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Chapter IX

Activities of Medical Consultants

CHAPTER IX

Field Armies

Garfield G. Duncan, M.D.

  Field armies were the last major commands to which consultants were assigned in World War II. The first assignment was to the Sixth U.S. Army operating in the Southwest Pacific Area.  In some field armies, the army surgeons were reluctant to receive or assign consultants. Misgivings as to their usefulness delayed appointments and prevented immediate adoption of the plan on all fronts.  However, as medical consultants to field armies proved their worth, they were welcomed by all.

The various consultants and the armies in which they functioned are presented in appendix A (p. 829).

  From the medical point of view, there was no more satisfying assignment than that of consultant.  At its best, it afforded an effective combination of clinical, research, supervisory, and administrative activities, which carried responsibility sufficient not only to satisfy but to tax the medical officer best qualified for the appointment.  There could be no greater challenge and stimulus than grappling with new medical problems involving large bodies of men and the effectiveness of the military effort.

  Officially, there was no clear definition of the duties of the medical consultants.  They were confronted by a great variety of problems under widely varying conditions in many parts of the globe.  Furthermore, owing to existing staff organization, the Surgeon General's Office exercised no direct control over medical activities overseas.  Consequently, in the field armies, the capabilities of the consultants were utilized wisely, or not so wisely, according to the vision of the army surgeon.

  The consultants themselves were quick to recognize the great opportunity to salvage sick and wounded in forward areas of a combat zone. Most of them had seen such patients as they proceeded back through the chain of medical evacuation (fig. 259) to the general hospitals and had been impressed with the wastage in manpower and its overall effect on fighting strength at the front. They were aware, as some apparently were not, that it was possible to provide excellent medical service to troops in the frontlines (fig. 260).

  The account in this chapter is drawn largely from the reports of consultants to the Ninth and Fifteenth U.S. Armies in the European theater and from the reports of consultants to the Sixth, Eighth, and Tenth U.S. Armies


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FIGURE 259.-Litter jeep, early link in chain of medical evacuation, Manila, Phillipine Islands, February 1945.

in the Pacific.1 The experiences of the consultants of the First and Third U.S. Armies in the European theater are briefly discussed in chapter IV.

INTERNAL MEDICINE AT THE FRONT

Clinical Problems

The variety and nature of the major problems in internal medicine with which consultants to the field armies were concerned are illustrated by experiences in the Sixth, Seventh, Ninth, and Fifteenth U.S. Armies.

The Sixth U.S. Army, in the Pacific, had problems concerning malaria, dengue, scrub typhus, hepatitis, schistosomiasis, poliomyelitis, dysentery (bacillary and amebic), and venereal diseases.

  The Seventh U.S. Army, operating in Tunisia and Italy, experienced malaria, trenchfoot, hepatitis, enteritis, and typhus (epidemic).

  The Ninth U.S. Army, in France and Germany (fig. 261), encountered major problems concerning traumatic shock, trenchfoot, venereal disease,

1 (1) McKee, Lt. Col. John B.: Medical Consultant's Activities, Ninth U.S. Army, 13 May 1944-9 May 1945. [Official record.]   (2) Smith, Lt. Col. Carter: Activities of the Medical Consultant of the Fifteenth U.S. Army, 1 September 1944-25 July 1945. [Official record.] (3) Duncan, Col. Garfield G.:  Activities of the Medical Consultant With the Sixth Army, 19 August 1943-8 May 1944.  [Official record.] (4) Shull, Lt. Col. Harrison J..:  Experiences of the Consultant in Medicine, Sixth U.S. Army, 6 June 1945-10 December 1945.  [Official record.] (5) Kimbrough, Lt. Col. Robert C., Jr.: Activities of the Medical Consultant to the Eighth Army, 1 June 1945-2 October 1945. [Official record.] (6) Martin, Col. Walter B.: Report of Medical Consultant With the Tenth Army, 3 July 1944-15 October 1945. [Official record.]


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FIGURE 260.-First echelon medical service. Aid station in France, 12 August 1944.

primary atypical pneumonia, and hepatitis and had lesser problems concerning primary pneumonia, diphtheria, scarlet fever, and meningococcic meningitis.

  The Fifteenth U.S. Army, in France and Germany, was concerned with tuberculosis, notably in displaced Soviet personnel presumably not exposed to infection previously (fig. 262) ; typhus (epidemic); malnutrition in displaced persons, refugees, and recovered  Allied military personnel; diphtheria, including cutaneous diphtheria; typhoid fever in displaced persons' camps; hepatitis; acute infections of the respiratory tract; recurrent acute attacks of malaria; an outbreak of methyl alcohol poisoning in a camp for displaced Soviet nationals; and venereal diseases.

  All illustration of a clinical problem, which was attacked through the efforts of a medical consultant, and of the solution, which resulted in the salvaging of combat personnel, is found in a study on malaria in the Sixth U.S. Army.  This study is described briefly in the following paragraphs.

  Two infantry divisions, the 32d and 41st, were returned to Australia from New Guinea after the   Buna-Gona campaign because the great majority of personnel were subject to recurring acute attacks of malaria. Several months elapsed, with the 32d Division staying at Camp Cable near Brisbane and the 41st at Rockhampton, with no greater prospect of the unit's returning to combat   (fig. 263).  In fact, recurrences continued to account for a  malaria attack rate of between 3,000 and 4,000 attacks per annum per 1,000 average strength.  In August 1943, Lt. Col. (later Col.) Garfield G. Duncan, MC
 

   

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FIGURE 261.-110th Evacuation Hospital, Ninth U.S. Army, Kamp, Germany, 24 March 1945.

(fig. 264), Consultant in Medicine, Sixth U.S. Army, was assigned to the Sixth Army Training Center at Rockhampton, organized to rehabilitate these malaria-ridden divisions.  The objective, the method of study, and the results are shown in the following summary.

  Objective. - The purpose in establishing the Sixth Army Training Center was to receive from combat units personnel proved to be infected with malaria and to prepare them, as regards health, for combat duty.  The medical consultant, appointed surgeon of the center, was instructed as follows:  In view of the disappointing results yielded in many cases by methods now in practice in both therapeutic and suppressive treatment of malaria, the Surgeon of the Center will, with the approval of proper authority, make a diligent search to discover and institute other and more promising means of dealing with this problem.''

  Methods and material. - In pursuing this objective, the malarial personnel were divided into companies, and Atabrine (quinacrine hydrochloride) was administered according to seven different programs.  In all instances, Atabrine was given after the evening meal, by roster, and under supervision of commissioned officers to insure that 110 personnel could escape taking the drug.  Four battalions of malarial troops were thus studied (fig. 265).


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FIGURE 262.-Processing liberated Soviet prisoners of war at Lippstadt, Germany, May 1945.  A. Entrance to camps 1 and 2.  B. Delousing at camp No. 17.


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FIGURE 263.-U.S. 41st Infantry Division at Rockhampton, Queensland, Australia.  A. Mrs. Franklin D. Roosevelt, inspecting tent area of Headquarters Company, 186th Infantry, with Maj. Gen. Horace H. Fuller, USA (wearing dark glasses), Commanding General, 9 September 1943. B. Division headquarters, 5 June 1944.


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FIGURE 264.-Consultants in medicine, field armies.


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FIGURE 265.- 4th Casual Company, Convalescent Battalion, 32d Division, marching to beach for supervised swimming, Point Fingal, New South Wales, Australia, 20 April 1943.

  Parallel studies were conducted so as to reveal unfavorable as well as favorable results following the several regimes of suppressive treatment.  The comparative studies were based on  (1) the average daily attendance at sick call from the respective companies,  (2) admissions to the hospital for all causes, and  (3) admissions to the hospital for proven recurrent attacks of malaria.  Closely observed were patients with tachycardia, splenomegaly, change hemoglobin value, loss of weight, abdominal pain, diarrhea, vomiting, fever, arterial hypertension, albuminuria, blood smears positive for malaria microorganisms, and increased ''Atabrine tint" in skin and sclerae.  Particular consideration was given to changes in body weight, to the concentration of Atabrine in the blood under the several regimes, and to reclassification of soldiers to light training.

Results. - The following results were observed:

  1. Each one of several Atabrine suppressive regimes was found effective in abruptly and completely eliminating recurring attacks of malaria, and it was concluded that poor administration of the drug previously had permitted a high percentage of the men to avoid taking it.

  2. Intensive military training for 4 weeks, including 2 in which time exercise periods exceeded 80 hours per week, did not precipitate acute attacks of malaria in any of the soldiers on suppressive Atabrine therapy (fig. 266).


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FIGURE 266.-Intensive military training for 3d Casual Company, Convalescent Battalion, 32d Division, Point Fingal, New South Wales, Australia, 29 April 1943.

  3.  Recurrent attacks reappeared from 2 to 4 weeks after discontinuing suppressive therapy.

  Outbreaks of malaria occurring subsequently were invariably traced to failure to comply with instructions issued from Sixth U.S. Army Headquarters regarding the procedures for administering Atabrine.  A notable outbreak occurred in the 127th Infantry of the 32d Infantry Division at Finschhafen on New Guinea.  The break in discipline was detected by the consultant, and, within 1 week after its correction, the malarial rate fell to zero.  As a result of adhering to the regimes of suppressive treatment instituted at the Sixth Army Training Center, the 32d and 41st Divisions were rehabilitated and returned to combat. Greater details of this enterprise have been published elsewhere.2

Clinical Investigations

  It is of course not so easy to carry on carefully controlled clinical observations in a field army as in the more stable circumstances of the communications zone or the Zone of Interior. Nonetheless, important problems arise

  2  Duncan, G.G..: Quinacrine Hydrocloride as a Malaria Suppressive Agent for Combat Troops. War Med. 8:305-318, 1946.


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FIGURE 267.-Col. John II. Hall, MC, Surgeon, X Corps, Sixth U.S. Army, demonstrating effects of atomic bomb to members of Far Eastern Advisory Commission, Hiroshima, Japan, 26 January 1946.

in these areas that need on-the-spot investigation.  Actual conditions existent in the field frequently cannot be reproduced for adequate trial of field problems in rear areas. Such questions as those posed by exotic diseases, by new therapeutic measures, and by new drugs and antibiotics cannot be postponed to a more convenient season.  Adequately trained personnel are rarely available for carefully conducted studies, but much can be done with personnel that are available if the medical consultant is alert to such needs.

Among such investigations, there was a study of amebiasis initiated in the Americal Division on the Island of Cebu during August of 1945 but not completed because of the collapse of Japan and the unexpected movement, of the division. Studies of the late effects upon civilians in the Hiroshima and Nagasaki areas of Japan following the explosion of the atom bomb were supervised by a special committee from General Headquarters, Army Forces, Pacific.  In this study, the medical consultant of the Sixth U.S. Army gave assistance in locating and gathering data from civilian hospitals within the time command (fig. 267). The study in the Sixth U.S. Army on the use of Atabrine has been summarized, with its results directly bearing upon the maintenance of combat strength.


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FIGURE 268.-Shock tent in a forward medical unit of the Fifth U.S. Army, Italy, 1944.

  In the future, it should be possible to expedite assignment of experienced investigators to undertake appropriate problems in forward areas.  This need was well filled during the later stages of the war.

Treatment of Shock

  The number of patients passing through the preoperative and postoperative shock wards was very large during the active phase of operations (fig. 268).  The surgeons being fully occupied in the operating rooms, the internists, including the medical consultants, became interested in the shock problem.  In general, teams had not been organized or instructed in shock therapy or in the proper physical setup of shock wards.  Considerable confusion and inefficiency resulted. Although the rate of recovery from battle wounds was extremely good, it could have been improved.  The use of large quantities of blood and blood substitutes in combating shock was an invaluable aid, but when not properlv directed it was capable of great harm (fig. 269


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FIGURE 269.-Use of blood and blood substitutes its field armies.  A. Plasma administered during difficult over-water evacuation in Philippines.  B. Blood distribution truck with 8th Evacuation hospital, Fifth U.S. Army, Cecina, Italy, May 1914.


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FIGURE 270.-Clinical laboratory of 8th Evacuation Hospital, Fifth U.S. Army, Italy, 13 January 1945.

  Laboratory muds were a necessary adjunct to a good shock service.  In the early period of a military tactical operation, the surgical demands were usually heavier than the medical load.  The physiologic problems involved and the frequencv of chest complications did, in fact, make th treatment of shock primarily a problem for the internist.  Accordingly, efficiency would have been promoted by putting the shock wards under the medical service of a medical treatment facility.  The chief of medicine would then be responsible for the organization, training, and instruction of shock teams and for the proper integration of the laboratory service and shock service.  This should have been accomplished before engaging in tactical operations.

Laboratory Work

  The medical consultants were inevitably concerned also with the work of the clinical laboratory (fig. 270).  Too frequently, in mobile medical units, the individual officer responsible for the laboratory had had no previous experience in laboratory service and often had little interest in it.  There is evidence in the tables of organization, especially for field hospitals and medical clearing companies, and in the individuals selected to perform laboratory work that its importance to clinical medicine was not always recognized.  Dependable parasitologic work was a prerequisite to superior professional dare in the Pacific.  The writer, as a medical consultant, believed that the laboratory service in mobile medical installations should have been made a supervisory


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responsibility of the chief of the medical service who was dependent upon this service for accurate assistance.  The consultant in medicine repeatedly encouraged as close an approximation as possible to such a relationship (p. 825).

A specialized laboratory unit under the direction of Lt. (later Maj.) Frederik B. Bang, MC, was of great assistance in determining the concentrations of Atabrine in the blood that followed the various malaria-suppressive regimes being evaluated at the Sixth Army Training Center.  Such highly specialized units proved of outstanding value in dealing with major medical problems.

Evacuation

  During the war, in the Pacific particularly, disease conditions greatly exceeded the number of surgical cases.  At least 70 percent of medical cases in the field can be treated and returned to their units in a relatively short time, so also can 70 percent of the less seriously wounded.  The medical evacuation of experienced soldiers over long lines of communications and their replacement by unseasoned recruits is an expensive and wasteful procedure, unjustified if medical facilities for the care of such casualties can be made available near the front.  Many thousands of minor medical and surgical casualties were so evacuated in World War II.  This practice was unfortunate because such casualties clog the lines of communication and crowd the hospitals to the rear (fig. 271).  They absorbed the attention of personnel much needed forward.  Furthermore, their disabilities tend to become fixed in their minds, particularly in the case of psychoneurotic patients.  It was the experience of the Army in all theaters, and especially in the Pacific, that patients once evacuated from field army areas returned to the fighting front only after long delays, if at all.  Their permanent loss from their units served to exaggerate in the minds of the remaining soldiers the severity of the units casualty rate.  The value of better medical treatment facilities near the front--better equipment and properly trained personnel--thus becomes evident.  In short, excellent medical care yields its highest return to the fighting strength of an army if it is brought to bear upon disease problems as near as possible to the point where they originate.

MEDICAL SERVICE IN FORWARD AREAS

  In World War II, advances in the science of medicine and improvements in equipment, communications, and transportation had made possible a forward movement of good medical service to the frontlines.  This, apparently, was not fully realized or accepted by some officers seemingly obsessed with a concept of evacuation to fixed hospitals.  The attitude of these officers was reflected in the lack of emphasis placed on the professional efficiency of field medical units and on the competency of pivotal medical officers.

It was fully recognized in the Office of the Surgeon General that in a rapidly expanding medical service with most of the officers drawn from civil life, the


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FIGURE 271.-Crowded facilities of 4th General Hospital at Manila Jockey Club, Manila, Philippine Islands, 16 April 1945.

field armies urgently needed the advice of highly trained internists who could visit and directly influence the units concerned with the care of the sick and wounded.  Evaluation of professional personnel, their assignment according to professional qualifications, professional training of units, estimation of the character and quantity of materials needed and of the overall medical service required to meet the demands of impending tactical operations--all were matters requiring expert medical advice.

During the planning phase of operations, however, the services of the medical consultants were not always fully utilized.  In some instances, they had no definite place or fixed responsibility in the office of the army surgeon.

  The evaluation of the professional capabilities of the medical units before entering on an operation makes possible the correction of many defects.  It was amply proved, as the war progressed, that, when the consultants visited units assigned to or earmarked for impending operations, their recommendations, properly implemented, were highly effective in increasing the standards of medical service in these units.  Inadequacies in the quality of personnel, in the training of shock teams, and in the quality of laboratory service noted during


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FIGURE 272.-Lt. Gen. Walter Krueger, USA, Commanding General, Sixth U.S. Army, on A-plus-2-day, visiting clearing station of 7th Infantry Division, Leyte, Philippine Islands, 22 October 1944.

active operations resulted from lack of attention to these matters during the planning and training period.

Unit and divisional medical services supported by surgical and evacuation hospitals--including field hospitals serving as evacuation hospitals--were most instrumental in saving lives and preventing disabilities.  Army consultants believed that the choice medical and surgical personnel should be concentrated at the division clearing station and evacuation hospital levels (fig. 272).  During operations, therefore, the consultants were engaged in briefing new units arriving in the combat area and in visiting units in operation particularly clearing stations; evacuation, surgical, and field hospitals; and, facilities where casualties were being concentrated for further evacuation (fig. 273).  They also supervised shock work and advised the army surgeon on the assignment, transfer, or reassignment of personnel. The greater part of the consultants' time was spent in the medical and shock wards in direct contact with the care of patients.  The experience thus gained brought into focus defects in the human and other material at hand or in the use of these materials.  Reports from the consultants to Sixth, Eighth, Ninth, Tenth, and Fifteenth U.S. Armies (fig. 274) comment in detail upon shortcomings in the


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FIGURE 273.-Extremely busy 24th Field Hospital at recaptured Fort Stotsenburg, Luzon, Philippine Islands. A. Casualties arrive by jeep and ambulance. B. Casualties, medical and surgical, crowded into field house.


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FIGURE 274.-Consultants in medicine, field armies.


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medical service of field units, criticizing particularly the lack of professional training of many of the officers in charge of the medical and laboratory services. The responsibility for this lay both within and without the field army. Officer assignments being usually made during the organization and planning period, field units often came to the army improperly staffed. Within the field armies, not enough attention was paid to evaluating the units on the basis of professional organization and the competency of their personnel. When such surveys were made and recommendations submitted, they were, in not a few instances, ignored. For example, repeated recommendations for the transfer of well-trained officers from subordinate positions where they were malassigned to positions of greater responsibility in keeping with their medical training and experience and in the interest of better medical care were repeatedly refused. In some cases, the problem was met by having a professionally competent junior officer take over the work and responsibility without the corresponding rank, pay, or recognition. This situation was in part, but by no means wholly, due to a shortage of internists. Experience shows that promotions of temporary officers should be conditioned principally by professional efficiency and not by length of service or age.

Within the Sixth U.S. Army area, there was an inadequate number of well-trained internists for the proper staffing of the medical units within the command. It is believed that each field hospital and each evacuation hospital should have as chief of its medical service a Medical Corps officer with qualifications equivalent to the requirements for certification by the American Board of Internal Medicine. The few installations in the Sixth U.S. Army that had well-qualified chiefs of medical service were without exception the units that provided medical service of superior quality. When Col. Harrison J. Shull, MC, reported on duty as Consultant in Medicine, Sixth U.S. Army, there was little evidence that any careful, systematic review of professional qualifications of internists in the Sixth U.S. Army medical units had been carried out, there having been no medical consultant assigned to the Sixth U.S. Army for more than a year. Such an evaluation was undertaken and, upon completion, reassignment was recommended for several medical officers who were obviously malassigned. Not one of the recommended changes was effected, although five of the officers recommended for reassignment had qualifications equivalent to the requirements of the American Board of Internal Medicine or the American Board of Pediatrics.

  Deference to the reluctance of lower echelon commanders to release well-qualified medical officers who had been malassigned, all too frequently prohibited such obviously needed changes.  In addition, the absolute shortage of specialists in internal medicine, and indeed of young Medical Corps officers without specialty training, further increased the difficulty of exchanging and transferring personnel.  As a result, officers once placed in an assignment frequently were fixed there for long periods, even though there might be general agreement as to the advisability of their transfer.  No more important problem


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faces the Army Medical Service in future operations than to provide an adequate method of evaluating and properly assigning its officer personnel.

  The indoctrination of the newly commissioned civilian physician in Army procedures need take relatively little time.  It would seem that services of medical officers in units awaiting active field service could, and should, be utilized by temporary assignments to hospitals in the Zone of Interior and the communications zone or used to augment units of a similar type already committed to combat.  A limited number of officers with units assigned to the latter echelons were brought forward early, and they gained invaluable experience, which added greatly to the effectiveness of their own units when the units entered into active operation.

The tables of organization of both the evacuation and field hospitals, but especially field hospitals, did not permit the assignment of specialists in internal medicine of the higher caliber that medical problems of these hospitals demand. There should be further consideration of the tables of organization of these hospitals with upward revisions to assure official approval of the type of professional officers needed in these installations.

SCOPE OF CONSULTANT ACTIVITIES

  In the preceding pages, the conditions and opportunities peculiar to consultant assignments to field armies have been briefly sketched and illustrated by some particular examples. In what follows, there is somewhat more emphasis on the principles that emerged as a result of these experiences.

  The consultant in medicine in a field army is the representative of the army surgeon in the field of internal medicine.  He is an advisor to the army surgeon general and special problems pertaining to the treatment of disease among the troops.  It is his duty to keep the army surgeon informed as to the quality of medical care being furnished by medical units of the command and to make such recommendations to the surgeon and upon approval of the surgeon, to the units in lower echelon of the command, as the consultant believes indicated for improved care of patients.  Within the army surgeon's office, there should be the closest relationship between the medical consultant and other members of the surgeon's staff to the end that the consultant may make appropriate recommendations concerning the proper assignment of Medical Corps officers with special training in internal medicine, the procurement of special drugs and equipment, and such changes in hospitalization policy as may be necessary for adequate care of the sick.  The consultant can also serve as an extremely valuable medium of exchange of information between units within the field army and between sources outside the field army and medical officers within the command. He also has an opportunity for stimulating excellence of professional


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performance and interest in clinical observations and in continuing self-education among medical officers.

It was unfortunate that a clear-cut, official statement of the duties of professional consultants did not appear in an appropriate War Department publication during the war. Such an official statement would have made it easier for the army surgeon to utilize appropriately the consultants' capabilities and would have made more uniform their activities in all organizations. It would have assisted the consultant greatly in making his way among Medical Department and line officers who frequently are not cognizant of the contributions the consultant is in a position to make.

  Since field armies were the last of the major commands to receive consultants, it is not surprising perhaps that certain aspects of consultant activities were not readily accepted in army commands as fully as they had come to be accepted in the Office of the Surgeon General and in service commands in the Zone of Interior.  When Sixth U.S. Army headquarters was first organized in the Zone of Interior, no professional consultants were assigned.  Absence of these officers during the early days of the army's operations subsequently handicapped the surgeon by a shortage of position vacancies when consultants became available. Furthermore, it made it more difficult for the consultant, when he was later assigned, to integrate his activity appropriately into the operating plan of the army surgeon's office.  The surgeon's office should be, in fact, a team of officers making their best collective contribution to the accomplishment of the surgeon's duties (fig. 275).  It is important, therefore, that the place of the professional consultant on this team be clearly defined and that a professional consultant in internal medicine should function from the beginning and continuously in order that his part in the team play may be utilized to the fullest.  The consultant in medicine should be assigned to each field army well before it starts on its oversea mission, and, when changes in assigned individuals become necessary, the vacancies created should be filled promptly.

Visits to Field Installations

  General activities - No other function of the consultant in a field army is more important than that of making regular visits to field medical facilities.  His activities there may be described briefly, as performed, typically, in the Sixth US Army.

Approximately 75 percent of the medical consultant's time was spent with medical personnel of the forward medical units. Systematic visits were made to each unit caring for patients; that is, field, evacuation, and portable surgical hospitals and clearing stations.  In addition, visits were made to division surgeons and corps surgeons and their assistants in venereal disease control and to the division medical inspector. In the Philippines and in Japan, transportation for such visits to readily accessible units was by motor, usually jeeps, while more distant, less accessible units were visited by plane or, in some instances, by boat.  Often, the medical and surgical consultants


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FIGURE 275.-Officers of the medical sections, Third and Eighth U.S. Armies. A. Medical Section, Headquarters, Third U.S. Army, Frankfurt Germany, April 1945.


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FIGURE 275.-Continued. B. Medical Section, Headquarters, Eighth US. Army, in the Philippines, 29 March 1945.

or the medical and neuropsychiatric consultants traveled together, as this joint effort proved mutually helpful.  The sharing of local facilities for shelter and food with officers of the unit being visited contributed to an understanding of the personal problems of medical officers mind to a closer relationship between the professional consultants of the army surgeon's office and individuals in the field units.  Every effort was made to have internists, in the field unit in particular, and all medical officers, in general, feel that in the medical consultant each medical officer had a professional friend with a keen interest in his personal problems, having himself no interests except those concerned with the care of patients.  Such relationships were often of value in extending the effectiveness of the consultant's work.

At each unit, care was taken to visit individual patients on the wards with the medical officer in charge.  Here, it was possible to evaluate the quality of diagnostic studies and therapy.  In bedside discussions, suggestions for further management, as indicated, could be made tactfully.  It was sought to have as many officers of the medical service as possible attend such ward rounds and, when possible, officers responsible for laboratory and X-ray studies were asked to be present also. These informal bedside discussions concerning patients proved to be exceedingly illuminating and professionally stimulating both to medical officers in charge of patients and to the consultant.


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FIGURE 276.-Army headquarters area, Sixth U.S. Army, San Fernando, Pampanga, Luzon, Phillipine Islands, 20 May 1945.

  Observations on the professional proficiency of individual medical officers would be used as a guide in making recommendations to the army surgeon's headquarters concerning appropriate assignments (fig. 276).

Supply problems at local installations were also reviewed as they related to the management of patients, in order to obtain assistance at army headquarters in correcting deficiencies (fig. 277).

  Exchange of ideas. -The movement of the consultants from one command to another served as a valuable means of exchanging ideas and information.  Every effort was made by means of available publications, directives, bulletins, and by conversation to bring to each group the latest information available bearing on field medicine; for example, the technique of penicillin therapy in the early days of its use.  By reason of their daily contact with all of the medical services in in the area, the consultants were able to keep the surgeon informed as to the capabilities of the various units and the patient load they could carry.  In addition, the consultants in an area were able to pass on to newly arrived units the experiences of units already engaged in active operations.  Often, newly arrived medical officers were assigned to the front to augment active units.  The consultants were able to train these officers before their own units were actually put into active operations.


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FIGURE 277.-Medical supply services in a field army. A Sixth U.S Army Medical Supply Depot, Tarlac, Phillipines, 1945. B. Medical supply point, 34th Infantry Division, Italy, 1945.


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Dissemination of Professional Information

  One of the unfilled needs of field armies during World War II was the provision of adequate professional information to medical officers with forward units.  The farther forward in the combat area the medical officer was assigned, the more difficult it was for him to get help from medical literature and Medical Department publications concerning professional practices. Thus, the battalion surgeon in his aid station frequently had little or no available reference material.  Although technical bulletins of the Medical Department are intended to reach medical officers in the forward areas, these bulletins frequently failed to arrive.  The facilities for distribution of the War Department technical bulletins were not adequate to place these publications in the hands of the medical officers with combat troops.  Nor indeed were these bulletins delivered with sufficient regularity and promptness into the hands of medical officers of mobile hospital units.  The distribution of the Bulletin of the U.S. Army Medical Department, which was mailed by APO number to individual medical officers wherever possible, was received with greater regularity and more promptly.  Library facilities in the form of textbooks were generally available in the mobile medical units. Current journals were received from time to time but usually several months late.  It was, therefore, needful for the medical consultant to interest himself in the dissemination of medical information.  He was sometimes able to assist in obtaining textbooks and journals. Because of the special value and importance of Medical Department technical bulletins, it was arranged to have published for all the hospitals of the commands an up-to-date list of the bulletins and instructions as to how the missing issues might be secured. The bimonthly Sixth U.S. Army Medical Bulletin served for timely comment concerning matters of importance. Also, as has been noted, the consultant transmitted verbally pertinent information obtained at one installation to others throughout the command.

Training and Refresher Programs

  Opportunity for continued training, professional refreshment, and self-education should be provided in maxim amount in Army installations.  Encouragement of medical meetings, formal ward rounds, journal clubs, and similar educational exercises in field armies during times of action did not, however, meet with much success.  Often, there was lacking in these hospitals the type of professional leadership that makes regular rounds on the medical services and between the medical and surgical services a stimulating experience.  In addition, the mobile character of the unit, with fluctuating patient loads under combat conditions, frequently in made organized rounds and, especially, formal medical meetings difficult to maintain.  Except in isolated instances, encouragement of these activities met with little enthusiasm.  With improvement of the quality of professional personnel in mobile units by the addition of medical officers with interest and training in teaching procedures, it should be possible to stimulate greater interest in local exercises for self-education.


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  After the close of the Luzon campaign, three plans were instituted with the purpose of professional refreshment. One of these had as its aim the further training of laboratory technicians, with the hope of continually improving the quality of laboratory technical work in forward installations.  It was arranged to send selected laboratory technicians from each army medical installation to the 26th Medical Laboratory (Sixth U.S. Army) for a period of refresher training. 3 A second educational plan was the holding of clinics at selected forward medical installations for members of their staffs and Medical Corps officers in the adjacent area on professional problems arising in forward areas.  One series of such clinics was concerned with dermatologic conditions.4 To supervise and conduct these clinics, the Sixth U.S. Army headquarters was fortunate in having assigned Lt. Co. Charles L. Schmidt, MC, as Consultant in Dermatology, Sixth U.S. Army.  The clinics in dermatology were received with enthusiasm.

The third type of refresher training was inaugurated and conducted under the auspices of Army Forces Western Pacific in fixed installations of the communications zone.  Refresher work of 4 weeks' duration was offered in tropical climates and laboratory procedures, as well as in general internal medicine.  This program was hardly under way when hostilities ceased, and the courses were abandoned.

Cooperative Relationships

  The medical consultant maintained the closest professional relationships with the surgical and neuropsychiatric consultants, to their mutual benefit.  Although in the Sixth U.S. Army the neuropsychiatric consultant was assigned officially as assistant to the medical consultant, he was requested by the medical consultant to carry on his activities freely and directly with the Army surgeon.  It is believed that the neuropsychiatric consultant should hold an assignment in the army surgeon's office comparably to that of the medical and surgical consultants.  Relationships with the medical inspector (preventive medicine officer) were likewise close and helpful.  Although a satisfactory working arrangement in relation to the army medical laboratory was agreed upon with the medical inspector, whereby the medical consultant was expected to interest himself in laboratory procedures as they relate to the care of patients in army hospitals, it should again be pointed out that clinical laboratory procedures are most intimately the concern of the internists in the army area.  Laboratory examinations related to preventive medicine, such as food and water analysis, constitute a relatively very small part of the work of the army laboratory.  Furthermore, the internist is by official and professional problems that

3 (1) Memorandum, Consultant in Medicine, Sixth U.S. Army, to Acting Surgeon, 23.July 1945, subject: Refresher Course in Laboratory Procedures. (2) Letter, Office of the Surgeon, Headquarters, Sixth U.S. Army, to Consultant in Medicine, 27 ,July 1945, subject: Refresher Course in Laboratory Procedures.

4 Memorandum, Consultant in Dermatology, Sixth U.S. Army, to Consultant in Medicine, 25 July 1945, subject: Instructions in Common Dermatological Problems and Outline of Instruction Course in Dermatology.


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concern the laboratory personnel than is the medical inspector.  Experience indicates that the consultant in medicine rather than the preventive medicine officer should have supervisory responsibility over laboratory procedures within the army area.

Liaison with the statistical section of the surgeon's office was close and satisfactory, as it was also with the supply section.

  In order to serve most effectively, the consultant should have a broad general knowledge of the plans for an operation as they are advanced.  He should be informed as to anticipated conditions of the objective, the terrain, sanitation, water supply, density of civil population, disease prevalence, and expected resistance.  He should have kowledge as to troop strength and as to the number and character of supporting medical units and the echeloning of such units.  In some instances, the rather curious attitute was taken that mature, highly trained officers accustomed to dealing with confidential matters in other branches with little background of experience or training.  The medical consultant is the adviser to the army surgeon in all matters that fall within the field of his special knowledge and should deal freely with the sections on plans, training and operation, personnel, preventive medicine, and supply.

  The consultant in medicine in the Sixth U.S. Army made a special effort to maintain closest relationship and frequently to exchange information with the consultants of medicine in the Eighth U.S. Army in Army Forces, Western Pacific and in Army Forces, Pacific.  On more than one occasion, arrangements were made to have one of these consultants visit installations within the Sixth U.S. Army area and to assist in the handling of professional problems existing there.

SUMMARY AND COMMENT

  The experience of medical consultants with the field armies was similar to that of medical consultants generally in the Second World War.  It was their particular mission to activate the principle that it is now possible to bring good medical care to the frontlines.  The policy of evacuation to fixed hospitals is wasteful from every point of view; some 70 percent of medical cases and of the less severely wounded, can be treated in forward areas and returned promptly to their units. The consultants were therefore basically concerned with the proper evaluation and full use of the professional capabilities of all medical officers and with the equipment and organization of all field installations.  It is here, indeed, that the best in medical care can make its most direct contribution to maintaining the fighting strength of the Army.

  The medical consultants were directly concerned with training medical units, before a tactical operation when possible, and with the dissemination of ideas and medical information.  By the logic of experience, clinical laboratory procedures in the field and the treatment of shock became their special interests.  They were concerned with clinical studies which, in spite of dif-


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ficulties in forward areas, yielded some results of great imediacy, as in the use of new drugs and antibiotics, and new therapeutic techniques.

The aim of this chapter has been to present, in a general way, the duties of medical consultants assigned to field armies, the difficulties they encountered, and the conditions they thought might be improved. A disproportionate amount of attention has perhaps been paid to these considerations and not enough to the excellence of the performance of the field army medical units. There is ample statistical proof that never before had such units reached such a high degree of efficiency as they did during World War II.