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Foreword

Activities of Medical Consultants

This volume, the seventeenth to be published in the total series concerned with the history of the U.S. Army Medical Department in World War II, deals with internal medicine and is the first of a series of three volumes on this subject. Its nine chapters were written by thirteen authors, all of whom speak with the authority of peacetime training and experience supplemented by their wartime service as consultants in internal medicine.

Because this is the first volume of the history to relate the story of the consultant system in World War II, some comments should be made which, while specifically applicable to internal medicine, are also applicable to all other specialties.

When the first consultant reported for duty in the Office of the Surgeon General, in February 1942, he found no official statement of a consultant’s functions. A Professional Services Division had existed in this Office since 1925, but its scope was limited and its functions were chiefly administrative. The organization and potentialities of the consultant system had to be established in World War II, and by trial and error.

For a number of reasons, the extension of the system was slow and difficult. The War Department, Services of Supply (later Headquarters, Army Service Forces), which had general cognizance of these matters in the Zone of Interior, was poorly informed on, or knew nothing at all about, medical needs. There were therefore long delays in setting up necessary positions. Even when malaria was incapacitating thousands upon thousands of troops, it was eight months after the request was made before a consultant in tropical medicine was appointed in the Office of the Surgeon General. The management of venereal disease was placed under preventive medicine officers, many without clinical experience in this field, while the internists, who necessarily treated it, acted as their agents. Similarly, laboratories, although their functions were almost exclusively clinical, were placed under preventive medicine control. This made for particular difficulties in the Pacific Ocean areas, where laboratory tests were frequently essential for diagnosis. Incidentally, in every theater, until the medical consultants stepped in, there was generally an excess of requests for laboratory work.

Since consultants had not been envisaged in prewar medical planning, both they and the command surgeons under whom they worked were plagued, until the end of the war, by the lack of position vacancies for them, as well as by embarrassing questions of rank. Moreover, the consultants, no matter in what command they were stationed, stressed the inconvenience and inefficiency caused by lack of effective channels of communication between themselves and the consultants in the Office of the Surgeon General. When such contacts existed, they were unofficial.

When the first consultants were appointed, there was a tacit understanding that they were to confine their activities to clinical problems. Before the war ended, these activities had been necessarily extended to a variety of other matters, including personnel, supply, and hospitalization and evacuation policies.

Personnel responsibilities, next to clinical responsibilities, became the major concern of the consultants, as might have been expected. In wartime, just as in peacetime, the availability and proper employment of qualified professional personnel determined the quality of medical care. Originally, the distribution of the limited number of such personnel was uneven and inefficient. Correction of the maldistribution was not easy, one reason being the lack of any standards of classification. The Military Occupational Specialty rating, which would have solved many questions of both assignment and promotion, did not become available until late in the war. Nevertheless, in spite of the handicaps under which they first operated, the consultants soon became the best informed officers in any command on the professional personnel in it, and officers in charge of personnel assignments soon learned not only to rely upon their advice but to ask for it.

The magnitude of the tasks of the consultants depended upon a number of considerations, including the size of the command, the number and type of installations in it, the total troop strength, and, most of all, the degree of their acceptance by the command surgeons under whom they served. This book relates frankly and realistically the troubles which arose because of the consultants’ lack of experience in military matters and the initial failure of Regular Army medical officers to appreciate what they had to offer in the way of specialized medical services. From their peacetime experience, most of these consultants had a correct concept of the functions of a consultant, and, because they were imaginative and resourceful, they were soon able to translate their peacetime concepts to military necessities. In most instances, they readily adapted themselves, as they sometimes had to at first, to working in headquarters that were at best indifferent and at worst hostile, without losing their independence and individuality. It is a tribute to their tact as well as their competence that the early opposition to them gradually disappeared and that the consultant system spread from a few commands in the Zone of Interior to other commands in this country and overseas, including field armies. Until the middle wall of partition was broken down, the medical care of the sick and wounded soldier did not reach its fullest efficiency.

The goal of the consultants in internal medicine and its subspecialties was prompt, accurate diagnosis and optimum therapy, in order to reduce hospitalization time and return soldiers to duty without unnecessary loss of time, in line with the Medical Department’s overall mission of maintaining an effective fighting force. The results were surprisingly good, though the degree of success naturally varied according to evacuation policies and special circumstances of the theaters.

Although the problems of every theater were fundamentally the same, they varied widely in details. In the Pacific Ocean Area, for instance, problems were both organizational and physical. Farflung hospitals, once built, had to be equipped, staffed, and then kept supplied. Bases were isolated. Living conditions were frequently primitive. Lines of evacuation were long. There was, as one consultant put it, “a startling lack of qualified personnel,” and there were few highly qualified replacements or increments during the course of the war. The most strenuous efforts of the consultants could not overcome an unavoidable misuse of limited personnel.

There were special problems in the Pacific Ocean areas as well as in the India-Burma theater even when there was no active combat. The stresses and strains of the hot, humid climate, the torrential rains, the mosquitoes and other insects, the lack of recreation, the sense of remoteness, the many frustrations, all presented the consultants with situations that involved human relations quite as much as professional matters. Their work had much to do with the fact that medical officers, fresh from civilian practice, to their everlasting credit, accepted uncongenial assignments; adapted themselves to environments in which they were neither comfortable nor happy and to regulations with which they had little sympathy; and, withal, performed an outstanding job of medical care.

Visits to hospitals and other installations were the principal means by which the consultants controlled clinical practices. All of them spent 75 percent or more of their time away from their headquarters; the consultant for the India-Burma theater traveled more than 40,000 miles. They were thus able to check completely, or spot check, the care of patients; correct errors; overcome areas of ignorance; disseminate information; observe and evaluate the performance of individual medical officers; and generally insure that the sick soldier was receiving the best possible care. The practice of all consultants of reviewing and analyzing all protocols had, as one of them noted, “a salutory anticipatory effect” on medical practice in all hospitals.

The medical consultants had to direct the care of every conceivable civilian disease. Many such diseases appeared in strange manifestations outside of their usual environment. Others had long since been controlled in the United States or did not occur at all here. Spot surveys showed the general accuracy of preinduction screening for tuberculosis, but special situations arose, as in the European theater, when Soviet prisoners of war and later Recovered Allied Military Personnel were released or when the notorious German concentration camps, such as Buchenwald, were liberated. Tuberculosis was also always a potential problem in thie United Kingdom, where milk was not pasteurized, and it was the custom to keep men with minimal disease in service on limited duty. Atypical pneumonia required special consideration because it was a relatively new disease. So was infectious hepatitis, which occurred, often alarmingly, in every theater.

The native smallpox rate in the India-Burma theater was the highest in the world, but there were only 40 cases in U.S. Army personnel, all attributable to errors in vaccination.

Allergic diseases ranged from trivial disorders, such as certain dermatologic conditions, to those which were very serious, such as bronchial asthma. They accounted for much incapacity, and it was soon learned that in some tropical areas the simplest and most efficient way to handle them was to send the soldier out of the environment. Dermatologic diseases formed a highly specialized field, in which most consultants in internal medicine had little to contribute except, as one remarked candidly and ruefully, “encouragement and interest,” plus the firm resolve that the postwar teaching of dermatology must be improved in all medical schools. A dermatologic consultant, along with the proper assignment of dermatologists, proved a paying investment, for in 90 percent of such conditions return to duty was possible within a 30-day period.

Malaria was no problem in the European theater until troops from the North African theater were redeployed in the fall of 1943 and the winter of 1943-44. Similarly, it was no problem in the Zone of Interior until casualties from the North African theater and the casualties from the tropical theaters began to return. It was originally a major problem, of most serious proportions, in certain areas of the Pacific, while in the India-Burma theater, probably the most malarious area in the world, 40,000 U.S. Army casualties were treated before the situation was brought under control. U.S. Army medical officers had had little practical experience with malaria, and what little experience they had had was entirely inapplicable to the disease in these areas. New lessons of both diagnosis and therapy had to be learned, particularly with respect to cerebral malaria, which accounted for most deaths from the disease. Relapses continued an almost insoluble problem until the end of the war.

The number of diseases encountered in the tropical theaters, in addition to malaria, ran a bewildering gamut. Fever of undetermined origin furnished endless diagnostic problems. Multiple diseases in the same victim were common. Because of the high native incidence and its insidious character, amebiasis was originally rampant, but it was brought under control by preventive measures, prompt diagnosis, identification of carriers, adequate therapy, and careful followup. Although cholera, plague, and yellow fever were endemic in the India-Burma theater, not a single authentic case occurred in U.S. Army personnel. Other diseases encountered in tropical theaters included every variety of diarrheal and dysenteric disease; typical and atypical lichen planus; schistosomiasis; filariasis; dengue fever; hookworm; Japanese B encephalitis; scrub typhus; sandfly fever; and typhoid and paratyphoid fever. A number of cases of lead poisoning occurred before it was diagnosed and its origin traced to careless exposures to leaded gasoline.

Neuropsychiatry was considered originally a subspecialty of internal medicine, and even when it became a separate specialty its management was always most effective when the consultants for all specialties worked in close cooperation. In every theater the problems were the same. In the beginning, too many patients were hospitalized who would have been better off if treated at the outpatient level. As a result, salvage was disappointing. It improved when major emphasis was placed on prevention and treatment in forward areas. There was no administrative provision for research, and the original policy was to discourage what could have been undertaken. Of necessity, this policy changed. New methods of therapy had to be worked out for unfamiliar diseases. New agents had to be tested, such as Atabrine, penicillin, and streptomycin. Sulfonamides in tropical climates required adjunct therapy. Prior to the availability of penicillin, the decision to use massive arsenotherapy in the European theater in the management of syphilis required both courage to institute it and clinical testing. In spite of all of these endeavors, there was a regrettable loss of valuable clinical material in every theater, as well as a loss of statistical data, because the machinery for their collection and preservation simply did not exist.

An interesting part of this book is the story of the warm and helpful relations of U.S. Army medical officers and their Allied opposite numbers. In the European theater, there were 24 Inter-Allied conferences, with 220 speakers, attended by more than 6,500 Allied medical officers, and furnishing, as the chief consultant in medicine for the theater remarked, “an object lesson in international amenities.” These and other conferences played an important part in the educational activities of the consultants, who followed the civilian principle that when educational standards are highest, medical care is best.

This book is a record of past wartime experience, but it has in it the plans and policies many of them based on the experiences recorded in the history of the U.S. Army Medical Department in World War I--which must guide us in our preparations for a possible future war. It should be read with calm reflection in peacetime, to determine the measures which can most usefully be employed in wartime. It contains a frank and realistic account of errors which must not be made again. The consultant system will be instituted in toto on the outbreak of another war, for it is now an integral part of medical care in the Regular peacetime Army. In World War II, there was a steady improvement in medical care from week to week and from operation to operation. If there is a next time, improvement must come even faster.

Like other clinical volumes in this series, this volume has much in it of value for peacetime medicine.

Even to one who knows the story of medicine in World War II because he was part of it, this book makes interesting, and frequently thrilling, reading. I express my gratitude to the consultants in internal medicine and allied specialties who helped to create the achievements related in it; to those who recorded them; and, again, to those who are producing these volumes.

LEONARD D. HEATON,

Lieutenant General,

The Surgeon General.