400 patients. All the prospects of engineer help consisted of blueprints. Colonel Thomas was experiencing difficulties in some of the forward hospitals because of transportation problems; on some of his trips, water buffaloes were used to ferry his vehicle across streams.

    Colonel Thomas reported that Colonel Hagins, at his suggestion, was planning to attach a team of one officer and three technicians from the 26th Medical Laboratory to an evacuation hospital which was to go in on D-plus-1-day or D-plus-4-day behind each of the corps in the next operation; the laboratory would revert to its parent unit when that unit was ready to function. These laboratories would provide service similar to the excellent service provided by 1st Lt. Walter L. Barksdale, SnC, on detached service, who provided the only clinical laboratory service available until the 27th Medical Laboratory began to function. He helped both the survey units and the hospitals. Colonel Hagins was very much pleased with his work, and the commanding officer of the 36th Evacuation Hospital wanted to keep him.

    Medical care near the front. - During his tour on Leyte, Colonel Thomas paid several visits to the front. The Consultant in Medicine, Sixth U.S. Army, had returned to the Zone of Interior on rotation, and the named request for his replacement had been refused. Colonel Thomas therefore performed some of the duties of Army consultant in medicine during this period.

    Transportation was provided for his various missions, although it was in short supply. The poor condition of the narrow muddy roads and the paucity of good airstrips also made for difficulties. One trip was typical. At dawn, a small L-5 observation plane taxied along the beach to the tent in which Colonel Thomas was billeted and flew him across the island to the Ormoc (MacArthur) area, where it landed in a flat pasture. Fighting was still brisk on this side of the island (fig. 172), but the jeep driver knew--or said he knew-- where to drive very fast to get by Japanese snipers. The field hospital, set up in a churchyard at Ormoc, where the consultant spent the night, was badly bombed the following night. Even the Sixth U.S. Army Headquarters area on the east coast was frequently darkened by air alerts. Once, a Japanese plane was shot down in clear sight and fell into the sea a quarter of a mile down the shore while most of the staff was at mess. The small group of U.S. night fighters spent many hours in the air.

    In a report to General Denit early in January 1945, Colonel Thomas made the following (summarized) observations on medical care near the front:

    In the Ormoc area (the combat zone on the western side of Leyte), he was much impressed with the commanders of two divisions from the Pacific Ocean Area. They were very medically minded and appreciated the importance of preventive medicine measures in the present campaign. Among these meas-


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FIGURE 171.-Dispensary No. 2 operated by Philippine Island Civil Affairs Unit 21, Manila, Philippine Islands, February 1945.

ures were daily replacemmnent, of socks; provisioim of spectacles for the troops, who were chiefly older men; dental care; provision of morphine-filled Syrettes for line sergeants; provision of waterproof paper bags to use in helmets when diarrhea developed in foxholes; taking a clearing company augmented by a portable surgical hospital forward with the troops; cleaning up areas; and the use of vitamin tablets. Both of these line officers were very enthusiastic about their medical officers and enlisted men, and they told about lifesaving surgery in the case of one of their valuable officers.

    Colonel Thomas was not too imnpressed with the medical service provided in the clearing companies and field hospitals which he visited in one area. The medical officers were chiefly young, poorly trained physicians, who had fallen into careless, superficial habits because of lack of facilities, pressure of work, and absence of professional supervision. They had to keep seriouisly ill patients because of the long and extremely difficult evacuation. In another area, the field hospitals were better, and the service was good.

    A laboratory visited had good talent but needed to be pulled together. Lieutenant Barksdale was being transferred to it from the 36th Evacuation Hospital, which was closing down.

    Hospitals for natives. - While he was at Port Moresby, Colonel Thomas visited a hospital for natives run by ANGAU (Australian New Guinea Administrative Units) (fig. 173). There were numbers of these small hospitals scattered through different areas of New Guinea, each able to house about 20 patients and each capable of treating a large number of outpatients. For the duration of the war, ANGAU had been taken into the Australian Army.


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FIGURE 172.-Collecting station near frontlines at Ormoc, Leyte, Philippine Islands, December 1944.

    At the hospital in New Guinea, there were 2 young medical officers, an experienced warrant officer, and 10 attendants on duty. Several of the attendants were able to speak English as well as pidgin English.

    Construction of these hospitals varied from area to area, but in the one at Port Moresby, the buildings had chiefly tin roofs and walls and wooden floors. In addition, three small wards, with thatched roofs and open sides, were built out on poles over the water. This arrangement was unnecessary because the shore rose abruptly from the beach, and, as frequently happens in New Guinea, there was a paucity of level ground on which to build. The patients lay on the floor, on blankets or on thin, palm-woven mats. Colonel Thomas was told that they preferred this to any kind of bed.

    The various diseases were more or less segregated, with dysentery and tuberculosis in one ward, lymphopathias in another, and tropical ulcers and yaws in another. There was a large group of arthritides, some from dysentery and many from the indigenous strain of gonococcus which was said to be very widespread but only occasionally to cause urethritis or ophthalmia. Most patients had hookworm; one was said to have 1,300,000 red blood cells per cubic millimeter and 15 percent hemoglobin; the highest healthy hemoglobin was 70 percent.


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    Malaria knocked these patients down when they moved to new areas and became infected by a strain different from the one to which they had immunity. The Australian medical officer on duty intended to try our therapeutic dosage of Atabrine, as he was not supposed to use quinine.

    Tuberculosis was said to be on the increase, hygiene being practically impossible to teach and many tribes back in the jungle not yet having had any contact with white men. The natives in Japanese territory were fairing badly, as their food was taken from them, and many developed beriberi and scurvy. Filariasis was encountered, and Colonel Thomas observed an instance of brawny edema of the breast said to he due to this condition, though in his opinion it looked more like tuberculosis. He saw little skin disease, though one patient had tinca imbricata covering the whole body. There was said to be a great deal of pneumonia, which responded well to sulfadiazine.

LABORATORIES

    The whole laboratory problem in SWPA was difficult. Each hospital had its own laboratory, which in station and evacuation hospitals was usually under the control of a young medical officer with no more than the average medical training. Techncians were locally trained, and, in many instances, laboratory work was not reliable.

    This was not the situation, of course, in units set up primarily as medical laboratories (fig. 174). One such unit (or a part of one) was usually assigned to each base, but it had no direct official contact with the laboratories of the various hospitals in the base.

    Colonel Thomas recommended that a consultant be appointed to arrange for correlation of laboratory work throughout each base and for proper training of technicians to be appointed to medical laboratories. Although this recommendation was not approved, a school was set up in New Guinea to train technicians in tropical medicine procedures. it was a considerable time before this school was established, and, when it was opened, the number of already fairly well trained technicians sent to it learned a great deal of tropical medicine which they did not need in that particular area.

    Colonel Thomas concluded that if he were confronted with the same situation again, he would persist in attempts to set up local arrangements in each base whereby well-trained laboratory personnel could instruct poorly trained personnel with the simple purpose of improving their techniques in such everyday problems as the diagnosis of malaria by thick-smear preparations. In a fast-moving war, there is time only for first things first.

    Medical general laboratory. - When it was learned in 1944 that a request had been made to The Surgeon General for a medical general laboratory to be sent to SWPA, plans were made for its most effective utilization. Colonel Pincoffs idea was that a 250-bed station hospital should be erected in close proximity to it and should function as the Hospital of The Rockefeller Institute functions in connection with the large Institute laboratories. Patients with


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FIGURE 173.-Natives receiving treatment in hospitals operated by ANCAU.

rare clinical conditions could be assembled in this hospital and would receive superior clinical observation and treatment while they were under study by the special personnel and with the special equipment available in the large general laboratory.

    There were a number of practical difficulties attached to this plan, but it was thought that they could be overcome. One concerned rank. The medical general laboratory would be under the command of a Regular Army colonel of real professional stature, while the clinical problems would be the responsibility of the chiefs of the medical and surgical services in the station hospital, who would be Reserve majors in the Medical Corps. This difficulty never arose because the laboratory never functioned in the capacity intended. It could have been settled readily by the issuance by General Denit of instructions to the commanding officer of the laboratory to support clinical research in the hospital.

    Another objection to Colonel Pincoffs suggestion was that the construction of the proposed station hospital would be a time-consuming operation, for which no personnel would be available except the personnel of the hospital and the general laboratory. By the time the construction work was completed, it was pointed out, the war would have progressed a long way up the island and possibly even into the Philippines. This is just what did happen. By the time this unusual organization was ready to function, the war had almost slid off the tip of New Guinea and was about to invade the Philippines.

    The medical general laboratory therefore split up into sections and followed the invading forces as best it could. Its officers were very useful in studying special problems on the spot as they developed, and later they per-


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formed good services on the outskirts of Manila. By this time, conditions in local laboratories had greatly improved.

    While this plan had been in preparation at headquarters, Colonel Thomas, then in New Guinea, sent in a request for Maj. (later Lt. Col.) A. McGehee Harvey, MC, of the 118th General Hospital, to be made available to supervise a special clinical research problem in a New Guinea hospital. Instead, Major Harvey was recruited by the Office of the Chief Surgeon, Headquarters, USASOS, to serve as chief of the medical service in the research station hospital planned, an assignment in which his special abilities could have been fully used. Maj. (later Lt. Col.) Frank Glenn, MC, was recommended by Colonel Parsons, Consultant in Surgery, USASOS, to serve as chief of the surgical service.

    As time passed and the research unit was not ready to function, Major Harvey was made available temporarily for the project for which he had been requested and joined with Capt. (later Maj.) Frederik B. Bang, MC, in an excellent clinical and laboratory study of the relation of Atabrine to atypical lichen planus (p.549).

CONVALESCENT CARE IN NEW GUINEA

    The general care of soldiers no longer ill enough to require hospitalization but much too weak to return to the frontlines was a problem encountered in every hospital visited in New Guinea. On 29 February 1944, Colonel Thomas submitted the following (summarized) report on the problem to the Chief Surgeon, USASOS, directed to the attention of Colonel Pincoffs, Chief, Professional Services:

    1. The important problem of convalescent care of patients in New Guinea involves features peculiar to the area.

    2. A beginning has been made by setting up the l39th Station Hospital (50 T/O-150 actual beds) in Oro Bay (Base B) (fig. 175) and the 90th Station Hospital (50 T/O-150 actual beds) in Lae (Base E). Similar units are needed in Milne Bay (Base A) and Finschhafen (Base F), even if general hospitals are later established in these areas, since all patients who remain in station hospitals 2 weeks or more require supervised physical reconditioning before they return to their units. Tent facilities can be expanded as the need becomes evident.

    3. The supervision and direction of patient activities in the proposed units should be in the hands of especially adapted medical officers who are outstanding in physical stamina, leadership, knowledge of military discipline, and comprehension of the psychology of the soldier. This type of officer is not common. Much might be done by training promising young medical officers.

    4. At the present time, an excellent convalescent unit is functioning at the 105th General Hospital, and a similar unit formerly functioned at the 42d General Hospital. Essential practical experience was gained in both


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FIGURE 174.-8th Medical Laboratory, Australia. A. Autopsy Room. B. Serology. C. Laboratory animals. D. Pathology.


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FIGURE 174.-continued. E. Bacteriology. F. Chemistry and hematology. G. Supply room. H. Officers quarters.


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FIGURE 175.-139th Station Hospital, Oro Bay, New Guinea, June 1944.

hospitals, and officer personnel of other general and convalescent hospitals would profit by being attached to them for short periods of observation and instruction in this specialty.

    5. Three specific recommendations were made, as follows:

    a. That an officer experienced in commanding units for convalescent care be designated to organize the operation of the 90th and 148th Station Hospitals.

     b. That a small hospital installation be constructed as soon as possible in Base F to function similarly and to grow in size as needs develop. These hospitals will not attempt rehabilitation of patients suffering from nervous disorders, although patients with mild conditions of this kind might well be able to return to duty after a short stay.

    c. Station hospitals intended for convalescent care should be located in areas in which facilities for outdoor work and recreation are available.

    The only direct action taken on these recommendations was the provision of two large convalescent hospitals in the Philippines, which provided much needed facilities for the overflow of general hospitals, leaving their beds for more acutely ill patients.

EVACUATION

    The evacuation of sick and wounded casualties from forward bases in New Guinea to Intermediate Section and thence back to Australia was an important problem, about which more than a little confusion arose. Once, for instance, a station hospital in the base at Oro Bay (Base B) sent patients


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for evacuation to a general hospital in Australia. A station hospital in the base at Port Moresby (Base D), however, where these patients were awaiting air or water transportation, studied them again and sent them back to duty with their unit in Base B. In other instances, an air force unit commander refused, on the advice of the unit medical officer, to keep patients, and the process of evacuation was begun again for them.

    These and similar experiences made it evident that final decision concerning evacuation must be left to one station hospital or another, and it was decided locally that the hospital which studied the case earliest in its course and was most familiar with the unit status should make the final decision. After the base surgeon had approved the decision, it would not be changed in any station hospital which subsequently received the patient. Under the evacuation conditions peculiar to New Guinea at the time, this procedure worked smoothly and efficiently.

    Confusion also arose when hospitals in advance sections and bases evacuated patients to general hospitals with  G.I. inscribed on both the Field Medical Card (Form 52c) and, in red pencil, on the Field Medical Record Jacket (Form 52d). Many errors were made, some due to hurried evacuation, some due to the unfamiliarity of units newly arrived in New Guinea, and some to the paucity of professional personnel in small forward hospitals with the qualifications and experience to make such decisions.

    It became evident that final decisions must be made by the first large hospital to which the casualties were admitted, since there would be available in it both the professional staff and sufficient time for proper evaluation of the needs of each case. Correction of these improper policies had not previously been effected because authority to instruct or correct advance bases rested in Headquarters, USASOS.

    The principle requiring reevaluation and sorting of patients in each hospital in the line of evacuation was sound in itself, but in New Guinea it led to delay and, many times, to improper therapy. In some cases, for instance, casts had to be removed many times.

    Since responsibility for proper treatment and disposition rested on each hospital, most hospital staff members were reluctant to release patients to the rear without first attempting to accomplish as much treatment as possible. This policy caused delay in the patients arrival at general hospitals and sometimes actually jeopardized the end result. Sorting of patients, if properly carried out, requires mature judgment and wide clinical experience. If these requisites are available, sorting can be properly accomplished in several hours. It was necessary to emphasize repeatedly that medical officers should not attempt final sorting or treatment of patients suffering from clinical conditions beyond the scope of their professional training to handle.

    In a report to the Chief Surgeon, USASOS, dated 27 January 1944, Colonel Thomas described this situation and made certain specific recommendations which may be summarized as follows:


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    1. Since evacuation follows the line of supply both by air and water and since the line of supply changes for military reasons, the whole problem of evacuation requires careful supervision on the part of base and port surgeons. The difficulties must also be called to the attention of, and fully explained to, the Surgeon, Intermediate Section, and surgeons of all bases and ports.

    2. Surgeons of bases and ports should refer individual cases for factfinding to suitable consultants whenever they are available.

    3. Base surgeons, acting with the advice of suitable consultants, should designate individual hospitals in their bases for the treatment and disposition of certain types of cases.

    4. Problems of air evacuation should be freely discussed between the local flight surgeon and the base or port surgeon, to settle such matters as conditions unsuitable for air travel; the selection of patients who require special preparation or care in transit; facilities for treatment which may or may not be available in transit; and care of property such as clothing, bed clothing, litters, and special equipment which may be in short supply.

    5. Ship platoon surgeons and other medical officers charged with caring for patients during evacuation by water should report to the local base or port surgeon s office for discussions and advice.

    6. Reports should be made to the Chief Surgeon, USASOS, through channels, by commanding officers of station and general hospitals, these reports to contain pertinent facts concerning the condition of patients evacuated to their hospitals.

    As a result of these recommendations and observations, an officer was appointed to supervise evacuation throughout the theater from the Office of the Chief Surgeon. Thereafter evacuation proceeded in a much more orderly and efficient manner.

    Utilization of bed space. - By the middle of the summer of 1944, the Chief Surgeon had become more than usually concerned over the difficulty of providing sufficient hospital bed capacity for casualties in forward areas. In an area composed of many small bases, some of which developed later into very large supply and staging areas, the problems of transporting, building, and supplying hospitals were not simple.

    There was a constant struggle with staff officers at General Headquarters and other headquarters to obtain authorization for sufficient hospital beds in the planning stages. Every step was difficult. There was never enough transportation or engineering to meet all the needs, and priority always went to combat projects.

    The scarcity of hospital beds required that patients be evacuated at the earliest moment that was safe and sensible. Basic rules of evacuation, however, sometimes had to be transgressed, and patients who should not have been moved, sometimes because their condition was too serious and sometimes because it was not serious enough for evacuation, were sent long distances to the rear. On the other hand, at every hospital, ward officers were guilty of retaining patients longer it an was really necessary.


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    To augment faster disposition of patients, Colonel Thomas prepared the following (summarized) letter which was approved by the Chief Surgeon on 2 August 1944 and was forwarded to hospitals through base section surgeons:

    1. While every effort must be made to retain in the area personnel capable of performing useful functions, valuable bed space should not be utilized for the care of men with time-consuming conditions when their subsequent usefulness is doubtful or likely to be seriously impaired.

    2. To a recent publication from the Office of the Surgeon General, it was stated that patients who required more than 120 days of hospitalization would be evacuated as quickly as possible, the majority between 30 and 60 days and all by 90 days. In the SWPA, however, only 27 percent of evacuees had left the area by 60 days and only 54 percent by 90 days, while 28 percent were evacuated after 120 days. Obviously, patients requiring evacuation were being held in the SWPA much too long.

    3. It is therefore desired that all patients be carefully screened, with a view toward evacuating those who will require an unusually long convalescence as soon as they can be transported safely. Such patients should be brought before a disposition board early, and all other administrative procedure should be completed promptly. These cases should be reported on the Weekly Bed Status Reports as awaiting evacuation to the Zone of Interior, so as to avoid all possible delays in evacuating them as soon as they are transportable. Only patients who give promise of being returned to duty within the area evacuation policy should be retained in hospital.

NURSES

    As soon as the station and evacuation hospitals in New Guinea had their tents and portable hospitals erected and the base had been cleared of the last lurking-and usually starving-Japanese, the nurses assigned to these hospitals were sent for (fig. 176). Even then, the danger from enemy snipers and air attacks, while less, still existed. Electricity was provided soon after the hospitals were set up, but, every night, the buildings were kept black most of the time for fear of bombings.

    Living conditions were always rugged, although every effort was made to make them tolerable (fig. 177). The overall motif was mud. In the early rush for locations for various installations, hospitals had to take what they could get, and their personnel had to get used to mud. For a long time, there was no running water. Shower baths were improvised from oil drums or Government-issue cans, but they made little impression on the mud. Facilities for laundry were scant. Security measures were complicated.

    Even after transportation to the base was available and nurses were housed, there were no facilities for them to visit other units. Each little group was isolated, and work, laundry, and letter writing were the only occupations. When casualties were received in large numbers, there was time only for work.

    Many of the nurses suffered from physical and nervous fatigue, but the sick rate among them was very low, and their efficiency, sense of duty, and


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FIGURE 176.-Nurses from 251st Station Hospital, who were first to reach New Britain, 24 July 1944.

cheerful endurance of hardships were high. Every unit visited was proud of its nurses, and nurses continued to catch up with their units as soon as possible.

    On one occasion, a C-47 carrying nurses and officers across the Coral Sea from New Guinea fell into the ocean, and the plane sent to search for it did not return.

VISITORS TO THE AREA

    Visitors to the Southwest Pacific were always welcome but were not numerous, for a variety of reasons. Seats in planes crossing the Pacific were few and hard to obtain, and repeated requests for visits by professional personnel to New Guinea were not answered.

    In September 1944, a large part of Colonel Thomas time was spent with Lt. Col. (later Col.) Francis R. Dieuaide, MC, from the Office of the Surgeon General, in New Guinea and later in headquarters in Brisbane. His visit, the only one in almost a year by a medical or surgical consultant from this office, was greatly appreciated. His fresh point of view was stimulating, and his years of experience with tropical diseases in China provided background for interesting comparisons.

    When the war in Europe was finally won, The Surgeon General, accompanied by the chief of his Preventive Medicine Service, Brig. Gen. James S. Simmons, arrived to inspect the area (fig. 178). The Surgeon General visited


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FIGURE 177.- Nurses at 30th Evacuation Hospital, Parang, Mindanao, Philippine Islands, May 1945. A. Nurses quarters. B. Shower bath improvised with oil drums.


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FIGURE 178.-Maj. Gen. Norman T. Kirk, The Surgeon General (with tropical helmet), and Brig. Gen. John M. Willis, Chief Surgeon, USAFPOA, extreme left.

the surgical services, particularly those on which orthopedic casualties were under treatment, in a few rear-area New Guinea bases, after which he went to Leyte, where USASOS Headquarters had been left when the fighting moved to Luzon. His request to the Commander in Chief of the Allied Forces, SWPA, for permission to visit his forward headquarters was refused on the ground that there were no tents or officers available to take care of visiting dignitaries.

    Meantime, Colonel Thomas spent several days with General Simmons, who was very much interested in the work being (lone by the malaria control units on schistosomiasis (fig. 179). He was, however, somewhat disdainful of the small and weak Preventive Medicme Section.

    When a request for permission to visit Luzon was denied, General Kirk, The Surgeon General, and General Simmons left the area. There was universal regret that their visit had not occurred 2 years earlier.

BLOOD BANK

    During his tour in Leyte in December 1944, Colonel Thomas learned from Major Glenn, Assistant Surgical Consultant, Sixth U.S. Army, that large


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FIGURE 179.-Brig. Gems. James S. Simmons, center, visiting 19th Medical Laboratory where a study of schistosomiasis is in progress, Col. Dwight M. Kuhns, MC, extreme right.

amounts of blood had been required by recent Navy casualties; several had required 3,000 cc., and one had received 5,000 cc. At this time, 80 pints daily were being received from the Zone of Interior, with additional amounts from Base G (Hollandia) and Base H (Biak). The prospect was that the needs in Base M (San Fabian) would be even greater, since there were likely to be more shell-fragment wounds and fewer rifle wounds.

    The situation in respect to blood bank supplies was somewhat complicated. Capt. Albert T. Walker, MC, USN, Surgeon, 7th Fleet Amphibious Force, had not heard officially about the visit of the blood bank officer from the Zone of Interior and was somewhat annoyed. Captain Walker was justifiably proud of the past blood bank performance in the SWPA, and, if possible, he would like it to continue as a local operation. At the moment, this seemed a formidable undertaking to Colonel Thomas. LST 464, which had been supplying the blood, was busy with casualties from harbor and Navy personnel and could not get donors. In addition, there were other problems of transportation, supplies and containers. It was Colonel Thomas idea that the major portion of the blood needed by the task force should be supplied for the invasion by the San Francisco Blood Bank, with augmentation from local supplies as unnecessary (fig. 180).


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FIGURE 180.-Whole blood in refrigerated container delivered to Parang by L5B light aircraft, Mindanao, Philippine Islands, May 1945.

SUPPLIES

    In spite of the obvious difficulties and problems attending their delivery, there were few shortages of supplies in the Southwest Pacific. Certain medical supplies were short in some items for the first time in Tacloban (Base K). Here such drugs as emetine, Diodoquin (diiodohydroxyquin), hexylresorcinol crystoids, and Fumadin (stibophen), as well as some surgical supplies, became exhausted. The shortage was promptly relieved by items flown from San Francisco. The shortage was accounted for by the unexpectedly long and extensive Leyte campaign and the constant remounting of shipping (fig. 181).

CLINICAL INVESTIGATION

    Clinical investigation was not encouraged by Headquarters, USASOS. It is true that medical personnel was always in short supply in the SWPA, particularly during the first 2 years. It is also true that medical officers in units stationed in forward areas did not have appropriate training for chemical research. There were a number of occasions, however, when it seemed to the medical consultant that, with very little effort, suitable officers could have been sent up to well-established station hospitals in which they could have made useful observations and collected valuable information.

    Recommendations to this effect were seldom approved. One of the exceptions was the study made by Major Harvey and Captain Bang on atypical lichen planus (p. 549). Captain Bang had been sent to the area to pursue research in malaria. His reports went directly to the Chief, Professional Serv-


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FIGURE 181.-A medical supply depot in the Philippine Islands

ices, Office of the Chief Surgeon, Headquarters, USASOS, and were not seen by the Consultant in Medicine.

    A skin test for filariasis was developed at the 52d Evacuation Hospital while stationed on Woodlark Island, New Guinea (p. 550).

    Various chemical observations were made on early acute cases of schistosomiasis, and an epidemiological survey of a large outbreak of hepatitis was carried out. On the whole, fortunately enough, the war moved too far too fast to permit much investigation.

Part II. Clinical Considerations

GENERAL OBSERVATIONS

    Before proceeding to the discussion of special diseases, it might be well to outline a few of the variety of problems which medical officers encountered in the Southwest Pacific, particularly after the invasion of the Philippines. Many of them were residual.

    The tropical native houses seem in the Philippine Islands as well as in New Guinea consisted of a single room raised 4 or 5 feet above the ground on stout bamboo poles (fig. 182). This elevation insured a certain amount of protection against such unwelcome visitors as snakes, ants, and pigs. Mud was less of an annoyance, and free ventilation was permitted in the usual heat of day.

    Sanitary arrangements were primitive. One sliding floorboard provided egress for all refuse and excreta, which eventually were cleared away by the pigs and dogs or spread around by surface rainwater. Under these conditions,


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FIGURE 182.-Elevated native house in the Philippine Islands. Note use of corrugated iron patches on thatched roof.

it was small wonder that each native as well as domestic animals carried three or four varieties of intestinal parasites, in addition to flukes and mosquito-borne organisms.

In New Guinea, the infrequent, small native villages usually were situmated in little clearings back of the forest, and they constituted no problem in sanitation to the U.S. Army except through stream pollution. By contrast, in Leyte, most available ground was raised above surrounding swampland used for cultivation of rice, and this land was spotted with groups of these little houses. Since the Filipino was a respected ally of the United States, there could be no invidious regulations and no off-limits areas. Fortunately, the hospitable natives had little to offer U.S. soldiers, and the soldiers had little time or energy left from their exhausting military duties. Otherwise, few would have escaped some tropical ailment, and a considerable number, of course, did not escape.

    In Leyte, the area assigned to the 44th General Hospital was heavily impregnated with hookworm larvae and E. histolytica left from a recently evacuated native village. Within a week or two, there was an outbreak of febrile bronchitis and general malaise accompanied by eosinophilia. It was suspected, and later proved, that the condition represented an outbreak of early, severe hookworm disease. At the 133d General Hospital, the residuary legacy was a large crop of E. histolytica infections. The 118th General Hospital, which had landed at the same time as the other hospitals, encountered schistosomiasis.


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    Observations at the 76th Station Hospital in Leyte were typical. Diarrhea accounted for over a third of about 3,000 admissions. Dysentery accounted for 400 admissions (bacillary, mostly Flexner type, in 190 cases; amebic, all trophozoites, in 21; and cause undetermined in the remaining cases). There were 130 cases of common diarrhea and 475 cases of acute gastroenteritis. The cause was not determined in any of the cases of this group, but it included syndromes that in some hospitals were diagnosed as influenza or dengue. Other diseases observed included malaria, poliomyelitis, balantidiasis, giardiasis, ulcerative colitis, and regional enteritis. There were three cases of syphilis, all new, and some other venereal diseases, but no gonorrhea. A possible case of scrub typhus with rising Proteus OXK titer was also observed.

    In some hospitals, a condition was observed which for the first 2 or 3 days looked like influenza. Abdominal cramps and diarrhea then developed, but neither amebae nor salmonellae could be found in the stools. Virus studies were planned for these patients.

MALARIA

    General considerations. - Malaria was not a disease which could readily be dismissed. In various areas of New Guinea, the malaria rate was as high as anywhere in the world. A good many of the natives were infected with filariasis, practically all of them had intestinal parasites, and malaria infection was almost universal. It was impossible to prevent contact of the U.S. soldiers with them, for they were very useful to the Army in helping to clear the jungle (fig. 183) coconut groves and in applying thatched roofs to rapidly erected buildings of native type.

    The particular strain of Plasmodium vivax encountered in New Guinea was extremely virulent, and mosquito control was particularly difficult under the conditions imposed by war. The military program was generally to neutralize the Japanese troops in a given area; to turn the base over to USASOS; to push back the jungle to make room for staging areas, airstrips, supply dumps, and hospitals; and, at the same time, to rid the area of malarial mosquitoes. The soldiers worked under great difficulties. The heat was intense. In some areas, it rained almost daily, the downfall totaling 180 inches per year in the Milne Bay area. Bulldozers and labor battalions worked in shifts around the clock, and their rations were limited to what could be shipped infrequently from Australia, where very little canned food was available because not much of it was used.

    Preventive measures. - It is an amazing fact that within 3 or 4 months, the U.S. malaria survey and control units, with the help of Army engineers, were able to convert the most highly malarious area in New Guinea, around Milne Bay, to an area in which the monthly malaria rate was frequently lower than anywhere else in the island. This was accomplished by a variety of precautionary measures. Natives working on Army projects were moved away from them for distances of 2 miles or more when daylight began to wane and


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FIGURE 183.-Pushing back the jungle.

malarial mosquitoes began to appear in numbers. Mosquito bars were required. Some outfits patrolled their areas and moved sleepers away from the bars when they had rolled against them. It was required that the body be constantly covered with clothing and that the shirts be worn with collars buttoned and sleeves rolled down, which seemed inhuman in the tropical heat. Repellents were used on exposed surfaces. These regulations were difficult to enforce in an isolated spot like New Guinea, but those who escaped being infected with malaria, in spite of visiting new bases before malaria control measures were in satisfactory operation, did so by obeying these regulations as well as by the use of Atabrine.

    Atabrine administration. - For a long time, the technique of administration of Atabrine was faulty and left much to be desired. To the ordinary enlisted man, this rule, like the others for mosquito control, was senseless. A silly rumor spread among the troops that this drug destroyed libido and potentia. They heard that Atabrine sterilized the bloodstream of malaria, and it was only a short step to the belief that it also sterilized men. Troops pretended to swallow the pills but spit them back into the cup or spit them out along the road as they walked away from the Atabrine line. It took a long time and much discipline to discover and thwart all the tricks employed to evade suppressive treatment (fig. 184). Men in the Army Air Forces were particularly casual in their disregard of malaria control procedures. Before the lesson was learned-the hard way-the 32d Division and other units became completely riddled with malaria and had to be sent back to Australia to be demalarialized.


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FIGURE 184.-Atabrine publicity campaign, 363d Station Hospital, March 1944.

    Treatment. - The management of malaria in SWPA is a fascinating historical episode, the complete description of which is beyond the scope of this chapter. Quinine, which formed with Atabrine and Plasmochin naphthoate (paraquine naphthoate) the so-called Middle East treatment, was still the therapy of choice in the British and Australian Armies. Quinine, however, was in short supply for U.S. Army personnel. On the other hand, the use of Atabrine was entirely new, and the original dosage-6 pills a week-left much to be desired. It was eventually determined that suppressive doses, taken regularly, eliminated all forms of malaria other than that caused by P. Vivax and suppressed clinical symptoms of that variety during therapy. The dosage for treatment of malaria attacks had to be established by trial and error. It is of considerable interest that the schedule finally worked out in SWPA, of large doses for several days (at first, 0.2 gm, every 4 hours) followed by maintenance doses, proved to be identical in principle, though slightly larger in dosage, than the schedule elaborated in the United States, with the help of blood-level determinations on treated patients, by Dr James A. Shannon. Lieutenant Bang, equipped with photofluorometer, was able to provide accurate data for the final determination of optimum dosage schedules.

    Research studies. - Malaria received more attention and had more manpower effort devoted to its prevention than all other diseases put together (fig. 185). The results were good. There were only two other cases of cerebral malaria and only a few of backwater fever. It is not too much to say that


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FIGURE 185.-Instruction at Malaria Control School, 8th Medical Laboratory, Australia, 1943. A. Didactic classroom instruction. B. Collecting larvae in field.


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FIGURE 185. - Continued. C. Demonstration DDT spraying. 1). Laboratory work.


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the effort devoted to malaria played a major part in enabling the U.S. Army to perform its role in winning the war in the Southwest Pacific.

    Lieutenant Bang, in addition to the photofluorometric studies just mentioned, carried out other studies of fundamental significance.

    The Australians, under the direction of Brigadier Fairley, set up elaborate clinical experiments at Cairns in northern Australia. When a malaria commission consisting of Dr. Fred C. Bishop and Dr. Robert B. Watson visited the area in July 1944 and were invited by Brigadier Fairley to visit this research unit at Allied Land Forces Headquarters, Colonel Thomas was allowed to accompany them. New Guinea mosquitoes were used to transmit New Guinea strains of Plasmodium to volunteer Australian soldiers. The good and bad points of treatment of malaria with quinine and Atabrine and of its suppression by these drugs were clearly defined, and Atabrine was finally adopted as preferable. Other interesting observations were also made at Cairns.

    One of many studies on malaria suppression conducted independently in U.S. Army hospitals was carried out in a general hospital then stationed in Australia. A group of 10 officers took large doses of Atabrine and submitted to daily examinations of the optic fundi for expected signs of changes in the optic nerves. No such changes occurred, but 1 serious and 4 mild psychoses developed among the volunteers. Since toxic reactions to Atabrine were seldom encountered, except for occasional men who suffered from vomiting and unfortunately influenced psychologically susceptible companions to follow suit, it was concluded that these volunteers had become confused and then, in error, had taken excessive doses.

    Toxic delirium from Atabrine, although it was occasionally observed, must have been extremely uncommon. At one general hospital, Major Harvey, chief of a section of the medical service, detected and described a group of patients who presented peripheral neuritis, which is a little-known complication of malaria. The association of atypical lichen planus with malarial suppressive therapy by Atabrine is described elsewhere (p. 549).

    More studies would have been carried out if the two photofluorometers in the area had been released, as requested, to the general hospitals which had arranged for their requisition. On 27 February 1944, Colonel Thomas made the following (summarized) observations to the Chief Surgeon, USASOS, on malaria:

    1. Many questions relating to suppression, treatment, cure, and immunity in malaria remain unanswered. The Office of the Surgeon General recognizes that many of them can best be sought when large groups of nonimmune soldiers enter highly malarious areas. Malariologists trained in special branches of malaria research have therefore been sent to the theater, and requests have been made for observations on particular phases of the disease.

    2. It is recommended that one or more hospitals situated in highly malarious areas in which environmental malaria control measures have only recently been initiated should be designated for the hospital study of malaria.


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    Major Harvey, of the 118th General Hospital, is suggested as an officer well suited to supervise such a study because of his thorough training in clinical medicine and his brilliant record as a research worker in pharmacological and physiological subjects. Lieutenant Bang, is suggested as a part-time or full-time laboratory consultant to the group of workers proposed, and Lt. Col. (later Col.) Gottlieb L. Orth, MC, is suggested as consultant in problems dealing with infection, suppression, and mosquito control. A small number of technical laboratory personnel will also be required.

    3. It was also recommended that a training center be established, in connection with all training of divisions which had been extensively exposed to mosquitoes infected with malaria parasites, for the purpose of rehabilitation and further study of soldiers experiencing primary or recurrent attacks of malaria. Followup studies can be made by the medical officers attached to these centers.

    4. The last recommendation in this letter was that frequent and rapid correspondence concerned solely with professional matters be carried on with appropriate officers on duty in the Office of the Surgeon General.

    This recommendation was included in an effort to open up direct communications between specialists working in the United States on all the problems involved in malaria and their opposite numbers in the SWPA. Such communication was forbidden for military reasons, and only routine monthly medical reports and similar correspondence were permitted. This restriction was a real handicap in the management of malaria, and it was responsible for some of the delay in establishing a satisfactory Atabrine regimen. Interchange of information by airmail would have been most helpful in this and in other medical fields.

    So far as is known, there was no direct action on any of these recommendations.

DYSENTERY

    Dysentery was never a major problem in the U.S. Army while it was in New Guinea or the Philippines. Through the foresight of Brigadier Fairley, the Australian authority on tropical diseases, Australian troops were provided with an ample supply of sulfaguanidine, which was most effective in suppressing dysentery. On the basis of this experience, the U.S. Army stockpiled large quantities of this drug, and, with its use and careful sanitation, the condition was usually under control.

    There were occasional breaks in sanitary technique, usually when one unit moved away from a location in a hurry and failed to observe adequate precautions in the final 2 or 3 days in the area. Then when another unit moved into the same area, outbreaks of dysentery were apt to occur before the area could be satisfactorily policed. Credit for the fact that so little trouble was encountered from dysentery in SWPA belongs directly to the routine sanitary measures insisted upon by the Army Medical Department.


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    In October 1943, when the hot weather became even hotter, a few cases of dysentery were observed in Base A. In Base D, while diarrhea diminished slightly, the number of cases of Shiga dysentery increased relatively, and one fatality occurred, after the patient was admitted to the 1l6th Station Hospital. Shigella dysenteriae (Shiga) was recovered from most patients, and treatment with large doses of sulfaguanidine usually brought about recovery.

    Because Colonel Thomas had been greatly impressed by the therapeutic effect of intravenous sulfadiazine in the treatment of another infection, meningococcic meningitis, he was anxious to test the effect of this drug in severe cases of bacillary dysentery, and chiefs of medical services in various appropriately placed station hospitals were requested to try it. In the only suitable case found, an immediate curative effect was observed.

DENGUE

    Dengue was widespread in a number of areas in New Guinea. Since this disease is transmitted by Aedes aegypti, which is not affected by measures commonly used to reduce or eliminate malarial mosquitoes, nothing much could be done except to give the patients symptomatic care. Although some characteristic breakbone fever cases were observed, with the typical secondary rise in temperature and extremely severe headache, most attacks were mild. The short duration of the attack and the absence of severe sequelae prevented dengue from being an important medical factor in New Guinea. This statement might not be concurred in by General Denit, who suffered one of the most severe attacks of the disease which occurred in SWPA.

SCRUB TYPHUS

    One of the most dramatic diseases encountered in SWPA was scrub typhus (tsutsugamushi fever). Small, scattered outbreaks developed steadily as the fighting progressed throughout New Guinea. A very virulent outbreak occurred onn Goodenough island, where the Sixth U.S. Army had set up headquarters in November 1944, and another very large one occurred on Owi, in July and August 1944 (fig. 186).

    Personnel of the 9th General Hospital had cleared an area on Goodenough Island, and, with some help from engineers, they had erected their own buildings. They worked in fields covered by kunai grass which, though it was unknown at the time, harbored the rodents (fig. 187) and the deadly little mites that transnnit scrub typhus. Some 30 or 40 cases developed among the personnel of this hospital, and there were a number of fatal cases, one in a medical officer.

    At the time this outbreak occurred, treatment was symptomatic, and the precise pathological lesions and deranged physiological functions were not known or understood. Later, as post mortem material was collected and it became evident that the widespread involvement of the capillary blood vessels produced lesions in all organs of the body, the signs and symptoms were more


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FIGURE 186.-Lt. Gen. Walter Krueger s Sixth U.S. Army Headquarters, Goodenough Island, December 1943.

understandable. Early in the experience with this disease, patients were seen to die from heart failure or from shock, with varying degrees of cyanosis and of moisture in the lungs.

    Ways and means of using oxygen, digitalis, and infusions of plasma or salt solution were widely discussed and variously employed. The dangers inherent in all these methods were very real and occasionally apparent. In Colonel Thomas opinion, the outcome in each case depended upon the virulence of the micro-organism present in the particular location rather than on the particular form of nonspecific therapy employed. In the large outbreak on Owi, the case fatality rate was 0.6 percent, but in the Goodenough Island outbreak and in another in the Finschhafen area, it was 35 percent.

    Early accounts of the extensive but mild outbreak on Owi were reported casually because of the greater seriousness of the disease as it was experienced elsewhere and the vigorous and time-consuming measures which had to be taken against it. When sick reports from the task force under Maj. Gen. Horace H. Fuller, which was having a particularly difficult time dislodging the Japanese from caves along the coastal cliffs and hills of Biak (northwest of New Guinea), began to show alarming numbers of cases of scrub typhus, the Chief, Professional Services, USASOS, sent a radiogram under the signature of the Commanding General, USAFFE, to the Sixth U.S. Army offering medical officers, nurses, and supplies. On 2 August 1944, under the signature of Lt. Gen. Walter Krueger, it was stated that only one medical officer was necessary at the time and Colonel Thomas was requested.


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FIGURE 187.-Bandicoot rat, host of mites transmitting scrub typhus

    This incident typified the unfortunate lack of understanding between the Office of the Chief Surgeon, USASOS, and the Sixth U.S. Army Medical Section. The offer of medical officers, nurses, and supplies was, in fact, impractical. On Owi, excess medical officers would have been a nuisance, and there was no place for nurses to live, even if safe transportation had been available. As for supplies, they became indequate as soon as they could replace essential ammunition on cargo aircraft. Colonel Hagins, however, could readily have used a medical officer to serve as one of his own staff, to keep him informed of the situation, and to make suggestions to him.

    On the night the radiogram from the Sixth U.S. Army was received, Colonel Thomas boarded a plane, carrying his musette bag and a cage containing 24 white mice. Early or doubtful diagnoses of scrub typhus were to be proved by inoculation of these laboratory animals.

    As already mentioned, this large outbreak was associated with the unprecedentedly low case fatality rate of only 0.6 perceint. The fright among line officers resulting from it, however, hastened cooperation in measures of prevention. Scrub growth was rapidly cleared and mite repellent freely used (fig. 188). Steps were takemn to obtain impregnated clothing for future operations in the same type of terrain.

    A number of useful lessons were learned from this mild outbreak. Another medical officer continued the study which Colonel Thomas had begun, and he prepared an account of the clinical picture and the distribution of cases among the troops assigned to the task force.

    Special investigations - The group sent from the United States of America Typhus Commission to New Guinea to study scrub typhus was headed by Dr. Blake and Dr. Maxcy and included entomologists, parasitologists, and well-trained laboratory personnel (fig. 189). Preparations for their arrival included the setting up of laboratories in new portable buildings in conjunction


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FIGURE 188.-Scrub typhus control, 360th Station Hospital, Goodenough Island, January 1944. A. Natives cutting and gathering kunai grass for burning. B. Cleared area after sand and gravel were spread; burning kunai grass continues in rear.


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FIGURE 189.-Members of U.S.A. Typhus Commission in New Guinea. 3d Medical Laboratory, Oro Bay, New Guinea, December 1943. Left to right, Capt. Glenn Kohls, entomologist; 1st Lt. John Bell, SnC, from Rocky Mountain Laboratory; Dr. Kenneth F. Maxcy, epidemiologist; Dr. Francis G. Blake, technical director; Lt. Col. Joseph F. Sadusk, Jr., commanding officer of commission; and Col. Francis E. Council, commanding officer, 3d Medical Laboratory.

with a station hospital in Dobodura, an area in which scrub typhus had been prevalent (fig. 190). Here the disease was studied, the location and transmission of the mites were determined, new forms of mites were described, and, finally, methods for the prevention of typhus were elaborated and clearly described (fig. 191).

    Technical Memorandum No. 9, published by the Office of the Chief Surgeon, Headquarters, USAFFE, 6 August 1944, included a brief description of the disease, detailed explanations of the vector and reservoir hosts, and instructions for control and prevention. The subject had been previously dealt with in Circular No. 117, Office of the Chief Surgeon, Headquarters, USAFFE, 31 December 1943; War Department Technical Bulletin (TB MED) 31, 11 April 1944; and an article in the Bulletin of the U.S. Army Medical Department in May 1944.3

    Impregnation of clothing. - Circular No. 117, just mentioned, contained the following (summarized) information on the impregnation of clothing and blankets with methyl phthalate emulsion:

    Experience with mass impregnation of clothing with a soap emulsion of methyl phthalate has been acquired in recent field tests with troops and as a

_________
3 Scrub Typhus. Bull. U.S. Army M. Dept. No. 76, May 1944, pp. 52-61.


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FIGURE 190.-Facilities of U.S.A. Typhus Commission. A. Laboratory building. B. Insectory.


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FIGURE 191.-Testing mite repellents. A. Method of rearing mites B. Testing repellents in the field.


531

control measure in a recent outbreak. As a result of these experiences, it is recommended that this metinod be used in all troops before their participation in combat or in combat training. In both circumstances, it is considered to offer the best protection available at this time. Engineer troops working in suspected areas and staging troops among whom typhus has appeared should also have the added protection of this measure.

    Methyl phthalate in 1-gallon tins is now being received in this theater for clothing impregnation. The issue is on the basis of 10 ounces per man per month. Issue is restrictedi to troops designated for duties which will involve exposure as just described (fig.192). Requisitions should be accompanied by details of the circumstances which render the use of this agent advisable.

    It was something of a triumph to persuade the fighting man to adopt andl carry out the painstaking measures which prevented scrub typhus (fig. 193). The complete story entails the pioneer work accomplished by the Australians; extensive research by the group from the United States of America Typhus Commission as well as by others; overcoming Sixth U.S. Army objections to the time-consuming and complicated control measures; and, finally, the mass impregnation of clothing by Army laundries. The story of prevention and control is told in detail in the preventive medicine volumes of the history of the U.S. Army Medical Department in World War II.

    Rehabilitation and disposition. - Patients recovering from scrub typhus were found to present a real problem in rehabilitation. The disease had acquired a fearsome reputation, and convalescent patients, as well as many medical officers, were frequently convinced that they had suffered some permanent damage to the heart or other vital organs.

    Technical Memorandum No. 10, published by the Office of the Chief Surgeoin, Headquarters, USAFFE, 29 August 1944, advised a carefully supervised program of physical reconditioning for these patients, combined witin ressurance as to their ultimate recovery, as follows:

    Reassurance may be soundly based on the careful studies carried out in this area on large series of convalescent patients in whom the physical signs, the X-ray findings, the electrocardiograms, the vital capacities, and the exercise tolerance tests were critically evaluated to determine the frequency of residual cardiovascular damage. The results of these studies indicated that there is no evidence of permanent organic damage and that functional neurocirculatory symptoms were no more frequent than they are after other severe febrile illnesses. It may be concluded that, though vascular and perivascular lesions occur in the heart as well as in the lungs, brain, and other tissues during the active stage of the disease, the recovery from these inflammatory processes is complete, with very occasional exceptions. When permanent disability persists, as it does in these very occasional cases, it takes the form of varying degrees of deafness, diminished vision, involvement of the peripheral in nerves, or other residual damage, chiefly of the nervous system.


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FIGURE 192.-Troops of 1st Cavalry Division impregnating their clothing, Los Negros Island, Admiralty Group, October 1944.

Recommendations for disposition consisted of grouping the patients as follows:

    1. The first group consists of patients in whom the course of the disease has been sufficiently mild to warrant the estimate that they will be in condition to return to general service at some time within 6 weeks after admission to the hospital. They should spend their convalescence in the convalescent section of the hospital or be transferred to a convalescent hospital within the same base. Careful medical supervision should be maintained over their progress through a graded schedule of exercise, recreational activities, and other measures of physical and mental upbuilding.

    2. The second group consists of patients whose course has been of medium severity and who would require at least a month of reconditioning after hospital treatment was no longer necessary before assignment to duty. Such patients should be transferred to a general hospital or a designated station hospital to be recommended, as soon as their condition permits, by a disposition board, for transfer to the First Training Center, Replacement Command, Oro Bay. Officers below the grade of lieutenant colonel as well as enlisted men should be so recommended for disposition.

    Hospital patients transferred to the First Training Center should be able to care for themselves without nursing attention and to perform light camp


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FIGURE 193.-Poster urging preventive measures against scrub typhus.

duties. It was desired that full advantage be taken of the resources of this center for the reconditioning of all long-term patients no longer requiring hospital care but not yet fit for return to their former assignment. The center provided a graded schedule of physical activities under medical supervision, a hospital scale of rations, and recreational and educational features. Training was carried on in an environment of military discipline until the convalescent was determined to be fit for reassignment.

    Careful judgment had to be exercised to be sure that patients who could not be expected to perform any militarily useful service, even after rehabilitation, were promptly evacuated to the United States.

    3. The third group of convalescents from scrub typhus fever consists of those who because of the extreme severity of their illness or the development of complications would plainly be unfit for military service within a period of 120 days, counted from the day of their admission to the hospital. These patients were to be transferred to a general or designated station hospital, to be evacuated to the United States on the recommendations of a disposition board.


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DIFFERENTIAL DIAGNOSIS OF ACUTE FEVERS

    Mild attacks of dengue were diagnosable only by the association of the patients with patients who were suffering more severe attacks. The same was true of mild attacks of many other febrile diseases encountered in New Guinea. The diagnostic difficulties, in fact, were such that the medical services in many station hospitals began to enter large numbers of cases as  fever of undetermined origin (FUO). At one time, there were so many such diagnoses that Colonel Thomas wins instructed by the Office of the Chief Surgeon, Headquarters, USASOS, to investigate the matter. In every case which he observed, the diagnosis was in real doubt, though occasionally there was a fairly well founded suspicion that the disease lay in one or another special category. In his opinion, very few of these cases represented mild breakthrough attacks of malaria.

    In view of the importance of accurate classification of disease, both for proper treatment and statistical purposes, Colonel Thomas prepared the following (summarized) material on the differential diagnosis of acute fevers, which was published as Technical Memorandum No. 7, Office of the Chief Surgeon, Headquarters, USASOS, 21 March 1944:

    Malaria. - A positive smear should be obtained in as many cases of malaria as possible. If the first smear is negative, additional smears should be taken at daily intervals. If the general condition is good, it is proper to withhold treatment for several days in the effort to get a positive smear, but, whenever this is done, the patient must be watched very closely; in primary falciparum infections, although parasites may be very scanty in the peripheral blood, he may pass into a serious condition within a few hours.

    The desirability of getting a positive smear before antimalarial treatment is begun must not prevent treatment in any patient who presents symptoms strongly suggestive of malaria, particularly a tertiary fever. Such cases should be reported as  malaria, clinical diagnosis. Symptoms of cerebral malaria demand prompt treatment, irrespective of what the smear shows.

    Withholding suppressive Atabrine for 2 or 3 days in an effort to get a positive smear is likely to be ineffective. Withholding the drug for a longer period is unjustified.

    When patients are treated on the presumption of malaria without a positive smear and the temperature does not remain normal after 48 hours of treatment, another cause for the fever should be seriously considered. Some patients with malaria will run a fever for 3 or more days, it is true, but they constitute only a small group.

    Dengue. - This protean disease is characterized by 5 to 7 days of fever, either so-called saddleback or continuous; headache; retro-orbital pain; conjunctival suffusion; backache and periarticular muscular pains; and a rash, which usually appears on the fourth to the sixth day. While there is considerable variation in the severity of symptoms and duration of fever, the diagnosis of dengue when the temperature elevation lasts less than 4 days


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should be viewed with suspicion. Very mild, afebrile cases of dengue probably do occur, but the differentiation of them from other short fevers is not reliable.

    Upper respiratory diseases. - Common nasopharyngitis, sinusitis, tonsilitis, and bronchitis are usually readily distinguished as such if the examination is adequate. Fever may persist for several days. Upper respiratory symptoms are usually minimal in dengue. At this time (March 1944), influenza had not yet been recognized in the forward area.

    Diarrheal diseases. - Diarrheal diseases are usually readily recognized. Fever is frequently associated with diarrhea and usually associated with dysentery, but diarrhea also occurs in malaria, dengue, and typhus. In the diarrheal diseases, fever and diarrhea either begin together, or the diarrhea precedes, rather than follows, the onset of fever. The degree and duration of the fever may be out of proportion to the number of bowel movements.

    Effects of heat. - Certain persons, particularly if unseasoned to hot weather, may develop fever, headache, abdominal cramps, and muscular pains after working in the heat. The picture observed un New Guinea, however, frequently does not correspond with textbook descriptions of heatstrokes, heat exhaustion, or heat cramps from loss of salt. Diagnosis should not he difficult when the history shows a definite relation between the onset of symptoms and heavy work in a hot atmosphere and when the response to rest and the administration of salt is prompt.

    Typhus. - Typhus may be difficult to diagnose in the first few days of the illness. The onset is likely to be more gradual than in dengue, with the fever rising gradually for the first 2 or 3 days and then persisting for 10 to 14 days or even longer.

    Helpful points in diagnosis include the presence of an eschar, which can be found on careful search in most cases; adenopathy, particularly if it increases over a period of a few days; and the rash. Confirmatory evidence is obtained by agglutination with Proteus OXK, which is usually present by the 10th day and which reaches a maximum 2 or 3 days after the temperature has returned to normal. A titer of 1:80 is considered suspicious, and a titer of 1:160 on greater is usually considered diagnostic. The diagnosis of typhus when the fever lasts less than 10 days is seldom justified, and the same holds for cases in which the fever lasts longer but there is no eschar and the OXK agglutination is negative.

    Enteric fevers. - Only a few cases of the enteric fevers (typhoid and Salmonella) have occurred up to this time, but these diseases must nonetheless be borne in mind. They are to be distinguished from typhus by the absence of an eschar; the differences in the skin rashes; the negative Proteus OXK agglutination; the increasing titer in the Widal test; and positive blood, stool, urine cultures.

    FUO. - The differential diagnosis of many of the fevers mentioned cannot be made on admission. In cases of short duration, the diagnosis is often best made when the patient is discharged, when the clinical course, the symptoms, and the character of the temperature curve can be carefully reviewed. Even


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then, a critical clinical appraisal may still not make it possible to place the case in any particular category.

    Cases of this kind may be recorded as FUO. Even under adverse conditions, however, the number of cases thus diagnosed should not constitute more than 10 to 20 percent of all febrile admissions.

INFECTIOUS HEPATITIS

    Infectious hepatitis began to be a problem in the spring of 1944, with the development of isolated cases in areas far removed from each other and with no apparent method of spread.

    The first large group of cases which might be described as epidemic occurred in the task force which invaded the neighboring islands of Biak and Owi, areas in which a scrub typhus epidemic had occurred. Although a few cases of hepatitis developed before the first case of scrub typhus was observed, from then on, the two outbreaks paralleled one another until the scrub typhus was controlled by eliminating the mites, which was accomplished by clearing away scrub growth and tall kumai grass, and by impregnating clothing with methyl phthalate. In July, August, and September 1944, the outbreak of infectious hepatitis assumed notable proportions.

    The invasion of Leyte took place just after the height of the outbreak on Owi, and all the hospitals in the Leyte area received a great many patients suffering from hepatitis.

    Clinical and Epidemiological Studies - With the concurrence of Colonel Hagins, Sixth U.S. Army Surgeon, the outbreak of hepatitis in Biak and Owi was studied by Maj. James L. Borland, MC, gastroenterologist from the 105th General Hospital, and Lt. Col. (later Col.) William B. Vandergrift, MC, Chief, Laboratory Service, 118th General Hospital. They spent about 6 weeks in August and September 1944, collecting information, observing patients, and making exhaustive laboratory tests. They also attempted to cultivate a virus. Their preliminary reports, which included all the data available, were sent to the Surgeon, Sixth U.S. Army, in October and November, and their final report was sent to the Chief Surgeon, USASOS, 18 December 1944.

    While in Brisbane, Colonel Thomas prepared material for the area ETMD (Essential Technical Medical Data) and also wrote Technical Memorandum No. 16, which was published on 1 October 1944 by the Office of the Chief Surgeon, Headquarters, USAFFE. The data on infectious hepatitis contained in these various reports and other publications may be summarized as follows:

    Historical note. - Outbreaks of jaundice have been reported for at least 100 years and have been particularly numerous in armies in wartime. Over 52,000 cases were reported in the Union Army during the Civil War in the course of 3 years. Outbreaks have occurred in World War II in British troops in the Middle East and among U.S. troops in North Africa and practically all other areas.


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    Epidemiology. - Opportunity for study has led to increased knowledge of this disease in recent years. It is now believed that the etiologic agent is a filterable virus or group of viruses, although attempts to cultivate it (or them) have been unsuccessful.

    The disease has been passed from patients to volunteers by several methods, including nasal insufflation and intracutaneous inoculation of serum and whole blood. More recently, filtered excreta have been shown to contain the virus and have produced the disease upon ingestion by volunteers. Thus observation has introduced an important concept concerning the possible transmission of the disease by contaminated water or food.

    The special epidemiologic studies in the investigation, just referred to, of the outbreak on Biak and Owi revealed no common water points, swimming areas, or messes. The affected units were not in closely adjacent areas and had no common meeting places except occasionally at open-air motion pictures. There were no common prior staging areas. The only Navy personnel who developed the disease had been ashore in the involved area. It was concluded that the virus had probably been brought in by U.S. soldiers and sailors and that the variety of spread pointed to a vector. The common fly and a species of Phlebotomus were suspected, especially the latter. The incubation period was between 3 and 5 weeks and was most often 4 weeks.

    Clinical picture. - When infectious hepatitis occurred in outbreaks, the clinical picture followed a definite and characteristic pattern. The onset in the majority of cases was characterized by fever, often followed by a latent period during which the patient might feel perfectly well. The onset might also occasionally be characterized by a chill, headache, and general malaise. Then would come an acute phase, from the fifth to the seventh day, ushered in by anorexia, nausea, sometimes vomiting, weakness, and pain in the upper abdomen. Jaundice ensued, associated with an enlarged and tender liver in about two-thirds of all cases and, occasionally, an enlargement of the spleen. About a third of the patients had a slight temperature elevation at this stage.

    About a third of all the patients observed had no history of a preliminary febrile stage and became aware of the disease only when they noticed yellow scleras or dark-brown urine, usually associated with a distaste for food and slight lassitude.

    In from 1 to 5 weeks, the jaundice began to clear, and recovery was usually rapid, lasting not more than a month. The mildness of the illness and the length of convalescence were thought to be directly proportional to the amount of rest. Patients kept in bed on Owi until the jaundice finally cleared practically all did well. The only fatalities and complications occurred in patients who were evacuated. It was thought that return to duty before the jaundice had fully cleared predisposed to relapse and prolonged the convalescence.

    In the occasional fatal case, a sudden lapse into delirious semicoma took place 4 to 10 days before death occurred from acute yellow atrophy of the liver.


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    In December 1944, Colonel Thomas observed two patients on Leyte who died of jaundice with unusual findings. Both died suddenly and unexpectedly after they had been jaundiced for 5 days before admission and 2 or 3 days in the hospital. Neither had fever, and neither was apparently very ill. Clinically the cause of death was acute pulmonary edema. In both cases, autopsy showed that all five lobes of the lungs were totally involved in an early bloody pneumonia. The trachea and bronchi were pale and did not contain pus. One patient had hemorrhages throughout the kidneys and in the interventricular septum, suggesting a sudden cardiac death, but these findings were not present in the second case. No pathogens (plague bacilli) were present in smears from the lungs, but inclusion bodies-a weak reed to lean on-were suspected. The liver in each instance showed minimal uniform cloudy swelling.

    Diagnosis. - During the outbreak of infectious hepatitis, it was possible to suspect the correct diagnosis during the early febrile stage. Confirmation was obtained by observation of bile in the urine several days before jaundice became evident.

    No instance of Weil s disease (infectious hepatitis caused by Leptospira icterohaemorrhagiae) was found in these outbreaks. The organism, however, was isolated from three natives of New Guinea by a U.S. medical officer. In each instance, the clinical picture was typical of Weil s disease, and all the patients responded promptly to treatment with penicillin.

    Treatment. - Treatment of infectious hepatitis consisted chiefly of rest and diet. Rest in bed was enforced as soon as the condition was suspected, and unnecessary movement of the patients was strictly prohibited.

    It was of major importance that a satisfactory state of nutrition be maintained. The diet was kept low in fat, but the addition of small amounts of milk, cream, or butter was permissible if the increased palatability thus obtained enabled the patient to emit more food. Polyvitamin capsules were administered twice a day.

    Fluids were taken freely. If vomiting interfered with an adequate intake, 5-percent glucose in physiological salt solution was injected intravenously in amounts sufficient to produce a daily output of 1,200 cc. of urine. Plasma was of possible value in the presence of ascites, but this complication was both late and unusual.

    When the hospitals on Leyte began to receive patients with infectious hepatitis, wounded soldiers required major attention, and many of the patients with hepatitis, who were less seriously ill, were transferred rapidly to a huge convalescent hospital, long before their jaundice had cleared up and in some instances even before it had begun to lessen. In this hospital, the patients were forced to walk long distances to and from meals. They had absolutely no nursing care and even had to take care of their own beds.

    It was interesting to Colonel Thomas and others, who were watching this situation with some misgivings, to note that these patients went on to complete recovery and that very few developed serious complications. In only a few cases did the disease progress to the chronic stage. The final word


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on these cases could, of course, come only from followup studies, which were not practical.

    While he was on Leyte, Colonel Thomas received some of the voluminous reports on studies of hepatitis in the Mediterranean theater. The military situation on Leyte prevented following any of the recommendations contained in these reports, and the cases just described therefore may be considered to have served as a rather interesting control series.

    Control. - Recommendations for control of infectious hepatitis, Colonel Thomas pointed out in his October 1944 report, were difficult to make in the present state of knowledge. It was thought that transmission might be by droplet infection, but attempts had also been made to incriminate an insect vector. On the other hand, demonstration of the infecting agent in the stool, and possibly in the urine, of patients with the disease suggested the prime importance of methods designed to prevent contamination of water and food. The following recommendations were therefore made:

    1. All the usual sanitary measures should be strictly enforced.

    2. Bathing in fresh-water streams should be prohibited.

    3. Hospitals should institute the isolation measures used in typhoid fever, with proper disinfection and disposal of patients excreta. Nurses and ward attendants should wash their hands thoroughly after every contact with a patient or his excreta. This recommendation was most important, for several nurses had contracted the disease in hospitals in which these patients had been cared for.

    4. Since the duration of infectivity was unknown, patients should be instructed to observe special measures of cleanliness during convalescence, to avoid possible contamination from their excreta.

AMEBIASIS

    In June 1945, Colonel Thomas paid a short return visit to Leyte with the double object of facilitating the work of the subcommission and other groups studying schistosomiasis and of setting up a study throughout the base on amebiasis, with particular reference to its prevalence and the correctness of diagnosis and treatment in the various hospitals.

    The amebiasis program was accomplished by arrangements with the base area surgeon to have Col. James Bordley III, MC, Commanding Officer, 1l8th General Hospital, instructed to make a survey and submit a report on this disease. In addition to factfinding, Colonel Bordley, in the course of his investigation, was able to disseminate a great deal of useful information and to institute valuable clinical and followup studies.

Essential Facts of the Disease

    The following facts are taken from a lecture on the subject which Colonel Bordley gave at the Office of the Surgeon, Base K, 25 June 1945:

    Incidence and epidemiology. - An increasing incidence of amebiasis has been reported in Base K among hospital patients, including not only cyst


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carriers but patients with active amebic dysentery. This increase may be due in part to greater awareness of the disease and better diagnostic study of all patients with diarrhea or abdominal complaints. Cases which formerly escaped attention have unquestionably been brought to light by (1) multiple stool examinations and rectal smears, (2) more frequent use of the sigmoidoscope, and (3) more frequent surveys of foodhandlers. The incidence of amebic dysentery is relatively, though not alarmingly, high at this time.

    As far as can be determined from recent stool surveys of the civilian population made by malaria units on Leyte, the cyst carrier rate is somewhere between 5 and 10 percent, no higher than might be found in certain sections of the United States. Possibly these figures are too low, since the surveys were not made with particular attention to amebiasis. There does, however, appear to be an alarmingly high carrier rate among civilians, though nothing approaching the high rates reported for Schistosoma eggs and Ascaris.

    If the amebic dysentery rate is high (in troops) and the cyst carrier mate is low (in civilians), then there may be some special explanation for the dysentery. It is known that in experimental amebic infections in animals, dietary and other factors may play an important role. According to Faust, there is no evidence to indicate that the amebic organisms in a community may suddenly become more virulent. It would therefore seem that a high carrier rate (in the Army) associated with a relatively low carrier rate (in the population) must probably be explained by factors other than the virulence of the organism. Among these factors may be:

    1. Decreased most resistance due to combat conditions and injuries and specific debilitating diseases prevalent here, particularly infectious hepatitis and schistosomiasis. A 34-year-old sergeant, for instance, was admitted to the 118th General Hospital, 2 January 1945, 48 hours after the onset of chills and fever. He was jaundiced and had an enlarged, tender liver and an enlarged spleen. On the third day of his illness he developed abdominal pain and diarrhea, which were thought to be part of the symptomatology of acute infectious hepatitis. He died on the 10th day of hospitalization, after a stormy illness. At autopsy, he presented what would be interpreted as an extraordinary example of reduced host resistance to E. histolytica. There was an enormous swelling, with extensive ulceration, of the wall of the colon, all layers of which were heavily infiltrated with the organisms, which had also infiltrated the walls of the small mesenteric arteries and veins, with resultant thromboses, and were also present in the regional lymph nodes. The liver was studded with small necrotic and hemorrhagic foci containing amebas.

    2. A large infecting dose. There was certainly ample opportunity for very considerable contamination of drinking water during the early days on Leyte. Because of the shortage of potable water, shallow wells were dug hurriedly in populated areas, and there was great difficulty in keeping them from becoming contaminated by surface water during the heavy November and December rains. The experience of the 133d General Hospital was typical of the results of these conditions. This unit arrived soon after the landing and


541

began to establish itself in a populated area on the highway on the southern edge of the village of Palo. Personnel had constant contact with muddy ground that had been the repository of the feces of the displaced populace. The native laborers doubtless contributed further to the contamination during the early period of hospital construction. Flies were all about. Meals were prepared and served in open, unscreened tents. Water came from 10-foot wells dug in low ground, where the ground-water level was only 2 or 3 feet below the surface. Amebic cysts were actually found in a sample of water from one of these wells. The report is perfectly credible, since none of the native huts removed from the area or still surrounding it had any sort of latrine. The well could easily have been dug through earth which had once been an informal latrine for a native family.

    It is not surprising that the incidence of dysentery was very high among the original personnel of this hospital. It was extremely difficult for them to staff their kitchens and messhalls because a survey of their foodhandlers showed that 23 were amebic carriers.

    A stool survey was made of two groups of the personnel of the 133d General Hospital by Maj. (later Lt. Col.) Irving J. Glassberg, MC, of the hospital laboratory. In the first group were approximately 200 officers and men of the original contingent which had been so heavily exposed; stools were positive for E. histolytica or trophozoites in approximately 37 percent. In the second group were approximately 150 nurses and enlisted men who had come from the United States to join the unit about 3 months before the survey was undertaken. In them, the incidence of E. histolytica was less than 2 percent.

    Conditions at this hospital were subsequently improved. Natives were moved from the immediate area. Water was piped in from the mains of the Palo municipal water system. Messhalls and kitchens were adequately screened and flies reduced to a minimum. Tent floors and raised walks, finally, kept the personnel out of the mud.

    Base K served as a hospital center for both combat and garrison troops on other islands and received large numbers of patients from Mindanao, Mindoro, Cebu, Negros, Luzon, New Guinea, Palau, and other islands, on which the carrier rate was unknown. The sanitary conditions on some of the more recently occupied islands were still much as they were on Leyte during November and December.

    Many of the patients hospitalized at the ll6th Station Hospital were members of a combat division said to have acquired their infections in Palau.

    Diagnosis. - As was generally suspected, the most recent survey of hospitals showed a wide divergence of understanding about the reporting of amebiasis. In conformity with Army Regulation (AR) 40-1025 (12 December 1944), there were three choices: (1) dysentery, amebic; (2) amebic infection, nonintestinal location; and (3) E. histolytica carrier.

    The survey disclosed that earlier a number of cases had been reported as amebic dysentery instead of amebic infection. Over 900 patients were presently under treatment in hospitals for amebic infection, but there seemed to


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be not more than 167 cases of amebic dysentery among them. A certain proportion of these patients undoubtedly had nonspecific diarrhea, and thorough stool examinations had disclosed a few amebic organisms.

    The differentiation between true amebic dysentery and diarrhea in amebic carriers is not always easy. Furthermore, the accuracy of the diagnosis cannot always be determined by reviewing the case records because the clinical notes often are not sufficiently detailed. In questionable cases, the diagnosis of amebic dysentery can best be established by demonstrating the typical ulcers through the sigmoidoscope or by studying the character of the exudate (pus and blood) in the feces.

    It is therefore strongly recommended that particular attention be paid to the character of the excreta and that sigmoidoscopic examinations be performed as often as necessary. If a patient with acute diarrhea does not have blood and pus in his feces and does not present demonstrable ulceration of the lower bowel, the primary diagnosis should be recorded as   diarrhea, causes undetermined, acute, and the secondary diagnosis as  E. histolytica, carrier. 

    It must, of course, be assumed that the specific bacterial dysenteries have been ruled out by culture of the stools before this diagnosis is made. The reports all seem to indicate a surprisingly low incidence of bacillary dysentery on Leyte. This is puzzling in view of the sanitary conditions which prevailed during the first several months after the landing. In November and early December 1944, many causes of acute diarrhea went unreported and were certainly not adequately studied. Among personnel of the 118th General Hospital, which established itself in November in an area not much better than that described for the 133d General Hospital, diarrhea was very common, but it was seldom accompanied by fever or constitutional symptoms. Most of the personnel accepted it and did not report sick. Many, during several nocturnal air raids, were personally faced with the decision whether to take the long, muddy walk to the latrine or to in head for the slit trench. Yet there was no bacillary dysentery, at least of a clinically recognizable type, because of settling in an area of poor sanitation. Perhaps some of this good fortune was due to the fact that the sulfa drugs were handed out liberally to the personnel of most units.

    Unlike bacillary dysentery, amebic dysentery does not make its clinical appearance during the early, poor-sanitation period of a campaign. This should be borne in mind in making the diagnosis. Owing to the bug and variable incubation period, manifestations do not appear for weeks or months, whereas in bacillary dysentery, the incubation period is usually 2 to 7 days. In volunteers who were fed amebic cysts by Walker and Sellards, the incubation period varied between 20 and 100 days. The prevalence of amebic infections is therefore likely to become evident gradually and insidiously, as in the famous Chicago outbreak and as happened on Leyte. There was none of the explosiveness which characterizes outbreaks of bacillary dysentery.


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Results of Survey

    Colonel Bordley s final report contained a detailed survey of the various hospitals studied; an analysis of divergent methods of diagnosis, including the use of such devices as purges, sigmoidoscopes or proctoscopes, and an elongated glass eyedropper for collecting material for microscopic examination techniques of treatment, including reported successes varying from 60 to 100 percent in ridding feces of cysts and trophozoites; and criteria for cure, disposition, and sanitary precautions.

    The survey created a great deal of interest in the hospitals on Leyte and raised the standard of medical practice in this particular disease. Had the war lasted longer, the usefulness of the investigation would have been extended to other areas.

    Colonel Thomas and Colonel Eppinger prepared a technical memorandum4 on amebiasis which was issued on 21 November 1944.

DIPHTHERIA

    On his way to Australia in October 1943, Colonel Thomas had stopped for a brief visit at the 18th General Hospital, then stationed in the Fijis. Col. Benjamin M. Baker, MC, Consultant in Medicine, SPA (South Pacific Area), gave him a full account of the prevalence of skin diphtheria in that area. Many of the early cases had been missed in the wards of the various hospitals scattered through these islands, but when medical officers were alerted to the possibility of the conditions, many more cases were brought to light, and the diagnosis was confirmed by culture. When he arrived in Australia and later went to New Guinea, Colonel Thomas passed on this information, particularly to officers of dermatological wards in which cultures of suspicious lesions had been made.

    The first active cases recognized in SWPA were observed on visits to Finschhafen and Hollandia in October 1944; there had been small outbreaks in each of these locations. Previously, cases of peripheral neuritis following skin ulcers or so-called jungle rot had been suspected but not proved to be caused by the toxin of the diphtheria bacillus.

    The following (summarized) information was prepared for Technical Memorandum No. 17, issued by the Office of the Chief Surgeon, Headquarters, USAFFE, 23 October 1944, and was also included in a section prepared for ETMD s:

    1. An increase in the number of reported cases of clinical diphtheria has recently occurred in SWPA. In one base, there has been a small outbreak of the disease in a virulent form involving the larynx and bronchi. The attention of medical officers is directed to these facts, so that individual cases may be promptly recognized.

    2. In tropical areas, the diphtheria bacillus attacks the respiratory tract but also, not infrequently, attacks any ulcerative skin lesion or open wound.

4 Technical Memorandum No. 20, Office of the Chief Surgeon, Headquarters, USAFFE, 21 Nov. 1944.


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Its presence in such lesions may readily go undetected. In some instances, outbreaks of pharyngeal diphtheria have been traced to contact with cases of diphtheritic skin infection.

    3. The frequent occurrence of peripheral nerve palsies and pharyngeal paralysis due to diphtheria has also been reported from another tropical area. In some instances, investigation of the cause of the motor nerve lesion has led to culture of the throat or of the base of skin ulcers which proved positive for virulent diphtheria bacilli. The possibility of this association should be borne in mind.

    4. All patients with sore throats should have throat cultures taken when they are admitted to the hospital and should be isolated pending receipt of the laboratory report. All skin lesions or infected wounds with suspicious characteristics should also be cultured, and necessary isolation should be maintained until the laboratory report is received.

    5. Throat cultures, nasopharyngeal cultures, and cultures from granulations at the base of ulcers or infected wounds should include routinely streaks on Löffler s media or other media selective for diphtheria bacilli, such as tryptasetellurite plates if they are available. Whenever necessary, hospital commanders should request the assistance of the nearest medical laboratory in the Army or the Communications Zones in establishing this technique. All positive cultures obtained in hospital laboratories should be forwarded to the nearest medical laboratory for control and for necessary virulence tests.

    6. Hospital commanders should immediately report the occurrence of clinical diphtheria in their commands to the Base or Task Force Surgeon. The institution of measures to prevent the spread of the disease within the hospital and in other units of the command is the responsibility of the Base or Task Force Surgeon.

    A few isolated cases of diphtheria were encountered in New Guinea and in the Philippine Islands, but the disease caused no further serious trouble.

POLIOMYELITIS

    The first cases of poliomyelitis encountered in SWPA were observed on Leyte in November 1944. It was known that the disease is endemic in the Philippine Islands, and that it might assume a particularly deadly form in the U.S. population.

    When the first cases occurred, it was thought that they might represent one of the more uncommon varieties of virus diseases, such as Japanese B disease or equine encephalomyelitis. For these reasons, on 20 November 1944, the Surgeon, Sixth U.S. Army, requested that a team be sent to Leyte, to study the outbreak. Colonel Thomas was dispatched with this team for the purpose of making clinical observations on these cases. Two virus bacteriologists, an epidemiologist, an entomologist, and four specially trained laboratory technicians departed from New Guinea, 25 November 1944, and arrived at Tacloban 48 hours later. All members of the team except Colonel Thomas


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were personnel of the staff of the 19th Medical General Laboratory. A report was sent to the Chief Surgeon, USASOS, on 17 December 1944. The following (summarized) data are taken from it.

    Incidence. - Between 13 November and 17 December 1944, 43 cases were observed in U.S. troops on Leyte, in personnel of Army and Marine Corps units scattered along the eastern coast from Taclobab down beyond Dulag to Abuyog. The cases were scattered throughout the task force, but no organization had more than one case except for a howitzer battalion of the Marine Corps, which had two cases. In 33 cases, there was residual paralysis. In the other 10 cases, the symptoms and signs consisted of headache, pain in the lumbar region, weakness, fever, and an increased spinal fluid cell count, but there was 110 residual paralysis.

    When three of the first five patients died early in the acute stage of the disease from bulbar involvement and a fourth died after 3 weeks in a respirator, the virulence of the prevailing microorganism could not be doubted. Subsequently, milder cases were observed. The mortality rate among troops previously staged in New Guinea, who were fighting in the northern part of Leyte, was extremely high, 61 percent, whereas among troops staged in Hawaii, who were fighting in the central part of Leyte, it was unusually low, only 5 percent.

    Ultimately, the rate per 1,000 average strength in the Philippines was to rise to 0.43 in 1945 and 0.84 in 1946, an incidence not exceeded in the Army until 1947, when it reached 0.98 in Korea.

    Diagnosis. - Specimens for virus study and for gross and microscopic examination were obtained from autopsies in six cases, and the virus team, in addition, collected stool and blood specimens from patients with the disease as well as from suspected abortive cases and from contacts. Injections were made immediately into laboratory animals, including monkeys from a neighboring island, and material from all specimens was sent to the 19th Medical General Laboratory and the Army Medical School laboratory. Preliminary reports of tissue examinations promptly confirmed the clinical diagnosis.

    The virus of poliomyelitis was isolated at the laboratory of the Army Medical School, Army Medical Center, Washington, as well as by Dr. John R. Paul, Director, Commission on Neurotropic Virus Diseases, Army Epidemiological Board, from two fatal and two nonfatal cases in the paralytic group. No pathogenic viruses were obtained from the 10 patients with preparalytic polio myelitis, although the clinical picture in all respects, including pleocytosis, was the same as in the paralytic group. In June 1945, a final and very exhaustive report of the laboratory studies in these 43 cases was made by Maj. Ray E. Trussell, MC, and his group on the virus team from the 19th Medical General Laboratory.

    A number of cases similar to the cases in the preparalytic group were observed among contacts who were not admitted to hospitals or who did not have lumbar punctures. Many such cases were undoubtedly diagnosed as typical dengue. In fact, retro-orbital pain and backache occurred in many


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of the paralytic cases, and the prevalence of dengue in the area made the mistake in diagnosis almost unavoidable.

    Evidence of meningeal irritation led to the diagnostic lumbar puncture in six cases. In the remaining cases, flaccid paralysis or unmarked weakness of one or more of the extremities pointed to the diagnosis.

    Source of infection. - The source or reservoir of this infection was a baffling question. No recent cases of poliomyelitis in Filipinos were discovered by visits to civilian hospitals, and none had been reported by the Philippine public health service. Certain facts pointed to the possibility that the disease might have been brought in by carriers among troops from the United States, where it was epidemic. In one area, the condition developed 5 days after the soldier had arrived on Leyte. In another area, three cases treated and discharged as lymphocytic choriomeningitis developed 2 weeks after the arrival of the men; these cases preceded the paralytic cases in that area by about a month. About half of the cases were in soldiers who had lived on farms or in very small rural communities. Although many individuals who had been in contact with patients who developed paralysis showed signs indicative of preparalytic poliomyelitis, only one man, a medical corpsman, developed the paralytic type of disease after contact with patients. He had attended poliomyelitis patients in respirators from 3 December to 6 December, and he came down with the disease himself on 17 December.

    Observations in the Middle and Far East, made during the war and subsequently, showed that similar outbreaks of poliomyelitis occurred in troops foreign to the particular country without any apparent increase in incidence in any age group in the indigenous population.

    It was impossible to make a proper investigation in the heat of battle, when distances were so great, transportation so difficult, and other duties so pressing. One could only conclude that, barring some extraordinary influences from previous military service in raising individual resistance to a virulent strain of poliomyelitis virus, the outbreak in the troops in the Dulag area was caused either by one or more very atypical poliomyelitis viruses of mild virulence or by one or more neurotropic viruses capable of producing the Guillain-Barré syndrome.

    Clinical picture. - Clinically, the disease followed the pattern usual in adults. The age varied from 19 to 35 years, with an average of 23.5 years.

    The initial invasive phase was not observed, although several patients reported having had slight colds a few days before becoming ill. In 10 cases, the onset was not unlike dengue, and the patients, in fact, were admitted to hospitals with this tentative diagnosis. They complained of intense headache, pain on moving the eyes, backache, and fever. Five patients had chills. Severe headache was the presenting symptom in 17 of the 33 paralytic cases and in all 10 of the preparalytic cases. Five patients were admitted complaining of severe abdominal pain; in this group, the admission diagnosis was appendicitis in three cases and gastroenteritis in the other two. One patient was


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thought to have a back strain, and another was hospitalized because of recurrence of a perirectal abscess.

    The majority of patients who died, as well as three who survived, had some involvement of respiration, and another patient had some involvement of the thoracic muscles on the left side. Abdominal respiration was absent in at least two of the fatal cases and in one patient who recovered.

    In the cases in which records of the temperature were available, there was a fair correlation between the height and duration of the fever and the severity of the disease. In three fatal cases in which the temperature was known, it was up to 103º F. in a patient who died on the 3d day; up to 105.8º F. in a patient who died on the 26th day, after being completely paralyzed and maintained in a respirator; and up to 103º F. In a patient who died on the 11th day. Most of the patients who recovered had fever no higher than 101º F., but two had fever up to 102º F. and three fever up to 104º F., for several days, with early residual paralysis.

    In 10 cases, paralysis was limited to one or both of the lower extremities, associated in three instances with weakness of the abdominal muscles. In three of the fatal cases, the legs and trunk were not involved. In another case, paralysis was limited to the pharynx and muscles of deglutition. In the other cases, involvement represented some combination of legs, trunk, thorax, arms, or cranial nerves. One patient had a transient facial paralysis, which cleared in 48 hours. Another had involvement of the 6th, 7th, and 10th cranial nerves, which disappeared entirely in a few days.

    In addition to the fatal cases, two other patients had evidence of bulbar involvement. Lethargy or delirium was present in three cases and insomnia in one.

    Six patients had to be catheterized, and two could not defecate without enemas. Three patients, two of whom were constantly in respirators, developed decubitus ulcers. In one case, jaundice appeared on the 11th day; it was thought to represent infectious hepatitis unrelated to poliomyelitis, since many sporadic cases of the kind were occurring at this time.

    The white blood cells were counted in 12 cases. They varied between 6,500 and 16,400 cells per cubic millimeter.

    There was no correlation between the number of white blood cells in the spinal fluid and the extent of early residual paralysis. In fact, seven patients with definite residual paralysis had fewer than 10 cells, with an average of 5. In contrast, in two of the preparalytic cases, the cells were over 100 in one and 330 in the other. The highest counts in the paralytic cases were 347, 458, 547, and 700; 10 other patients had more than 100 cells. Lymphocytes predominated, usually in the range of 75 to 95 percent. In a few early punctures, the spinal fluid showed a predominant and marked shift to lymphocytes.

DERMATOLOGICAL CONDITIONS

    Skin diseases constituted a worrisome problem for most units, few of which had the services of a trained dermatologist. Every unit expressed the desire for


548

FIGURE 194.-Consultants in medicine, Southwest Pacific.

a consultant in dermatology, and the large number of faulty diagnoses and the amount of overtreatment of skin diseases observed by Colonel Thomas confirmed this need.

    When a consultant in dermatology, Maj. (later Lt. Col.) John V. Ambler (fig. 194) reached the area early in 1944, he performed a most useful service


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in improving and standardizing the diagnosis of skin diseases, which were most difficult to manage in a tropical climate under the stress of wartime Army life.

Atypical Lichen Planus

    A study of 26 cases of atypical lichen planus in December 1944 from the Malaria Research Unit, 3d Medical Laboratory, was of considerable interest. When this unusual form of skin disease made its appearance in New Guinea, no cases had been seen in SWPA, nor were others known to exist. Before very long, the suspicion arose that there was sonic connection between the long continued use of Atabrine to suppress malaria and the development of atypical lichen planus. The information was deliberately suppressed, because Atabrine discipline was extremely difficult to maintain and because this drug had to be employed to prevent the military handicap of a high malaria rate.

    Reports on the subject were written by one or two dermatologists serving with hospitals in New Guinea, and finally, at the suggestion of Colonel Thomas, the subject was studied and reported by Major Harvey, Captain Bang, and Lt. (later Maj.) John M. Myer, MC, with the help of several Sanitary Corps officers. Their work showed that some atypical patients with lichen planus in which Atabrine therapy had been interrupted exhibited an acute flare up of the lesions when the drug was resumed. This observation was substantiated in various studies on patients who were returned to the United States. In these studies, it was also found that lesions which had completely cleared reappeared after several months of renewed Atabrine therapy.

    The study of Harvey, Bang, and Myer was the first to give some clear-cut evidence of the connection between atypical lichen planus and the long-continued ingestion of Atabrine. It was Colonel Thomas opinion that this sort of clinical research, limited and pragmatic though it was, which was set up as the problem developed and the opportunity permitted, was about all that could be hoped for in an area like SWPA.

    There were good reasons, as the Chief Surgeon, and the Chief, Professional services, USASOS, pointed out, for not publicizing the connection between Atabrine and atypical lichen planus, as follows

    1. The number of cases was small, and the patients were all receiving careful study and treatment.

    2. If even a rumor of such a relationship became widespread among the troops, it would result in still further evasion of the instructions to them that they must take Atabrine (p. 518).

    3. The use of this drug was absolutely essential to prevent large bodies of troops from being incapacitated by malaria, and, therefore, no such statement, based, as it still was, largely on inference, should be made official or circulated.

    The situation in respect to Atabrine and atypical lichen planus was typical of the misinformation and misapprehension which were always recurrent and troublesome in this area.


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FILARIASIS

    On his first trip to New Guinea, in October 1943, Colonel Thomas learned that cases of filariasis contracted on Tongatabu Island in SPA were under observation in the 52d Evacuation Hospital, which was then on Woodlark Island, off the eastern tip of New Guinea, under the Sixth U.S. Army. With the assistance of Colonel Dart, then serving as Surgeon, Intermediate Section, in New Guinea, Colonel Thomas obtained permission from the Commanding General, Sixth U.S. Army, and Colonel Hagins, the Army Surgeon, to proceed to this island. On the way there, and again on the way back, profitable visits were paid to Colonel Hagins at Sixth U.S. Army Headquarters on Goodenough Island.

    Maj. (later Cob.) Joseph B. VanderVeer, MC, Chief, Medical Service, 52d Evacuation Hospital, arranged a demonstration of the patients with filariasis then under treatment. Only one or two then showed activity in the form of swollen lymph nodes and lymphangitis. The information collected on this visit was incorporated in the ETMD, SPA, for October 1943, as follows:

    Since occupation of Woodlark Island by U.S. forces, about 30 cases of an atypical epididymitis and vasitis were observed, all in men who had previously served in Tongatabu.

    This disease is peculiar and atypical in the following respects: In a large number of cases, there is no history of a previous urethral discharge. Vasitis, evidenced by lower quadrant pain, is the first manifestation. The spermatic cord is involved to a much greater degree than is usual in a gonorrheal epididymitis. An inflammatory hydrocele is generally present in the early stages of the disease.

    A single microfilaria (Wuchereria bancrofti) was observed in a wet blood smear (coverglass technique) from one of these patients. The specimen was secured from the peripheral blood at 2100 hours, and the presence of the microfilaria was confirmed by three qualified medical officers. No microfilariae were observed on stained blood smears, many of which were taken at various times through the day and night. The disease was presumed to be due to filariasis (Bancroft s) on the basis of the observation of the single microfilaria just mentioned and the fact that all the patients with the syndrome had previously served in Tongatabu, where this disease was prevalent.

    The clinical manifestations began with a dull, aching pain in one of the lower quadrants, which gradually radiated down the spermatic cord of the affected side. The abdominal pain was followed by painful swelling of the epididymis and vascular structures of the cord, without involvement of the vas deferens. About 30 percent of the patients developed hydroceles, two of which were of such size that aspiration was necessary for relief of pain.

    These patients were isolated in the hospital at the time of Colonel Thomas visit, and further studies were being carried out in an attempt to substantiate the presumptive diagnosis. Their infectivity could not be readily determined, and since their period of hospitalization would be longer than 30 days and


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treatment in a temperate climate was probably indicated, it was desired that a high echelon decide upon their disposition.

    Colonel Thomas suggested to Major VanderVeer that an antigen be made from a lymph node subsequently shown to contain filariae and that it be used cautiously for skin testing. The suggestion was carried out, and a report on the experiment was submitted to the Office of the Surgeon General for publication. Permission for publication was refused, for two reasons, that the photomicrograph submitted could not be definitely identified as showing filariasis and that experts did not believe that the antigen used would have given positive results in the patients and negative results in a control series, as was reported. The reasoning was perhaps sound, but it was felt that a piece of clinical research accomplished in the jungles of New Guinea, without benefit of equipment or consultation of the medical literature, deserved some commendation and encouragement.

    On the recommendation of Colonel Thomas, these 30 patients were transferred to the ll8th General Hospital in Sydney, where they were carefully studied and later reported by Maj. (later Lt. Col.) Thomas McP. Brown, MC. The return of some of these troops to a nonfilarious tropical location 6 months after their symptoms had disappeared, showed that this interval had served to desensitize them to the lymphangitis syndrome..

    Filariae were observed in thick smears taken in malaria surveys among New Guinea natives, but no other active cases were encountered by the medical consultant. No case is known to have developed among U.S. military personnel in the SWPA, no doubt owing to the active avoidance of contacts between soldiers and natives and to the sanitary regulations which reduced flies as well as mosquitoes in camp areas.

SCHISTOSOMIASIS

    Schistosomiasis constituted a major clinical problem in the Philippines. The risk of infestation with Schistosoma japonicum flukes had been anticipated before the invasion of Leyte, and both medical and line officers had been warned not to drinnk or wash with water from streams and not to eat native or any uncooked food. It was not always easy to obey these regulations. The terrain through which the early fighting took place necessitated standing for days in wet rice paddies and drinking unfiltered water. Superchlorination of drinking water was advised, but it could not be supervised. Doubtless, too, the sight of civilian Filipinos standing waist deep in all the streams while they washed their clothes encouraged carelessness. Before suitable shower baths were provided, many soldiers probably washed with water from streams.

    By the time the campaign in the Philippines was concluded, it was estimated that more than a thousand U.S. Army personnel had been infested with S. japonicum. They represented the first cases of this infestation in the U.S. Army. The majority of cases developed during the early days of the invasion, when, as already mentioned, the troops had to fight through infested rice paddies and Army engineers had to work in water up to their armpits repairing bridges


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that the retreating Japanese had destroyed. There was no known way that these men could have avoided contact with the cercariae, which were abundant in most of the fresh water on the eastern side of the island.

Research and Publications

    At a meeting of survey units called by the Sixth U.S. Army malariologist, Maj. David R. Minter, MC, in November 1944, a far-advanced case of schistosomiasis in a native was presented, and a number of pertinent questions were raised. Among them were what forms of clothing other than rubber boots could prevent infection; does superchlorination purify water; and what measures should be used to eradicate snails. It was agreed that very little was known about the early stages of the disease and that local bites and urticaria were likely to be overlooked by troops who had been immersed in water for 5 to 7 days.

    Capt. Malcolm S. Ferguson, SnC, made a survey of the coast and found water available in some wells and two rivers free of cercariae. He found no snails on the west side of the island. The snails were small, about 0.5 cm. long, and about 1 in every 200 to 300 was infected (fig. 195). The technique was to dry them 2 days, then mash them and examine them under a low-power microscope. The Japanese were making an elaborate survey of schistosomiasis when they were interrupted; they were using German stains, which were better than those available in U.S. laboratories.

    Fortunately, records of a careful survey of Leyte for snails infested with Schistosoma cercariae made in 1939-40 by the Philippine bureau of health from Manila were found undisturbed by the Japanese Army. These records showed areas up and down the eastern coast of the island and well up the Leyte Valley harboring the snail host, Oncomelania quadrasi. Captain Ferguson confirmed this, finding as many as 1 infected snail inn every 75 to 100 snails examined near houses in some areas.

    Captain Bang transferred his interest from malaria, which was not a problem in Leyte, to schistosomiasis, and was given small but quite adequate facilities at the 118th General Hospital. Here he and his associate, 2d Lt. Nelson G. Hairston, SnC, together with Captain Ferguson and the 5th Malaria Survey Unit, made interesting observations on the effect of treatment in schistosomiasis japonica in laboratory animals. They also made some progress in establishing methods for the use of repellents when infested water could not be avoided.

    At the 126th General Hospital, Colonel Tillman, Chief, Medical Service, studied and reported a series of patients who showed signs of early cerebral involvement. At the 117th Station Hospital, Maj. Albert S. Johnson, Jr., MC, and Maj. (later U. Col.) Maxwell G. Berry, MC, discovered and described the sigmoidoscopic picture found to he pathognomonic of acute schistosomiasis. Maj. (later Lt. Col.) Mark M. Bracken, MC, Chief, Laboratory Service, 27th General Hospital, published original observations on fatal early cases. In the spring of 1945, after Colonel Thomas had returned to Manila


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FIGURE 195.- Snails of the type harboring cercaria, transmitters of schistosomiasis. Scale in centimeters.

from the Sixth U.S. Army, he and Major Bracken prepared an article on schistosomiasis for the newly planned USAFPAC monthly medical bulletin. This article summarized the historical, clinical, and laboratory observations made on the disease in various hospitals and laboratories in New Guinea and Leyte.

    As a result of observations on the first acute cases of schistosomiasis (p.551), Colonel Thomas prepared a paper with the help of Capt. David P. Gage, MC. It had been hoped that this report would prove instructive to medical officers throughout the theater, but publication was delayed in the Office of the Surgeon General because the article recommended that treatment based on a conclusive clinical diagnosis be instituted even before mature ova could be demonstrated in the stools. The need for the earliest possible treatment to put a stop to tissue damage from further deposition of ova was regarded in the theater as a real and urgent problem. The paper was finally published in the Bulletin of the U.S. Army Medical Department.5

    The information contained in Technical Memorandum No. 15, 6 prepared by Colonel Eppinger and Colonel Thomas in October 1944, is summarized elsewhere.

5Thomas, H. M., Jr., and Gage, D. P.: Symptomatology of Early Schistosomiasis Japonica. Bull. U.S. Army M. Dept. 4: 197-200, August 1945.

6 Technical Memorandum No. 15, Office of the Chief Surgeon, headquarters, USAFFE, 21 Oct. 1944.


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    On 25 April 1945, the Subcommission on Schistosomiasis, of the Commission on Tropical Diseases, Army Epidemiological Board, arrived in Leyte and was housed in prefabricated buildings in Tacloban. The members of the Subcommission were Dr. Ernest C. Faust, professor of parasitology, School of Medicine, Tulane University of Louisiana; Dr. Willard H. Wright, Division of Zoology, National Institute of Health, U.S. Public Health Service; Dr. Donald B. McMullen, associate professor of hygiene and public health, School of Medicine, University of Oklahoma; Maj. George W. Hunter III, PhC; Sgt. Preston W. Bauman; and Sgt. James W. Ingalls. Their work was implemented by the use of laboratory animals transported by air across the Pacific, and much gratitude is due the medical supply section of the Chief Surgeon s Office, USASOS, for its effective cooperation. The Subcommissiomm studied the clinical observations made in Army hospitals and confirmed and amplified Captain Bang s observations.

    Early observations. - All medical officers had been instructed to look out for early clinical cases of schistosomiasis, even though it was hoped that protective clothing, particularly shoes, leggings, trousers, shirts, and in some instances rubber boots, would prevent penetration of the skin by S. cercariae and that other precautionary measures would reduce the chances of exposure to a minimum.

    Early in December 1944, Colonel Thomas was asked to see two patients with possible early schistosomiasis in the 36th Evacuation Hospital. They had been in rice paddies (not yet surveyed for snails) for about 4 days. Later, when they lay down on dry ground, they bad severe itching about the hips, which they thought due to ants. Still later, they were in foxholes filled with water for about a week. A week before Colonel Thomas saw them, they had developed severe cramps in the abdomen, without fever or diarrhea; the single loose stool each had passed was without mucus or blood. The leukocytosis was 40,000 to 50,000 per cubic millimeter, with 30 percent eosinophiles in one case and 20 percent in the other. There were numerous hookworm ova in the stools in both cases. The formaldehyde test on blood serum was negative, as was the euglobulin test. No schistosoma ova were found. The lungs were clear, and the abdomen was negative except for one fingerbreadth hepatic enlargement; the liver edge was smooth.

    It was concluded that these patients had hookworm and, possibly, schistosomiasis. About the same time, Colonel Thomas examined several late cases of the disease in Filipinos.

    In other patients, the first suspicious clinical entity was generalized urticaria, with or without abdominal discomfort or diarrhea and with or without leukocytosis and eosinophihia. The clinical symptoms cleared up promptly, and stool examinations were either negative or, as in the cases just described, revealed hookworm ova. The cases were regarded as suspicious, and the soldiers were told to return in 2 weeks for repeat stool examinations.

    Meantime, on 30 December 1944, in the laboratory of the 36th Evacuation Hospital, a specimen stool from an officer patient was found to contain ova


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with characteristics of immature Schistosoma ova, and 2 days later, another officer from the same unit presented similar findings. The summarized histories of these patients follow:

    Case 1. - A 25-year-old Medical Corps captain, serving in a portable surgical hospital, arrived in Leyte on 20 October 1944. His unit supported a division which fought from the beach landing near Tacloban through rice paddies along the road to Palo. Later, the unit was camped near Dulag on the road to Abuyog.

    About 1 November, the patient had a mild attack of dengue, from which he recovered in 5 days. He remembers swimming in a stream for 20 minutes on 15 November. The current in midstream was too swift for swimming, so he and his companion (case 2) stayed in the still water near the bank. Two hours later, he took a shower bath and washed with soap.

    During the first week in December, he, like many of the soldiers throughout the task force, suffered a mild attack of dysentery, which lasted 4 days. The illness was characterized by anorexia, diarrhea with blood and mucus, urticaria around the waist and thighs, and fever. He seemed to respond to the usual course of sulfaguanidine. About 10 days later (16 December), however, he noticed vague upper abdominal discomfort, and his appetite became poor. He also developed a dry cough.

    He was sent to the hospital on 27 December. Here his temperature rose daily from normal in the morning to 101º F. in the evening; one evening it reached 102º F. Examination was negative except for a slightly enlarged, tender liver. The spleen was not palpable, and the lungs were clear. Roentgenograms of the lungs on 28 December showed a few very small areas of infiltration in the central portion of the left lung. The findings on 3l December were the same.

    Blood counts, which revealed no anemia, were as follows:

    28 December, 12,300 white blood cells per cubic millimeter; 67 percent neutrophiles, 13 percent eosinophiles, and 20 percent lymphocytes.

    31 December, 12,750 white blood cells per cubic millimeter; 56 percent neutrophiles, 23 percent eosinophiles, and 21 percent lymphocytes.

    Stool examination on 28 December was negative for blood, pus, ova, or cysts. A repeat examination on 30 December, after magnesium sulfate, was positive for Schistosoma ova.

    After ova had been found on two other stool examinations, treatment with Fuadin was begun 2 January 1945.

    Case 2. - A 33-year-old Medical Corps captain, serving in the same portable surgical hospital as the patient just described, had the same history of swimming on 15 November, and his movements were the same. During the last week in November, he was hospitalized with what was thought to be dengue; he returned to duty in 10 days. For some years he had had a smoker s cough, in which there had been no recent change.

    On 23 December, this patient began to run an evening fever, with chilly sensations, and 5 days later he was admitted to the 36th Evacuation Hospital. There his temperature curve was similar to the curve described in case 1. On physical examination, the lungs were clear, which was confirmed by roentgenograms. The abdomen was slightly distended, and there was well-marked tenderness over the liver, best demonstrated by fist percumssion over the epigastrium and just below the right costal margin. The spleen was not palpable.

    The red blood cell count was 4,200,000 per cubic millimeter. On 28 December, the white blood cell count was 14,400 per cubic millimeter, and on 1 January 1945, it was 14,450. The neutrophiles were, respectively, 64 percent and 41 percent; the eosinophiles, 22 percent and 34 percent; and the lymphocytes, 14 percent and 24 percent.

    Stool examinations on 24 December and 31 December were negative. On 1 January, after magnesium sulfate, the examination was positive for Schistosoma ova.

    Treatment with Fuadin was begun on 2 January.


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    At this time it was not thought that swimming in a large, swift river, in the still water near the bank, was sufficiently significant to eliminate the need for careful investigation of these patients activities to search for other possible causes of their illness.

Clinical Considerations

    The etiology, clinical aspects, treatment, and prevention of schistosomiasis had already been described. In Technical Memorandum No. 5,7 31 March 1945, clinical aspects of the disease, laboratory refinements in diagnosis, and precautionary measures were described in more detail. Observations of U.S. Army troops had indicated a characteristic clinical syndrome upon which in presumptive diagnosis might be made before the ova of S. japonicum could be demonstrated in the feces. This was important in initiating early treatment, for the period of diagnosis was sometimes prolonged, even in patients with severe symptoms. The diagnosis could not be properly made from clinical findings alone unless there was a clear-cut history of exposure in waters known or suspected to be infested. Persistent efforts should be made to demonstrate ova in feces when treatment had been started on the basis of a presumptive diagnosis.

    A summary of the clinical and laboratory data in Technical Memorandum No. 15 follows:

    1. Clinical symptoms leading to the diagnosis of schistosomiasis appear during the sixth, seventh, or eight week after exposure and are of varying severity. Some patients are seriously ill, with high fever and great loss of weight. Other patients are asymptomatic, and their disease is discovered only in the course of routine stool and blood examinations. More severe manifestations apparently appear earlier after exposure and may represent massive infections. In an analysis of 40 cases, symptoms in order of frequency were fever in 38, headache in 33, anorexia in 30, nonproductive cough in 27, chills in 21, abdominal cramps in 12, urticaria in 10, diarrhea and backache in 7 each, and pruritus in 4. It should be noted that neither urticaria nor diarrhea is a frequent symptom.

    2. Physical examination reveals a slightly or moderately enlarged liver, which is nearly always tender to palpation or heavy percussion. The spleen is felt early in the disease in about a quarter of all cases. The lungs are usually clear, though occasionally, coarse rales or bronchi can be heard. Roentgenologic examination of the lungs occasionally demonstrates scattered small areas of infiltration.

    3. The temperature is usually low in the morning but rises in the afternoon, reaching from 101º to 105º F., depending upon the severity of the toxemia in the individual case (Katyama disease). A septic, spiking temperature curve is very characteristic, but elevations may be irregular. The fever falls by lysis after the second week. It is affected only slightly by treatment. The

7 Technical Memorandum No. 5, Office of the Theater Surgeon, Headquarters, USAFFE, 31 Mar 1945.


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pulse rate is proportionate to the fever. In a few cases, the respiratory rate is elevated, and respirations many be somewhat shallow.

    4. On proctoscope examination, characteristic pseudotubercles can be seen in the wall of the rectum on lower sigmoid in about two-thirds of the proved cases. Biopsy of these nodules which is not advised is a routine procedure yields groups of ova. In appearance these nodules resemble those seen in the bladder wall in cases of Schistosoma haematobium.

    5. The stool is normal or soft. Schistosoma ovum are found for the first time from 6 ½ to 10 weeks after exposure.

    A simple technique for stool examination follows: From 15 to 20 gm. of stool is emulsified in 300 cc. of normal salt solution, then filtered through six levels of gauze and allowed to settle for one-half hour. The supernatant fluid is poured off, the specimen is washed twice more with normal salt solution, and the sediment is examined microscopically. This technique gives excellent results. Direct smear of fecal mucus yields only about a third as many positive examinations as the concentration method.

    Under high power, the large ovum (60¼ to 80¼.) is seen to contain a well-differentiated miracidium which may exhibit movement, and so-called flame cells can be made out . Immature ova are found in the stools fairly often. They may be much smaller than mature ova and only be confused with ova of other worms such as the fish tapeworm (Diphyllobothrium latum) or the roundworm (Ascaris lumbricoides). This finding should be recorded as   Immature ova - possibly S. japonicum,  but it should not be accepted as conclusive diagnostically. Subsequent examinations usually reveal mature ova.

    6. Eosinophilia is present in nearly every case. A rapid rise in the total number of eosinophiles is characteristic of the acute phase, in which they often reach 20,000 per cubic millimeter. In this phase, an increasing leukocytosis accompanied by an increasing percentage of eosinophiles (from 50 to 70 percent and sometimes 90 percent) is almost pathognomonic. In later stages, the eosinophile count often falls to 5 to 10 percent.

    High eosinophile counts may also be encountered in the acute phase of infestation with hookworm or Ascaris. There are other differences in the clinical picture, however, which distinguish schistosomiasis from these diseases.

    7. In occasional cases, a hitherto undescribed syndrome has been associated with cerebral involvement. There is slight or moderate disorientation, or even coma. The arms are weak, and one or both seem paralyzed. The legs are ataxic. Deep reflexes are exaggerated, and there may be ankle clonus. Sensation is usually normal. Cerebellar symptoms may be present. There is low-grade fever, as well as a characteristic leukocytosis with eosinophilia. The spinal fluid may contain a few lymphocytes or may be normal.

Treatment

    Standard forms of treatment for schistosomiasis were outlined in USAFFE Technical Memorandum No. 15.8 It was recommended that treatment be

8See footnote 6, P. 553.


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started in typical cases even before ova were demonstrated in the stools. A preference for one drug or another could not be expressed at this time. Both tartar emetic and Fuadin were used.

    Tartar emetic had caused a number of unpleasant reactions, and it was recommended that it be used with caution. The solution could be made by adding chemically pure tartar emetic to pyrogen-free distilled water which had been brought to a boil. In several hospitals, it had been found useful after the first three doses to dilute the tartar emetic in 1,000 cc. of 5-percent glucose solution and administer it slowly over the course of an hour. Injections were stopped if a reaction occurred. Coughing was not a serious reaction, but vomiting, undue nervousness with shrinking, severe arthralgia, or collapse with fall in blood pressure were serious, if they occurred, the next dose should be reduced by 0.03 or 0.06 gm.

    Fuadin, to date, had been well tolerated. The efficacy of emetine had not been proved, and Anthiomaline lithium antimony thiomalate) was still on trial.

    All patients with a diagnosis of schistosomiasis should be given a complete course of treatment before arrangements were made for their subsequent care.

Disposition

    Seriously ill patients and those with involvement of the central nervous system were evacuated to the United States without delay. Those who had persistent clinical signs or positive laboratory findings after a course of treatment should also be evacuated. Patients who appeared to have been cured and to have regained their health could be returned to duty but required frequent examination of their general condition and of blood and stool specimens, in accordance with instructions in a letter from Headquarters, USAFFE.9

Preventive Measures

    Before the invasion of the Philippines, an attempt at widespread distribution of information concerning schistosomiasis had been made, but so many troops were on the move that large numbers did not receive adequate information. This situation was corrected promptly when the troops arrived on Leyte (fig. 196). The Sixth U.S. Army had taken pains to inform all its medical officers concerning this disease before the invasion. That the forewarning was not in itself adequate protection was clearly apparent. As soon as possible, all fresh water streams and rivers were posted with signs and cartoons depicting the dangers of schistosomiasis, but drivers of Army motor vehicles persisted in washing their vehicles in these infected streams (fig. 197). It seemed, when the plan was instituted, that the horrors of schistosomiasis were made to sound almost too dreadful when they were broadcast through the wards of hospitals in which patients with the disease were being treated, but past experiences

9 Letter, Col. R. E. Fraile, AGD, Adjutant Genera1, headquarters, USAFFE, to commanding generals of major commands, 5 Mar. 1945, subject: After-care of Patients With Schistosomiasis.


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FIGURE 196.-Schistosomiasis exhibit and demonstration on Leyte

with the difficulties of maintaining Atabrine discipline suggested the necessity of employing the most drastic warnings possible.

    The personnel of the 118th General Hospital was particularly well informed about schistosomiasis. The commanding officer had stopped by the Office of the Surgeon, USAFFE, at Hollandia, when the unit was en route to Leyte, and he had passed on to each member of the hospital all the information hr secured. This hospital set up in an area directly bounded by a fresh water stream which was highly infested. Lectures to all the personnel were given on a number of occasions, and they were warned against any contact at all with water from this river. Swimming was permitted in the ocean. Later on, when a large number of enlisted men in the unit came down with schistosomiasis, it was learned that they followed instructions and went swimming only in the ocean, but some of them could not resist washing the salt water off their bodies with a little fresh water out of the river, and they were the ones who contracted the disease. That no officer or nurse in this unit, only enlisted men, were affected must be an example of one of the cardinal laws that define the limitations of preventive medicine.

PSYCHONEUROSES

Causative Factors

    In New Guinea, Army troops lived under unusual stresses and strains even when they were not engaged in active combat. These included the equatorial weather, which was always hot and humid and usually rainy; the broken


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FIGURE 197.-Prevalence of snails in Philippine streams and ponds

sleep, under mosquito bars; the work under constant pressure to get things done; the long hours without time off; the stringent limitations of recreational facilities; the feeling of being a long way from home, possibly for the last time; the constant repetition of big and little frustration; the sapping of one s own energy in the effort to give the other man a lift; the frequently observed Army tradition of working late into the night 7 nights a week; the feeling of being far up in front without any understanding of the situation from headquarters in Australia; all of the worry about strange diseases such as so-called jungle rot and elephantiasis; and the bright-yellow hue of the skin which so many of the soldiers developed from Atabrine. All of these things, and many others, combined to provide continued nervous strain. In addition, frontline troops had to fight in repeated task force engagements of landing operations followed by jungle warfare (fig. 198).

    It is no wonder that the hospitals were partially filled with neuropsychiatric patients. Many had developed an ill-defined form of acute psychosis which was similar in many respects to acute schizophrenia. Surprisingly, however, these patients recovered when they were removed from the area of stress and strain and given reasonable psychiatric nursing care.

Management

    For some time, in the absence of correct diagnoses and proper psychiatric care, patients with borderline mental conditions were evacuated from New Guinea for time long distance back to general hospitals in Queensland, Australia.


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FIGURE 198 -Rest after three continuous days in battle without relief, Los Negros, Admiralty Group, March 1944.

After quick rehabilitation, they were returned to duty, only to report to sick call again and repeat the same process. After several failures of this sort, many of these men were evacuated to the United States until it finally became necessary to forbid evacuation for psychoneurosis alone.

    The neuropsychiatric service was gradually built up with station hospitals provided in New Guinea for the sole purpose of treating minor psychiatric disorders. Later, when the general hospitals moved closer to the combat areas in New Guinea and in the Philippines, they also helped provide the earlier diagnosis and treatment that are of such great value in these cases.

    Medical ward officers were confronted by all possible forms of minor psychiatric disorders and were poorly prepared, either by training or experience, to handle them. The psychiatric service could give only limited help, it had more than it could do to arrange for the simplest and crudest care of seriously ill neuropsychiatric patients in New Guinea.

    Colonel Thomas sent a concise report of this situation to the Chief, Professional Service Division, Office of the Surgeon, Headquarters, USASOS, but the report was not commented on. A year later, Colonel Thomas learned, from the neuropsychiatric consultant himself, that the report had been interpreted to mean that the medical consultant did not recognize the limits of his responsibility and wished to take over psychiatry as well as medicine. Colonel Thomas, who had worked closely in the Fourth Service Command with Col.


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(later Brig. Gen.) William C. Menninger, MC, Consultant in Neuropsychiatry, Office of the Surgeon General, had naturally done nothing to correct this erroneous impression since he had been entirely unaware of it.

    In the Sixth U.S. Army, there was similar misunderstanding of the value of a consultant in psychiatry to an army on the march. It does not seem likely that the same difficulties will ever occur again from lack of understanding and cooperation between the medical and neuropsychiatric services. In the isolated and farflung area in which the New Guinea fighting occurred, consultants seldom encountered each other, and they were left to solve their own problems, with no one to guide or help them. Unfortunately, from the standpoint of the Army neuropsychiatric service, peacetime provides more of the stresses which cripple soldiers during war. The Medical Corps, as well as the whole medical profession, should not forget the important lessons it learned the hard way from its experiences, both positive and negative, in psychiatry during World War II. Enlightened chief consultants and medical consultants can and should contribute to progress in this field.

Conclusion and Recommendations

    So that the same situation does not recur, areas of cooperation and ways and means for combined effort should be elaborated in some detail for the future instruction of military medical consultants. During one period at Headquarters, USASOS, Colonel Thomas prepared a preliminary draft of a report on the recognition and treatment of functional symptoms. Because there was no opportunity to rewrite it in conjunction with the neuropsychiatric consultant, the report was never submitted for approval and publication. The proposals made in it, however, pointed to a borderline problem which needed the combined attention of the senior consultants in neuropsychiatry and medicine.

    The substance of this report was as follows:

    1. The organization of special station hospitals for the treatment of nonpsychotic psychiatric patients was required in SWPA by the shortage of trained neuropsychiatrists and the need for additional facilities for treatment. Most station, evacuation, and field hospitals had no neuropsychiatrists. Unearthing, recognizing, and handling properly the functional aspects of medical and surgical states was the responsibility of members of the hospital staff and was the greater because officer patients with functional complaints were not treated in the special station hospitals.

    2. Most medical conditions have, to use a simple term, an important psychological side. Neuropsychiatrists reported that patients received from medical and surgical services in other hospitals have not been benefited psychologically during their hospital stay but instead have been actually impeded. This correctable state of affairs requires prompt attention.

    3. Great improvement in the diagnosis and care of functional disease can be effected in medical and surgical wards if chiefs of service will keep the problem uppermost in their minds. They should familiarize themselves with


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available technical memorandums and articles in current medical journals on this subject. Opportunities should be made available to attend staff meetings at psychiatric hospitals and to obtain formal and informal instruction from consulting neuropsychiatrists.

    4. Much so-called psychotherapy consists of studying the patient s psychologic reactions and giving him appropriate encouragement, an explanation of his position, or both. This is no easy matter but one that requires understanding and tact. There are, however, a few primary rules which should govern the approach to every hospital patient, as follows:

    a. The medical officer should treat every patient as a soldier, with due regard to his rank, branch of service, and Army experience. That is, the patient should be given full credit and suitable complimentary comment - often better implied than expressed directly - for bravery or interesting experiences or simply endurance when the going was tough. Such an approach shows the patient, as well as other patients on the ward, that his Army career is recognized as of primary importance; it is the reason he is in the hospital and is the reason for his getting out of it as quickly as is consistent with his disease or wound.

    This attitude is the hospital medical officer s biggest contribution to Army morale. It does not mean rigid military formality, but it does mean punctilious observance of a respectful attitude to the patient as a soldier.

    b. The medical officer should be alert for indications of worry, discouragement, discontent, or anxiety and, when he observes them, should develop a technique for drawing the patient out. This holds not only for the patient with a majority of functional symptoms (often loosely called psychoneurotic) but also for the patient with organic disease colored by, or associated with, minor but still important psychologic difficulties. Every good history should reflect the patient s state of mind as well as of body.

   c. Many battle injuries and diseases, if not most of them, in combat troops introduce new psychological situations. Perhaps, for the first time, the individual s physical integrity is threatened, and he develops concern and a feeling of insecurity. On the other hand, he may develop a sense of relief at merely being wounded and not killed and may have-at least in his own eyes- an available and justifiable excuse for escaping from further danger. Everyone has, in some way or other, used illness as an escape mechanism or as a means of obtaining sympathy or attention. These and other psychological effects of disease and wounds required careful consideration and treatment.

    d. Prompt and thorough study of each case from an organic point of view is essential. Unless this is done, the patient s doubts are unresolved and magnified. As time drags on, he senses uncertainties on the part of the medical officer, and having had time to learn the ways of the ward, he subtly takes control of the management of his own case. These developments complicate the solution of the psychological problem. In a station hospital, 5 days should be sufficient to reach a stage in the diagnostic study at which immediate disposition can be determined; that is, transfer to a general hospital (though not necessarily at once), or further treatment in a station hospital with a view to


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return to duty or transfer to a convalescent hospital, or consultation with a psychiatrist to help outline further disposition.

    5. Specialists in the care of borderline psychiatric cases have been assembled in special station hospitals devoted to psychiatric diagnosis and treatment. Here, accurate differentiation of cases into various scientific subdivisions takes place. Seriously ill psychotic states are quickly diagnosed, and the patients are transferred to general hospitals. Milder cases are divided into psychoneurosis, simple adult maladjustment, and constitutional psychopathic state, and appropriate treatment is accorded each group. Group psychotherapy, occupational therapy, exercise, and controlled relaxation provide essential features to augment a limited amount of individual treatment.

    These hospital units have proved highly efficient and are returning 85 percent of patients to duty in an average of 16 days.

    6. The function of the original field, evacuation, and station hospitals is to assist this program by considering every patient a potential psychological problem. This attitude will save a great deal of time in the first hospital to which the patient is admitted, and, more importantly, it will save even more time in the special hospitals. Finally, it will return to duty some patients who must otherwise be crowded into special hospitals, and it will make all other patients leave the hospital with improved morale.

    In New Guinea, as might have been expected, medical units were also affected by the tremendous stresses already listed, and in some instances, officers broke down. A medical laboratory, in one such instance, lost its commanding officer, who was evacuated on the diagnosis of psychosis-confused state, and the next senior officer, a major, assumed command. When the laboratory was investigated during a routine visit by an inspector general, it was immediately apparent that he had neither the administrative nor the professional ability requisite for the position. None of the subdivisions of the laboratory was receiving appropriate supervision. No one could accomplish effective work. The morale was so bad that one excellent officer was found guilty by the inspector general of having consumed a considerable part of the laboratory alcohol. Had it not been for the timely visit of the medical consultant, this young officer might have been found guilty by a court-martial and returned home in disgrace. When he was transferred to another unit, however, he found a congenial metier in working on scrub typhus, and he did brilliantly thereafter and was finally promoted to the rank of major.

Part III. Conclusions and Recommendations

ANALYSIS AND CONCLUSIONS

    During wartime, the professional activities of the U.S. Army Medical Corps, which from numerical necessity are carried out chiefly by recently inducted civilian physicians, require supervision and correlation. This fact has been demonstrated and is widely accepted.


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in World War II, the machinery that developed to accomplish this supervisory and correlative function, in large part through the efforts of General Morgan, consisted of a loosely organized body of consultants. The group, which began with consultants in medicine and surgery, and, somewhat later, in neuropsychiatry, in this office, was gradually extended to include the theaters, service commands, armies, and base sections. The program developed without a table of organization, without an established standing operating procedure, and without any individual direction. It answered a different need in each command and assumed a different position in relations to each local organization.

    The consultant system blossomed under some surgeons and struggled under others. It correlated the work of good units, and it supervised and, through training and education, improved the work of poor units. In the end, it played a major role in the medical activities of all commands.

    The success of the system was based on three factors, as follows:

    1. It fulfilled a need.

    2. Its personnel was chosen on the basis of professional training and competence and, to some extent, on the basis of military experience, not on the basis of academic or military rank.

    3. It operated on the principle that the visiting of units was its starting point and that visits must be painstaking and helpful. From their own firsthand study of actual situations, the consultants discovered and attacked existing problems.

    A consideration of the consultant system as it operated in SWPA leads to certain general conclusions, and these conclusions, in turn, suggest methods for effecting improvement.

The Professional Consultants Position in the Army Organization

    Consultants are staff officers serving on the staff of a surgeon. Their province is professional services, each in its own specialty. In a sense, they perform the well-understood Army function of inspection, including visits to units, with subsequent reports and recommendations. In addition, they accomplish another new and less well understood function, that of instruction.

    The consultants in World War II were drawn from the faculties of the leading medical schools in the country. They encountered questions from newly inducted medical officers, and they assumed tine role of instructors by force of necessity.

    The types of advanced instruction needed in wartime Army hospitals included bedside, ward, and clinic demonstrations, as well as instruction in Army methods of admission, disposition, and recording. To fulfill this function in a single unit required time-several days time-in each unit. At the end of this time, the consultant knew the unit medical (or other) service, and the service knew the consultant. Each learned from the other, and morale was strengthened. This was a new kind of Army inspection.

    The surgeon should know and rely on his consultants. They in their role as staff officers, should advise him and should understand him and each


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other. Whenever practical, the surgeon should personally select his staff officers. Having chosen them, he should require and bring to pass the closest cooperation among them. This applies possibly more to the chief professional consultants than to other staff officers because their duties involve the initiation of innovations as well as varied intersectional cooperation and contact with major commands.

    Whenever surgeons have chosen their own consultants, often with advice from higher headquarters, the resultant relations have been agreeable and have been functionally successful. Whenever practical, newly appointed surgeons should therefore be permitted to select their own consultants. The three chief consultants to The Surgeon General should combine to help to provide the most suitable group of consultants in the various headquarters at lower levels.

    Other staff officers spend from 90 to 98 percent of their time performing staff duties at headquarters. Professional consultants major functions are performed away from headquarters, in the hospital units themselves. Difficulties then arise in developing them into competent staff officers

    Consultants who spend half or two-thirds of their time in the field find themselves writing reports and making recommendations which are returned to their own desks for implementation and completion. The need for close cooperation between the consultant section and the sections of personnel, plans, supply, preventive medicine, and records requires constantly available officer personnel in the consultant section. It therefore becomes important to establish the consultant system in the overhead tables of distribution and to provide adequate personnel for the accomplishment of the duties that are to be performed at the various headquarters on the different levels.

The Place of Consultants in the Wartime Medical Corps

    In World War II, the approximately 1,300 medical officers in the Regular Army were used to fill important command and staff positions. As it ultimately developed, the direction of practically all professional matters relating to medicine, surgery, and neuropsychiatry became the responsibility of a consultant system composed entirely of civilian physicians called to active duty. This was not true of preventive medicine, dentistry, veterinary medicine, nursing, nor was it true of other activities such as planning and training, hospitalization, and medical supply.

    Since the final responsibility in practically every major command rested in a Regular Army command surgeon and since staff action at the highest level was often involved, it would have been valuable to have officers in the Regular Army Medical Corps integrated into the consultant system. Officers such as Brig. Gen. Henry C. Coburn, Jr., Col. Frank L. Cole, MC, and Colonel Dart would have contributed greatly to the effectiveness of the system and would have relieved inducted civilian specialists of many of their staff duties, which were always time-consuming and which at first were poorly accomplished.


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Specific Delegation of Duties to Consultants at Various Levels

    The actual operational activities of the consultants, as already mentioned, varied widely at various levels. On the other hand, they overlapped in many particulars and required clarifications and delimitation. The preparation of technical memorandums and directives is an illustration.

    Before the Leyte campaign, in October 1944, a number of surgeons prepared technical memorandums calling the attention of medical officers to important professional matters. Thus, the surgeon of the 24th Division, the medical consultant of the Eighth U.S. Army, and the medical consultant, USASOS, all prepared and circulated material relating to schistosomiasis japonica. Later, in June 1945, a TB MED on the same subject was published by the Office of the Surgeon General. Similarly, directives relating to malaria, scrub typhus, amebiasis, infectious hepatitis, and other subjects were circulated from the offices of a number of different surgeons

    In addition to the wasteful duplication and the confusion of conflicting recommendations, this overlapping of function led to misunderstanding between various officers in the consultant system. Cooperation between consultants at different levels on matters pertaining to professional subjects should have been close and clearly understood, as it would have been if their duties at each level had been clearly defined.

Functions Relating to Personnel

    The consultants came to play a large part in the evaluation and assignment of professional personnel. This is another function that should have been carefully considered and fully described as part of the standing operating procedure of consultants.

    Should the need again arise to call 40,000 or more Reserve or civilian physicians into the Army, it would be wise to obtain the services of a prominent civilian physician to serve as deputy chief of the personnel section in the Office of the Surgeon General. Only in this way could direct, immediate contact be established with the local sources of new personnel to obtain information necessary for the most efficient utilization of these personnel. Direct cooperation between consultant and personnel sections is simple at the army level. At the theater level, it will reflect the system that is in operation in the Office of the Surgeon General. To have the part the consultants are expected to play in the control of professional personnel clearly outlined in a manual or other official publication will do much to eliminate the difficulties in this regard that existed in World War II.

RECOMMENDATIONS

    The following recommendations are made with a view to eliminating these and other difficulties and increasing the efficiency of the consultant system:

    1. A standing operating procedure should be delineated for wartime consultants separately at the level of each headquarters.


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    2. Tables of distribution or organization should be authorized for necessary consultant personnel at the level of each headquarters.

    3. An assistant consultant or executive officer should be added to the consultant section in higher headquarters, to remain at headquarters and be available to implement the duties and recommendations of the consultant there.

    4. The activities of all consultants in a given headquarters should be placed under a deputy surgeon in charge of consultants. This officer should not be burdened by other duties usually handled by the chief of the professional services division.

    5. Surgeons of major commands should have a prominent part in the choice of their medical consultants, just as they have in filling other staff positions.

    6. Medical, surgical, and neuropsychiatric consultants in the Office of the Surgeon General should combine to help provide each headquarters with a suitable group of consultants capable of cooperating with each other.

    7. In time of emergency, in all sections of the Office of the Surgeon General and particularly in the personnel section, a deputy chief should be drawn from nationally prominent and specially trained civilian specialists.

    8. Consultants should be rotated from theaters into the Office of the Surgeon General to serve as assistant chiefs of appropriate sections.

   9. Consultants in higher headquarters should have as one of their primary duties the assistance of consultants at lower levels by visits to various headquarters and by the maintenance of close communications.