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HISTORY OF THE OFFICE OF MEDICAL HISTORY
South Pacific Area
Benjamin M. Baker, M.D.
FACTORS IN MEDICAL CARE
The professional care for Casualties in the South Pacific was significantly influenced by several factors which at first seem unrelated. No historical account of the medical problems faced on that widespread battlefield would be complete without first considering the influence upon professional practice of a joint Army-Navy command, the meager training given many medical officers for their mission, the vast area in which operations were conducted, and the distribution of diseases in that area.
The training and indoctrination of most medical officers for the various problems they were to encounter was far from ideal and, under the circumstances, understandably so. The demands of the overall military emergency submerged all others, and medical support for oversea tactical and service forces, whether it was adequate or not, had to be provided when those forces were ready to move. There was neither the time nor the organization at unit activation and staging areas in the United States for ascertaining the professional competence of hospital staffs. There was no opportunity to obtain more personnel for those that were deficient nor to transfer personnel from those that had an excess of able men in certain departments. Pertinent military medical intelligence was fragmentary, and the dissemination to professional men of such information as was available at the time was limited for reasons of military security. Consequently, doctors, for the most part only recently recruited from civilian life, were often suddenly confronted on isolated island bases with disease problems that they were ill prepared to meet. Competent professional leadership was often not available. One base with a medical load far exceeding the capacity of its hospitals was staffed with medical officers whose professional qualifications were not up to demands, whereas another had an abundance of specialists who, if they saw the patients at all, were seeing them long alter the critical period for the treatment of their disease had passed.
In SPA (South Pacific Area) (map 4), the U.S. Navy was in command over all forces. The Senior Medica1 Officer, U.S. Pacific Fleet, had the final responsibility in all matters relating to the treatment and prevention of disease.
Decisions on the deployment of medical installations in the area, the use of supplies, evacuation policies, and actual professional practices were made by Navy command and implemented by island commanders through their surgeons. As a result, the responsibilities of the Senior Medical Officer, U.S. Pacific Fleet, were enormous. Though his cooperation with the U.S. Army in all medical problems was admirable, his organization was small, and medical control was too loose to provide for efficient operation.
There was a shortage of administrative personnel familiar with professional problems and the means for meeting them, which led to a lack of efficiency in the use of medical organizations and personnel. The sick and wounded frequently passed rapidly and repeatedly through a succession of Army and Navy hospitals, and consequently there was little uniformity in professional practice and evacuation policies. It was not until August 1942 that a U.S. Army commander and his surgeon arrived and a start was made in coordinating Army medical activities.
Geography had an important influence upon the care of patients in the South Pacific. Troops were stationed on a series of widely separated islands from Bora-Bora and Tongareva to the east of New Zealand in the south and eventually to Bougainville and Emirau Island in the west. Bora-Bora, in the Society Islands, is 3,051 miles from Bougainville, in the Solomons, and 2,545
miles from Auckland, New Zealand. Auckland is 1,127 miles from New Caledonia, 1,598 miles from Espiritu Santo in the New Hebrides, 2,107 miles from Guadalcanal, in the Solomons, and 2,467 miles from Bougainville (fig. 199). The rapid shifting of personnel and hospital equipment from one island to another was always difficult and at times impossible because of a shortage of transportation, and plans for movements of any size had to be made long in advance. As the military situation changed, lines of supply and evacuation routes altered. Unavoidable inefficiency in the use of professional personnel frequently resulted as troop strengths diminished on one island and increased on another. Often, by the time hospitals were constructed and in operation at one location, the military situation had changed to such a degree that they were badly needed in an entirely different area. This led to long, unnecessary, and costly evacuation of patients.
Definitive medical support had to be given to small garrisons on isolated islands when personnel could not be quickly transported to an adequate hospital in the next medical echelon. This frequently led to long periods of relative inactivity for competent medical officers who were badly needed elsewhere.
Distribution of Diseases
In a region so diversified geographically, economically, and socially, there were widely varied disease hazards. In New Zealand, the problems of the internist were similar to those encountered in the Middle Atlantic States, but in the Solomon Islands they were vastly different. New Zealand, New Caledonia, and the Fiji, Cook, Society, and Marquesas Islands were nonmalarious, whereas tile New Hebrides and the Solomon Islands were intensely malarious. This epidemiologic peculiarity permitted the transfer of malarialized individuals or whole organizations from intensely malarious areas to areas where the disease did not exist. It made possible valuable research concerning malaria. Filariasis of the nonperiodic variety was hyperendemic on islands in the eastern portion of the area, and the disease affected large numbers of troops before control measures were instituted. On the islands of the New Hebrides and the Solomons, native reservoirs as well as vectors of filariasis were abundant, but the transmission was periodic, and for reasons that are not altogether clear the disease never became of real military importance. Large epidemics of dengue developed on Espiritu Santo and New Caledonia, and sporadic cases were encountered elsewhere. On all islands, with the exception of New Zealand, troops came into close contact with native populations whose hygienic practices, chiefly those concerned with the disposal of feces, were primitive, and diseases spread by contact with human excreta were common.
The natives of the South Sea Islands were highly susceptible to common contagious diseases such as influenza and measles. In spite of the occasional occurrence of a disease of high communicability in U.S. troops, that no notable epidemic developed is a tribute to Army preventive medicine practices.
Deployment of Hospitals
From what has been said of geography and the deployment of troops over scattered island bases, it is clear that the chain of medical evacuation and supply was a difficult one (fig. 200). In general, transportation from one island to another could not be effected quickly, and the sick and wounded, whether or not they needed the services of specialists, were often treated by whatever medical officers were available on the spot. Undoubtedly, the Operations Service, Office of the Surgeon General, was greatly limited in its choice of hospitals and individual specialists for specific assignments in the area. It was necessary to send what was available where it was needed most urgently rather than to select, according to a previously well integrated plan, the kinds of units that would best meet specific needs. The same may be said of the redeployment of medical units after they reached the area.
For example, the 7th Evacuation Hospital, a 750-bed affiliated unit from the Post Graduate Hospital of New York City, provided medical support for the force that in April 1942 occupied Tongatabu, 1,808 miles from Guadalcanal where the first combat occurred. The hospital's large complement of surgical specialists was largely surplus in the Tonga Islands, but at Guadalcanal there was no evacuation hospital, and specialists of all sorts were critically needed. A fine installation of cantonment type was constructed at Tongatabu, and the hospital functioned as a station hospital for the small garrison force until early in 1943 when it was moved in two parts to Fiji. There, it was filled to overflowing with station-hospital type cases from a heavily malarialized infantry division, which had been removed to Fiji for rest and rehabilitation. The hospital was moved to Guadalcanal in February 1944 to stage for an operation that was scheduled for April 1944 but was abandoned. Consequently, the 7th Evacuation Hospital never delivered the service for which it was intended until it participated in the invasion of the Philippines in January 1945.
The 52d Evacuation Hospital, an affiliated unit from the University of Pennsylvania Hospital, Philadelphia, Pa., had a somewhat similar experience. This hospital accompanied the task force that occupied New Caledonia without opposition in 1942. It served largely as a station hospital there, although some casualties were received by air and hospital ship from Guadalcanal. When the Americal Division left New Caledonia for combat in the Guadalcanal operation, its sole medical support consisted of the 101st Medical Regiment. The 52d Evacuation Hospital, which was filled to capacity at the time, was left behind.
The 250-bed 71st Station Hospital and two 500-bed general hospitals--the 18th from Johns Hopkins Hospital and the 142d from the University of Maryland--occupied Viti Levu in the Fiji group in June and July 1942 in support of the task and garrison forces (fig. 201). These hospitals received a number of Marine, Navy, and Army casualties from the Guadalcanal and New Georgia operations, but, with air evacuation to Fiji almost negligible, the seriously ill and wounded patients had been treated during their passage through
higher Army and Navy echelons, and thus the great bulk of work done in the Fiji hospitals was of the routine station hospital variety. Although important investigations on malaria were carried out, a large number of highly qualified specialists in all branches of medicine were relatively inactive, and during this period of inactivity there existed an urgent riced for such specialists ill all hospitals in the forward area.
Before the opening of the 20th Station Hospital on Guadalcanal in February 1943, the sick and wounded of all Army troops on that island were cared for in provisional hospitals for combat troops, which were not supplemented by specialist teams, or the casualties were evacuated to the rear. The 20th Station Hospital made an outstanding contribution to medical care in the area, but it had neither enough professional personnel nor beds to meet the demands placed upon it. As a result, large-scale evacuation from Guadalcana1 was necessary.
CONSULTANT ACTIVITIES AT HEADQUARTERS
In August 1943, Lt. Col. (later Col.) Benjamnin M. Baker, MC (fig. 202), Chief, Medical Service, 18th General Hospital, was assigned to the Medical Section, Office of the Chief Surgeon, Headquarters, USAFISPA (U.S. Army Forces in the South Pacific Area). Although Colonel Baker was never officially designated as the consultant in medicine for the area, except in an organiza-
576 FIGURE 202.-Consultants in medicine, South Pacific. A. Col. Benjamin M. Baker, MC, Senior Consultant in Medicine, Office of the Surgeon, IJSAFISPA; Consultant in Medicine, Office of the Surgeon, USAFPOA; and Consultant in Medicine, Office of the Surgeon, USAFWESPAC.
tional plan of the Chief Surgeon, USAFISPA, he served in this capacity during most of the war in the area and will be referred to in this chapter as time area consultant in medicine.
When Colonel Baker reported for duty, he began at once, through conferences with the Chief Surgeon, USAFISPA, and members of his staff, to familiarize himself more thoroughly with the medical problems confronting internists in the area. One of Colonel Baker's first activities was to inquire into the quality of professional care being given patients with diseases and to advise the Chief Surgeon on corrective procedures indicated. The consultant had authority only insofar as he spoke unofficially for the Chief Surgeon and made recommendations to him. The Chief Surgeon himself was limited in authority by the position of the Medical Department in established Army command and, because the top command in the area was vested in the Navy, the influence of Army Medical Department personnel in establishing and directing medical procedure was further limited.
Colonel Baker was poorly prepared to meet many of the problems that confronted him. His previous military experience was limited, his training in Army administrative procedures negligible, and his viewpoint on military medical matters stemmed from less than a year's service on a single island base. There were many factors affecting the care of patients either directly or in-
directly that required study and recommendations for corrective measures. Some of these were of such urgency that they demanded immediate and concentrated attention. The result was that, frequently, more important but less urgent problems were overlooked entirely or had to be neglected until the more urgent ones could be solved. As time went on, it became obvious that the availability and proper employment of qualified professional personnel constituted the difference between good and bad medical care. This concept is axiomatic in civilian practice, but Colonel Baker was slow to realize how much readjustment of personnel in the area was indicated and slow in effecting such changes. Experience proved again that good doctors did good work under conditions that superficially seemed unsurmountable and poor ones did poor work no matter how favorable their surroundings.
Personnel management. - The Personnel Section, Office of the Chief Surgeon, Headquarters, USAFISPA, consisted of a Medical Administrative Corps captain who knew little of the professional qualifications of medical officers or of the dependence of sound professional practice upon the availability and proper employment of specialists. The excellent plan eventually worked out in the Office of the Surgeon General for coding medical officers according to their professional qualifications, the MOS (Military Occupational Specialty) rating, and distributing them on the basis of manning tables did not arrive in the South Pacific until too late to be of any value. The common
Army practice of considering its doctors qualified to render practically any professional service was too widespread. The information on personnel records in the Office of the Chief Surgeon, Headquarters, USAFISPA, was not sufficient to inform Colonel Baker as to the real professional qualifications of medical officers. Only after a considerate delay and frequent visits by Colonel Baker to far-flung hospitals did it become apparent that there was a startling shortage of well-qualified medical personnel. It was also noted that many able men were lost through normal evacuation, and the qualifications of replacements were often disappointing.
The most outstanding deficiencies of hospital staffs were eventually corrected by the shifting of personnel and the employment of specialists, singly and as teams, on temporary duty. Far too little permanent redistribution was accomplished, however. The Chief Surgeon, USAFISPA, was in an extremely difficult position in regard to personnel matters. He was constantly short of medical officers, especially those with real administrative ability. Island bases were semi-independent, and island commanders, their surgeons, and the commanding officers of their hospitals all too frequently attempted to block the transfer recommended by higher command of highly qualified medical specialists.
A further impediment to the efficient shifting of medical officers was the matter of rank. Promotions of men within hospitals were usually rapid. Promotions often depended more upon length of service, hospital assignment, personal relationships, and the pressure of hospital commanders and island base surgeons than upon professional ability. An incompetent lieutenant colonel who was chief of a medical service could not be replaced by a highly qualified captain assigned to his service, and there were few position vacancies in other installations or headquarters to which incompetent professional officers could be reassigned. Reclassification procedures were almost never employed. Supply services. - The professional consultants were frequently concerned with matters of supply. On some islands, there were completely equipped hospitals in a well-integrated arrangement. Under these circumstances, there were relatively few major supply problems. What was lacking in one hospital could frequently be obtained in another, or patients could be moved from one to another hospital. The situation was entirely different when large garrison forces had access to only a small station or field installation. The equipment of these units did not enable them to provide all of the laboratory and special examinations required. Therefore, it was necessary to arrange for special issue of supplies and equipment to such hospitals in order to provide the essential requisites for the proper diagnosis and treatment. The lack of supplies was particularly prominent in extremely forward areas where critical shortages seriously interfered with medical care.
Liaison activities. - Colonel Baker frequently visited the surgeons of bases and of tactical units throughout time area. He assisted the base surgeons
along professional lines and served in a liaison capacity between them and the Chief Surgeon, USAFISPA, on matters of personnel, supply, and evacuation. These associations were, in general, mutually helpful to surgeons and Colonel Baker. Though many objections to the ways in which professional consultants operated will appear in the records of medical activities in the South Pacific, there were many favorable reactions to the assistance they gave in improving the quality of medical care. The following extract from a report by a division surgeon speaks favorably of the consultant system:
The recent detailing of consultants to the staff of the Chief Surgeon, USAFISPA, has been a great aid and has given a healthy stimulation to field medical installations. Colonel Oughterson, Colonel Baker and Major Sofield--surgical, medical and orthopedic consultants of General Maxwell's staff--have been ideally suited to their assigned duties. Their visits and discussion, their help and their advice have all been invaluable. They provide the necessary liaison to higher medical echelons and are warmly welcomed by all units. They live with, talk with, and work with the medical officers of all medical installations in the chain of medical evacuation. They bring new ideas, reports of cases evacuated, and in general provide the link that up to their coming had been lacking. Items of equipment have been obtained promptly and efficiently with the help, and even personal delivery, of these officers. All three hold meetings, give most interesting lectures, and are continually seeking new means of improving the Army Medical Service. They have certainly been most helpful and their intelligent, friendly and close approach to the medical officers of this division has been greatly appreciated.
Statistical data evaluation. - The Statistical Section, Office of the Chief Surgeon, Headquarters, USAFISPA, was small. The section consisted of one officer and a varying number of enlisted men, most of whom had little or no specialized training. The officer, a Medical Administrative Corps major, had been a noncommissioned statistical clerk in the Army for many years. At Headquarters, USAFISPA, his primary function was to consolidate the weekly and monthly Statistical Health Reports (Form 86ab) from various bases and medical units. This meant that only a very limited amount of statistical data was available to the professional consultants. It was possible to obtain reasonably accurate information upon broad trends of disease, but more detailed information had to be garnered through other than routine channels.
Accurate statistical reports were obtained in several ways. The Malaria and Epidemic Control Organization in the South Pacific, a joint Army-Navy organization, gathered reliable information by an individual case card system. Through this, the medical consultant was always apprised of the situation concerning malaria. Other data could be collected through special studies and special reports obtained through chiefs of service in the hospitals. The Machine Records Unit, Adjutant General's Section, Headquarters, USAFISPA, was extremely helpful in several special studies, the amount of time the unit could devote to medical material was greatly limited.
The wealth of important clinical material that was never collected was a constant source of disappointment to those concerned with professional work, but under the circumstances there was nothing that could have been done about it. A sufficiently large machine records unit serving the Medical
Department exclusively would have made it possible to collect a large amount of complete and accurate information.
Preventive medicine interest.- In the area, preventive medicine was under the direction of the Malaria and Epidemic Control Organization. Maj. Carlos D. Speck, Jr., MC, a highly qualified malariologist, represented this organization in the Chief Surgeon's Office. He also integrated preventive medicine with other Medical Department activities. The Chief Surgeon, USAFISPA, was represented in the office of the Malaria and Epidemic Control Organization by Lt. Col. (later Col.) Paul A. Harper, MC, who was of great assistance to Colonel Baker in helping him handle professional problems that overlapped into the field of preventive medicine. The efficient management of preventive medicine activities contributed enormously to the discharge of Medical Department responsibilities in the area (fig. 203).
CONSULTANT ACTIVITIES IN THE FIELD
Colonel Baker spent a disproportionate amount of time upon two urgent problems, to the relative neglect of others. These two objectives-to improve the treatment of malaria and to provide adequate medical care in forward and combat areas--were time consuming, and Colonel Baker was often absent from headquarters for long periods. At the same time, there were available in the area internists with excellent professional qualifications who could have been employed as deputy consultants. Some of these men were utilized as instructors, others on special projects and specialist teams, but full advantage was never taken of their abilities. Accordingly, it will be apparent in what follows that undue emphasis had to be placed on certain phases of the consultant's work.
Visits to hospitals. - All hospitals were visited as frequently as time would permit, except those in small and particularly isolated bases. Colonel Baker would report to the commanding officer and discuss medical service problems. The quality of teamwork existing between the medical and surgical service--the two major services in Army hospitals during wartime--could usually be determined by conferring with the two chiefs. Colonel Baker's attendance at ward rounds, disposition board meetings and staff conferences and his examination of clinical and autopsy records enabled him to evaluate the professional qualifications of the chief of the medical service and his staff.
Through these visits, Colonel Baker frequently learned of new problems from both the professional and administrative points of view. It gave him an opportunity to disseminate information he had gathered in other hospitals and to attempt to answer some of the questions that constantly arose in the minds of medical officers, whose outlook was necessarily narrowed by their separation from area wide activities.
Supervision of laboratory services. - For a long time, there was no laboratory consultant in the area, although there was great need for one. The area had a shortage of competent officers and technicians, and the work of the lab-
ratories required constant supervision by Colonel Baker. During hospital visits, he thoroughly investigated the laboratory and observed technical procedures. He had to learn essential techniques himself and spent much time teaching where deficiencies were found. The Malaria and Epidemic Control Organization operated excellent schools at various bases to which technicians could be sent for instruction in parasitologic techniques. As a result, the quality of malaria diagnosis greatly improved. It would often happen that certain tests were done well in one hospital and poorly in another. Technicians and instructors had to he shifted about on a temporary duty status to fill gaps and undergo periods of instruction, and Colonel Baker had to ascertain the needs of any given hospital and take necessary corrective steps. Teams of officers and enlisted men were occasionally moved from one base to another for the purpose of conducting special investigations, and the services of these men were utilized in providing specialized instruction. Laboratory service was distressingly inadequate in the forward areas of Guadalcanal (fig. 204), the Russell Islands, New Georgia, and Bougainville. South of Guadalcanal, there were general hospitals with well-trained laboratory staffs. Evacuation of patients was frequently necessary simply for the
purpose of obtaining laboratory examinations. When the 6th Medical Laboratory arrived in the area in 1944, it was sent to Guadalcanal. To this, the only Army laboratory in the area, was assigned the task of supervising and assisting all laboratories in the forward area. A memorandum describing the service and establishing a standard procedure was prepared and circulated to all hospitals in the Solomom Islands. This memorandum clearly defined what examinations the laboratory could provide and the means of collecting, packaging, and shipping specimens.
The Commanding Officer, 6th Medical Laboratory, was appointed laboratory consultant for the forward area, in addition to his other duties. He, or his representative, made routine visits to hospital laboratories for the purposes of studying their needs, instructing personnel in laboratory procedures, and determining what supplies, special solutions, and mediums were lacking that could be provided by his unit. Teams from the 6th Medical Laboratory were occasionally sent to various bases in the forward area to help hospital laboratories that were particularly overworked and to assist in special investigations of unusual problems.
Nevertheless, in early operations, many patients received inadequate laboratory examinations or were evacuated far to the rear to have relatively simple tests made. The professional consultants were convinced that a laboratory in the combat zone was badly needed to provide reliable examinations of the blood, urine, and feces and to make appropriate tests in cases suspected of gas gangrene, diphtheria, dysentery, and rickettsial diseases. Capt. Max
Michael, Jr., MC, of the laboratory service of the 18th General Hospital was selected to organize such a provisional laboratory.
The work of this officer contributed inestimably to the high quality of medical care given the sick and wounded in the Bougainville operation. The medical service for this landing was organized under great pressure. It took considerable imagination and ingenuity to select, procure, package, and transport essential laboratory supplies. The laboratory went in with the second echelon of Army troops, and much of its equipment was scattered in the confusion of the invasion beachhead. However, Captain Michael managed to collect his equipment and established his laboratory with surprising speed (fig. 205). Soon after its establishment, the hospital changed its location, but this was accomplished with remarkably little interruption in the laboratory service. All essential examinations were provided under the difficult conditions of combat. "The Pasteur Institute, Bougainville Branch," was stamped as an unqualified success (fig. 206).
Teaching. - The dissemination of information that would assist medical officers in giving the best possible care to the sick was one of Colonel Baker's chief objectives. Various means were used to accomplish thus, but the principal method was through personal contact. Opportunities were provided during general ward rounds, by consultation on special cases, by observation and teaching of laboratory procedures, and by participation in staff conferences during hospital visits. Colonel Baker carried with him a projector and a number of slides of educational value. Regular hospital staff meetings were supplemented by scheduled meetings attended by all medical officers on a given base. Special meetings were organized whenever circumstances permitted, and a symposium was held whenever special subjects required additional attention in a certain area.
Visits to field units. - Colonel Baker made a special point of regularly visiting the medical battalions of all divisions in the area. He met with their medical officers, held conferences, and attempted more effectively to integrate the activities of field medical officers with those of hospital staffs. Officers or enlisted technicians of field units who needed special instruction were often placed on temporary duty in an installation that had personnel qualified to teach.
A serious cause of dissatisfaction among medical officers of field units was their feeling that in some ways, men assigned to hospitals were favored. There can be no question that this objection was a valid one, and the consultants realized the hardships imposed by inflexible assignments. In the South Pacific, a sustained effort was made to make some amends to field medical officers by the creation of as many educational opportunities as conditions would permit. An area directive set up regular programs of instruction and provided for limited rotation of officers through fixed hospitals for purposes of specialized instruction.
Distribution and preparation of medical literature. - Early in the war, hospitals were seriously short of medical books and journals. In some affiliated
units, this deficiency had been corrected before leaving the United States by assembling libraries and arranging for the mailing of journals. As time went on, supplies of books and journals became more plentiful, and the system of distribution worked admirably. The consultants constantly attempted to obtain through regular and personal channels whatever technical literature was needed by hospital staffs.
TB MED's (War Department technical bulletins, medical) and other publications dealing with in medical procedure went through command channels, and distribution was poor. Consultants often heard high praise for the quality of the TB MED's, and it was most unfortunate that the time and ability put into their preparation was partly wasted because of their failure to reach the officers for whom they were written. Colonel Baker always received advance copies of these publications from the Medical Consultants Division in the Office of the Surgeon General. He carried these from hospital to hospital so that at least the chiefs of service could see them and pass on to their staffs the substance of the bulletins.
The system of distribution broke down at several points. It was not unusual to find publications in the files of commanding officers of hospitals
that had never reached the professional staff. It would have been better to distribute technical publications through medical channels, preferably to individual officers directly. This was done most successfully with the Bulletin of the U.S. Army Medical Department.
The Chief Surgeon, USAFISPA, distributed through medical channels a number of circular letters dealing with professional problems, hospitalization and evacuation policies, and the conservation of manpower and medical supplies. The professional consultants prepared the circulars dealing with professional practice, and these received wide distribution. Colonel Baker prepared circulars on the treatment of malaria, the use of Atabrine (quinacrine hydrochloride) as a malaria suppressive, Atabrine metabolism, pharyngeal and cutaneous diphtheria, hookworm infestation, eosinophilia, and scrub typhus. He collaborated with the surgical consultant in preparing circulars on the use of penicillin, the sulfonamides, and the management of common dermatologic conditions.
Reports. - Brig. Gen. Hugh J. Morgan, Chief Consultant in Medicine to The Surgeon General of the Army, and his staff were highly efficient in their communication of informational material to the medical consultant in the South Pacific. This kept the area consultant abreast of developments at home and in other operational theaters. The bulletins of the National Research
Council reached him regularly. They were an important source of information and often helped to clarify subjects under discussion or investigation within the area.
Colonel Baker was responsible for preparing portions of reports that dealt with the diagnosis and treatment of disease. Basic information was gathered by personal contact with medical officers and by study of regular monthly ETMD (Essential Technical Medical Data) reports from the bases, but the system of reporting was deficient in an important respect. The separate reports of several hospitals located on one base would be consolidated in the base surgeon's office and forwarded to area headquarters. Colonel Baker had no regular opportunity to see these individual hospital reports, and much valuable material was lost in the consolidation process, in addition to time and effort.
When Colonel Baker was away from headquarters, the many reports that arrived created a large backlog. Command reports on medical topics often had to be prepared hurriedly when they would have been made more valuable had there been more time to devote to their preparation. The same comment applies to Colonel Baker's educational activities and general correspondence with chiefs of service in hospitals. The professional consultants discussed frequently the desirability of having a publications officer in the Chief Surgeon's Office; but the plan was never pursued to completion. This plan would have resulted in more efficient dissemination of valuable technical information.
Research projects. - One of Colonel Baker's duties was to develop research projects, to advise the Chief Surgeon, USAFISPA, of their practical application, and to keep The Surgeon General informed of results that might have application to medical practice elsewhere than in the South Pacific.
This chapter will include a summary of some of the more important research projects related to internal medicine in the area (p. 607).
MEDICINE IN THE FORWARD AREA
Soon after his assignment as medical consultant, Colonel Baker made brief visits to the four 500-bed station hospitals on New Caledonia. All of these hospitals were crowded with patients who had been admitted directly from the garrison force or by evacuation from the forward area. Medical problems were primarily similar to those with which the Consultant had become familiar in the previous 11 months in a general hospital at Fiji. The visits to New Caledonia strengthened his conviction that too many patients were evacuated from forward areas. A constant stream of patients flowed to the rear, pausing but briefly at one medical installation after another because the number of beds was insufficient to hold them.
New Georgia Operations
At Munda, on New Georgia Island in the Solomons, where combat was just ending, professional problems were studied with the help of the Surgeon,
XIV Corps. The greater part of three divisions had been employed in the combat operations. Hospitalization had been provided by the clearing companies of the three divisions augmented by one platoon of a field hospital and a small convalescent facility organized by the 37th Infantry Division. These hospitals were quite unable to provide adequate medical care for the large number of casualties. Not only were the physical facilities inadequate but also the professional qualifications of Medical Corps personnel assigned there were not equal to the difficult professional service demanded by the situation.
Disease casualties were very numerous, consisting chiefly of patients with diarrheal diseases, infectious hepatitis, exhaustion states, anxiety and panic states, malaria, and common tropical dermatoses. Because of the shortage of beds, there was no alternative to rapid evacuation to the rear on a distressingly large scale (fig. 207). Guadalcanal was the next base in the evacuation chain, but hospital accommodations there were quickly filled beyond maximum capacity, and further evacuation, first to Espiritu Santo in the New Hebrides, then to New Caledonia, to Fiji, and finally even to New Zealand was the inescapable result.
Conferences with hospital staffs throughout the rear area brought to light certain highly significant facts. In general, the most seriously ill patients could not initially be moved. They were hospitalized in the forward area, although the shortages of physical facilities and qualified professional personnel were greatest there (fig. 208). When those patients finally arrived at rear area hospitals where specialist talent was concentrated, they had usually reached the convalescent stage of their illness or were simply to be moved on to the United States. The vast majority of patients evacuated early were those with disease conditions that did not warrant their evacuation, except in the sense that they were physically fit to travel. They were consequently moved from one hospital to another in an effort to keep hospital beds available in the combat zone.
When the records of hospitals in rear areas were examined later, it was found that time after time patients arrived who had largely, if not entirely, recovered from the illnesses that had originally led to their evacuation. This practice used transportation facilities and hospital beds uneconomically, caused much duplication in the use of medical personnel, and was detrimental to preserving the combat effectiveness of troops who were urgently needed.
An illustration of this unfortunate practice can be found in tracing the course of two hypothetical soldiers admitted from combat to a hospital at Munda for the treatment of exhaustion and diarrhea. One was retained in a clearing station on New Georgia. After several days of rest, feeding, hydration, and symptomatic treatment, he was returned to his organization no less fit, physically or psychologically, than one of his fellows who had patiently accepted his fatigue and diarrhea and recovered while remaining on duty. The second, evacuated because of the shortage of beds, eventually ended up in a hospital in New Zealand, although he had recovered from his fatigue,
hunger, and diarrhea a day or two out of Guadalcanal in the clean, comfortable, and secure surroundings of a hospital ship.
The psychologic effect upon a high percentage of soldiers who had similar experiences is inescapable. The difficulty with which they could be returned to duty in the forward area was roughly proportional to the distance they had been evacuated.
A newly appointed surgical consultant reached a similar conclusion after a 1-month tour of the forward area. Urgent measures were deemed necessary to improve the inadequate professional care being given surgical patients in combat zones.
A study of corrective measures was immediately undertaken by the Chief Surgeon, USAFISPA, with the help of the professional consultants. Steps had already been taken to alleviate the situation partially. A large general hospital and a 250-bed station hospital were routed to Espiritu Santo, two 500-bed station hospitals were in the process of construction at Guadalcanal, and an additional field hospital was being sent to Munda. The consultants strongly urged the movement of one of the general hospitals from Fiji to Guadalcanal, but this move was prevented by administrative objections.
The analysis of the New Georgia operation showed that inadequate
FIGURE 208.-Forward area medical treatment facilities in the Solomon Islands. A. 43d Division Clearing Station, Rendova Island, 13 .July 1943. B. 25th Division Clearing Station, New Georgia Island, 15 October 1943.
medical support was common in the combat area. Efforts were made at once to avoid a similar difficulty during the pending campaign on Bougainville.
A task force composed mainly of the 3d Marine and 37th Infantry Divisions was scheduled to assault the Empress Augusta Bay area of Bougainville on 1 November 1943. This bold plan involved bypassing two strong Japanese bases directly in the line of evacuation. With this plan in mind, the professional consultants urged that a field and evacuation hospital be landed soon after the assault, instead of later in the operation as called for in the landing schedule. The Chief Surgeon, USAFISPA, was in entire accord with this recommendation, but troop lists and shipping allowances were already firm, and the responsible command was not sympathetic to altering them.
The time was short, and compensation for the lack of hospitals had to be improvised quickly. A plan to bolster the deficient medical support was formulated by the Chief Surgeon, USAFISPA, with the aid of the medical and surgical consultants. It was presented directly to Lt. Gen. Millard Harmon, Commanding General, USAFISPA, Maj. Gen. Robert G. Breene, Commanding General, Services of Supply, and subsequently to Maj. Gen. Robert S. Beightler, Commanding General, 37th Infantry Division. The plan presented in detail the deficiencies of the medical support in Guadalcanal and New Georgia, the anticipated saving in manpower and improvement in morale of troops, and the increased treatment possible for sick and wounded.
The plan received the complete approval and support of the high command, as did many future suggestions from the Chief Surgeon, USAFISPA, on behalf of the professional consultants. Administrative corners were cut, permitting the rapid collection of additional medical, quartermaster, and engineering supplies. A high priority was obtained for the transportation of additional specialists and the assignment of personnel and supplies to scattered units of the 37th Infantry Division.
Sufficient supplies were obtained to expand the clearing station to a facility with a 1,000-patient capacity. Great care was exercised in the selection of these supplies in order to provide for definitive treatment for all surgical, medical, and psychiatric casualties who could be returned to duty within a period of 30 days.
The necessary personnel were obtained by the transfer to the 37th Infantry Division of officers and enlisted men of the 52d Field Hospital. This hospital had been scheduled to arrive at Bougainville on approximately D-plus-45 day. Medical, surgical, psychiatric, and laboratory teams were selected from the 18th General Hospital, 142d General Hospital, Fiji, and 39th General Hospital, Auckland, New Zealand, and from the 25th Evacuation Hospital. These men were assigned to the 112th Medical Battalion and were distributed among component units.
The 37th Division had fought in New Georgia. Although it had contributed less than its share of nonbattle casualties and was justly proud of its medical record, the evacuations of personnel had been unavoidably great. A certain evacuation tradition had developed in the division, as well as in all
591 South Pacific troops who had been in combat with inadequate medical support. It was thought that an open discussion of this with the division's medical and line officers might help to foster a healthier attitude. A series of indoctrination talks on contemplated changes in dealing with the sick and wounded at Bougainville was given by Colonel Baker to small groups of both commissioned and noncommissioned officers. The background of medical service in the area was clearly and frankly described. The reasons for the shortage of medical support in previous operations were outlined. It was pointed out that a precedent had been established which led soldiers to believe they would be evacuated quickly from the combat zone to the comparative comfort and safety of a rear area hospital if they became casualties. It was emphasized that this practice seriously reduced combat efficiency by unnecessary loss of manpower and frequently jeopardized the future health and well-being of casualties.
Line officers were informed of some details of the medical plan, such as the provision of an adequate number of hospital beds to take care of expected casualties within the combat area and the presence of teams of medical officers qualified in all important specialist categories. The advantage to serious casualties of having the best possible definitive care readily available in the combat zone was strongly emphasized.
Line officers were urged to consider the merits of the plan and explain it to their men. It was pointed out that confidence could be built up in troops by assuring them that the best medical care in the area was to be provided for them on the spot, not days later in hospitals hundreds of miles away. The chief causes of medical and psychiatric problems during combat were reviewed, together with the indispensable role that line officers play in the control of disease conditions such as malaria, diarrhea, dermatitis, and psychiatric disorders.
The consultants, the assembled specialists, and the permanently assigned medical officers of the task force held frequent conferences concerning supply, professional procedures, the distribution of specialists among units, and the administrative and operational control of all anticipated medical activities. The initial assault and establishment of a small beachhead on Bougainville was made by the 3d Marine Division. Six days later the first echelon of the 37th Infantry Division arrived and began to extend the beachhead.
The tactical situation had an important effect on the kinds and numbers of medical problems encountered. The objective of the operation was to take and defend an area in which airfields could be constructed. The locality had not been occupied recently in any numbers by either Japanese or natives. As the perimeter of the defense was extended (fig. 209), the natives, who had originally scattered to the hills, began to seek the security of U.S. lines. Large patrols sortied well beyond perimeter limits, and communicable disease rates began to rise (fig. 210).
During the initial phase, neither disease nor battle casualties were great, and the demand for hospitalization was slight. Recurrent malaria, upper
FIGURE 209.-Troops of the 37th Division passing vehicles stalled in the muddy roads, Bougainville, 9 November 1943. respiratory infections, diarrhea, dermatitis, and exhaustion and panic states were the common disease problems. Cases of pharyngeal and cutaneous diphtheria appeared sporadically. Excellent laboratory arid X-ray services provided necessary diagnostic aid preventing many unnecessary evacuations, and the general care of medical disease casualties was considered highly satisfactory. Excellent cooperation was established between the division personnel section and the medical service. As a result, convalescent patients were expeditiously reassigned within the division to duties commensurate with their physical and psychologic limitations (fig. 211). Conservation of manpower was far beyond expectations because of ready reassignment and surprisingly few evacuations for medical and psychiatric disease. An overall statistical account of disease casualties and evacuations in the operation is given later (p.598).
Plans for Assault on Kavieng
An assault upon the Kavieng area of New Ireland in the Bismarck Archipelago by a task force composed of the 3d Marine and 40th Infantry Divisions was scheduled for 1 April 1944. It was again necessary for the consultants to improvise medical support because a field and an evacuation hospital would
not accompany the assault force and it was estimated that casualties would be unusually heavy. The lessons learned at Bougainville enabled the consultants to formulate a similar, but greatly expanded, plan for the assault on Kavieng. Teams of specialists were assembled at the Guadalcanal staging area, and assault transports were partially loaded, when the operation was abandoned.
Both physicians and patients were subjected to strange and unfamiliar conditions which influenced the practice of medicine in the South Pacific. In civilian practice, doctors learn that one diagnosis generally suffices to explain clinical problems. In the Pacific, the reverse was true. More often than not symptoms indicated a combination of diseases. Many medical officers failed to give adequate attention to the probability that more than one diagnosis was necessary to fit together such groups of symptoms.
Malaria was the most common partner in such compound diseases. Often, an acute respiratory infection, an attack of dysentery, or a surgical condition
reactivated latent malaria and led to confusion in diagnosis. Such perplexities were most common early in the war when it was not generally realized that repeated search for malaria parasites in all febrile conditions was a necessary diagnostic precaution.
Observers who possessed training in trustworthy laboratory techniques were not numerous at the time. Gradually, as more experience was acquired by hospital staffs and the great frequency of malaria became apparent, the disease was more universally suspected. As time passed, reliable measures to exclude it as a contributing factor in difficult diagnostic problems were more commonly and efficiently employed.
Both dengue and infectious hepatitis were frequently accompanied by malaria. Hepatitis caused particular concern because textbook descriptions of jaundice in malaria and a constant fear of the hepatotoxic effect of Atabrine combined to confuse medical officers in the proper interpretation of jaundice. The treatment of hepatitis by antimalarial drugs was rarely if ever harmful to patients, but fear of the significance of jaundice added to the general confusion surrounding the treatment and suppression of malaria.
The combination of eosinophilia, light hookworm infestation, and any one of a variety of common medical conditions in a single patient was often encountered among combat troops. This resulted in confusion in the inter-
pretation of vague symptoms, mind many patients were treated for hookworm disease when their symptoms were caused by something else. The difficulty of demonstrating hookworm ova in light infestations and the stubborn response to therapy lead to further diagnostic difficulty.
"Disease awareness," a diagnostic pitfall whenever disease occurs in epidemic proportions, was common in the Pacific. This awareness is a good guide to diagnosis, but it can lead to serious errors when followed too far. Common diarrheas were so universal soon after the landings on nearly all islands that carriers of bacillary dysentery were often unwittingly discharged to duty and many cases of amebiasis were overlooked because adequate laboratories were lacking. Most febrile diseases were quickly called malaria without laboratory confirmation and were treated as such. This caused considerable harm to the patient in those cases when wounds of the head, cerebral hemorrhage, or meningitis were treated as cerebral in malaria. The reverse was also the case, as examples were discovered proving that death from cerebral malaria too often resulted after a faulty diagnosis which delayed the use of antimalaria therapy until it was too late.
Frustration, maladjustment , malassignment, nostalgia, and monotony had a profound effect upon the acceptance by the soldier of his military fate (fig. 212). It is undeniable that these psychologically deteriorating influences were unusually intense on Pacific islands. The islands were isolated, living conditions were bad, food was monotonous, recreational facilities scarce, climatic condition oppressive, and there was an abundance of strange diseases which could result in permanent ill health (fig. 213). The universal use of Atabrine gave me a sickly and repulsive complexion. There was a general loss of weight, frequently of alarming proportions, as well as dermatologic conditions that stubbornly resisted therapy. Patients with malaria, dysentery, a battle wound, or infectious hepatitis presented usually more difficult emotional problems than they would have done in the civilian practice of medicine.
The psychologic reaction of soldiers to strange diseases was particularly troublesome in cases of filariasis and malaria. Medical officers themselves were uncertain of the course these diseases would take and frequently made contradictory statements regarding them. Since patients, soldiers or line officers, frequently regarded any medical officers opinion as authoritative, they were often ill-informed and unjustifiably afraid of their illnesses. The natural consequence was emotional reactions leading to exaggeration of the symptoms of organic disease, the creation of fanciful ones, invalidism, prolongation of hospitalization, and loss of men for oversea service by evacuation.
An important insight into the psychologic reactions of soldiers to their environment, their military experiences, and their diseases was shown through an inquiry into the attitude of infantry soldiers who were presumably in good health and on duty at the time. Veterans of mini infantry division that had
been in Guadalcanal and New Georgia for approximately 11 months were questioned regarding their general health. The questioning took place after a rest and recuperation period of several months in a favorable climate, where living and recreational conditions were good, and after a number of the men been hospitalized in an Army hospital. The men were asked: "In general, what sort of physical condition would you say you are in at the present time?" They answered as follows: Physical condition very good, 2 percent; good, 4 percent; fair, 34 percent; poor, 41 percent; and very poor, 19 percent. Of the total group, 70 percent said they had been in sufficient good condition to engage in their initial combat, but only 39 percent felt that they were ready to return.
This information provides an enlightening background for study of the high percentage of psychoneuroses among hospitalized patients in the South
Pacific. A large number of men were ready for a psychiatric label before they were hospitalized. It was difficult to return these patients to duty because they knew that hospitalization protected them and, if they were hospitalized long enough, in accordance with evacuation policy they would be returned to the United States.
In civilian life, the average doctor deals with the minor emotional difficulties of his patients. In the Army, the ready availability of psychiatric service made it altogether too simple for the doctor not to treat components of patients' illnesses in which he had no professional interest. The term "psychoneurosis'' became a diagnostic pigeonhole often used when medical officers were tired of struggling with complaining patients. There was always a shortage of psychiatrists in the South Pacific, and the medical consultant had to make a constant effort to keep internists from passing on to psychiatrists simple behavior problems which the internists themselves should have handled.
The general pattern of disease in oversea hospitals was similar throughout the world. The notable exceptions that did exist were caused by epidemiologic peculiarities of specific localities. In the South Pacific, serious respiratory
diseases were uncommon. Acute rheumatic fever, hemorrhagic nephritis, and other diseases associated with virulent hemolytic streptococcal infections were rare.
Through large geographically, the South Pacific Area contained a comparatively small number of troops. No more than six combat divisions were ever in the area at one time. The incidence of malaria was high in time first four divisions to arrive in the theater, but by early 1944 mosquito control had greatly deterred malaria transmission.
MORBIDITY STATISTICS 1
Data from the official statistical records have been analyzed to show the incidence of disease in the South Pacific under varying conditions of medical care.
Malaria and other causes of evacuation, 1943. - The havoc wrought by malaria in the South Pacific is strikingly illustrated by the following figures: In 1943, as the area strength increased from 110,000 to 176,000 there were 151,577 patients admitted to hospitals. Of these, 60,000 were treated for malaria. The number of available hospital beds increased from 4,200 in January to 14,815 in December 1943. Some 22,265 patients, more than 14 percent of those hospitalized, were evacuated to the United States. The breakdown of the classes of ailments that caused evacuation and the percent of total cases were as follows: Neuropsychiatric disorders, 28.45; malaria, 14.97; gunshot wounds, 7.06; gastrointestinal disturbances, 4.88; skin diseases, 3.67; filariasis, 1.98; jaundice, .85; and other, 38.14. Disease casualties on Guadalcanal, November 1942. - The only hospitalization available during the critical phase of Army operations in Guadalcanal was that provided by three provisional field hospitals of the 101st Medical Regiment of the Americal Division. These hospitals were later aided by the clearing company of the 25th Infantry Division. The hospital staffs were not augmented by specialist teams. A breakdown of disease casualties in these field hospitals between late November 1942 and mid-February 1943 is as follows:
1 Statistics presented in this section the author's compilations and interpretations of data in official statistical South Pacific Area records.
Diagnoses and disposition on Bougainville, November 1943. - The situation was vastly different during the Bougainville operation. Only one Army division was committed during the early phase, combat was much less in tense, and preventive medicine was of a high order. Th provisional hospital was competently staffed with specialist teams and had excellent laboratory. There were just under 1,000 admissions during the initial 6 weeks of combat. Medical service patients on 24 November 1943 had the following diagnoses:
It had been decided that patients would not be evacuated if it was likely they could return to duty within 30 days. During the first month of combat, only 22 patients with medical or psychiatric disease were moved to the rear.
and disposition on Guadalcanal,
February 1944. - In February
1944, there were
three 500-bed station h
There was a 30-day evacuation policy on Guadalcanal at the time. Of the 845 patients processed, 62 percent were discharged to duty and the remainder were evacuated to hospitals at Espiritu Santo, Fiji, New Caledonia, and New Zealand for further treatment (fig. 214). No deaths from medical conditions occurred during the month.
A further breakdown of these cases reveals the following diagnoses and dispositions, with those not evacuated being discharged to duty:
Troops in New Zealand, 1943. - A different impression of the incidence of disease was reported in the area ETMD for January 1944, in a study of hospitalization of personnel in the 25th Infantry Division, which had been removed to an area favorable for rest and recuperation. This combat division was moved to New Zealand in November and December 1943 after approximately
11 months forward-area service in both the Guadalcanal and New Georgia operations. The division was ordered to take 0.6 gm. Atabrine weekly as a malaria suppressive, though this did not prevent the development of a considerable number of cases of the disease.
All patients who could not be treated upon a quarters status were admitted to the 39th General Hospital in Auckland. The following analysis deals with the first 1,000 nonsurgical patients admitted. In addition to a history and general physical examination, each man was given a thick blood-film examination, a complete blood count, a urinalysis, an X-ray of the chest, and a stool examination if he complained of diarrhea or had an eosinophilia in excess of 10 percent. There were 55 admissions for contagious diseases with the following breakdown:
Of the 700 patients admitted as malaria suspects, 564 were found to have positive blood smears and were given antimalaria therapy. The parasite species found in these cases were as follows: Plasmodium vivax, 541 cases; P. falciparum, 15 cases; mixed, 1 case; and undetermined, 7 cases.
Hookworm ova were found in stool specimens from 88 patients and Strongyloides in 5. In 68 men, ova were found on the first stool examination, while from 2 to 5 examinations were necessary for the remaining 25. The first stool examination was negative for hookworm ova in 67 men who had eosinophilia greater than 10 percent. Of the 1,000 men in this series, 23 percent had eosinophilia greater than 8 percent.
The incidence of anemia was remarkably low. Of the 93 men with hookworm or Strongyloides ova in their stools, 20 percent had red blood cell counts below 4 million, and 34 percent had hemoglobin values below 80 percent. On time other hand, of 907 men without helminthiasis, 15 percent had red blood cell counts below 4 million, and 37 percent hemoglobin values below 80 percent. The lowest red blood cell count was 3.1 million, and time lowest hemoglobin percentage was 60.
The urine examinations were essentially normal except in one case of chronic nephritis and one case of diabetes mellitus.
Among the 1,000 men, 22 had cutaneous diphtheria, which accounted for, roughly, one-third of all admissions for dermatologic disease.
Chest X-rays of the 1,000 men revealed the following diagnoses:
Causes of death from disease 1942-44. - An attempt was made to obtain information concerning the causes of death from disease in the South Pacific between 1 September 1942 and 31 August 1944. No claim can be made that the figures compiled are entirely accurate, but they are the closest approximation that can be made under the circumstances since complete records were never available for study. A number of deaths occurred on Navy hospital ships, in Navy hospitals, and in small Army hospitals in the forward areas, and data on these patients that could be thoroughly analyzed were never available. Colonel Baker reviewed the records of as many deaths as he could. A summary of the data revealed that there were 133 deaths due to medical and psychiatric diseases. The combined medical and psychiatric disease death rate per annum per thousand was 0.44, based upon an average area strength during the period of 150,678. Eighteen percent of disease deaths and 0.78 percent of all deaths were due to malaria. Between 1 October 1942 and 1 August 1944, the best available figures indicate that 78,042 attacks of malaria occurred among Army personnel in the area. This means the attack death rate for malaria was 0.036 percent, ignoring the 2 months in which no deaths were reported. During the same period (1 October 1942- August 1944), there were 1,356 cases of pneumonia with 21 deaths, or a immortality rate of 1.5 percent.
Treatment of malaria occupied so much of the of medical officers in the area that any account of medical activities would be incomplete without special consideration of that disease. This will be done briefly, as various aspects of the subject are dealt with in another volume in this series.2
The majority of doctors who went to the South Pacific early in the war had little practical knowledge of malaria. Those with specialized training were reserved for malaria control organizations, but the development of control on a large scale was slow (fig. 215). Medical officers were forced to learn by their own experiences. Many mistakes occurred because of the shortage of officers familiar with the difficulties found in treating malaria.
A few medical officers, particularly some from the southeastern section of the United States, came to the Pacific with a superficial background in the ordinary management of clinical malaria, but their influence was generally bad. Their experience with the use of quinine in the control of relapse in malaria due to a strain of P. vivax that relapses slowly had led them to attribute properties to the drug that it does not possess. Supplies of quinine were small in th Pacific, and its use was limited by order to patients who could not tolerate Atabrine. The chance scattering of these "malaria specialists" throughout many medical units is believed to have done much harm, for most of them retained their enthusiasm for quinine mind blamed the failure to control relapses in malaria caused by P. vivax on the enforced use of Atabrine.
2 Medical Department, United States Army, Internal Medicine in World War II. Volume II. Infectious Diseases. [In preparation.]
Nature of Malaria Observed
Epidemicity. - Doctors located on both highly malarious and no nonmalarious islands had ample opportunity to deal with the disease In the New Hebrides and the Solomons, which were intensely malarious, control by suppressive medication was poorly formulated and supervised. Consequently, in the early stages of the war, clinical attacks were numerous. When troops were evacuated from these areas to rear hospitals, whether evacuation was for malaria or not, suppressive medication was usually withdrawn, and after a short latent period initial attacks or reactivation developed.
Whole organizations were moved from nonmalarious to nonmalarious islands in the hope they might regain the physical fitness lost in the unfavorable environment of combat areas. Part of the program of rehabilitation for these troops in 1943 was to withdraw suppressive medication in the hope that malaria would burn itself out The discouraging result of this practice was the development of an alarming amount of chronic, rapidly recurring disease.
Species incidence. - Malaria in the South Pacific was almost entirely from infection with P. falciparurn or P. vivax. Cases of quart an malaria were almost a curiosity. Infections from P. falciparum predominated during epidemics, with the number of infections from P. vivax increasing as control measures progressed or when troops were removed to nonmalarious areas and transmission ceased.
This reversal of species incidence is strikingly illustrated by the experience on Guadalcanal, where a large-scale epidemic of malaria occurred during the latter part of 1942 and the first half of 1943. Early in 1943, many troops who had acquired malaria on Guadalcanal were removed to nonmalarious areas, and suppressive medication was withdrawn. It was observed that the infections due to P. falciparum decreased steadily but were replaced by ones due to P. vivax.
The experience of the 147th Infantry is particularly pertinent (p. 612). The greater part of this regiment was on Guadalcanal from late 1942 to May 1943 before being moved to Western Samoa for demalarialization In May 1943, cases of malaria on Guadalcanal were about equally due to P. falciparum and P. vivax. 0n Samoa, after several different therapeutic regimes based on use of Atabrine had been given to the entire regiment with extraordinary supervision, malaria caused by P. falciparurn almost disappeared; roughly 4,000 cases of malaria developed within a period of just over 6 months, only 14 of which were due to P. falciparum.
Specific effect of Atabrine on the disease. - Medical officers concluded that Atabrine, even in suppressive doses, exerted a specific effect on infections from P. falciparum that prevented the development of clinical activity. This has been conclusively established elsewhere by carefully controlled experimental study. The amazingly low malaria mortality rate, the rarity of blackwater fever, and the comparatively low incidence of malignant malaria the area has been attributed to the apparent specific effect of Atabrine.
Morbidity and mortality. - In May 1944, Colonel Baker sent a memorandum to all hospitals in the area requesting information on the number of cases of cerebral malaria, blackwater fever, rupture of the spleen, severe anemia associated with malaria, and deaths attributable to malaria. All hospitals replied, and the following information was compiled: Cerebral malaria, 46 cases; severe anemia, 14 cases; blackwater fever, 13 cases; and spleen rupture, 6 cases.
The casualty records in the Adjutant General's Section, Headquarters, USAFISPA, were examined for information concerning malaria as a cause of death. Between 3 October 1942 and 1 September 1944, 24 deaths were directly attributed to malaria. Of these, 16 (66 percent) were diagnosed as cerebral malaria. Undoubtedly, some of the remaining 8 recorded as malaria were actually instances of cerebral malaria. Blackwater fever was most recorded as the cause of a single fatality. This illustrated the importance of cerebral malaria as a cause of death.
Occasional cases of hemoglobinuria in Negro troops with malaria treated by Plasmochin napthoate (pamaquine naphthoate) were observed. Ten of these cases were studied as carefully as laboratory facilities would permit, by Lt. Col. Henry E. Swartz, MC, amid Capt. (later Lt. Col.) Milward W. Baylis, MC, of the 25th Evacuation Hospital and were reported in May 1944.
Diagnosis and treatment. - The diagnosis of malaria depends upon the identification of plasmodia in the peripheral blood. In spite of endless effort to teach this fundamental fact through circulars, letters, directives, and personal instruction, careless diagnostic habits persisted. Medical officers repeatedly claimed that the clinical features of malaria were so characteristic that it was neither just to the patient nor of scientific importance to withhold treatment until laboratory tests had confirmed a suspected diagnosis. Medical officers frequently defended diagnoses based on clinical findings alone with the erroneous contention that prolonged suppressive medication made it difficult to demonstrate parasites during clinical attacks.
The danger of withholding therapy in suspected cases of cerebral malaria was admitted, however. Officers were urged personally and by written directive to treat these patients promptly without waiting for laboratory confirmation.
Epidemics increase awareness of a disease and lead to erroneous diagnoses in a variety of conditions that develop coincidentally. In the South Pacific, some troops were so heavily seeded with malaria that it was a constant menace to diagnostic clarity in cases of infectious hepatitis, dengue, scrub typhus, pneumonia, meningitis, or intracranial hemorrhage.
An area directive on malaria emphasized the importance of the closest sort of diagnostic search and prompt, vigorous treatment for all suspected cases of cerebral malaria as well as other malignant forms of the disease. Diagnostic lumbar puncture was recommended for all patients suspected of having cerebral malaria, meningitis, or cerebral hemorrhage. The procedure undoubtedly prevented many serious errors.
Relapse as the chief problem. - An inherent characteristic of malaria due to P. vivax is its tendency to relapse. As time passed, the major malaria problem to internists was the control of such relapses, which vary considerably with different strains of P. vivax.Because of the known inadequacies of the other drugs in the treatment of malaria, Atabrine was considered the drug of choice in the area. Objections were raised that it was toxic, that it could not control clinical malaria after long suppressive and frequent therapeutic use, and that it failed to alleviate fever and other symptoms of malaria as quickly as quinine.
The malaria strains on Guadalcanal proved to have a frequent relapse rate. Early in 1943, hospitals to which patients were evacuated from Guadalcanal were having the same experience. Attacks of malaria were treated by the currently directed methods, and the patient would often have a relapse before he left the hospital.
Failure to use quinine in adequate amounts was the explanation most frequently given for a situation that fast became serious. Hospitals were overcrowded, physical aid psychologic fitness of malaria patients deteriorated rapidly, and many evacuations to the United States resulted.
Quinine had been proven to be less effective in controlling malaria relapses than Atabrine, yet medical officers throughout the area were quietly conducting experiments with quinine and were spreading rumors that results were far superior to those obtained with Atabrine. Mapharsen (oxophenarsine hydrochloride), bismuth, and later even penicillin were all tried by enthusiastic therapists, with discouraging results.
Study of Relapse on Fiji
An extremely favorable condition for investigating the problem of relapse in patients with infections from P. vivax existed at Fiji, a nonmalarious island. The heavily seeded Americal Division, which had been removed from suppressive medication in the hope its malaria would burn itself out, was stationed there and provided abundant clinical material.3 The division was to remain at Fiji for approximately 9 months, providing a suitable analysis period (fig. 216).
Orders were issued directing the admission of all suspected malaria patients to the 142d and 18th General Hospitals, the 7th Evacuation Hospital, the 71st Station Hospital, or to the clearing company hospital of the 117th Medical Battalion. A card system for recording individual malaria attacks and a followup plan for all hospitals were evolved.
Letters and verbal instructions from higher echelons urged that the use of quinine as an antimalarial be abandoned except in highly selected cases in order to conserve diminishing stockpiles of the drug. Experience of Fiji had proved conclusively that Plasmochin naphthoate, in the doses employed, was of little, if any, value in controlling relapse in cases due to infection with P. vivax. Furthermore, its effects on the gastrointestinal tract were so troublesome that medical officers considered its use undesirable and large numbers of soldiers refused outright to take it.
3 Essential Technical Medical Data, Headquarters, USAFISPA, for April 1944.
Medical officers on the scene knew little of the fundamental pharmacologic facts about Atabrine, and the results of studies of the drug in the United States had not reached the South Pacific. The medical staff of the l8th General Hospital concluded that knowledge of the absorption and excretion of the drug and the relation of its concentration to clinical activity was needed. If these data could be supplied, they reasoned, Atabrine might possibly be used in a way that would improve the control of relapses in patients with infections from P. vivax.
Therapeutic value of drug. - Capt. Roger A. Lewis, MC, was assigned the task of developing a method for making quantitative estimates of Atabrine in the blood. In spite of the critical lack of specialized equipment and shortage of reagents, Captain Lewis and Lt. Col. Alexander J. Schaffer, MC, developed a practical method for making such a quantitive analysis. Their system depended upon visual fluorometric comparisons of unknown serums with a stand-
and series of serums made up with Atabrine and extracted as the unknown serums were.4
The studies that followed were organized by Colonel Baker, who was then chief of the medical service of the 18th General Hospital. They were later taken over and expanded by Colonel Schaffer.
A variety of treatment routines was allotted to the several hospitals at Fiji. Atabrine was used in large and conventionally sized doses, for short and long periods, with large initial doses, and in various combinations with quinine and Plasmochin naphthoate. It was soon apparent that no combination of these drugs and no reasonably sized dose of Atabrine would control the high relapse rate. These conclusions were based on relapse rates in cases of malaria caused by P. vivax after various treatment regimes over two specific periods of time.
1. The relapse rates after treatment over an 84-day period were as follows:
2. The relapse rates after treatment over a 70-day period were as follows:
The following conclusions were drawn from the studies that have been briefly described here:
1. The serum concentrations of Atabrine of a large group of men taking the same dose vary over a wide range but are remarkably fixed for the individual. Thus, "high level" and "low level" men remain so.
2. Excessive urinary excretion of Atabrine does not account for low blood levels.
3. Most Atabrine disappears from the blood quickly when its administration is stopped, but detectable amounts remain for weeks.
4 Schaffer, A J, and Lewis, R. A: Atabrine Studies in the Field. I. The Relation of Serum Atabrine Level to Breakthrough of Previously Contracted vivax Malaria. Bull Johns Hopkins Hosp 78: 265-281, May 1946.
4. Rapid reactivation of malaria following treatment is associated with exceptionally low blood-Atabrine concentration.
5. Large initial doses of Atabrine control the fever, parasitemia, and symptoms of malaria due to P. vivax as quickly and as well as quinine.
6. None of the treatment regimes employed reduce the relapse rate below 62 percent for a given period of observation.
7. The interval between relapses is much shorter when quinine is the antimalarial employed than it is when Atabrine is used.
8. High initial doses of Atabrine, as compared with conventional doses, do not alter significantly the relapse rate. The same is true when high and low serum concentrations of the drug are used as the basis for comparison, except as just noted in conclusion 4.
Toxicity of drug. - Throughout the course of these studies, the dangers of Atabrine toxicity were carefully heeded. Observers were impressed by the unanticipated gastrointestinal tolerance of men for huge doses of Atabrine. There were few exceptions to thus occurrence. Jaundice, suppression of bone marrow activity, and dermatitis attributed to the use of Atabrine were not observed.
The only important manifestation of intolerance arose in the central nervous system. It was the subject of special study by Maj. (later Lt. Col.) Horatio W. Newell, MC, of the 142d General Hospital, and Capt. (later Lt. Col.) Theodore Lidz, MC, of the l8th General Hospital.5 Parts of the summary of their report indicate they reached the following conclusions:
Twenty-eight cases of toxic psychosis during or following the therapeutic administration of Atabrine are reported Although the psychotic reactions occurred in less than 2 patients per 1,000 treated with Atabrine on this island, the number of mental reactions observed is believed the consequence of the heavy dosage frequently utilized in the treatment of malaria Psychoses during treatment with 03 gm. daily for 7 days occurred rarely, for only two cases were seen, though large numbers of patients were treated in this manner. There appears to be a relationship between the frequency of psychotic reactions and the amount of Atabrine and the rapidity with which it is given.
Two cases are reported in which the psychosis not only cleared after withdrawal of the drug, but recurred when Atabrine was again given, and again cleared after cessation of therapy. Another case is cited of a subject who took the drug experimentally, never having had malaria, and became mildly psychotic. The three cases together indicate clearly that Atabrine causes psychotic reactions, amid that malarial fever and the release of malarial toxins need not be etiologic factors as has sometimes been hypothesized.
In most instances the psychosis appeared during, or immediately following, the course of treatment. In a few patients, who received very large amounts of Atabrine over a short period of time, the onset was delayed and occurred a few days after the cessation of therapy.
Toxic psychoses are expected to clear after removal of the toxic agent Eight of the 28 patients failed to recover adequately but only 2 were observed for more than a month after the onset of the psychosis it is probable that two reactions represented schizophrenic psychoses which had been precipitated by the illness or the therapy, although the possibility of the production of permanent damage by large amounts of Atabrine cannot be excluded.
5 Newell, II W., and Lidz, T: The Toxicity of Atabrine to the Central Nervous System. Am. J. Psychiat. 102:805-818, May 1946.
The clinical pictures observed varied widely, and resembled acute excitements of a manic or schizophrenic nature, severe depressive reactions, and paranoid schizophrenia. The presence of confusion, and particularly a sudden onset, with confused behavior and clouded sensorium, in a patient who had received Atabrine distinguished the reactions from nontoxic psychoses. Rapid recovery after cessation of therapy usually helped confirm the diagnosis.
The occurrence of psychotic reactions was found to be the major limitation to the amount of Atabrine which can be given safely. Because of these reactions and because of complaints of mild confusion and the occurrence of convulsive seizures in other patients, very heavy dosage was abandoned by one hospital, after which Atabrine psychoses again became a rarity.
Awareness of the possibility of Atabrine psychosis should lead the physician to appreciate the importance of early signs, such as feelings of confusion and of intoxication. Such awareness will permit more prompt withdrawal of the drug and, in some instances, might prevent a frank psychosis. Prompt diagnosis is essential to proper therapy, both in the immediate stoppage of Atabrine and in the handling of the psychotic reaction.
Seven cases are reported in which the patient suffered a generalized convulsion during or immediately following a course of Atabrine administered orally for the treatment of tertian malaria. One patient had experienced a single convulsion 8 years before, and in one case the seizure may have been caused by hypoglycemia In the remaining five cases no basis for the convulsion could be found in the patient's history or by the examinations which were carried out, other than the coincidence with Atabrine therapy. It is known that Atabrine, particularly in large doses, can be toxic to the human central nervous system as it produces psychoses; and animal experimentation and the reports of the intramuscular use of Atabrine musonate have shown that toxicity can take the form of epileptiform seizures It is therefore believed that the convulsions here reported were the result of Atabrine toxicity. The occurrence of convulsions during Atabrine therapy is extremely infrequent. Only one case is reported following conservative therapy, and despite the frequent usage of unusually large amounts of Atabrine on the island, the 7 cases represent an incidence of far less than 1 case per 2,000 malaria attacks treated with Atabrine.
value of sulfamerazine in the treatment of rnalaria caused by P.
vivax was investigated by
Capt. Ephraim T. Lisansky, MC, of the 142d General Hospital and his
collaborators.6 This study was
most carefully controlled and executed and led to the following
Sulfamerazine and sulfadiazine exerted a slow and mild action against
naturally acquired Plasmodium vivax in vivo. Oral Atabrine dihydrochloride exerted
a much more rapid and now
definite action against this parasite.
4. The sulfonamide drugs were only partially effective in clearing the peripheral blood stream of trophozoites and schizonts. In many of these cases gametocytes persisted. Atabrine dihydrochloride cleared the peripheral blood stream of parasites in all cases.
5. Positive smears and clinical symptoms recurred in almost all cases treated with either sulfonamide within 25 days after either of these drugs was discontinued. Those
6 Board for Coordination of Malarial Studies: Malaria Reports, vol. 1, No. 17, Washington, 1943-46.
cases treated with Atabrine had no clinical break-throughs or positive smears during the same period of time.
6. A comparison of the relative efficacy of the two sulfonamide drugs could not be made from this small series of cases.
7. Hematuria occurred in 1 of 14 cases receiving sulfamerazine. Toxic reactions [were] manifested by 2 of 10 cases receiving sulfadiazine Hematuria occurred in one and the other developed leukopenia and a reduction in granulocytes. Those cases treated with Atabrine revealed no toxic reactions.
8. This report submits evidence that neither sulfamerazine nor sulfadiazine was a practical therapeutic agent against this strain of naturally acquired vivax malaria. Atabrine dihydrochloride was a much more effective therapeutic agent than either of these sulfonamides against this strain of naturally acquired vivax malaria.
Study of end results
The Americal Division lost large numbers of men through evacuation to the United States because of malaria. Others were transferred to service organizations and continued to exhibit frequent reactivations of malaria. These men afforded an excellent opportunity to study the total effect of chronic malaria.
Capt. Philip A. Tumulty, MC, Capt. (later Maj.) Edward Nichols, MC, Maj. (later Lt. Col.) Martin L. Singewald, MC, and Major Lidz, all of the 18th General Hospital, selected for complete physical and psychologic study. 50 men who had suffered 10 or more attacks of malaria.7 This comprehensive investigation gave confidence to men in the area responsible for malaria policies by demonstrating that no measurable organic damage or dysfunction resulted from the weight loss and debility that were almost a constant sequel to chronic malaria. These symptoms seemed more related to the way individuals adjusted to chronic malaria and to concurrent situational factors than to the effects of the malaria alone.
Attempted Demalarialization on Samoa
The term "demalarialization" refers to attempts to rid heavily infected troops of malaria by removing them from malarious islands, withdrawing suppressive medication, administering to each man a course of antimalaria therapy, and allowing clinical attacks to develop. It was hoped that malaria would burn itself out.
This practice repeatedly produced unsatisfactory results. Malaria caused by P. falciparum subsided promptly, but, in that caused by P. vivax, relapses were frequent. Splenomegaly and parasitenia, without symptoms, became established in many men. Troops failed to gain weight or to regain vigor, evacuations were numerous, and the waste of hospital beds was enormous.The entire procedure proved to be highly ineffective.
This regiment arrived at Guadalcanal in several echelons; the 1st Battalion on 4 November 1942, the 3d Battalion plus special units on 29 November
7 Tumulty, P. A., Nichols, E., Singewald, M. L., and Lidz, T.: An investigation of the Effects of Recurrent Malaria; Organic and Psychological Analysis of 50 Soldiers. Medicine 25: 17-75, February 1946.
1942, and the 2d Battalion on 7 February 1943.8 These troops were given quinine sulfate as a malaria suppressive for a short time, but, on 29 November 1942, a weekly dose of 0.4 gm. of Atabrine became standard for suppression. On 12 May 1943, the entire regiment left Guadalcanal for the Territory of Western Samoa, a nonmalarious group of islands.
On Samoa, Atabrine was withdrawn from all troops at various rates. One group stopped Atabrine suddenly. A second took Atabrine 0.1 glum. 3 times daily for 7 days, rested 10 days, and their repeated the course before discontinuing medication. A third group stopped Atabrine for 10 days and was then treated precisely as the second group was. The fourth group took Atabrine 0.1 gm. 3 times daily for 1 week, rested for 2 days, took Plasmochin naphthoate 01 gm. twice daily for 5 days, rested for 10 days, and then repeated the cycle. The fifth group continued Atabrine suppressive medication for 6 weeks and then stopped. All clinical attacks of malaria were treated by the standard quinine, Atabrine, Plasmochin naphthoate regime. Patients were then given no antimalarial drugs unless further attacks developed.
Approximately 90 percent of the men with long malarial exposure developed the disease, and approximately 85 percent relapsed at least once. The following conclusions can be drawn from the results of the various treatments given:
1. The suppressive regime followed on Guadalcanal cured few, if any, cases of malaria caused by P. Vivax. Mass therapy with Atabrine or with a combination of Atabrine and Plasmochin naphthoate also was ineffective in curing latent infections due to P. vivax.
2. Mass therapy did not alter significantly the number of first relapses. When Plasmochin naphthoate was included in the mass therapy, it seemed to aid in lowering the peak malaria rates and to spread the experience over a longer period. It did not alter appreciably the final outcome insofar as initial attacks and first relapses were concerned. Plasmochin naphthoate may have aided in reducing slightly the number of total relapses, but this point was not clearly established.
Physical fitness at beginning and end of demalarialization attempt. Between 24 May 1943 and 27 November 1943, there were 2,313 first admissions and 2,597 readmissions on Samoa, making a total of 4,910 admissions from the regiment for malaria. The troops had been removed to Samoa for the purpose of rehabilitating them. Soon after their arrival there, Maj. Paul Harper, MC, conducted a physical survey of every fourth man on the company rosters.9 He obtained the following results:
8 1) Essential Technical Medical Data, Headquarters, USAFISPA, for April 1944. (2) Levine, N. D., and Harper, P.: Malaria and Other Insect-Borne Diseases in the South Pacific Campaign, 1942-1945, IV. Parasitological Observations on Malaria in Natives and Troops, and on Filariasis in Natives. Am ..J. Trop. Med. 27: 119-128 (suppl.) May 1947 (3) Downs, W. C.: Results in an Infantry Regiment of Several Plans of Treatment for Vivax Malaria. Am. J, Trop. Med. 26: 67-86, January 1946.
9 Report, Maj. Paul Harper, MC, to Commanding General, Samoan Group, 7 June 1943, subject: Medical Survey of Every 4th Man in 3 Battalions of the 147th Infantry After Leaving Guadalcanal.
Percent of soldiers
Shortly after it became necessary to resume suppressive medication in November 1943, a similar survey was conducted by Lt. Comdr. (later Capt.) Walter G. Reddick, MC, USNR, and 1st Lt. (later Maj.) Benjamin L. Huntington, MC, who reported the following to the Chief Surgeon, USAFISPA, on 1 December 1943:
Percent of soldiers
It can be seen that the number of palpable spleens had increased considerably and that slightly over a fifth of the men had a febrile parasitemia. Otherwise, for practical purposes, the variations were not significant, except that the November survey was made after the troops had spent 6 months in a non-combat area with good food and regular hours for eating, sleeping, and working.
In order to render the regiment fit to return to a specific assignment, it was necessary to reinstitute Atabrine suppressive medication. This promptly reduced the high malaria rate. It is significant that a survey conducted a year after the resumption of suppressive medication revealed only 0.3 percent of
men with palpable spleens. Time general physical fitness of the regiment had improved remarkably.
Attempts to demalarialize the Americal Division on Fiji met with much the same results. Physical and psychologic rehabilitation of these troops failed to occur, and it became necessary to reinstitute Atabrine suppressive medication in order to rehabilitate these troops and return time division to a combat assignment.
It was apparent that troops in the condition of those of the 147th Infantry and Americal Division were not fit to return to active duty after many months of attempted demalarialization. A large number of malaria patients were evacuated to the United States, but many remained who were having frequent relapses of malaria due to P. vivax.
Studies of Suppressive Therapy
The only course of action available was to attempt to control the remaining malaria by resuming suppressive medication. It was hoped, but not known, that this procedure would be effective. Many medical officers believed that Atabrine might lose some of its suppressive properties because the parasites acquired a tolerance to the drug. It was important to settle this question so that plans for reemploying heavily malarialized troops and treating those in malarious areas could be formulated.
Americal Division. - An experiment was set up on Fiji to furnish the needed information. The subjects for this study were combat units of the Americal Division which were to engage in maneuvers under conditions simulating as closely as possible those of jungle combat.
One group was kept as a control and given no suppressive medication. Another was given Atabrine in quantities sufficient to establish blood levels equal to those that would be obtained by time current suppressive regime when equilibrium had been reached.
The results of time experiment were clear. Malaria in time control group remained roughly at the level it had been during previous months. Malaria in the experimental group was almost completely eliminated. The cases of clinical malaria that did develop were usually in men who had low Atabrine blood levels.
This information led to a policy change concerning the use of heavily malarialized troops. Thereafter, troops were kept on continued suppression whether they remained in malarious areas or were removed to nonmalarious ones for rest and recreation.
25th Infantry Division. - This was the first organization to continue suppressive medication after removal from a malarious area. This division arrived on Guadalcanal, 25 December 1942, and became heavily seeded with malaria (fig. 217). Atabrine suppressive medication, although directed, was not
rigidly administered. In April 1943, a peak malaria rate of 2,385 per annum per 1,000 average strength was reached on Guadalcanal.
In December 1943, the division went to New Zealand, and Atabrine suppressive medication was continued. Throughout the rest period, it was suspected that Atabrine discipline was not satisfactory, although, as reported in time area April 1944 ETMD, repeated checks were said to disclose that every precaution was being exercised to insure faithful ingestion of the drug.
In early March, sample groups of men were questioned confidentially regarding their adherence to orders, and Atabrine blood levels were checked in these men. Suspicious of poor discipline were entirely confirmed. It was found that many men were careless in their suppressive medication habits. When this information was taken to the commanding general, a renewed effort at perfect Atabrine discipline was promised, and flume results were obtained.
147th Infantry Regiment. - Many responsible medical officers were concerned, however, over the decision to continue suppressive medication with Atabrine. Military necessity forced control of malaria by the use of continued suppression, but it was widely believed that time evil day was only being postponed. It was feared that when suppressive was finally withdrawn there
would be the same outburst of malaria that had been repeatedly observed after shorter periods of suppression were terminated.
A group of heavily exposed men of the 147th Infantry gave promise of providing an answer to this important question. The group was followed through various malaria experiences from its arrival on Guadalcanal in November 1942 to Iwo Jima in August 1945. The period of observation included heavy malaria exposure, light exposure, initial atabrinization, deatabrinization, long-continued suppressive medication, and finally terminal deatabrinizatiori.10
It was concluded from a study of this group that long-continued Atabrine use is highly effective in controlling clinical activity of heavy P. vivax malaria seeding over a prolonged period, provided proper attention is given to the all important matter of Atabrine discipline. Furthermore, it seemed justifiable to conclude that Atabrine in suppressive doses over long periods destroys a large amount of malaria due to P. vivax that would have become clinically active had suppressive control been withdrawn sooner.
In November 1943, a letter from The Surgeon General to the Commanding General, USAFISPA, requested a study of the value of totaquine in the treatment of clinical malaria. The medical consultant organized this study under the direction of Capt. (later Maj.) Robert A. Green, MC, and Maj. (later Lt. Col.) Evrela A. Larson, MC, at the 31st Station Hospital.
Comparative study of quinine, totaquine, and Atabrine. - The antimalarial effects of quinine, totaquine, and Atabrine were compared in a series of patients with clinical malaria from a heavily seeded artillery battalion, and the study was reported in the area ETMD for April 1944. Cases were treated in rotation with the three drugs. With a negligible number of exceptions, the malaria was all caused by P. vivax. The results of this study may be summarized as follows:
1. Totaquine caused disappearance of malaria parasites from the blood stream in a time slightly greater than was the case when quinine and Atabrine were employed.
2. Totaquine controlled fever and symptoms as well as quinine or Atabrine.
3. Incidental effects consisting of nausea and vomiting were somewhat greater with totaquine than with either quinine or Atabrine.
4. The intervals between attacks and subsequent relapses were shortest in cases which had been treated with totaquine (13.7 clays), longer (15.2 days) in cases treated with quinine, and longest (37.4 days) in cases treated with Atabrine.
5. Of 80 cases treated with totaquine, 65 percent relapsed at least once during the 8 weeks of observation; of those treated with quinine, 70 percent relapsed; and of those treated with Atabrine, 38.7 percent relapsed.
10 Baker, B. M., and (by invitation) Platt, D.: The Effect of Long-continued Suppressive Atabrine Medication Upon Relapses of Vivax Malaria. Trans. Am. Clin. & Climatol. Assoc. 58: 145-152, 1946. See also Bull. Johns Hopkins Hosp. 81: 295-304, November 1947.
Studies on Immunity
Medical officers wondered whether the prompt and effective treatment of clinical attacks might not prevent, or at least limit, the development of biologic resistance.
In the summer of 1943, Maj. (later Lt. Col.) George G. Carter, MC, of the 39th General Hospital investigated this matter. He permitted the attacks of malaria caused by P. vivax to pursue a part of their clinical course in a small group of patients by withholding antimalarial drugs. However, satisfactory results were never obtained because the group was a transient one and Major Carter had no means of making certain his subjects did not take Atabrine of their own volition in order to enjoy the pleasant attractions of New Zealand.
Early in 1944, General Morgan, The Surgeon General's chief consultant in medicine, requested Colonel Baker to organize a new study of the problem. The fundamental prerequisite was to obtain an experimental group that could be kept under observation for a sufficient period to provide reliable data. Through the cooperation of the Chief Surgeon and the Commanding General, USAFISPA, and the Commanding General, 43d Infantry Division, a group of volunteers was made available for 1 year.
Major Carter was selected to head the investigation, which began in March 1944. Seventy-two men were allowed to have from 10 to 12 paroxysms of malaria due to infection from P. vivax. Their relapse experience was compared with that of a control group whose malaria was promptly terminated by Atabrine therapy. It was shown that a certain amount of immunity, as gaged by subsequent relapse experience, could be reduced, but the immunity was not sufficient to justify the use of the procedure in the practical management of relapses in patients with malaria.11
In early 1944, Capt. Frank McCarry, MC, Capt. (later Maj.) Owen B. Royce, MC, and Lt. Col. Bert E. Mulvey, MC, all of the 21st Evacuation Hospital (fig. 218), observed and reported on a peculiar condition on Bougainville which was not recognized on any other island in time area.12 The disease occurred in widely scattered organizations of the Bougainville force. During March, April, and May of 1944, there were 124 cases admitted to time 21st Evacuation Hospital. It is known that many more with milder clinical manifestations were treated and returned to duty by unit medical officers.
Forty-one cases were selected for particular study, although the clinical findings were generally similar in all of them. All but six of time patients were mildly febrile for an average of 2 days. The average fever was 100º F., with the highest reaching 101º F. All had polyarthritis consisting of pain,
11 Essential Technical Medical Data, Headquarters, USAFMSPA, 15 May 1945, Inclosure No. 16.
12 Essential Technical Medical Data, headquarters, South Pacific Base Command, for August 1944.
limitation of motion, and joint effusion. Redness and increased skin temperature were rare. The knees were most frequently involved, with the duration of joint disability averaging 14.6 days between extremes of 3 and 43 days.
Faint maculopapular rashes occurred in 13 cases; 7 had moderate general enlargement of the lymph nodes, and 7 others had regional enlargement. Splenomegaly was not observed. Leukocyte counts ranged from 3,900 to 12,500 per cm., and the average sedimentation rate was 12 mm. per hour. Joint fluids had the characteristics of exudates, but repeated cultures were sterile. The results of other laboratory examinations including urinalyses, blood counts, serum agglutination tests, and microscopic and bacteriologic examination of feces were not noteworthy.
A certain similarity between this condition and one observed by Lt. Col. Frederick C. Weber, Jr., MC, Lt. Col. Theodore W. Oppel, MC, and Capt. (later Maj.) Robert W. Raymond, MC, in the Schouten Islands of the Southwest Pacific (off the northern coast of New Guinea) was discovered later.13
During the early days of the war, it was not generally known that diphtheria occurred in the tropics. However, when casualties from Guadalcanal began to arrive in rear area hospitals, it was not uncommon to find cases of neuritis of undetermined etiology.
13 Weber, F. C., Oppel, T. W., and Raymond, R. W.: A Mild Exanthematous Disease Seen in the Schouten Islands. Am. J. Trop. Med. 26: 489-495, July 1946.
Just how many cases there were is not known, but Colonel Baker's experience later led him to conclude that the number was considerable. Among these were a few instances of serious bulbar paralysis, suggesting diphtheria. Suspicions were confirmed when a small epidemic of pharyngeal diphtheria developed in the Americal Division after it moved from Guadalcanal to Fiji.
Cutaneous diphtheria was first recognized by Capt. (later Lt. Col.) Averill A. Liebow, MC, early in 1943 on New Zealarmd. A series of investigations by Colonel Liebow, Lt. Col. John H. Bumstead, MC, Maj. Louis G. Welt, MC, and Capt. (later Maj.) Paul D. MacLean, MC, of the 39th General Hospital, continued until the end of the war.14
Medical officers were slow to accept the rather frequent occurrence of cutaneous diphtheria among troops who had been exposed to extreme tropical conditions as more than a mere medical curiosity. This was largely owing to a shortage of adequate laboratory facilities and properly trained laboratory personnel. Even after the existence of the disease was widely publicized by Colonel Baker through personal interviews and two circular letters, medical officers remained skeptical and often failed to obtain laboratory confirmation of diagnostic suspicions.
Colonel Liebow and other diphtheria experts traveled throughout the South Pacific giving demonstrations and teaching elemental diagnostic facts. The disease gradually became accepted as an important one, isolation was enforced, and case totals fell.
Troops throughout the South Pacific, with the exception of those in New Zealand, came into close contact with native populations heavily infested with intestinal parasites. Examinations of stools eventually became almost routine for hospitalized patients. The incidence of ancylostomiasis was discovered to be surprisingly high, whereas the incidence of amebiasis was surprisingly low. Sporadic cases of infections from Endamoeba histolytica were continually observed throughout the area, but only one significant epidemic of the disease occurred. This was in 1944 among troops of time 37th Infantry Division on Bougainville (fig. 219). preliminary reports indicated a high rate of infection. But Bougainville passed to the control of the Southwest Pacific Area in June 1944 before the study of this epidemic was complete.
Stool examinations made at the 39th General Hospital during two comparable periods of 1944 and 1945 illustrate the parasitism encountered in troops who had been evacuated from the Solomon Islands or sent to New Zealand after combat.15
A summary of stool specimens examined between 27 April arid 27 July 1944 is shown in the following tabulation:
14 Liebow, A. A., MacLean, P. D., Bumstoad, J. H., and Welt, L. G.: Tropical Ulcers and Cutaneous Diphtheria. Arch. Int. Med. 78: 255-295, September 1946.
13 Liebow, A. A., Milliken, N. T., and Hannum, C. A.: Isopora Infections in Man. Am. J. Trop. Med. 28: 261-273, March 1948.
Patients for whom examination was madeNumber
Parasitized patients.........................................................................1 155
Stool specimens examined
Parasitized stools (positive)............................................................ 2 463
1 Of the 155 parasitized patients, 112 harbored significant parasites.
2 Of the 463 parasitized stools, 405 were significant.
A breakdown of the species of parasites found in time 463 parasitized stools appeared as follows:
1 Some of the 155 parasitized patients harbored more than one species of parasite.
2 Percentages based on the 544 parasitized and nonparasitized patients.
A summary of stool specimens examined between 27 April and 27 July 1945 is shown in the following tabulation:
Patients for whom examination was made Number
Parasitized patients.......................................................................... 1 205
Stool specimens examined
Parasitized stools (positive)............................................................ 2 416
Nonparasitized stools (negative).................................................... 613
1 Of the 205 parasitized patients, 129 harbored significant parasites.
2 Of the 416 parasitized stools, 278 were significant.
A breakdown of the species of parasites found in the 416 parasitized stools appeared as follows:
1 Some of the 205 parasitized patients harbored more than one species of parasite.
2 Percentages based on the 387 parasitized and nonparasitized patients.
Colonel Liebow made an exhaustive study of the relation of eosinophilia to ancylostomiasis and strongyloidosis in the area.16 The following conclusions are quoted from one of his reports:
1. In certain areas of the South Pacific eosinophilia has been closely correlated with recently acquired hookworm or Strongyloides infection; consequently its detection has served as a convenient and rapid tool for the investigation of the natural history and epidemiology of these conditions.
2. Even light infections may be associated with a marked eosinophilia during the first 4 months. Consequently, before drawing conclusions concerning the significance of the eosinophilia many stool examinations may be necessary to demonstrate the ova or larvae, even if sufficient time has elapsed for oviposition to have taken place in the intestine.
3. Study of large numbers of hospital patients continuously evacuated from the islands has shown that peaks of eosinophilia and leukocytosis occur between 3 and 4 months after infection, but the eosinophilia is probably still useful as a criterion of hookworm or Strongyloides infection as much as one year later 4. Hookworm infection as indicated by eosinophilia has been widespread among combat troops in the islands of the South Pacific, although severe hookworm disease is rare.
5. The infection affects chiefly front-line infantry soldiers, is in the main acquired during combat, is proportional in extent to the duration of the fighting, and is increased by the use of native or captured enemy bivouac areas.
6. Ancylostoma duodenale has been time common species in troops infected in the South Pacific.
7. Biological cure, using tetrachlorethylene, has been difficult to attain, even in lightly infected individuals. 8. Continued re-exposure of the large number of men already involved, as by further campaigning in heavily seeded areas, or a decline in the quality or amount of the diet, may convert subclinical infection into disease of military importance. Diarrheal diseases, infectious hepatitis, filariasis, dengue, and scrub typhus were all encountered in the South Pacific, some of them in large epidemics. They presented important problems to preventive medicine personnel and to internists who were responsible for the diagnosis, treatment, and disposition of cases. No particular contributions were made by internists to the management of these conditions.
16 Liebow, A. A., and Hannum, C. A.: Eosinophilia, Ancylostomiasis, and Strongyloidosis In the South Pacific Area. Yale J. Biol. & Med. 18: 381-403, May 1946.