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Chapter XX

Contents

CHAPTER XX

Dermatology

Donald M. Pillsbury, M.D., and
Clarence S. Livingood, M.D.

Part I. Administrative Considerations

GENERAL CONSIDERATIONS

Diseases affecting the skin, though not of great importance from the standpoint of the deaths they cause, are of major importance to an army operating in the field, because of the high morbidity and ineffectiveness that they can produce.1 Hospital admission rates for these conditions give an incomplete and inaccurate picture of their potentialities for producing ineffectiveness for the reason that a very large proportion of them are treated in dispensaries and at sick call on a duty status.

When the "Manual of Dermatology,"2 which was prepared under the auspices of the NRC (National Research Council), was published in 1942 (p. 548), the latest figures available for skin diseases in the U.S. Army were for 1940, which means that they were for peacetime and that they did not reflect the rapid increase to be expected-and that occurred-under conditions of military expansion and actual warfare. In 1940, nonetheless, diseases affecting the skin accounted for 9.8 percent of all entries on the sick list and for 10.41 percent of all man-days lost. Venereal diseases (exclusive of gonorrhea), that is, syphilis, chancroid, lymphogranuloma venereum, and similar diseases, accounted for an additional 3 percent of all hospital admissions. In the U.S. Navy, over the preceding 10 years, diseases of the skin produced 9.79 percent of all admissions to the sick list, and 8.65 percent of all man-days lost; venereal diseases (exclusive of gonorrhea) accounted for about 8 percent of all hospital admissions.

It was evident, well before the United States entered World War II, that dermatologic diseases would constitute a major cause of partial disability and lost man-days. In the Zone of Interior, where their impact was first felt, their incidence varied with the location of the troops and the season of the year. It was much higher, understandably, in the southern part

1Appreciation is expressed to Dr. Robert Stolar for his work in assembling the source material upon which much of this chapter is based.
2Pillsbury, Donald M., Sulzberger, Marion B., and Livingood, Clarence S.: Manual of Dermatology. Military Medical Manuals. Issued under the auspices of the Committee on Medicine of the Division of Medical Sciences of the National Research Council. Philadelphia: W. B. Saunders Co., 1942.


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of the country, particularly during hot, humid summer months, because of insect bites that became excoriated or infected, superficial pyogenic and fungal infections, severe miliaria, and dermatitis from plants and other contacts. It was far higher in some oversea theaters, such as the Pacific Ocean Areas, than in more temperate climates, such as the European theater. Everywhere, however, medical officers were confronted with active and latent dermatologic diseases, with all the circumstances favorable to recurrence, reinfection, and relapse, as well as to fresh infections in new hosts. These were superficial conditions, it is true, but they required an undue amount of attention when they were treated on an outpatient or sick call basis, and they accounted for undue bed occupancy in hospitals.

Many wartime hospital reports carry the statement that dermatologic disabilities could have been cut in half with improved methods of treatment and if the patients had been brought into contact, in the initial phases of their illness, with properly qualified dermatologists. It was also frequently noted, in hospital and other health reports, that, if battalion surgeons and other medical officers assigned to dispensaries had had adequate training in dermatology, there would have been significant decreases in the so-called overtreatment syndrome. These comments assume special significance if it is borne in mind that, in some tropical oversea areas, dermatologic diseases accounted for as much as 75 percent of all visits to dispensaries.

Obviously, these are diseases of serious military potentialities. Yet in spite of that fact, the statement may be made with considerable confidence that before the outbreak of World War II, and indeed until it was almost half over, diseases of the skin received less attention, both administratively and therapeutically, than any other major source of disability. Both civilian and military medicine contributed heavily to this situation for a number of reasons, some of which will be discussed in greater detail later in this chapter.

1. As late as 1942, diseases of the skin were still being cared for in Army hospitals on the urology service, an archaic arrangement that had been discontinued in civilian practice a quarter of a century earlier. This policy was not officially discontinued in the Army until 1943, except upon the initiative of commanding officers of a number of individual station and general hospitals. These officers organized dermatologic services and handled all patients with diseases affecting the skin on wards that ordinarily included both dermatology and syphilology. This plan was firmly established in all hospitals by the end of the war, though the changeover was accompanied by numerous administrative difficulties.

2. Before World War II, the United States had seldom had large bodies of troops in tropical areas for long periods of time. There was therefore little realization of the tremendous increases in the incidence of common skin diseases that would occur under conditions of prolonged heat and humidity. The attention given to unusual medical diseases peculiar to the


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Tropics, fully justified though it was, far overshadowed the attention given to the remarkable exacerbation to be expected in frequently encountered but less exotic dermatologic conditions. The British, with their long and worldwide colonial and military experience, fully appreciated the situation. The United States, with its smaller and more limited experience, did not.

3. Little attention was paid to dermatology by the National Research Council.3 In the prewar period, and well into the war, a single civilian physician was charged with all dermatologic problems in the Division of Medical Sciences. There was no subcommittee for dermatology, as there was for numerous other specialties, and no specific research was directed toward either the prevention or the management of diseases of the skin under military conditions. In fact, there was no national research program in depth set up to investigate physiologic and pathologic factors in dermatologic disability.

3Lest the impression be created that little assistance was provided by the National Research Council in dermatological matters to the Army during World War II, it is desired to point out the very specific and valuable assistance given in the matter of control of fungal infections of the feet ("athlete's foot"). This was a chronic and perennial problem amongst troops forced to live close together in a barracks environment.

Prewar instructions for the prevention of athlete's foot required the use of chlorine solutions prepared daily (usually made from calcium hypochlorite) for footbaths in shower rooms, and the daily exchange and sun-drying of duckboards placed on the floor of such rooms. Moreover, responsibility for the supervision of such measures was made a command responsibility and therefore placed directly on the shoulders of the unit commander. Labor details were assigned to this task and many man-hours were expended daily throughout the Army in their execution.

Despite these vigorous measures over the years there appeared to be no appreciable impact upon the incidence of athlete's foot and the question of their continuing value was raised. To resolve this matter, the question was placed before the Division of Medical Sciences, National Research Council, during 1944. Opinion was divided amongst the dermatologists, but the most anyone would say on behalf of existing prophylactic measures was that they could do no harm. With this consensus, it was finally agreed that the Army could safely discontinue such measures, and action was initiated to that end by the Sanitation and Hygiene Division of The Surgeon General's Office.

At a talk given at the Service Command Medical Inspectors' Conference in Baltimore, Maryland, on 14 February 1945, Lt. Col. (later Col.) Arnold L. Ahnfeldt, MC, Director of the Sanitation and Hygiene Division, Preventive Medicine Service of The Surgeon General's Office, stated that widespread doubt concerning the value of present footbaths had now been confirmed by the National Research Council. As Colonel Robert J. Carpenter, the Executive Officer for The Surgeon General, reported in an indorsement to the Commanding General, Army Service Forces, on 29 March 1945, the comments of Colonel Ahnfeldt at the Medical Inspector's Conference were being translated into action. As a result, War Department Circular No. 146 of 17 May 1945 was prepared and published. Paragraph I, Athlete's Foot, directed that "The use of foot baths containing chemical solutions for the prevention of dermatophytosis of the feet is hereby discontinued."

This directive resulted in a substantial saving of calcium hypochiorite which was in critically short supply and was needed for other highly important purposes, such as water purification. Moreover, there was no further need to spend time on the daily preparation of chlorine solutions for footbaths.

A short while later, the publication of War Department Circular 262, dated 30 August 1945, made the use of "duckboards" in shower rooms optional, pointing out they "are of value only in the prevention of accidents" and thereby indicated their lack of value in the prophylaxis of athlete's foot. This circular led to the almost immediate discontinuation of the use of duckboards in showers and on aprons of swimming pools Army-wide.

Thus, the two War Department Circulars cited did away with long-standing practices within the Army mistakenly designed to prevent athlete's foot. Attesting to the wisdom of the recommendations of the Division of Medical Sciences, National Research Council, in this matter is the fact that there was no subsequent increase in the incidence of athlete's foot amongst troops with discontinuation of these prophylactic measures, and no increase since that time attributable to the change in policy. Instead, unit commanders were able to breathe a sigh of relief, and many man-hours expended in labor details Army-wide were diverted to other uses.-A. L. A.


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4. The training of specialists in dermatology was, in many civilian centers, superficial and narrow. Trained dermatologists were in short supply throughout the war, and the shortages were increased by the lack of any system in the Army for assigning those with special training to areas or units with high admission rates for skin diseases (p. 571).

5. The consultant system, which operated so successfully in many other branches of medicine, was slow to operate in respect to dermatology, a situation that helped to explain the poor assignment of dermatologists just mentioned.

6. Numerous large general hospitals, including some affiliated hospitals, were sent overseas without a single medical officer on the staff who had even a cursory knowledge of diseases of the skin. The tables of organization for these units originally had no provision for a dermatologist, and the Personnel Division, OTSG (Office of The Surgeon General), apparently saw no need for providing one.

7. Tables of equipment were extremely inadequate, and often entirely deficient, in provision of agents necessary for topical medication.

8. Finally, as was true of other specialists, dermatologists failed to realize the potent sensitizing capacity of many new therapeutic agents, whether injected, ingested, or used topically. When the war began, the potentialities for harm of the sulfonamides were slowly being realized, but the story of penicillin, Atabrine (quinacrine hydrochloride), and many other compounds remained to be told.

EVOLUTION OF DERMATOLOGIC MANAGEMENT

By the fall of 1941, when it was evident that the United States would be drawn into the war and that dermatologic disability would be a considerable problem in the Army, many commanding officers, particularly of hospitals in training areas, began to request the assignment of medical officers with some experience in dermatology. Their requests were often based on the initial requests of chiefs of medical services, who found themselves unable to deal effectively with the numbers of patients with skin diseases who, under the existing arrangements, were occupying medical beds for long periods of time.

Improvement of the situation was accomplished, for the most part, by the individual efforts of individual medical officers and civilians rather than by any single centralized effort. Until late in the war, chief surgeons, medical consultants, and individual hospital commanders met the problem in various ways, and, as might have been expected, with varying degrees of success.


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Action in National Research Council

The first general efforts to remedy the situation were made in the National Research Council, with the appointment of Dr. Donald M. Pillsbury, Professor of Dermatology, University of Pennsylvania School of Medicine, as Consultant in Dermatology to the Committee on Medicine, Division of Medical Sciences. His specific responsibility was to make recommendations concerning this specialty for the Armed Forces by way of this committee. It was a small beginning, but highly important; it was the first time any governmental or quasi-governmental organization had ever concerned itself specifically with diseases affecting the skin.

The previous lack of interest in this specialty was not hard to explain. The NRC Committee on Medicine, although composed of physicians of the highest ability and repute, was only mildly concerned with dermatology. Most of the members of the Committee on Medicine came from medical schools on the eastern seaboard, where skin diseases were regarded as minor problems and where, with occasional exceptions, dermatology had never achieved any special recognition. The appointment of a consultant on dermatology to the Committee on Medicine was an advance, but in retrospect, the additional appointment of a subcommittee on dermatology would have been a wiser move.

A development that was ultimately related to Dr. Pillsbury's activities was, as already mentioned, the initiative of the commanding officers of certain station and general hospitals in setting up sections of dermatology and syphilology headed by qualified dermatologists who were called to active duty from civilian practice. Col. Asa M. Lehman, MC, for instance, sponsored and actively encouraged the organization of such a section at the Indiantown Gap Station Hospital, Pa., which served a large training camp that had been set up early in 1941. Colonel Lehman, a veteran medical officer with a large oversea experience, was an extremely astute physician, who had a considerable knowledge of disability from dermatologic disorders, particularly in the Philippines. He was greatly disturbed by the lack of any organization within the Medical Corps, as well as the lack of personnel and supplies, to deal with this group of diseases. He solved the problem by setting up a dermatology and syphilology section, with Capt. (later Maj.) Clarence S. Livingood, MC, as chief of the section.

At Colonel Lehman's invitation, Dr. Pillsbury visited this hospital on numerous occasions and held long conferences with him and Captain Livingood. The latter soon accumulated an impressive body of statistics that showed very clearly that skin diseases were extremely frequent and that early mismanagement of even simple conditions could lead, at times, to prolonged disability and, on occasion, to separation from service. In a number of instances, key combat personnel, for this reason, had been unable to accompany their units overseas.


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Preparation of Manual on Dermatology

The substance of these discussions was communicated to Brig. Gen. Charles C. Hillman, Chief, Professional Service Division, OTSG, who was then representing the War Department on the National Research Council. General Hillman brought the matter to the attention of Maj. Gen. James C. Magee, The Surgeon General, with the recommendation that special policies be developed to deal with dermatologic disability. He also recommended that a short technical directive be issued for the information and guidance of medical officers who had to deal with the more common dermatologic syndromes.

As the result of these recommendations, The Surgeon General invited Colonel Lehman, Captain Livingood, and Dr. Pillsbury to a conference with him and General Hillman early in 1942, to discuss the preparation of a manual on dermatology, which General Hillman proposed be carried out under the auspices of the National Research Council. The Surgeon General approved the plan, and the National Research Council concurred in the arrangement.

Dr. Pillsbury and Major Livingood had only just begun their work on the proposed manual when Capt. Charles S. Stephenson, MC, USN, who was representing the Navy on the National Research Council, became interested in the project and asked that it be pursued as a joint Army-Navy effort. Lt. Cdr. (later Capt.) Marion B. Sulzberger, MC, USNR, was therefore added to the authors. With the warm encouragement of General Hillman and Colonel Lehman, the work proceeded rapidly in spite of the transfer of Major Livingood, in May 1942, to the 20th General Hospital, Camp Claiborne, La.

Though the format was different, this manual became one of the series developed under the auspices of the Division of Medical Sciences, NRC, and designed to furnish the Medical Departments of the U.S. Army and Navy with compact presentations of essential information in the field of military medicine. While it is unfortunate that it was not ready when mobilization began in 1940 and 1941, in one sense the delay was an advantage: The whole text was written in the light of current, practical experience in military dermatology, with the most pressing needs of the general medical officer in mind. The subject matter was strictly limited. It concerned only the common skin diseases affecting males of military age. Methods of treatment were restricted to those expected to be available in the usual Army and Navy installations. The manual had a wide distribution, though it did not become available in many units overseas for a year or more after its publication. The total printing of 40,500 copies made it, in this respect, much the largest of all the NRC manuals published.

It is difficult to assess the real impact of any technical bulletin or manual upon medical practices in the Armed Forces. It is believed, however,


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that this small, compact volume exerted a great deal of influence. For one thing, since it had the personal attention and backing of The Surgeon General in the Army Medical Department and the Navy Bureau of Medicine and Surgery, as well as of ranking officers in both services, attention was focused on the medical problems with which it dealt. There seems no doubt that, as the result of its publication, increasing efforts were made to achieve better professional care of dermatologic diseases. There were also improvements in the supply tables of drugs essential for the treatment of these diseases.

Recommendations for Development of Dermatology Service

Meantime, dermatology was receiving further attention in the Office of The Surgeon General. Shortly after Col. Arden Freer, MC, became Director of the Medical Practice Division, OTSG, in October 1942, he requested Lieutenant Colonel (later Colonel) Pillsbury, who had entered the Medical Corps and had been assigned to Walter Reed General Hospital, Washington, D.C., to submit recommendations for the organization and equipment of Army station and general hospitals, for the improved care of dermatologic patients.

Colonel Pillsbury regarded "the request for the opinion from a military medical neophyte" as presenting "a calculated risk," but, with the collaboration of Major Livingood, undertook the assignment. Their recommendations were based on the material included in the "Manual of Dermatology" and on data collected from various sources for the Committee on Medicine, NRC, during the previous year. In one way or another, the organization and facilities recommended were achieved in almost all station and general hospitals by the end of the war.

The substance of Colonel Pillsbury's reply to Colonel Freer, on 25 October 1942, was as follows:4

Incidence.-During 1940, skin diseases were responsible for about 8 percent of admissions to Army hospitals, but the proportion can be expected to vary widely under different conditions. Troops in warm climates will show sharp increases in fungal and pyogenic infections. Troops on maneuvers will show increases from extensive contact with plants. Parasitic skin diseases will increase in some theaters of operations.

Facilities.-On the basis of these estimates and projections, about 5 percent of all hospital beds should be kept regularly available for dermatologic patients, and provision should be made for the expansion that may be necessary.

Since most dermatologic patients are ambulatory and are treated on an outpatient basis, facilities for their examination and treatment, as well as for the maintenance of adequate records, must be correspondingly larger than for other dispensary sections. Figures from the Indiantown Gap Station Hospital show outpatient visits to the dermatology clinic to be two or three times more numerous than inpatient admissions. These figures are likely to be duplicated in other hospitals in isolated areas. In general hospitals serving large numbers of posts, outpatient dermatology visits will be at least 10 times as

4Letter, Lt. Col. Donald M. Pillsbury, MC, to Col. Arden Freer, Services of Supply, Office of The Surgeon General, War Department, Washington, D.C., 25 Oct. 1942.


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numerous as hospital dermatology admissions, and the disparity may be even greater. Statistics from Walter Reed General Hospital for August and September 1942 support these estimates.

Regular progress notes are particularly essential on dermatologic patients, and provision for storage of records must be adequate.

Complete examination of dermatologic patients is essential, and often it must be made with them stripped. Privacy and good lighting are therefore necessary in outpatient clinics. Examination of outpatients with skin diseases in open wards has a bad effect on both the outpatients and the occupants of the wards. Private examining rooms or cubicles must be provided.

Unit organization.-While policies of hospital organization vary from installation to installation, there is now rather general agreement that syphilis should be treated on dermatologic wards. Certainly, it is hard to justify its treatment on a surgical service. At the present time [October 1942], there is no specific provision for a dermatology section in the table of organization of a general hospital (TM 8-260, 13b), but there is such provision in the table of organization of a station hospital (TM 8-260, 275c). In some station hospitals, such as the hospital at Indiantown Gap, skin diseases, syphilis, and all other venereal diseases except gonorrhea are treated on a single section, a plan that requires about double the bed space necessary for dermatology alone. The advisability of combining the management of these diseases has long been under discussion in the Army, and combined management is the established policy of the Navy. The plan also has the complete approval of Dr. Joseph Earle Moore and Dr. John H. Stokes, both members of the Subcommittee on Venereal Diseases, NRC. An argument in favor of the arrangement is the fact that all physicians trained in good dermatology clinics in recent years have also had adequate training in the diagnosis and treatment of syphilis.

Wards for dermatology and syphilis require the same facilities as are provided on any general medical wards. In recent years, dermatologists have been more and more inclined to study the systemic background of skin diseases as well as their surface aspects.

Personnel.-Whenever practical, a medical officer experienced in dermatology should be assigned to station and general hospitals, since there is no other branch of internal medicine in which general practitioners have as much difficulty in diagnosis and management. It is hoped that directives and other instructional efforts will enable medical officers untrained in dermatology to treat the more common skin diseases effectively, but these materials will not be helpful in the management of uncommon and chronic diseases. It would lessen disability from dermatologic causes, including overtreatment, if board-certified dermatologists were available for consultation on patients with such diseases.

The ward officer on a dermatology-syphilology section should preferably have had some special training in these fields. The assistant ward officer does not require it. Nurses and enlisted personnel who have had some training in dermatology greatly improve the efficiency of a dermatologic service. A noncommissioned officer, who is a keyman on such a ward, can be trained by a ward officer within a month, by reading assignments and demonstrations, to clean lesions, make topical applications, obtain scrapings, prepare solutions for injection, and assist at such minor surgical procedures as biopsy and electrodesiccation. Nurses, enlisted men, and officer personnel should not be rotated to other services; frequent changes of dermatologic personnel invariably mean less effective treatment. In military practice, as well as civilian, the difference between cure and chronicity can often be attributed to nursing care and attention to small details of treatment.

It is always desirable for the ward officer on the dermatology section to maintain good rapport with the laboratory. In the management of syphilis, regular comparisons of clinical and serologic findings redound to the good of the patient. Close cooperation on darkfield examinations is particularly useful.

Equipment and supplies.-Provision should be made for the performance on the dermatology section of minor surgical procedures such as biopsy; electrocoagulation of


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warts, small papillomas, and epitheliomas; drainage of acne cysts; and similar procedures. The performance of biopsies by surgical consultants is often unsatisfactory because of the amount of paperwork involved as well as because the site is not always properly selected for the dermatologist's purposes. The treatment of small warts by X-ray is an uncertain and expensive method. Small electrocoagulation units, without cutting current, which cost no more than $30 or $40, are entirely adequate for their removal and, in fact, are less hazardous and more efficient than some of the larger obsolete units now in use. If space must be conserved, these units can be hung on the wall.

At the present time, the greatest obstacle to treatment of dermatologic conditions is the lack of certain common therapeutic agents. These basic preparations are essential and should be kept on all dermatologic wards ready for immediate use. The supply list is presently undergoing considerable revision, but the need for these agents is immediate and urgent.

Minimal organization.-Colonel Pillsbury closed his communication to Colonel Freer with recommendations for a tentative minimal organizational dermatology setup, with practical considerations in mind, for a thousand-bed station or general hospital. He made it clear that some additions would be necessary for a hospital like Walter Reed General Hospital, in which difficult cases were treated and to which newly inducted medical officers were sent for training.

Colonel Pillsbury's specifications were as follows:

1. Wards of 35 or 40 beds would be required for both the dermatology and syphilology sections, with, at a minimum, 1 or 2 examining rooms and 1 or 2 treatment rooms. Additional facilities would be required if a considerable number of outpatients were treated. Also required would be offices for the ward officer and the ward nurse; three cubicles for infectious patients on the dermatology section and six to eight (possibly less) for infectious patients on the syphilology section; and the usual closet and storeroom facilities required on any medical ward.

2. Standard items for ward and office equipment should include a sufficient number of filing cases; outpatient and other records should not be kept in desk drawers.

3. Equipment for the dermatology section should include a set of simple instruments (2 forceps, straight and curved scissors, scalpels, 2 ring curettes, a stilet, a biopsy punch, 2 syringes for skin tests and for local analgesia, and a microscope which, if there were difficulty in procuring it, could be dispensed with). The need for an electrodesiccation unit has already been mentioned. An ultraviolet unit should be provided unless treatment was readily available in the physical therapy department. The X-ray section of the hospital should provide the facilities for superficial X-ray therapy. If standard equipment was not available, the diagnostic units used in field hospitals could be calibrated and used for skin therapy.5

Special equipment for the syphilology section should include adequate numbers of syringes, needles, and mixing glasses; material for Frei and Ducrey tests; and anti-syphilitic drugs. The needles presently in use for intramuscular injection are usually too heavy and too short. A darkfield microscope is not considered necessary; ward officers can use the one in the laboratory.

5This plan was widely used in oversea hospitals as well as in hospitals in the Zone of Interior during the war.


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CONSULTANTS IN DERMATOLOGY

Zone of Interior

Early in the war, consultants in medicine, surgery, and neuropsychiatry were appointed in the Office of The Surgeon General. Later, consultants were appointed in various subspecialties, including orthopedic surgery, ophthalmology, otolaryngology, radiology, and physical medicine. Still later, consultants in medicine, surgery, and neuropsychiatry, as well as in some subspecialties, were assigned to all nine service commands, and, in time, to the headquarters of all oversea theaters, as well as to all armies and many base sections.

Office of The Surgeon General.-Consultant service in venereal diseases was provided in the Preventive Medicine Division, OTSG, early in the war, but a consultant in dermatology was not appointed in that office until April 1945, shortly before the end of the war in Europe and only 4 months before the end of the war against Japan. The position was filled by Major Livingood, who served from that time to January 1946.

A review of the various changes of policy by which the care of dermatologic patients was improved, chiefly by better utilization of medical officers with special training in this field, makes it clear that a large share of the credit for the improvement evident during the last year of the war should go to Brig. Gen. Hugh J. Morgan, Consultant in Medicine, Office of The Surgeon General. General Morgan requested the appointment of a consultant in dermatology, 18 months before the request was honored. The policies he introduced in internal medicine greatly influenced the correct utilization of all medical officers and encouraged their accurate classification on the basis of their training and experience. Through the use of consultants in internal medicine in the service commands and the ultimate addition of Major Livingood to his Medical Consultants Division, OTSG, General Morgan was able to direct increasing attention to dermatologic disability in the Zone of Interior. His efforts to assign consultants in this specialty to all major commands, both in the United States and overseas, were largely thwarted by the fact that there was no provision for them in tables of organization.

The following letter from General Morgan to all service command surgeons early in 1943 illustrates his broad point of view:

In my visits to army hospitals, overseas and in this country, I have been impressed by the fact that dermatological diseases are somewhat neglected. The reason for this is obvious-we haven't enough good dermatologists to go around (and a poor dermatologist is often worse than none) and the dermatologists assigned often must work in the medical service alone without the benefit of any exchange of ideas with fellow practitioners. I am perfectly certain that much good could be accomplished by good dermatological consultations. I believe that a great deal can be done in army hospitals to raise the level of dermatologic practice by providing occasional visits from an expert in the field. I realize


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that our medical consultants are interested and that, in a general way, they keep their eyes on the dermatological problems; nevertheless, I suspect they adopt the same attitude that I do about the matter. Personally, in visiting army hospitals, I am very loath to put my opinion up against the opinion of the dermatologist on the ward. Moreover, I find it difficult to even evaluate his professional performance. Actually, my knowledge of, and experience with, dermatologic problems are limited and in the army, I make little or no contribution to hospital practice in this field. I expect a large majority of the medical consultants share my feeling in this regard. This letter is being written to the end of asking you to consider the suggestion that you select one of the best dermatologists in your service command and have him visit the hospitals throughout the service command to the end of stimulating better dermatological practice and bringing you information regarding the performance of personnel. You could do this of course, by having a dermatologist work out of your office from time to time on a temporary duty status. I am certain that many of our station hospitals would profit by such visits and I think that it is highly probable that regional, station, and general hospitals would also, and I am equally certain that the hospitals would welcome such a consultant. The system has been used successfully in the European and Southwest Pacific theaters as a supplement to the work of the permanently assigned medical consultants.

Service commands.-It was difficult, as just noted, to appoint consultants in dermatology in service commands because there was no provision for them in tables of organization. Some officers trained in dermatology were able to perform dermatologic duties on an informal basis, but the only consultant formally appointed was Maj. Herbert L. Traenkle, MC, who was assigned to the Fifth Service Command as venereal disease control officer and who was authorized to serve as consultant in dermatology in this command on 5 January 1945. The clear understanding, however, was that his dermatology assignment was strictly "in addition to other duties." He was the only consultant in dermatology who functioned as such in the Zone of Interior during the war. He made an extremely important contribution, and the standards of dermatologic care in the hospitals of the Fifth Service Command were raised as the result of his efforts.

The background of this odd situation should be emphasized: Venereal disease control had had a high priority in Army medicine for many years before the war, and control officers were therefore assigned at once to headquarters of all service commands as well as to oversea theaters and many base sections. The training and interests of these officers varied. Most of them were trained primarily in epidemiology and venereal disease prevention. Others were primarily dermatosyphilologists. It is unfortunate that the dermatologic abilities of this latter group of officers were not also utilized for dermatologic purposes. They were not so utilized. The officers were assigned to preventive medicine, and while their work in venereal disease control was extremely important and rewarding, a considerable part of it concerned matters far removed from medicine.

Oversea Commands

Consultants in dermatology were eventually appointed in ETOUSA (European Theater of Operations, U.S. Army) and in SWPA (Southwest


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Pacific Area), but none was ever formally appointed in MTOUSA (Mediterranean Theater of Operations, U.S. Army) or in the CBI (China-Burma-India) theater.

European theater.-The consultant system in the European theater was unusually well developed early in the war. It included medicine, surgery, orthopedic surgery, plastic surgery, neurosurgery, otolaryngology, ophthalmology, and radiology.6 In the summer of 1942, Brig. Gen. (later Maj. Gen.) Paul R. Hawley, Chief Surgeon, Headquarters, ETOUSA, requested the Office of The Surgeon General to make a consultant in dermatology available to him. In December of that year, Colonel Pillsbury joined General Hawley's consultant staff and functioned on it until the end of the war, with ultimate responsibility for dermatology and for diagnostic and therapeutic venereology.

The European theater differed from other commands in two important respects:

1. It was the only major Army command with a formal, full-fledged consultant system that received consistent and vigorous support from the theater surgeon. The system was distinctly on trial when it was instituted, and it suffered in its early days from organizational and other growing pains. With General Hawley's unwavering support, however, it was able to function efficiently in the European theater, and by V-E Day, there was no doubt of its value.

2. The European theater was the largest of all theaters, and by 1945, it had a considerably greater number of medical installations and medical officers than the Zone of Interior itself.7

The appointment of a consultant in dermatology in the European theater provided the same advantages that were inherent in the total consultant system, as well as certain advantages peculiar to the specialty:

1. Personal visits by the consultant to hospitals and armies permitted him to keep abreast of current problems and to anticipate others long before he might have been alerted to them by reports through official channels.

2. Observation of therapeutic methods at the bedside and in outpatient dispensaries permitted prompt correction of poor techniques and deficiencies.

3. Contacts with large numbers of medical officers on a personal as well as professional basis had many advantages.

4. Personal observations permitted intelligent recommendations for transfer of specially qualified personnel to installations in which there was special need for their services.

6(1) Medical Department, United States Army. Radiology in World War II. Washington: U.S. Government Printing Office, 1966. (2) Medical Department, United States Army. Internal Medicine in World War II. Volume I. Activities of Medical Consultants. Washington: U.S. Government Printing Office, 1961. (3) Medical Department, United States Army. Surgery in World War II. Activities of Surgical Consultants. Volume I. Washington: U.S. Government Printing Office, 1962. (4) Medical Department, United States Army. Surgery in World War II. Activities of Surgical Consultants. Volume II. Washington: U.S. Government Printing Office, 1964.
7Medical Department, United States Army. Personnel in World War II. Washington: U.S. Government Printing Office, 1963.


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5. Dissemination of information concerning improved methods of treatment, changes in methods which had not proved satisfactory, and other items was greatly facilitated.

6. Because of the short lines of communication between installations in the United Kingdom Base as well as on the Continent, at least until well into 1945, it was possible for all consultants to visit medical installations frequently, sometimes as many as four or five in a single day. These visits permitted a considerable amount of on-the-job training in dermatology for medical officers with no previous experience in skin diseases. This informal training was supplemented by seminars and by discussions at the Medical Field Service School at Cheltenham, England, and at the Eighth Air Force Provisional Medical Field Service School at PINETREE (High Wycombe, Headquarters VIII U.S. Bomber Command). In all discussions and classes, great emphasis was put upon the common diseases of the skin that could be treated in the field or in dispensaries if they were recognized early but that, if neglected or maltreated, could produce prolonged disability and sometimes require hospitalization.

Separate sections of dermatology were set up within the framework of the medical service in all hospitals in which the patient load justified such subdivision. With the introduction of intensive arsenical therapy for early syphilis and the later use of penicillin (p. 581), the diagnosis and treatment of all venereal disease became the responsibility of the section on dermatology. In installations of 500 beds or more, as a result, the patient load was sufficient to occupy the full-time attention of one medical officer and sometimes of two.

When it became evident that penicillin therapy for early syphilis would become available shortly after D-day, detailed plans were drawn up by the Consultant in Dermatology with the surgeons of the various armies for centralization of all patients with acute venereal disease; they were usually cared for in convalescent centers, in charge of specially qualified personnel. By this plan, all but a few patients in this large group were kept out of station and general hospital areas and were returned to duty as soon as their treatment was concluded. A great waste of manpower was thus prevented.

As of 1 January 1945, the number of dermatologists classified by MOS (military occupational specialty) ratings in the European theater was 47, while the number of fixed medical installations was 146. With the representation which dermatology had in the Office of the Chief Surgeon, ETOUSA, it was possible for Colonel Pillsbury to assign the limited number of well-qualified dermatologists in the theater, either formally or on an ad hoc basis, to the installations in which they were most needed. Difficulties arose later, of course, when the number of hospitals increased, casualties were heavy, and lines of communication lengthened. Then, with the support of the Chief Surgeon, the base surgeons, and the commanding officers of strategically located general hospitals, all dermatologic patients who presented difficult and resistant conditions were grouped in certain hospitals with competent dermatologists on the staffs. In addition, dermatologic officers with wide experience made regular rounds at adjacent hospitals without qualified dermatologists on their staffs. Among those who functioned in this informal


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consulting capacity were: Capt. Frank E. Cormia, MC, 49th Station Hospital; Capt. (later Maj.) C. J. Courville, MC, 298th General Hospital; Maj. Emerson Gillespie, MC, 67th (later 5th) General Hospital; Maj. Herbert H. Holman, MC, 40th General Hospital; Maj. Adolph Loveman, MC, 49th Station Hospital; Capt. (later Maj.) Thomas W. Murrell, Jr., MC, 28th General Hospital (Major Murrell was later attached to dispensaries in London and in Paris); Maj. (later Lt. Col.) Maurice H. Noun, MC, 30th General Hospital; and Capt. (later Maj.) Samuel R. Perrin, MC, 58th General Hospital.

The service was not always easy to provide, but it was provided, and it seems fair to say that, by the plans just outlined, every patient with a skin disease of significant severity received prompt and adequate consultation service. The validity of this statement is borne out by the fact that, in spite of the large troop strength in the theater, not more than 30 or 40 patients per month were boarded to the Zone of Interior for skin disease. The maximum, 40, was reached only once, in June 1945.

Southwest Pacific Area.-In September 1943, General Morgan, noting the increasing number of dermatologic conditions in the Southwest Pacific Area, made a consultant in dermatology available to it on his own initiative, without a request from the area. When the consultant (Maj. (later Lt. Col.) John V. Ambler, MC) arrived, he found himself unable to function because of the indifference, bordering on hostility, of the area surgeon. When this incumbent was replaced, early in 1944, by Brig. Gen. (later Maj. Gen.) Guy B. Denit (Chief Surgeon, U.S. Army Services of Supply, SWPA), a general officer with a real understanding of the value of the consultant system, Major Ambler was able to function efficiently for the first time.

It is only fair to interpolate at this point that while some administrative officers took the attitude toward consultants just described, others welcomed them cordially. It is also only fair to note that the difficulties attendant on operation of the consultant system were often not helped by the habit of some consultants, fresh from civilian practice, of making recommendations without sending them through proper channels and by their lack of appreciation of the problems of commanding officers. In other words, attitudes on both sides sometimes furnished serious roadblocks to the achievement of better methods of prevention and treatment of diseases and injuries and also militated against the most profitable assignment of specially qualified personnel.

Once he was able to function unhampered, Major Ambler recognized the existence of certain problems:

1. Were some of the more unusual skin disorders encountered caused by infection by fungi?

2. Were the numerous cases being diagnosed as trichophytosis or epidermophytosis really fungal infections? There was little clinical, and no laboratory, support for these diagnoses.


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At the direction of General Denit, an investigation to settle this point was undertaken by Dr. J. Gardner Hopkins, a mycologist of wide experience, Professor of Dermatology, Columbia University College of Physicians and Surgeons, Civilian Consultant in Dermatology to The Surgeon General, and investigator (dermatophytosis) for the Committee on Medical Research, OSRD (Office of Scientific Research and Development). Dr. Hopkins was not eligible for military service because of age and other reasons, but he devoted most of his time during the war in a civilian capacity to the Office of Scientific Research and Development. His numerous field studies were an outstanding contribution to the work of the Medical Corps.

Dr. Hopkins reached the Southwest Pacific Area on 2 September 1944, and after his survey made his report to General Denit on 13 March 1945.8 By the time Dr. Hopkins reached the area, diseases of the skin had become an extremely serious problem. In some hospitals, 20 percent of the medical admissions were for this cause, and many hospitals had from 100 to 300 patients on the dermatology wards. The rate of evacuation to the Zone of Interior for skin diseases had reached 17 percent of all medical cases and was exceeded only by the rate for neuropsychiatry.

Under Major Ambler's guidance, Dr. Hopkins visited station and base hospitals in Brisbane, Australia; Oro Bay, Dobodura, Lae, Nadzab, Finschhafen, and Hollandia, in New Guinea; and Leyte and San Fabian in the Philippines. He also visited dispensaries at Lae (New Guinea) and Leyte, and battalion aid stations on the Rosario Front, in the Philippines. He was thus able to obtain a comprehensive view of dermatologic problems at different points in the line of evacuation, from the frontline to general hospitals in the rear. His observations are reported, under appropriate headings, elsewhere in this chapter.

China-Burma-India theater.-As already mentioned, there was no dermatology consultant in the China-Burma-India theater during the war, but Col. Herrman L. Blumgart, MC, served as Consultant in Medicine during the latter months of fighting.

Three general hospitals assigned to India had dermatology sections. The 20th General Hospital, which arrived in March 1943, was located in Assam, near the border of Burma. The 69th General Hospital, also assigned to Assam, arrived in June 1944, during the height of the intensive campaign being conducted by Merrill's Marauders at Myitkyina. The 142d General Hospital arrived in Calcutta in September 1944.

Each of these hospitals had from three to five wards set aside for dermatology and syphilology, and the two hospitals located in Assam also had wards for treatment of these conditions in Chinese soldiers. The experience of all three hospitals was essentially the same.

8Letter, J. G. Hopkins, M.D., Technical Observer, Office of Field Service, Office of Scientific Research and Development, to Brig. Gen. Guy B. Denit, Theater Surgeon, Headquarters, USAFFE, 13 Mar. 1945, subject: Report of Observations on Fungus Infections and Other Dermatoses in the SWPA.


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PERSONNEL AND ASSIGNMENT

Before the beginning of mobilization in September 1940, there was not a single qualified (certified) dermatologist in the Regular Army Medical Corps, nor was there a section of dermatology in any Army hospital. With the mobilization of the members of the Medical Corps Reserve, in 1941, a few officers with special dermatological training came on duty, and some of them were assigned to hospitals in the Zone of Interior.

When maneuvers began, in the summer of 1941, it became abundantly clear that dermatologic admissions to station hospitals would be significant. The maneuvers in Louisiana were especially instructive in this regard (p. 572), for a continuing flow of soldiers were rendered ineffective by complications of insect bites, especially chiggers; primary or secondary bacterial infections; contact dermatitis caused by plants; miliaria; and the sensitizing effects of topical medicaments, particularly the sulfonamides. The commanding officers of the station hospitals that received these patients soon found it necessary to set up special dermatologic sections, even though in many instances they had no qualified dermatologists to put in charge of them.

Even though tables of organization did not provide for them, some affiliated general hospital units were able to recruit dermatologists by various methods. Other hospitals did not recruit them, and such university-sponsored units as the 2d General Hospital (Columbia University), the 18th General Hospital (Johns Hopkins University), and the 30th General Hospital (University of California) went overseas without dermatologists on their staffs.

Original Misassignments

Dermatologists called to active duty in 1941 were sometimes assigned to dermatologic duties but very frequently were not. Those who were not assigned as dermatologists communicated their dissatisfaction rather vigorously to civilians in high academic and organizational positions, and inquiries arising from these complaints were sent to appropriate authorities.

The first communication on the matter was a letter from Dr. (later Captain, Medical Corps) William B. Guy, Chairman, Section on Dermatology and Syphilology, American Medical Association, to The Surgeon General and to Maj. (later Brig. Gen.) Sam F. Seeley, MC, Chief, Office of Procurement and Assignment Service, War Manpower Commission, Office for Emergency Management. In this letter, dated 17 April 1942, Dr. Guy requested from Major Seeley specific information regarding (1) the need for dermatologists in the Armed Forces; (2) the official policy regarding the utilization of specialists in their own branches of medicine; (3) the routine by which dermatologists should proceed when they applied for commissions


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in the Armed Forces, so that they would be utilized in their special field; and (4) the possibility of transfer of dermatologists presently assigned to nondermatologic duties in the Armed Forces.

Col. (later Maj. Gen.) George F. Lull, MC, replied for The Surgeon General, on 19 April 1942, in substance, as follows:

1. Because of the difficulty of assigning all specialists to positions in which they will do work they are accustomed to do in civilian life, many medical officers will have to adjust themselves in the Army and learn new occupations.

2. Dermatologists will be needed in the Armed Forces, but how many is not known. They can be utilized in the larger hospitals, but usually there will not be sufficient work to utilize them exclusively in their specialty.

3. An attempt will be made to assign dermatologists who volunteer for service to hospitals in which they will be used in the treatment of skin diseases and syphilis, but no promises can be made in this regard. Moreover, in many hospitals, skin diseases are treated in one department and syphilis in another.

4. If the names of those now in service who are not now doing dermatology and syphilology are provided, it may be possible to transfer most of them.

5. Dermatologists applying for commissions should state their preference for assignment, and every attempt will be made to grant their requests.

Major Seeley's reply to Dr. Guy was even less encouraging. In substance, he wrote:

1. The number of dermatologists needed by the Armed Forces would be so limited that he would be disinclined to encourage dermatologists to think their duties would be strictly in this field.

2. Those recognized in the specialty and now in service must continue to serve in their present capacities until such time as The Surgeon General had the advantage of an oversupply of medical officers. There would be no justification in asking him to make assignments until the rest of the profession had come forth for service and rearrangements were feasible.

3. Dermatologists applying for commissions should emphasize their training and ask for assignment to their specialty on the form for statement of preferences.

4. Many physicians who anticipated that military service would make specialists out of general practitioner's must be satisfied with being made better practitioner's if they were not engaged as specialists. "We must win this war," Major Seeley concluded, "and then enjoy our highly developed specialization in peacetime."

The replies to Dr. Guy's letter from Colonel Lull and Major Seeley are indicative of the misunderstandings and dissatisfaction that prevailed at this time. Newly inducted medical officers, without previous military experience, failed to understand the tremendous difficulties inherent in the assignment of personnel to the professional activities that would best utilize their previous training and talents. On the military side, it is clearly evident from these letters-entirely unrealistic in the light of later experience-that there was no anticipation of the volume and complexity of the dermatologic problems likely to be encountered in a global war. The lack of understanding before and early in the war led to a gross underestimate of the need for medical officers with special training in dermatology. For these and other reasons, adequate staffing for dermatologic diseases was never achieved. As the war progressed, it became clear that the Army alone


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could have used every qualified dermatologist in civilian practice if they had become available.

After the formal declaration of war on 8 December 1941, an increasing number of dermatologists came on active duty and, almost without exception, requested dermatologic assignments. They did not always get them, one reason being, as mentioned several times already, that the table of organization of a general hospital did not provide for a dermatologist, though the table of organization of a station hospital did. The chief reason for the original misassignment of dermatologists, however, was that the Personnel Division, OTSG, had had no previous experience with the need for dermatologists in any type of hospital. Moreover, there was then no dermatologic consultant in the Office of The Surgeon General, no classification existed for medical specialists, and the need for medical officers was urgent without regard to specialty. Dermatologists were in the particularly unenviable position of having a specialty that had no official recognition.

Transfers

Some dermatologists, when they entered service, joined the AGF (Army Ground Forces), in which they did not function except at sick call. Some joined the AAF (Army Air Forces) which, during the first years of the war, did not operate enough hospitals to utilize the special experience of the dermatologists available to it. Since, however, neither of these groups came under the jurisdiction of The Surgeon General, it was impossible to change the assignments of the dermatologists in them. The ASF (Army Service Forces), in May 1945, had the responsibility for staffing some 108 general, regional, and station hospitals in the Zone of Interior, each with a bed capacity of 800 or more, and had available for them only 42 qualified dermatologists. At the same time, the Army Air Forces had 12 regional hospitals, each with the same bed capacity, and had some 28 qualified dermatologists available for them. Evident as was the disparity, it was impossible to effect a single transfer from the Air Forces in spite of the vigorous efforts of General Morgan and the Personnel Division. The only concession offered by the Air Forces personnel was the suggestion that ASF patients with dermatologic conditions be sent to their hospitals, an obviously impossible plan.9

There was similar difficulty in transferring dermatologists from one service command to another; the concurrence of all headquarters concerned had to be secured, and that was no simple matter. This lack of flexibility made it almost impossible to adjust changing situations in the dermatologic sections in the various hospitals.

9This situation is an excellent illustration of the forced ineffectiveness of The Surgeon General occasioned by his subordination in the command structure to the Commanding General, Army Service Forces, early in World War II.-A. L.A.


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Dermatologic situations were not static. Early in the war, during the training period, the greatest concentration of patients with skin conditions was in station hospitals. Later in the war, when patients with skin diseases were being evacuated from overseas, the concentration was heaviest in general hospitals. It was one of the principal functions of the Consultant in Dermatology, OTSG, once he had been appointed, to recommend assignments of personnel on a preferred basis. Though it was never achieved, the assignment of qualified dermatologists which he recommended in order of preference was to-

1. General hospitals designated as dermatology centers (p. 575).

2. General hospitals designated as neurosyphilis centers.

3. General hospitals designated as medical centers.

4. Regional hospitals.

5. Station hospitals.

6. General hospitals.

If this list had been prepared in 1941 rather than in 1945, high preference would have been given to the station hospitals that provided care for troops in training and on maneuvers, such as the station hospitals in Louisiana and the hospital at Indiantown Gap. A major factor in the change of preference was the large, active campaigns conducted overseas. To anyone who viewed the situation broadly, the changing hospital functions and the changes in the types of patients cared for in general and station hospitals were most impressive and instructive.

Another factor that complicated personnel assignments in dermatology was the necessity of utilizing a certain proportion of available dermatologists for the management of venereal diseases. Dermatologists furnished the principal professional reservoir of officer's with training in syphilis and in other nongonorrheal diseases. Almost all neurosyphilis centers in general hospitals were staffed by dermatosyphilologists. It was possible to train general medical officers quite adequately in the management of early syphilis and other acute venereal diseases within a few months, and the plan was generally followed in the European theater, but trained dermatologists had to be kept available to provide the training.

Certification

At the close of the war, the Army Service Forces had 137 medical officers with recognized competence in dermatology. Of these, 107 were certified by the American Board of Dermatology and Syphilology, and the other 30 had demonstrated their competence and had had sufficient formal training to warrant their certification when and if they chose to apply to take the examinations for it.

Another group of 151 medical officers had had only a small amount of formal training but enough previous experience in civilian practice to


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justify an MOS rating of C. Many in this group had increased their proficiency and experience in the Army. These officers were usually capable of serving as chiefs of dermatologic services in small hospitals or in hospitals whose primary mission was the care of battle casualties.

Still another group of officers, of considerable size, had had no training in dermatology other than what they had obtained in the Army but had developed an interest in it during their service.

A precise appraisal in the Medical Consultants Division, OTSG, after the war in Europe had ended indicated that at least 275 qualified dermatologists were then needed to carry the dermatologic load in the various installations of the Army Service Forces in the Zone of Interior and overseas.

Despite all the problems of personnel assignment just outlined, it is gratifying to note that on V-E Day, 102 of the 107 medical officers certified in dermatology were in posts offering the opportunity to do professional work in dermatology, syphilology, or both. Furthermore, almost all the officers who were not certified but who had had sufficient formal training and experience to qualify as dermatologists also had relevant assignments. This favorable situation was finally brought about by the efforts of many medical officers in various headquarters with broad interest in providing adequate medical service for all patients. They had been impressed by the increasing evidence throughout the war that dermatologic disease was responsible for much disability and that lost manpower could be greatly curtailed if these patients with skin conditions were treated by qualified specialists early in their illness.

FACILITIES, EQUIPMENT, AND SUPPLIES

When the United States entered the war, in view of the status of dermatology in the Army, it was not surprising that no special provision had been made in most hospitals for dermatology or syphilology wards. When the need for these facilities arose, they had to be improvised, for both clinic and ward patients, from whatever space was available.

Early in the war, a great deal of equipment needed on these wards and clinics was on the critical list because of shortages and priorities, and treatment of patients was sometimes adversely affected. Even such items as tubs, basins, hotplates, bandages, dressings, instruments, and ordinary drugs could not be procured at all or were in continuously short supply. Vitamin B and zinc oxide, both badly needed, could be procured only in small amounts.

The medical supply officer at each station received from the medical depot certain items regularly used in dermatologic practice, such as ingredients for lotions, baths, ointments, and pastes (particularly zinc oxide); that is, starch, benzoic acid, salicylic acid, phenol, boric acid, potassium per-


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manganate, sodium chloride, coal tar, ammoniated mercury, sulfur, alcohol, lanolin, and petrolatum. Local medical officers, depending upon their special needs and their own experience in dermatology, used these items as best they could, making up for shortages with substitutes among available pharmaceutical stocks. The usual situation developed: Each dermatologist desired the items he had been accustomed to use in private practice. The supply policy was somewhat flexible, and in late 1942, Col. Charles F. Shook, MC, then Assistant Chief, Finance and Supply Service, OTSG, recommended that dermatologists in the Zone of Interior be permitted to use local funds for pharmaceuticals they particularly desired, especially when only small quantities were needed. One reason for this recommendation was to avoid further changes in the master supply catalog, which by this time had been completed.

During the last year of the war, only a few dermatologic categories were in short supply, such as benzyl benzoate for scabies, tragacanth as an emulsifying agent, sulfurated potassium for lotio alba, and olive oil for lotions. In the summer of 1945, the Consultant in Dermatology, OTSG, recommended the addition of accepted dermatologic items to the standard supply tables. When the war ended in August of that year, most shortages had been overcome.

ARMY AIR FORCES

Administrative Considerations

In spite of the number of dermatologists on duty in the Army Air Forces (p. 560), no special professional attention was paid to dermatologic diseases in this service until August 1944. Then, in accordance with recommendations made to the Air Surgeon several weeks earlier, a dermatology branch was created in the Professional Division of his office, and Lt. Col. Jud R. Scholtz, MC, was appointed to direct it.10

In the recommendations made to the Air Surgeon in June 1944, it was pointed out that dermatologic diseases were an important cause of morbidity in military personnel. Separate statistics were not available for the Army Air Forces, but it was noted that collective figures for the Army in the continental United States revealed that time lost from duty from this cause each year approximated 3 million man-days, with an average loss of 11 days per patient. It was estimated that about 20 percent of all diseases in the Army required dermatologic management, and it was emphasized that hospital admissions did not give a true picture of the situation, since half or more of all cutaneous conditions did not require hospitalization.

10The material for this section on the Army Air Forces was supplied by Dr. Jud R. Scholtz who, as Lieutenant Colonel, served as Chief of the Dermatology Branch, Office of the Air Surgeon, when the dermatology program was set up in that office.


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It was therefore considered desirable to institute a dermatology program in the Army Air Forces; to establish dermatologic services in the regional hospitals of the service; to develop a consultation system in dermatology for station hospitals; to utilize to the maximum specialist personnel in the Army Air Forces; to set up a consultative and preventive program for civilian employees of the ATSC (Air Technical Service Command); and to develop a teaching program in dermatology for residents and general service medical officers.

Personnel.-When these recommendations were made in June 1944, there were in the Army Air Forces in the United States 31 medical officers classified as dermatologists; of these, 17 were board certified, and many of the others were well qualified, by training and experience, to be considered specialists. When the Dermatology Branch was created in the Office of the Air Surgeon in August 1944, 22 medical officers, 16 of whom were certified by the American Board of Dermatology and Syphilology, were available for assignment. Some of them were already working on dermatologic services in AAF hospitals. By March 1945, dermatologists had been assigned to 26 regional hospitals, and an additional 6 medical officers had been certified by the board.

Establishment of program.-The recommendations made in June 1944 were generally put into effect when the Dermatology Branch was established in the Office of the Air Surgeon in August 1944 in the following steps:

1. Regional AAF hospitals were staffed with qualified dermatologic personnel in relation to the availability of such personnel, the geographic location and bed capacity of the hospitals, and the prevalence of skin diseases in each area.

2. An official letter was issued announcing the creation of a dermatologic consultant service and listing the stations at which dermatologists would be available for consultation. Recommendations were also made concerning the area hospitals to be served by regional consultants; the routine treatment of common skin diseases; and the disposition of special categories of patients with skin conditions.

3. Consultant functions included initial visits to area hospitals to determine the scope and nature of the dermatologic problem; investigation of patients currently under treatment, to determine whether they should be transferred to the dermatologic service; the establishment of a basic routine of treatment; and the identification of qualified dermatologists who had not yet been classified as such.

4. After the initial visit to each hospital just described, provision was made for consultation service to area hospitals by telephone or by personal visits as indicated. It was part of the consultant function to recommend the transfer of patients from area to regional hospitals.

5. The dermatologic needs of the Air Technical Service Command in relation to its civilian employees were investigated and implemented.

6. Information was disseminated concerning treatment practices in both dermatology and venereal diseases.

7. An attempt was made to accumulate and analyze data on morbidity due to dermatologic diseases, the sick call load, and time lost from duty by hospitalization. An attempt was also made to institute clinical studies in skin diseases of particular significance in AAF personnel by virtue of type of duty or geographic location.


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8. After the program was in full operation, return visits were made to AAF medical installations to evaluate the quality of dermatologic service in them.

Regional hospitals.-Each dermatologist assigned to a regional hospital developed a separate dermatologic service in it. A ward was set aside for the hospitalization of patients with severe, disabling dermatoses and for the definitive treatment of patients referred from satellite hospitals at which specialized medical care was not available. Clinics for outpatients who could be treated on an ambulatory basis were conducted several times a week, the number of clinics depending upon the caseload.

In his capacity as regional consultant, the dermatologist at each regional hospital visited each satellite station hospital once a month, to handle special problems and to evaluate the quality of dermatologic service provided.

Duty-assignment training.-In October 1944, a duty-assignment training program was set up in each major AAF command, intended to indoctrinate medical officers without training or experience in dermatology in the management and treatment of the common skin diseases encountered in military service. Each trainee was assigned for a 3-month period to a board-certified dermatologist who had been associated with a teaching institution in civilian life. The trainee assisted in the management of ward and clinic patients and, when it was practical, visited adjacent civilian teaching institutions.

The medical officers trained in this manner were assigned to station hospitals and proved of great assistance to the consultants in dermatology. It should be emphasized that the training program was set up only because of the shortages of qualified dermatologists in the Army Air Forces and the need for larger numbers of medical officers who could treat common skin diseases in installations to which no dermatologists were assigned. There was no idea that the training provided would qualify the trainees as dermatologists; in fact, it was specifically directed that officers thus trained would not be classified as dermatologists.

Manual.-The survey of dermatologic practices and patients in AAF hospitals and clinics undertaken when the new program was put into effect in August 1944 revealed that perhaps half of all admissions to the dermatology wards were the result of improper early treatment and overtreatment. It was also found that about 90 percent of all skin disorders encountered in the Army Air Forces were included in a small number of diagnoses. Similarly, large numbers of patients seen in outpatient clinics also presented conditions overtreated and aggravated by improper and irritating sensitizing therapy.

To remedy this situation, a manual was prepared particularly for AAF medical officers who had had no special training in dermatology. This manual, "Management of Common Cutaneous Diseases" (AAF Manual 25-1), which was the composite effort of several dermatologic officers, was dis-


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tributed to all AAF installations in the continental United States for use in dispensaries and station hospitals. The manual was not a directive and did not restrict the exercise of clinical judgment by individual medical officers.

The initial distribution of this manual was 1 copy each to stations with strengths of 500 and under; 2 copies each to those with strengths between 500 and 1,000; 3 copies each to those with strengths between 1,000 and 5,000; 5 copies each to those with strengths between 5,000 and 10,000; and 9 copies each to those with strengths over 10,000.

Requests were subsequently received from several AAF commands for individual copies of this manual for all medical officers within the commands. Some 2,000 copies were distributed as the result of these requests, including 800 copies to the Army Air Forces in the Mediterranean theater. The manual was also reproduced in toto and used as a circular letter by the Tenth Air Force in the China-Burma-India theater.

Categories of Disease

In the recommendations made to the Air Surgeon in June 1944 on the establishment of a dermatologic program in the Army Air Forces, it was pointed out that skin diseases in the age group in this service fell into three categories:

1. Approximately 90 percent of all cutaneous morbidity were accounted for by a group of conditions which were not in themselves disabling and most of which, if properly treated initially, did not require hospitalization. In this group were pyodermatoses, superficial fungal infections, parasitic diseases, disturbances caused by excessive perspiration, and contact dermatitis, including plant dermatitis.

2. Major dermatoses, which caused serious disability and required prolonged hospitalization, included erythema multiforme, drug reactions, generalized eczema, exfoliative dermatitis, dermatoses caused by photosensitization, chronic granulomas, and lupus erythematosus.

3. Emergency situations were so uncommon in dermatologic practice that they required no consideration in the routine of dermatologic care and could be handled, usually by telephone consultation, when they arose.

Occupational dermatoses.-The Air Technical Service Command had among its other duties the responsibility for maintenance and repair of aircraft. For this purpose, it operated a number of large depots in the United States, where several hundred thousand civilians were employed, 35 percent of whom, it was estimated, were exposed to occupational hazards and chemical agents that could cause dermatitis. The annual report of this command for 1943 revealed that the time lost from work for occupational reasons was almost entirely the result of occupational dermatitis. This was clearly an important condition, not only because of the time lost from work


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but also because the treatment of occupational disease in civilian employees was an Air Forces responsibility. The depots at which it occurred were served by medical officers trained in industrial medicine, but with few exceptions, they were not trained in dermatology and experienced dermatologists were not available for consultation.

Another problem of considerable magnitude because of the large number of employees involved in these AAF projects was the cutaneous complications of sulfonamide prophylaxis, which was widely used for protection against bacterial disease. Reactions to this technique were fairly frequent, and cutaneous reactions were the most common of all. Qualified medical personnel had to be available to classify and treat these dermatoses and to advise, on an individual basis, concerning the propriety of continuing the medication.

As the result of these observations, a consultation service was set up by which AAF dermatologists in the general area of ATSC depots made regular visits to them, to assist in the diagnosis, classification, and management of skin diseases in civilian employees engaged in the care and repair of aircraft. This arrangement resulted almost immediately in more accurate classification of occupational dermatitis and in shorter periods of disability. It also laid the groundwork for the collection of valuable information concerning the cutaneous occupational hazards encountered in the maintenance and repair of aircraft.

In January 1945, a conference on occupational dermatoses was held in the Office of the Air Surgeon, the participants including Lt. Col. George Sladczyk, MC, Chief of the Industrial Medicine Branch, Headquarters, ATSC; Maj. (later Lt. Col.) Frank J. Lacksen, MC, Chief, Dermatology Section, Mitchel Field AAF Regional Station Hospital; Maj. (later Lt. Col.) Shepard Quinby, MC, dermatologic officer, Headquarters, Personnel Distribution Command; and Colonel Scholtz.

The agenda for this conference covered the following items:

1. The dermatologic consultation service in the Office of the Air Surgeon.

2. The scope of the problem of occupational dermatoses as indicated in reports available to Headquarters, Air Technical Service Command.

3. The desirability of preparing a manual on the prevention and management of occupational dermatoses for use by medical officers and contract physicians engaged in the industrial hygiene program.

4. The need for standardization of hand cleansers.

5. The need for increasing the number of medicaments available for treatment.

6. The need for further investigation of causes of dermatitis in ATSC depots and the development of engineering techniques for their elimination.

The conferees reached the following decisions:

1. The consultation service provided in the dermatologic program was by far the most important and most essential phase of the program. Headquarters, ATSC, agreed to institute a survey to evaluate its adequacy as it was presently operated.

2. Headquarters, ATSC, also agreed to make an additional effort to determine the


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extent and nature of the problem of industrial dermatoses by compilation of reports to be secured from consultant dermatologists.

3. Any one of several hand cleansers was considered acceptable, and none of them could be regarded per se as the cause of dermatitis. Recommendations for standardization of these agents was not considered advisable.

Pressures engendered by the final campaigns of the war explained why these plans were not carried through to definitive conclusions.

DISTRIBUTION AND ADMINISTRATIVE MANAGEMENT OF  
SKIN DISEASES IN ZONE OF INTERIOR

Induction Centers

As might have been expected, diseases of the skin encountered in inductees occurred in about the same proportions and were of about the same character as in civilian practice. Some men who wished to avoid military service overemphasized their dermatoses. Others who wished to serve tried to underemphasize them and gave incomplete or misleading histories of past skin troubles.

There were few established policies for the acceptance or rejection of men with these diseases. Many physicians on examining boards, at least early in the war, tended to recommend for induction candidates with a variety of skin diseases, on the ground that a trial of military life was justifiable. As time passed, it became evident that a decidedly less liberal policy would have been wiser and would have eliminated a heavy burden on Army dispensary and hospital facilities. Experience showed that soldiers with extensive psoriasis, significant atopic dermatitis and related allergic diseases, extensive seborrheic dermatitis, severe acne involving the face and upper trunk, and chronic eczematous eruptions of the hands and feet were seldom able to do full duty. These men constituted problems in the Zone of Interior and constituted more difficult problems when they were sent overseas, especially to tropical areas. The burden on outpatient dispensaries and the long periods of hospitalization that many of them required far outweighed the military effort contributed by the small numbers able to do general or limited duty.

The literature before the United States entered World War II contained numerous studies of the incidence and age distribution of diseases of the skin but none of them dealt with diseases in the age group (18 to 45 years) encountered at induction stations. Lt. (later Maj.) Eugene S. Bereston, MC, and Lt. (later Capt.) Edward M. Ceccolini, MC, remedied the deficiency in 1943 by a study of the incidence of dermatoses in 20,000 men who passed through the U.S. Army Recruiting and Induction Station at Tacoma, Wash., in both the enlistment and selective service systems.11

11Bereston, E. S., and Ceccolini, E. M.: Incidence of Dermatoses in 20,000 Army Induction Examinations. With Note on Syphilis With Negative Serologic Reactions. Arch. Dermat. & Syph. 47: 844-848, June 1943.


569

All the men were examined stripped, with at least ordinary care, but not by physicians with any special dermatologic training. One of the points made in the report of the investigation, in fact, is that a consultation dermatologic service that could have been called upon as needed would have been extremely helpful.

In these 20,000 candidates for induction into the Army, 733 (3.67 percent of the total number) were found to have diseases of the skin,12 but of these, only 44 (6.00 percent of those with skin diseases and 0.22 percent of the total number of candidates) were rejected for diseases of the skin as compared with 4,650 (23.25 percent) of the total number rejected for all causes. Some candidates with skin diseases were, of course, rejected for other causes.

The 733 men with skin diseases presented 77 different clinical entities, the most common of which (except for dermatophytosis of the feet and small pigmented and nonpigmented nevi) are shown in table 101. Generalized psoriasis was the chief cause for rejection in the group of skin diseases, with disseminated neurodermatitis second and neurofibromatosis third. Other causes of rejection, in addition to those tabulated and discussed in footnote 11, were parapsoriasis (2 of 5 cases); epithelioma of the lip (4 of 4 cases); latent syphilis (3 of 3 cases); squamous cell epithelioma of the eyelid (1 case); epithelioma of the penis (l case); generalized combined vascular and pigmented nevus (1 case); sarcoma (1 case); and epidermolysis bullosa (1 case).

Dispensaries

Most soldiers with dermatologic complaints were first seen at sick call. They were usually treated in company or training camp dispensaries that were staffed by one or more medical officers without any training in dermatology and with only limited facilities for treatment.

There was considerable variation in policy regarding the duration of dispensary treatment. In some camps, the patien ts were treated daily, often for several weeks, until they were cured (at least relatively) or were incapacitated from overtreatment. In others, patients with even simple and uncomplicated dermatoses, such as mild dermatophytosis, were promptly referred to the outpatient departments of station or regional hospitals. Their management depended to some degree on whether medical officers qualified in dermatology were on the staffs of the station or regional hospitals to which they would be sent. As in civilian practice, some medical officers without special training in it were interested in dermatology and some were not.

12Included in this number are nine cases of central nervous system syphilis, one of which was an instance of dementia paralytica. These cases deserve special comment. All occurred in selectees who, before coming to this station, had had negative complement fixation or precipitation reaction tests reported by their local draft boards. It is not unusual, in central nervous system syphilis, to encounter positive clinical findings with negative serologic reactions.


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TABLE 101.-Rejections for skin diseases in 20,000 candidates for induction at U.S. Army Recruiting and Induction Station, Tacoma, Wash.

Diseases in order of frequency

Number of cases

Number of rejections

Acne vulgaris

248

0

Psoriasis

55

11

Pyoderma

35

0

Tinea

27

0

Varicose eczema

20

0

Neurodermatitis disseminata

20

3

Lipoma

18

0

Sebaceous cyst

18

0

Seborrheic dermatitis

17

1

Naevus flammeus

17

1

Neurodermatitis, localized

15

0

Neurofibromatosis

14

2

Rosacea

14

0

Contact dermatitis

12

0

Giant pigmented nevus

12

0

Scabies

11

0

Pilonidal sinus

11

3

Vitiligo

10

0

Ichthyosis

9

0


Source: Bereston, E. S., and Ceccolini, E. M.: Incidence of Dermatoses in 20,000 Army Induction Examinations, With Note on Syphilis With Negative Serologic Reactions. Arch. Dermat. & Syph. 47: 844-848, June 1943.

It soon became evident, however, that most medical officers had no familiarity with even the most common forms of dermatitis. Overtreatment of minor dermatologic diseases at the dispensary level, particularly overtreatment of scabies, inflammatory eruptions of the feet, insect bites, and contact dermatitis, was therefore distressingly frequent and frequently produced major disabilities. The situation was not helped by the self-treatment practiced by the soldiers themselves. It should also be noted that if there was no qualified dermatologist at the station hospital to which the patient was referred, his referral to it did not insure him care superior to that he was receiving at the camp dispensary.

An analysis of the referral slips accompanying the patients sent to one station hospital, considered typical, showed that most dispensary medical officers were inclined to diagnose all eruptions of the hands and feet as fungal. Others made conscientious efforts to single out patients who could be treated in the camp dispensary on an ambulatory basis and referred others selectively to the dermatologic clinic of adjacent station hospitals. Frequently, an informal liaison was established between the dermatologist at the hospital, if there was one on the staff, and medical officers in the field, to the benefit of all concerned.


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Station Hospitals

Although during the training period station hospitals were the most important units from the standpoint of dermatologic care, almost no provisions for it were originally made in them. Dermatologic care was entirely inadequate when it was most needed. As already mentioned, about 20 percent of all dermatologists who came into service expressed a preference for the Army Air Forces, and the majority of the remainder were assigned to general hospitals in the Zone of Interior or to units going overseas. Only a small number were left for duty in station hospitals, in most of which a medical officer became a dermatologist simply by order of the commanding officer.

From November 1940 to the middle of 1943, station hospitals supporting the various training camps in the Zone of Interior were much more important in meeting the problem of dermatologic disability than were general hospitals. Yet in late 1942, not a single qualified dermatologist was on the staffs of the hospitals caring for the large numbers of troops in training in Louisiana, and this situation was not unusual.

An occasional patient with severe, intractable, or obscure cutaneous disease was sent from the camp dispensary to a general hospital or, later in the war, to a regional hospital, but most patients with skin diseases were sent to station hospitals from dispensaries. The number referred to general hospitals from station hospitals was in inverse ratio to the skill and experience of the medical officers handling dermatologic conditions in the station hospitals. By this time, personnel in the Office of The Surgeon General, as well as surgeons of the service commands, fully recognized the importance of dermatologic care at station hospitals and tried to staff them accordingly, but their efforts, as already indicated, were seldom effective (p. 560).

One of the major responsibilities of station hospitals was the physical reclassification of inductees. Their staffs had the authority to recommend a man's change of status from full combat duty to limited service, as well as to recommend his discharge from service. After his induction, a soldier with a dermatosis first came to the attention of the medical officer in his unit either through his own professed inability to perform his duties or through detection of this inability by his superiors. When, usually after some treatment at the company dispensary, he was referred to a station hospital, he was either observed and treated tentatively on an ambulatory basis or was hospitalized at once for investigation. If it was determined, after careful examination, that his dermatologic condition warranted a change of status, he was recommended to the hospital disposition board, by the officers who had examined him, for reclassification for limited duty or for discharge from the Army. The procedure described was eventually streamlined, at least in comparison to the earlier routine, but it was always long, costly, and cumbersome, and as already pointed out, much time and


572

effort would have been saved if men with certain skin conditions had been rejected when they appeared at the induction station.

There were several reasons why it was difficult to determine whether a man with skin disease was able to perform full duty or limited duty or should be discharged from service. One was that if he wished to escape full combat duty or to be separated from service, he could achieve his desire simply by aggravating his objective findings by vigorous scratching or by the application of irritating local agents.

It became clear early in the training period that medical practice in the treatment of soldiers with skin diseases on a duty status was quite different in an army in active training and a peacetime army. A soldier with partly disabling dermatitis in a combat unit had to be fit for full duty or classified as not fit for duty at all. Early hospitalization was necessary for soldiers with dermatoses that were disabling, contagious, or so extensive as to make dispensary and self-treatment impractical. Once the situation was recognized, admissions for dermatologic disease constituted an increasing proportion (from 6 to 12 percent) of all admissions to station hospitals, depending upon the time of year and the part of the country in which the hospitals were located. Annual reports13 from various station hospitals bear out these remarks. Many of them were located in areas in which climatic conditions were ideal for the development of a high incidence of disabling dermatoses.

Camp Polk, La.-Maneuvers were conducted in Louisiana during August and September 1941 for a total of 53 days. During this period, 4,391 patients were admitted to the station hospital at Camp Polk, which had a bed capacity of 600 and an expansion capacity of 804 beds. Gastroenteritis came first in the 10 leading causes of admission, but cutaneous diseases of various types came next, including dermatitis of various origins, dermatophytoses, pyogenic infections, insect bites with complications, eczematous dermatitides, scabies, pediculosis, and contact dermatitis of various types, including that caused by poison ivy. The dermatologic clinic set up to handle these patients registered 1,030 new patients in 1942 and 1,040 in 1943, when there were 31,553 hospital admissions. In the 1943 report, it was noted that delays of 4 to 8 weeks occurred before [dermatologic] patients could be transferred to general hospitals.

Camp Livingston, La.-At Camp Livingston, La., in 1942, 788 patients were hospitalized on the dermatologic section that had been set up in the station hospital, and 1,629 were hospitalized in 1943. The 858 hospitalized in 1944 constituted 9 percent of the total admissions. In 1943, 6,137 dermatologic patients were seen in consultation, and in 1944, there were 9,547 visits to the outpatient clinic. Many uncommon dermatoses were observed, including systemic lupus erythematosus, leprosy, hidradenitis suppurative,

13When it is evident from the text that an annual report is the source for the material presented, no footnote reference is furnished for such source.


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Fox-Fordyce disease, creeping eruption, epidermolysis bullosa, scleroderma, and prurigo nodularis. This was a burden far too heavy to be carried by a medical officer without special qualifications in dermatology.

Camp Shelby, Miss.-The station hospital at Camp Shelby, Miss., treated patients with skin diseases on a separate ward in the medical section in 1941 but did not establish a dermatology section until 1942. During the latter year, 453 patients were seen in the outpatient dermatology clinic. In 1943, 1,126 were seen in this clinic, about 19.7 percent of the total number of outpatients (5,699), and a figure second only to the neuropsychiatric visits.

Fort Bragg, N.C.-The station hospital at Fort Bragg, N.C., had 3,438 beds, which could be expanded to 4,469, and had other facilities for the care of about 75,000 troops in training. Diseases of the skin were first cared for entirely in the camp dispensary, but in 1942, three wards were established for the care of patients with these conditions, and a special clinic organization was also established. In 1943, a total of 1,721 patients were admitted to the dermatologic wards, 4,801 were seen in consultation, and 5,370 were treated in the outpatient clinic. This hospital had facilities for superficial X-ray therapy, and 851 treatments were given in 1942. A qualified dermatologist was assigned to the staff early in the training period, but most of his time had to be devoted to the diagnosis and treatment of syphilis and other venereal diseases.

Regional Hospitals

After regional hospitals were organized in the Zone of Interior, in the middle of 1944, an effort was made to assign qualified dermatologists to them, with priorities second only to certain named general hospitals and units going overseas. Excellent dermatologic services were eventually established in most of them.

The experience of the regional hospital at Camp Lee, Va., may be cited as typical. During 1945, when the average camp census was about 25,000 men, 2,884 dermatologic patients were seen, an average of about 9 new patients per day. The distribution of diseases appears in table 102. The unusually high incidence of scabies is explained by the fact that many of the patients had returned from Europe, where this condition was extremely frequent (p. 631). Before 1945, the incidence of scabies in station and regional hospitals was not more than 1 or 2 percent.

Staging Areas

Dermatologic conditions in station hospitals in staging areas presented rather special problems. The experience at Camp Kilmer, N.J., was typical:

Between its opening in June 1942 and 1 September 1945, this hospital admitted 52,788 patients, 38,209 to the medical service, and 2,968, about


574

TABLE 102.-Proportionate distribution of skin diseases in Dermatology Clinic, ASF Regional Hospital, Camp Lee, Va., 1945


575

6 percent of the total admissions, to the dermatology wards. In addition, 7,183 patients were observed in the dermatology outpatient clinic.

Every soldier who arrived at this camp was immediately examined by a medical officer and was reexamined 48 hours before he was scheduled for departure. The second inspection sometimes disclosed dermatoses that had originally been mild but that had recently become aggravated to such a degree that the soldier had to request treatment just as his unit was preparing to go overseas. At this point, the medical officer had to make an important and often difficult decision: It was his responsibility to send men forward with their units, but it was also his responsibility to hold back men who could not perform full duty. This was a decision that required wide experience and sound judgment and that involved more than strictly medical considerations. The individual's importance to his unit also had to be taken into account; it was much more difficult, for instance, to replace a trained technical sergeant than a private. It is worth noting that the majority of men in this group did not attempt to remain behind; most of them, even when their dermatoses were relatively severe, pleaded to be allowed to proceed with their units.

General Hospitals

The function of named general hospitals in the Zone of Interior was to provide definitive care for all types of patients. For this reason, patients with difficult diagnostic and therapeutic dermatologic problems were referred to them. Later in the war, when patients began to be evacuated from oversea theaters and were sent directly to general hospitals, Zone of Interior patients with special problems were sent to regional hospitals, leaving the bed space in general hospitals for patients from overseas.

In 1941, when Reserve officers who were qualified dermatologists began to come into service, general hospitals were given a high priority in their assignment, and the majority of these hospitals had excellent dermatology and syphilology sections during most of the war. In many instances, the dermatologist first assigned to a particular hospital remained in it until the end of the war; commanding officers were understandably reluctant to release qualified specialists for whom there were no suitable replacements.

In 1945, Moore General Hospital, Swannanoa, N.C., and Harmon General Hospital, Longview, Tex., were designated as tropical disease centers. Both had large, well-staffed dermatology sections, and it was planned that these general hospitals, as well as six others, should be designated as dermatology centers and that the best qualified dermatologists available should be assigned to them. The war ended before these plans could be implemented.

The dermatologic experiences of several general hospitals in the Zone of Interior are worth relating in some detail.


576

LaGarde General Hospital.-The first dermatology section on the medical service of a general hospital in the Zone of Interior was set up in the summer of 1941 at LaGarde General Hospital, New Orleans, La., with Capt. (later Maj.) Robert Stolar, MC, as chief of the section. Captain Stolar remained in this assignment throughout the war. As in other hospitals, dermatology had originally been part of the urology service, but the chiefs of the medical and surgical services decided, wisely and promptly, that this was a totally illogical arrangement, and as just noted, a separate dermatology section was established without delay.

LaGarde General Hospital was located in a city that was a seaport as well as an important rail center. Many training areas were in Louisiana and other adjacent States, and during the training period and later, this hospital received large numbers of patients who required specialized dermatologic care. During the same period, it also received patients from the Caribbean Command and the Panama Canal Zone, and it therefore had a larger dermatologic section during the last half of 1941 and all of 1942 than other general hospitals. The annual report for 1942 records 10,800 visits to the dermatology outpatient clinic, and the 1943 report shows an average of 1,075 visits per month to this clinic.

By 1944, the routine of diagnosis and treatment was well established at this hospital, and the report for this year emphasizes several points:

1. All dermatologic conditions, as well as all primary and secondary syphilis, were treated on the dermatology and syphilology section. Darkfield apparatus was obtained for use on these wards, and examinations were made on them rather than in the laboratory. Patients with tertiary syphilis were admitted to other sections, depending upon the particular system involved.

2. Early in the year, a number of patients with neurosyphilis were treated with fever (malaria) therapy. This modality was discontinued with the establishment of neurosyphilis centers. The therapy of syphilis underwent a notable change with the introduction of penicillin.

3. The variety of skin diseases encountered was challenging and instructive. Biopsy was frequently necessary for diagnosis, and many pathologic examinations were made.

4. The number of fungal infections conformed to the general impression that cutaneous conditions of this origin were less frequent than had generally been supposed.

5. The incidence of psychosomatic manifestations in the form of skin disease was impressive.

6. Cold quartz ultraviolet light therapy, as well as other forms of therapy, produced good results, and most patients were returned to duty.

Brooke General Hospital.-At Brooke General Hospital, Fort Sam Houston, Tex., the dermatology section of the medical service in 1943 consisted of an 84-bed ward and an outpatient clinic, in which soldiers and their


577

civilian dependents were seen daily. As many dermatoses as possible were treated on an outpatient basis. The admission rate to the hospital varied with the season of the year but averaged 110 per month. During the spring and summer, when field units were maneuvering in the vicinity, the admission rate was high. Most admissions were for fungal infections, pyodermas, and contact dermatoses, chiefly caused by poison ivy (Rhus toxicodendron).

In addition to standard equipment, the dermatology section had three large tubs available, in a separate room, for medicated baths. The equipment of the clinical laboratory, on the floor below, was used for fungal cultures and other diagnostic procedures. The radiology and physical therapy sections cooperated closely with the dermatology section. All X-ray therapy was administered by the radiology department, but the indications for it and the dosage were the province of the dermatologist.

Walter Reed General Hospital.-In 1943, patients with skin conditions were hospitalized at Walter Reed General Hospital, on the communicable disease section, under the supervision of Maj. (later Lt. Col.) Zeno N. Korth, MC, who also conducted the dermatology clinic. This clinic operated 4 mornings a week and had 3,341 new patients during the year. X-ray therapy was administered by the radiology department. In 1943, 2,550 patients received 5,025 treatments.

Foster General Hospital.-When Foster General Hospital, Jackson, Miss., began to receive patients in September 1943, a dermatology section was part of its original table of organization. The workload was always heavy. In 1944, 1,508 patients were hospitalized on this section, and 1,125 others were seen in consultation from surrounding posts and station hospitals. Microscopic studies and cultures for fungi were carried out, and biopsies and other standard diagnostic procedures were performed as indicated. The most frequent dermatologic conditions encountered were trichophytosis and acne vulgaris. The disease of greatest interest in 1944 was so-called New Guinea dermatitis, a then obscure and puzzling type of dermatitis apparently endemic in this part of the Pacific Ocean Areas and later diagnosed as atypical lichen planus (p. 638).

The chief of the dermatology section gave numerous demonstrations in the hospital and also provided instruction in dermatologic diseases here and elsewhere.

Harmon General Hospital.-Harmon General Hospital did not become operational until December 1942, and dermatology is not mentioned in its annual report for that year. In 1943, the report states that there were 400 admissions, with 366 dispositions, to its 66-bed dermatology section. Visits to the dermatology outpatient clinic averaged 100 per month. By 1944, the dermatology section had expanded to 8 wards, and there were 1,142 admissions with 908 dispositions. The highest daily census was 315. The 2 medical officers assigned to the section also saw 822 patients in consultation


578

on other services and supervised the X-ray treatments (422) of 182 patients. Many patients with resistant chronic dermatoses showed great improvement after superficial X-ray therapy.

In March 1945, Harmon General Hospital was designated a tropical disease center, with dermatology a subdivision. The report covering the period from 1 January to 1 November of that year showed 1,053 admissions to the dermatology section, with an average daily census in September of more than 500 patients. By this time, many patients were being received who did not need intensive dermatologic care; their original condition had improved with the elimination of the etiologic factors and predisposing causes of the diseases after the end of the war in the Pacific and their evacuation to the Zone of Interior. Their disposition, usually by furlough to convalescent hospitals, was rapidly accomplished.

Among the wide range of dermatoses seen at Harmon General Hospital were bacterial infections; cutaneous ulcers, some with Corynebacterium diphtheriae as the etiologic factor (p. 607); and the variety of dermatitis later traced to the use of Atabrine (p. 646).

The variety of dermatoses observed at this hospital and the concentration of patients there provided, theoretically, opportunities for close and prolonged study and created a field for many investigations. There were several reasons why the opportunities were not utilized. One was the small number of dermatologists on the section, whose professional duties kept them fully occupied. Another was the constantly high census, which generated an urgency for the rapid turnover of patients, to provide bed space for others. Still another was the pressure created by the end of the war, which required rapid demobilization of patients with the imminent closing of the hospital. It is unfortunate that a planned, well-controlled series of studies was not possible; such an investigation could have opened up avenues of further research that would have resulted in important advances in military dermatology.

Lovell General Hospital.-Little dermatology was done at Lovell General Hospital, Fort Devens, Mass., during 1941. During 1942, the section had 123 admissions for both skin diseases and syphilis. The skin conditions more frequently encountered were eczematoid dermatitis, dermatophytosis, disseminated neurodermatitis, and seborrheic eczema. In most instances, these conditions were difficult to handle because they were chronic and had been treated-and often overtreated-for many months in dispensaries and station hospitals.

In 1944, Lovell General Hospital became a 4,000-bed hospital, with an allotment of 500 beds for the dermatology section. It was one of the hospitals that was designated, the following year, as a dermatology center but did not become operational because of the end of the war.

During 1945, of the 22,923 admissions to the hospitals, 2,068 were to the dermatology section, and from 10 to 15 new patients were seen daily in


579

the outpatient clinic. This was another section that was constantly under pressure because of the heavy influx of patients. It was imperative to handle these incoming patients as promptly as possible, to clear the beds for other patients. The annual report for 1945 mentions with regret that, chiefly because of these pressures and because of understaffing, the wealth of dermatologic materials available could not be handled as scientifically as it should have been.

Fitzsimons General Hospital.-Between June 1943 and late in 1945, most of the patients on the dermatology service at Fitzsimons General Hospital, Denver, Colo., were evacuated directly to it from various oversea hospitals because of incapacitating disease. Between 1 July 1944 and 1 July 1945, there were 969 admissions to the dermatologic section and 5,652 consultations. The peak dermatologic load occurred in January and February 1945, when the ward census reached 154 and the average monthly admissions were 120.

The survey of the various diseases observed in this hospital made at the end of the war by Lt. Col. Arthur R. Woodburne, MC, Chief of the Dermatology Section, is discussed under appropriate sections elsewhere. Many of the patients flown directly to the hospital from overseas, especially from the Southwest Pacific Area and the China-Burma-India theater, could be held long enough for careful observation and definitive treatment. An interesting feature of this survey concerned the skin diseases common in civilian dermatologic practice but altered by military conditions.

DISTRIBUTION AND ADMINISTRATIVE MANAGEMENT OF 
SKIN DISEASES IN OVERSEA COMMANDS

Mediterranean Theater of Operations

With the notable exception of plant dermatitis, the major dermatologic problems in the North African (later Mediterranean) theater paralleled those encountered in troops under similar conditions of deployment in the Zone of Interior. In order of prevalence, they included bacterial infections; fungal infections; dermatitis of unknown etiology, including psoriasis, lichen planus, erythema multiforme, and the eczemas; dermatitis of known etiology, including dermatitis venenata, dermatitis medicamentosa, and infectious eczematoid dermatitis; and parasitic infections. The majority of these were bacterial infections, in which penicillin proved a valuable agent, fungal infections, and parasitic infections. A considerable number of cases of cutaneous diphtheria were observed in North Africa. Details of special diseases are commented on under appropriate headings.

Not very many trained troops were lost to duty in the Mediterranean theater because of skin diseases. A survey of 3,030 patients hospitalized for


580

these conditions in 4 general hospitals showed that 95.75 percent were returned to full duty after treatment.

European Theater of Operations

In the European theater, the proportion of admissions to hospitals for dermatologic conditions was at first similar to what it would be in civilian hospitals in peacetime except for the higher incidence of scabies (p. 631). When the care of battle casualties became of major importance, the number of dermatologic conditions increased in all categories because of the increased troop strength in the theater. Because of the pressing need for manpower, the pressure to return patients with medical diseases to duty was even greater than it had been before D-day.

The incidence of disability from skin diseases was significant in the European theater but not excessive as it was in the Pacific Ocean Areas and the China-Burma-India theater. Certain personally collected statistics will make this clear:

In the 21st Evacuation Hospital, from 26 December 1942 to 5 March 1943, 10 percent of all medical admissions were to the dermatology section and 30 percent of all dermatologic admissions were for scabies.

In the 5th General Hospital, during the latter part of 1942, 6.8 percent of 7,049 admissions were for the primary diagnosis of skin disease.

In all hospitals of the European theater, during November and December 1943, 7.2 percent (1,035) of 14,408 admissions were for skin disease.

Interviews with medical officers in the European theater revealed that the incidence of skin disease at sick call in both service and combat units ranged from 15 to 40 percent. Medical officers in the Mediterranean theater reported about the same proportions.

Syphilis.-Venereal diseases (fig. 64) are dealt with extensively in other volumes of this historical series,14 but certain aspects of therapy in the European theater should also be mentioned here:

1. All patients with ulcerative venereal disease were admitted to the dermatosyphilology sections of hospitals, to insure more accurate diagnosis and adequate treatment. The responsibility for their care rested with the Professional Services Division, Office of the Chief Surgeon, but close liaison was maintained with the Preventive Medicine Division.

2. Individual treatment records were issued, which were carried on his person by the individual soldier. They served as guides to medical officers when, as often happened, syphilis registers were not transferred from unit to unit.

14(1) Medical Department, United States Army. Internal Medicine in World War II. Volume I. Activities of Medical Consultants. Washington: U.S. Government Printing Office, 1961, pp. 281-318. (2) Medical Department, United States Army. Internal Medicine in World War II. Volume II. Infectious Diseases. Washington: U.S. Government Printing Office, 1963, pp. 409-435.


581

FIGURE 64.-Syphilitic lesions. A. Typical penile chancre. B. Anal syphilitic condylomata. C. Acute florid secondary syphilis. D. Later recurrent secondary syphilis.

3. All syphilis registers of presumably cured patients were submitted to examination at the Medical Records Division, Office of the Chief Surgeon, by the Consultant in Dermatology and Syphilology before they were transferred from the theater to the Office of The Surgeon General. Deficiencies, which consisted of inadequate treatment or insufficient evidence of cure, could thus be detected and corrected at once.

4. Massive arsenotherapy was introduced into the theater early in 1943. Between April 1943 and July 1944, approximately 4,000 patients were treated by this technique; the absence of fatalities proved the value of careful supervision.15 The technique was criticized later in some quarters

15See footnote 14 (1), p. 580.


582 

because of presumed infectious relapses, but the experience was fairly comparable to the experience after penicillin therapy was introduced; biologic cure was frequently achieved, but reinfection on subsequent exposure was common.

5. Penicillin therapy for early syphilis was officially introduced into the theater on 26 June 1944, 20 days after D-day. In January 1944, it had been recommended that penicillin be used for the treatment of syphilis in operational Air Forces crews in the theater, but permission was refused by the Air Surgeon in Washington.

6. One of the most impressive figures to come out of the Army medical experience in World War II is the man-days lost because of venereal disease as compared with the figures for the American Expeditionary Forces in World War I.16 For 1918, in World War I, the figure was 6,804,818 days, almost 19,000 men per day per year. For 1944, the comparable figure in the European theater was 221,184 days, a rate of 606 men per day per year. Over half of the World War II figures covered the period before the introduction of penicillin.

Southwest Pacific Area

Incidence.-Dr. Hopkins, in his report to General Denit after his survey of installations in the Southwest Pacific Area,17 stated that time had not permitted extensive microscopic or cultural studies. It had also not been possible to obtain statistical data concerning the incidence of diseases observed in his survey because the number of troops from which the hospitalized patients were drawn could seldom be determined. His conclusions were therefore based on extensive discussions with medical officers who had studied these diseases; on clinical examination of numerous patients; and on mycologic examination of a few representative samples.

It was Dr. Hopkins' impression that the majority of patients who were hospitalized in the Southwest Pacific Area for severe skin conditions fell into two groups. The first, and larger, group of hospitalized patients had what was termed "symmetrical eczematoid dermatitis." The second group of hospitalized patients had what was termed "atypical lichen planus." Other men in the Southwest Pacific Area, who constituted an even larger group than those hospitalized, presented characteristic blue pigmentation of the nail beds. They had no symptoms, and they reported for treatment only when they became disturbed by the cosmetic appearance of their nails.

Although these three groups of skin conditions bore some resemblance to well-known dermatoses, none of them seemed precisely identifiable with

16Medical Department of the United States Army in the World War. Communicable and Other Diseases. Washington: U.S. Government Printing Office, 1928, pp. 263-310.
17Unless otherwise indicated, the discussion of dermatologic diseases, presented for the Southwest Pacific Area throughout this chapter, is based on Dr. Hopkins' report to General Denit, submitted on 13 March 1945. See footnote 8, p. 557.


583

any disease which Dr. Hopkins, an experienced dermatologist and mycologist, had previously observed. It was his conclusion that they represented either three new clinical entities or three phases of a single new entity.

An analysis of all patients admitted to the dermatology wards of the 27th General Hospital, Hollandia, New Guinea, from 1 August 1944 to 7 July 1945 by Maj. (later Lt. Col.) Charles L. Schmitt, MC, Chief of the Dermatology Section, showed that 1,820 had been observed during this period. Of this number, 1,182, more than two-thirds, were returned to duty, and 636 were boarded to the Zone of Interior. There were two deaths, one from exfoliative dermatitis. The cause of the other death was not stated.

Investigation of these 1,820 cases showed that a considerable number previously diagnosed as dermatophytosis and dermatitis venenata were in reality early eczematoid dermatoses and were due, at least in part, to a drug intolerance. The investigation also showed that drug intolerance represented the principal cause for boarding patients to the Zone of Interior.

In this single hospital, for the 11-month period studied, 38,430 mandays were lost from duty because of skin diseases.

Recommendations.-At the conclusion of his survey of skin conditions in the Southwest Pacific Area, in his letter to General Denit, dated 13 March 1945, Dr. Hopkins made a number of suggestions, many of which were generally applicable, as follows:

1. Mycologic problems in the Southwest Pacific Area would not be solved until one or two mycologists competent in research were sent to the area. They must be provided with technical assistance, the necessary apparatus and media, and dustproof rooms for inoculation and preservation of cultures.

2. For accurate diagnosis of fungal infections (figs. 65, 66, 67, and 68), each medical laboratory sent to the Tropics should have on its staff an officer sufficiently trained to identify common pathogenic forms of fungi. Each hospital should have a technician competent to detect fungi by direct slide examination.

At the time Dr. Hopkins made his report, there seemed to be only a single officer in the whole Southwest Pacific Area with any training or experience in the identification of fungi. In only a single clinic, the 13th Medical Service Detachment, did Dr. Hopkins see practical use made of slide examinations for diagnosis; here, with the excellent cooperation of the 27th Medical Laboratory, examinations were made promptly and accurately. The same favorable situation might perhaps prevail in some of the installations that he had not visited, but in those that he had investigated, he did not encounter a single dermatologist who believed that he could obtain reliable examinations for fungi. Laboratory officers who were, reluctantly, making cultures for fungi stated that they were at a loss to identify any positive cultures that they might observe.


584

FIGURE 65.-Erythrasma or fungal infection of thighs.

FIGURE 66.-Acute tinea cruris.

In Dr. Hopkins' opinion, the situation could be corrected at once if a few laboratory officers were trained in mycology before they were sent to the Southwest Pacific Area and if short laboratory courses were substituted for the one or two lectures that now seemed to constitute the only mycologic training given to technicians.

The use of mycologic methods for diagnosis was more important than research in this field. Slide examinations would usually be sufficient, but cultures were necessary for the detection of Monilia and some of the more


585

FIGURE 67.-Typical acute dermatophytosis caused by Trichophyton mentagrophytes.

FIGURE 68.-Tinea corporis.


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uncommon parasites. The routine use of such techniques would improve the accuracy of diagnosis and eventually result in therapeutic improvement.

3. As a therapeutic test, 1,000 tubes each of undecylenic acid and sodium propionate ointment should be issued to each of several infantry divisions, so that division surgeons could report on their effectiveness under field conditions. Liquid preparations of fatty acids might be similarly tested.

4. Sandals should be issued to infantrymen, for use as permitted by command after consultation with the medical officers concerned (p. 602). It was also recommended that troops be allowed to work during the day without shirts at such times and in such areas as were considered safe. External infection might sometimes be a causative factor in dermatophytoses of the groin and other parts of the body, but the prevalence of these eruptions in the Southwest Pacific Area, just as in the southern United States during the summer, could more reasonably be attributed to the wearing of impervious clothing that prevented the evaporation of sweat. Giving permission for troops to go naked during the sunny hours of the day would probably almost abolish extensive ringworm of the trunk without endangering the antimalarial program and would have an equally good effect on miliaria and the impetigoes. If this plan was considered undesirable, then it was recommended that the fabric used in Army shirts be changed. Closely woven, uncomfortable herringbone twill might be necessary under combat conditions, but in rear areas, a more loosely woven fabric, such as was used in the Australian Army, would be preferable.

5. To prevent ecthyma, which was prevalent among troops in combat areas, medical officers and company commanders should be instructed in the use of Freon-12 aerosol insecticide or DDT for the control of flies. Both were practical agents for forward use.

6. To prevent so-called tropical immersion foot (p. 600), mineral oil should be issued before landings on wet terrain, and the troops should be instructed to grease their feet before they went ashore and as often thereafter as possible. Careful check should be made of the condition of the feet and legs of the men thus treated as compared with a control group of similar size without treatment.

7. To prevent disability from acne, medical officers who examined troops before embarkation from the Zone of Interior should be informed of the bad prognosis for the cystic type of acne in the Tropics (p. 617) and should be advised against sending men with this disease to the Southwest Pacific Area.

8. One or more permanent hospitals should be designated for the treatment of warts by X-ray. A standard technique should be developed for their management in dispensaries. Formalin therapy18 was considered well worth a trial.

18Thomson, S.: The Treatment of Plantar Warts by Formalin. Brit. J. Dermat. 55: 267-269, November 1943.


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9. Every effort should be made to clarify the etiology of eczematoid dermatitis, which was the most serious dermatologic problem in the Southwest Pacific Area and the most frequent dermatologic cause for evacuation of personnel from this area to the Zone of Interior. It would be well if some of the men evacuated would volunteer to continue suppressive doses of Atabrine after their return to the United States.

10. The issue of multiple vitamin tablets should be increased, in the hope that their use might lower the incidence of dermatoses.

11. The following research studies were recommended:

a. Determination of the presence of fungi in the lesions of lichen planus or in symmetrical eczematoid dermatitis, especially in the lesions of the nail so frequently seen in New Guinea (p. 643).

b. The frequency of fungal infection as a cause of intertrigo of the toes and dermatitis of the feet.

c. Identification of the species of fungi found in dermatomycoses on different parts of the body.

d. The relation of Monilia albicans to miliaria.

e. The relation of fungal infection to so-called tropical immersion foot.

f. The possibility of sensitization to bacteria or fungi in lichen planus and eczematoid dermatitis with allergies.

China-Burma-India Theater

Venereal diseases.-The venereal disease rate in India among U.S. troops was one of the highest encountered in any theater or area in World War II. Maj. Harry M. Robinson, Jr., MC,19 reported that one laundry battalion station in Calcutta had a rate of 1,500 per 1,000 per year. Although syphilis and gonorrhea were the major problems, chancroid and lymphogranuloma venereum were common. It was not unusual for a man to report for treatment with two, three, or even four separate venereal diseases at the same time, following several exposures over a short period.

Dermatologists of the 20th, 69th, and 142d General Hospitals played an important part in the management of these patients. During 1944 and early 1945, one of three wards in each of these hospitals was continuously filled with men with early syphilis, chancroid, lymphogranuloma venereum, or combinations of these diseases. Penicillin became available in the theater for the treatment of syphilis in September 1944, but supplies were limited.

Dermatologic diseases.-The major dermatologic problems in Burma and India were quite similar to those encountered in the Southwest Pacific Area. Many skin diseases with a high incidence in the United States were also common in the China-Burma-India theater. During the hot, humid monsoon season in particular, primary bacterial infections were widely

19Robinson, H. M., Jr.: Personal communication


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prevalent, especially ecthyma and bullous impetigo. Secondary bacterial infections of eczematous eruptions, contact dermatitis, and tinea pedis were common, and their course was protracted. During the summer months, the incidence of miliaria rose to 75 percent in some units, and the condition was often incapacitating. Scabies was an important cause of disability in Chinese troops but was uncommon in U.S. Army personnel.

A unique form of contact dermatitis observed in the China-Burma-India theater was dhobie mark dermatitis (p. 626). Other cutaneous diseases of interest and importance in U.S. personnel included cutaneous diphtheria (p. 613) and the lichenoid and eczematoid dermatitis syndrome caused by Atabrine (p. 638). Among the unusual cutaneous diseases and systemic diseases with cutaneous manifestations seen in Chinese troops were leprosy, kala-azar, tuberculosis, syphilis of the bones and other deeper structures, and true tropical phagedenic ulcer associated with malnutrition. Superficial fungal infections were identical with those that occur in the United States, but they were more frequent, more extensive, and more difficult to control.

In summary, the effects of the hot, humid climate in India and Burma, plus the skin trauma incidental to active military campaigns and engineering activities in a jungle type of environment, led to a high incidence of incapacitating cutaneous bacterial infections, miliaria rubra, infected indolent insect bites, contact dermatitis, superficial fungal infections, eczematoid dermatitis, and cystic acne. In addition, the total disability caused by cutaneous diphtheria, dhobie mark dermatitis, and the lichenoid and eczematoid dermatitis syndrome was significant. Comment is made on certain of these conditions under appropriate headings.

Part II. Clinical Considerations

FUNGAL INFECTIONS

General Considerations

Zone of Interior.-The popular impression that fungal infection was a serious condition in U.S. troops in World War II was universally disproved whenever adequate methods of diagnosis and evaluation were employed. At Fitzsimons General Hospital,20 over a period of months, all patients hospitalized on the dermatology service were studied by direct examination of all lesions, fungal cultures, and the trichophytin test. The generally negative results of this careful study showed that superficial fungal infections were not a cause of significant disability among troops evacuated to the Zone of Interior because of skin diseases. Similar studies at other hospitals were to the same effect.

20Woodburne, Lt. Col. Arthur R., MC: Dermatology at Fitzsimons General Hospital, n.d.


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At Fitzsimons General Hospital, the incidence of onychomycosis of the nails was somewhat greater than in civilian practice. It was treated by removal of all infected material by nail clippers, files, curettes, and dental burs, after which the fingertips were soaked in soapsuds or in a 20-percent sodium hydroxide solution. Whitfield's ointment, full strength, was rubbed vigorously into the nails at night, and the affected parts were painted with a 3-percent iodine solution in the morning.

Mediterranean theater.-In the Mediterranean theater, mycotic infections accounted for about a fifth of all skin diseases, as the following personally collected figures show:21

1. These infections accounted for 16.7 percent of the admissions and dispositions for skin conditions and for the patients remaining in MTO hospitals in the week ending on 22 September 1944.

2. They accounted for 19.3 percent of all skin diseases in the Fifth U.S. Army for the same week.

3. They accounted for 21.9 percent of all skin diseases in the 34th, 85th, and 88th Infantry Divisions for the 3-week period ending on 22 September 1944.

4. They were less frequent in rear echelon troops. According to one survey, they accounted for only 13.3 percent of all the skin conditions treated in the outpatient dispensary of a large general hospital.

These figures, however, need some explanation before they are accepted absolutely. The Army figures were collected in September, when fungal infection was frequent. The outpatient dispensary figures just cited were collected over a period of several months. Furthermore, a higher incidence of fungal infections would be expected in combat troops because of long marches and their frequent inability to bathe, remove their shoes, change their socks, and use foot powder. Nonetheless, the fact that fungal infections accounted for 13.3 percent of all skin conditions in an outpatient dispensary in a base section, where living conditions were at least fair and where reasonable personal hygiene was possible, indicated that they were rather prevalent. When field and combat conditions are taken into account, it is small wonder that these conditions were recorded so frequently and meant the loss of so many man-days. One reason for the amount of disability they produced lies in the fact that most mycotic infections involved the feet or the genitocrural region.

Two conditions secondary to primary fungal infection in the Mediterranean theater require special comment:

1. In many instances of cellulitis (figs. 69, 70, 71, and 72), the portal of entry of the invading organism was a fissure or ruptured vesicle in which dermatophytosis was the original lesion. The primary disease was not in

21All data for the Mediterranean theater were provided by Dr. R. N. Buchanan, Jr. (formerly Lieutenant Colonel, MC), Dr. R. E. Imhoff (formerly Major, MC), Dr. C. Barrett Kennedy (formerly Major, MC), and Dr. Richard C. Manson (formerly Major, MC).


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FIGURE 69.-Proved leishmaniasis of toe, with numerous Vincent's spirochetes.

FIGURE 70.-Cutaneous leishmaniasis.

itself disabling, with the secondary condition was potentially serious, likely to be disabling, and very often entirely preventable.

2. Dermatophytids developed in a great many instances of fungal infection. Many patients were sensitized to the products of infection because


591

FIGURE 71.-Diphtheria of skin of foot.

the fungal infection had been allowed to persist; to go through phases of more or less activity; to become acute, with fissuring and oozing; then to improve but never to heal completely. Often, patients of this type, when they were received in the Zone of Interior, had not only primary mycotic infections but also eczematous vesicular dermatitis, usually on the palmar and plantar surfaces, which was quite resistant to treatment. It was repeatedly stressed to medical officers that early, appropriate treatment of primary fungal and other infections would result in their control and would prevent complications. Many of these conditions, unfortunately, resulted from sensitization by the use of strong fungicidal preparations, particularly ointments issued for use on a duty status.

When soldiers with fungal infections presented themselves on sick call, it was often because of secondary infection, to which primary thera-


592 

FIGURE 72.-Scrub typhus with eschar.

peutic attention had to be directed. Measures most frequently used included compresses and soaks of boric acid solution, dilute potassium permanganate solution, aluminum acetate solution, or a saturated solution of magnesium sulfate. After secondary infection had been controlled, therapeutic measures included Lassar's paste; Whitfield's ointment, half strength; keratolytics; a 3-percent sulfur and salicylic acid ointment; 4 percent salicylic acid; 2 percent thymol in tincture of benzoin compound; and a 5-percent crude tar ointment. Some patients with chronic fungal infections were benefited by superficial X-ray therapy. When treatment was concluded, the patient was given a can of GI (Government-issue) foot powder and urged to use it.

Most men with fungal infection seen in the Mediterranean theater were returned to duty, but occasional patients with chronic diseases and dermatophytid reactions were resistant to all types of therapy. They were usually evacuated to the Zone of Interior, but only after they had been hospitalized for long periods of time and spent many days away from their units.

Southwest Pacific Area.-Fungal infections in the Southwest Pacific Area have been discussed in detail elsewhere (p. 582) and will be discussed further under appropriate headings.


593

Inflammatory Conditions of the Feet

Zone of Interior.-The extremely unsatisfactory terminology of athlete's foot was used by many medical officers to cover a wide variety of disturbances of the feet (figs. 73, 74, 75, and 76). The nomenclature was not scientific. It had no etiologic significance, and it was even more unreliable as a basis of treatment.

At Fitzsimons General Hospital, after classification and appropriate studies, patients referred with this diagnosis were divided into the following categories and proportions:22

1. The hyperhidrosis (dyshidrosis) syndrome, 51 percent.

2. Pyoderma secondary to trauma, maceration, or the hyperhidrosis (dyshidrosis) syndrome, 14 percent.

3. Dermatophytosis, 20 percent.

4. Dermatitis venenata produced by medication (which had usually been prescribed for the treatment of the presumed fungal infections), 11 percent.

5. Other dermatitis venenata, 2 percent.

6. Resistant pustular eruptions (the so-called bacterid of Andrews), 1 percent.

7. Pustular psoriasis, 0.5 percent.

8. Acrodermatitis continua of Hallopeau, 0.5 percent.

Hyperhidrosis (fig. 77) was the most frequently observed entity at this hospital. It was psychogenic in origin, and it was seen not only on the dermatology wards but also in consultation on neuropsychiatric wards and on other services. It was readily explained by removal of men from their normal environment, disciplinary restrictions, their often hazardous living conditions, and similar precipitating causes. The correctness of these theories of etiology was proved by the fact that a quiet, restful environment, without other treatment, was frequently sufficient for a cure.

Hyperhidrosis in the Zone of Interior and elsewhere was an annoying and uncomfortable condition, but one that was seldom disabling per se. What made it important was that it was widely prevalent and that the lesions that developed in it constituted portals of entry for secondary bacterial invasion, with resulting and disabling pyoderma, cellulitis, lymphangitis, and lymphadenitis. Another consideration was that the diagnosis of fungal infection as the cause of the hyperhidrosis was often made incorrectly, and the strong and irritating fungicidal agents used unnecessarily often resulted in severe and disabling dermatitis.

Local therapeutic measures included 20 percent benzoic acid in Lassar's paste; 1:500 solution of formalin used as a soak for a brief period once daily; compresses of Burow's solution; and foot powder. The inclusion

22See footnote 20, p. 588.


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FIGURE 73.-Allergic dermatitis.

FIGURE 74.-Allergic dermatitis.


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FIGURE 75.-Severe fissuring bilateral keratosis of heels. The patient was completely disabled.

FIGURE 76.-Epidermolysis bullosa.

in the supply tables of one or more soluble aluminum salts, such as aluminum chloride or aluminum sulfate, would have provided additional agents for the treatment of ambulatory patients and would have been useful in preventing recurrences.

It was the opinion at Fitzsimons General Hospital that elimination of the so-called fungicidal prophylactic footbath and the substitution of indi-


596

FIGURE 77.--Hyperhidrosis of hands.

vidual prophylaxis, including thorough drying of the feet and the liberal use of foot powder, would have materially decreased the incidence of fungal infections of the feet.

Mediterranean theater.-Hyperhidrosis of the feet was extremely common in the Mediterranean theater where, as elsewhere, it was associated with emotional stress and strain. It was also secondary to vascular changes, particularly those associated with trenchfoot.23 It was frequently antecedent to that condition. It was difficult to handle and extremely resistant to treatment. Indeed, it often required reclassification of the soldier.

Among the multiple treatments used were painting the area with straight formalin once daily for 3 days; 1-percent formalin soaks; potassium permanganate soaks; and foot powders, such as tannic acid powder or the regular-issue foot powder. Lumbar sympathetic ganglionectomy was occasionally necessary to convert disabling hyperhidrotic feet to dry and serviceable members.

European theater.-In the European theater, inflammation of the feet, whether from fungal infection (figs. 78, 79, 80, and 81), mechanical irritation, sensitivity to footgear, or hyperhidrosis, particularly after mild trenchfoot,24 represented an important aspect of dermatology, because soldiers with any degree of inflammation of the feet were frequently unable to do full duty either in the rear or in the field.

An epidemic of what was diagnosed as fungal infection occurred in July 1943 and well illustrated the factors that can contribute to such a condition. Word of the incidence of the infection reached the ears of the Commanding General, SOS, who had had difficulties with a presumed fungal in-

23Medical Department, United States Army. Cold Injury, Ground Type. Washington: U.S. Government Printing Office, 1958.
24See footnote 23.


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FIGURE 78.-Typical dry tinea pedis caused by Trichophyton rubrun.

FIGURE 79.-Typical dry tinea pedis caused by Trichophyton rubrun.

fection himself and who was correspondingly preoccupied with the problem. The Senior Consultant in Dermatology was directed to investigate the situation and correct it immediately. The circumstances were as follows:

A large detachment of men at Depot G-25 were doing heavy work in the machine shops or elsewhere that often involved long periods of standing


598 

FIGURE 80.-Secondarily infected interdigital fungal infection.

FIGURE 81.-Symmetrical lividity of soles.


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on cold, damp concrete floors. When the depot was visited by Mrs. Eleanor Roosevelt in 1942, she apparently heard a number of complaints of cold feet from the men with whom she talked, and with her usual sympathetic understanding, she arranged for heavy British-issue socks to be supplied to them. These socks were much heavier than any regular U.S.-issue socks, and they proved very satisfactory during the winter of 1942-43. Over the same period, there was a steady increase in the issue of GI shoes with rubber soles.

In late May and early June 1943, the weather in England turned unseasonably warm, and with the change came a precipitous rise in the incidence of inflammatory conditions of the feet at this particular depot. Medical officers reported that between 50 and 75 percent of the soldiers serving there were examined at the post dispensary and showed some changes, ranging from mild scaling between the toes to more severe involvement, with blisters and fissures. It was estimated, without benefit of microscopic examinations and cultures, that about two-thirds of these men were suffering from true ringworm infections, a percentage that, at a distance of years, now seems somewhat excessive.

In any event, the epidemic was promptly brought under control by the institution of foot inspections, issue of lighter footgear, particularly socks, and emphasis upon the importance of foot hygiene, including regular washing and careful drying of the feet and the application of foot powder.

This minor episode was instructive. It emphasized the relation between proper footgear and climatic and industrial conditions, as well as the great importance of individual foot hygiene, with special relation to thorough drying of the feet, particularly the intertriginous areas, and the regular use of foot powder to promote dryness and prevent friction.

A survey of showers, sterilization of duckboards, and similar matters showed that they played no part in the increased incidence of infection at this depot or elsewhere. The provision of chemically treated footbaths served no useful purpose. In fact, there was some evidence that, if the solution in them was not changed regularly, they might serve as a means of transmitting infection rather than of preventing it. During 1942-43, when shipping space to the European theater was desperately short, tubs for these footbaths were received on a regular schedule. The Consultant in Dermatology, ETOUSA, could not understand why they were ever introduced into Army dermatologic practice.

Southwest Pacific Area.-In base and station hospitals in the Southwest Pacific Area, well removed from the front, interdigital infection of the feet accounted for only a small number of cases, fewer, indeed, than might be found in a group of healthy soldiers on active duty. All these patients had been hospitalized for varying periods, and their infections had cleared, with or without treatment. In many cases in which the diagnosis of epidermophytosis had been recorded, Dr. Hopkins found no fungi on


600

examination. He could not, it is true, exclude the possibility that the eruptions observed were primary fungal infections secondarily infected with pyogenic bacteria, but he found very few cases in which there seemed a sound basis for this assumption.

In base dispensaries, fungal infections of the feet were far more frequent than in hospitals, but the incidence was apparently no higher than in military dispensaries in the Zone of Interior. In regimental aid stations, however, and in clearing companies directly to the rear, fungal infections of interdigital areas and of the soles of the feet among troops in combat were far more numerous and were often severe.

After the Leyte landings, men stood, marched, and even slept for long periods in flooded rice paddies. There was a significant amount of disability from the resulting dermatoses. Patients were sent back to rear hospitals with the diagnosis of immersion foot (tropical cold injury),25 though no evidence of peripheral vascular damage was ever obtained. Dr. Hopkins, who obtained his information about the condition from Maj. James R. Webster, MC, at the 54th General Hospital, considered the term unfortunate. No fungi were identified in the lesions during the acute phase, which suggested that they were essentially bacterial, but in many instances, fungi were found after acute symptoms had subsided, which suggested that bacterial infection was secondary to fungal infection. Whatever the chronology, the essential etiologic factor was maceration of the stratum corneum by prolonged immersion.

Etiology.-Available evidence in both the Zone of Interior and the Southwest Pacific Area indicated that attacks of dermatophytosis were almost never caused by external infection or by reinfection from shoes or clothing. Probably few men contracted the infection in the Southwest Pacific Area. More likely, most of them brought it with them, in latent form, and it simply flared up under climatic conditions. Acute outbreaks were usually caused by sudden lowering of the natural resistance of the skin, which permitted fungi already present on the surface to multiply. The essential factor was lowering of resistance by maceration of the skin by sweat or water. It was a common observation, as already mentioned, that when patients were confined to bed for some reason, their dermatophytoses healed without treatment.

Apparently some individual immunity existed to dermatophytosis of the feet because, in any platoon or company, a certain number of men, constituting not more than 10 percent of the total number, would never develop the condition though they mingled freely with infected men and for the most part used no special prophylactic measures. The basis of their immunity was unknown, and Dr. Hopkins considered that a study of it might be rewarding.

25See footnote 23, p. 596.


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Therapy.-The treatment of dermatophytosis in men on active duty was frequently ineffective. The tendency was to use irritating fungicides, such as salicylic acid in alcohol, full-strength Whitfield's ointment, and Frazer's solution. These agents were frequently curative, but they sometimes produced severe irritation and led to the development of the acute dermatitis seen later in many hospitals.

In a study conducted at Fort Benning, Ga.,26 it was found that water-soluble ointments prepared from undecylenic acid or sodium propionate could be used in dermatophytoses without the risk of irritation inherent in the agents just listed. When these ointments were tested at base and station hospitals, the results were fairly satisfactory but not striking. When, however, they were issued to groups of infantry in combat, results were highly favorable. Capt. William B. Guy, MC, for instance, who served as battalion surgeon with the 136th Infantry, reported, after he had used them for several weeks, that these ointments had given more prompt relief than any preparations he had previously used and that they caused no irritation. He thought solutions somewhat more satisfactory than ointments but was unwilling, because of the brief period of observation, to commit himself definitely on this point.

In some instances, an ointment containing 5 percent undecylenic acid and 10 percent peroxide was used for testing purposes, but as a rule, fatty acid preparations of the following composition were employed:

Sodium propionate ointment: Sodium propionate, 16.4 percent; propionic acid, 3.6 percent; n, propyl alcohol, 10.0 percent; zinc stearate, 5.0 percent; and Carbowax base, 65.0 percent.

Undecylenic ointment: Undecylenic acid, 5.0 gm.; triethanolamine, 3.0 gm.; methocel 15 CP, 2.0 gm.; propylene glycol, 22.0 cc.; zinc stearate, 13.0 gm.; and Carbowax 1500, 55.0 grams.

Undecylenic solution: Undecylenic acid, 5.0 gm.; triethanolamine, 3.0 gm.; ethyl alcohol, 30.0 cc.; and propylene glycol, 62.0 cubic centimeters.

Prophylaxis.-Dermatophytosis of the feet, as already indicated, was seldom disabling in itself in rear areas. Practically all the patients hospitalized with it either had secondary infections or had been so overtreated that their lesions had become eczematized. The number of such cases was, unfortunately, quite large. Under combat conditions, in which men had little opportunity to care for their feet and could not remove their shoes for days at a time, a significant amount of complete disability apparently occurred, though Dr. Hopkins did not consider his investigation of troops in combat sufficient to warrant generalizations.

Tests of prophylactic measures were also not conclusive:

1. Nothing at all was achieved by measures aimed at preventing con-

26Grauer, Franklin H., Helms, Samuel T., and Ingalls, Theodore H.: Skin Infections. In Medical Department, United States Army. Preventive Medicine in World War II. Volume V. Communicable Diseases. Washington: U.S. Government Printing Office, 1960, pp. 83-125.


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tagion, such as the use of hypochlorite footbaths or disinfection of shoes, socks, and shower room floors.27

2. At Fort Benning, systematic attempts were made to prevent recurrences of dermatophytosis by prolonged treatment after manifestations had subsided. They failed utterly, as might have been expected. Experiences with attempted surgical disinfection of the hands have always shown that it is impossible to rid the skin of Staphylococcus; the application of antiseptics simply reduces the number of organisms present. It was found equally impossible to rid the skin of fungi; once the infection had occurred, it was unlikely that the application of any fungicide would destroy all the spores present.

3. Even under combat conditions, if the terrain was dry and the dermatophytosis was latent or very slight, the use of a mild fungicide, such as regular-issue foot powder, seemed reasonably effective in preventing severe outbreaks. It was also more comfortable and convenient to use routinely than were ointments. Whatever the explanation, the use of this powder seemed to prevent fungi from multiplying to the point at which they would become troublesome.

Civilian experience had showed that painting the toes once weekly with Frazer's solution was even more effective than the use of fungicidal powder in preventing recurrent attacks of dermatophytosis, but this measure was aimed at the suppression of latent infection, not at cure. Reports from dispensaries and hospitals indicated that it was effective in chronic cases. It was often irritating in active infections and therefore was not suitable for the emergency relief of acute conditions, though it was included in jungle kits for this purpose.

4. All the evidence indicated that the most effective prophylaxis in dermatophytosis of the feet was strict skin hygiene, which meant keeping the skin as dry as possible, provision of ways for evaporation of sweat, and direct exposure to sunlight for its tonic and sterilizing effects.

A convincing controlled study along these lines was conducted by Maj. (later Lt. Col.) Laurence Irving, Chief, Physiology Section, Headquarters, Eglin Field, Fla.28 Sandals were issued to approximately 1,000 men, who were permitted to wear them on the post as much as they wished; most of them practically gave up wearing shoes. A similar number of men wore shoes as usual. Within a month, the proportion of severe dermatophytoses in men wearing sandals fell from 30 to 3 percent, while in the control group, the disease remained as troublesome as usual.

A similar study was conducted in New Guinea, while the 43d Infantry Division was in a rest area. Some 300 men with unclassified skin diseases, many of whom undoubtedly had dermatophytosis of the feet, were kept on the beach for 4 hours daily, without clothing or shoes. They bathed, exer-

27See footnote 26, p. 601.
28See footnote 26, p. 601.


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cised, or just lay in the sun as they wished. Within a month, the majority of infections had cleared without any other treatment.

Any measures adopted in the Southwest Pacific Area for prophylaxis of skin conditions had to avoid serious interference with the antimalarial program or with the protection against hookworm and other parasites. These considerations made the wearing of sandals impractical in many areas, though it was entirely practical in New Guinea for men on ground duty on airstrips and in headquarters. In the Philippines, the plan was considered practical during the dry season except for troops in combat or training for combat. In most areas, it seemed safe to expose the feet during the middle of the day; they would never be more exposed to mosquito bites than the face, neck, and hands were exposed at all times. The use of thick-soled sandals, with some sort of guard in the toe to prevent scuffing up of dirt, would afford reasonable protection against hookworm. The plan seemed worth a trial to Dr. Hopkins. He believed that the issuance of sandals to the majority of troops, with permission to wear them in areas and during hours defined by the surgeon in charge, would be the most effective measure that could be adopted for the prevention of dermatophytosis of the feet. When the ground was extremely muddy, this plan, of course, was impractical from any point of view.

5. Comparative tests of undecylenic acid ointment, sodium propionate ointment, and regular-issue foot powder during the landings at Lingayen in the Philippines were too fragmentary to permit conclusions, but Dr. Hopkins believed that a full field test with them was warranted. In all such tests, it had to be remembered that any study that involved self-treatment was subject to error, beginning with doubt as to whether the agents issued were used at all.

Other Dematophytoses

Dermatophytosis of the hands.-Dermatophytic infection of the skin of the hands was extremely infrequent. Dr. Hopkins saw only 1 proved instance in his survey of SWPA installations, and in a study that he had directed at Fort Benning, of 1,472 cases in which dermatophytes were isolated, the hands were involved only twice.

Eczematous eruptions frequently seen on the hands in the Southwest Pacific Area and frequently diagnosed as dermatophytids were not so regarded by Dr. Hopkins because they were far more exudative and far more inflammatory than true dermatophytids and also because they occurred in many soldiers with no visible mycotic lesions of the feet. He did not exclude the possibility of a mycotic origin, but he considered it highly improbable.

Even in the Southwest Pacific Area, dermatophytosis of the hands was not of military significance.


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Dermatophytosis of the groin-Dermatophytosis of the groin (tinea cruris) had a high incidence in the Southwest Pacific Area, especially among troops in combat or in active training. While it was seldom the cause of complete disability or an indication for hospitalization, it was a frequent source of great discomfort, and it handicapped many men in the performance of their duties.

No extensive trials of therapy were made in the Southwest Pacific Area, but in the cases of tinea cruris treated under Dr. Hopkins' direction at Fort Benning, undecylenic acid and sodium propionate proved as satisfactory for the treatment of lesions in this location as it had proved for similar lesions on the feet.

Dermatophytosis of the trunk and extremities.-Widespread involvement of the skin of the trunk, arms, and legs (tinea corporis) was frequently encountered in the Southwest Pacific Area and was sometimes severe enough to require hospitalization. In almost every dermatologic ward that Dr. Hopkins visited, he found 3 or 4 patients with generalized ringworm in each 100 to 200 patients. The condition was no more severe, however, and the incidence was probably no higher, than at Fort Benning during August and September. The condition was of military significance in the Southwest Pacific Area chiefly because it was perennial.

The growth of fungi on the skin of the trunk and limbs seemed to depend upon the presence of unevaporated sweat, which was related, in turn, to the wearing of clothing in hot, humid weather. The effect of clothing on the distribution of these infections was strikingly illustrated in a group of some 700 prisoners of war, among whom there were almost 100 cases of extensive tinea corporis. Most of the prisoners had confluent lesions extending from the ankle to the knee, a distribution seldom observed in U.S. troops. Questioning revealed that these men had worn spiral cloth puttees, which most certainly increased sweating and prevented evaporation of sweat on the lower legs. In U.S. soldiers, the eruption was often concentrated in a band about the belt and over the buttocks, where there were several layers of clothing.

Dr. Hopkins had little success in identifying the species of fungi responsible for tinea corporis in the Southwest Pacific Area. His visits to hospitals were brief, and cultures had to be made and studied in laboratories housed in temporary buildings or tents, without assistants trained in mycology. Reliable mycologic work was impossible under such conditions. In a total group of 13 positive cultures, 2 of which were isolated by Lt. Walter L. Barksdale, SnC, 10 were Trichophyton gypseum, 2 Trichophyton purpureum, and 1 Epidermophyton floccosum (inguinale). These findings were in sharp contrast to those obtained in a study at Fort Benning: In 62 cultures of tinea corporis, 68 percent were T. purpureum and 32 percent E. floccosum; T. gypseum was not represented. In 198 positive


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cultures in dermatophytosis of the groin, 36 percent were T. purpureum, 62 percent E. floccosum, and only 2 percent T. gypseum.

These differences, of course, are not statistically significant. It was also noted in the Southwest Pacific Area, however, that, in dermatophytosis of the body, a pattern was frequently observed of small, well-defined annular lesions. Less often, there were large areas of involvement, with serpiginous borders, corresponding to the type frequently observed in Georgia. It was thought that these differences might be corrected with the species of causative fungus present. The observations in the Southwest Pacific Area, though few, confirmed the opinions expressed by Lieutenant Barksdale and a Navy colleague that dermatophytoses seen in the Pacific were caused by the same fungi that caused similar lesions in temperate climates.

The best therapy of tinea corporis was the application of gentian violet, wet boric acid solutions, or undecylenic acid or sodium propionate ointment until the acute inflammation had subsided. Then Frazer's solution was applied, or tincture of iodine, or a solution of 3 percent salicylic acid in Mercresin (mercocresols).

Dermatophytosis of the beard-Dr. Hopkins saw only one instance of tinea barbae in a U.S. hospital in the Southwest Pacific Area. The culture was positive for T. purpureum. He observed two additional cases in an Australian hospital.

Tinea versicolor-Tinea versicolor was frequently observed at Fitzsimons General Hospital in troops received from tropical oversea theaters.29 The eruption usually disappeared promptly after the application of an ointment consisting of 3 percent salicylic acid and from 6 to 8 percent ammoniated mercury in a standard emulsion base. Treatment was continued for several weeks, until all evidence of infection had disappeared.

Tinea versicolor was also extremely prevalent in the Southwest Pacific Area. It presented no military problem, since it seldom caused symptoms, and most men complained only of the discoloration of the skin. If the body had been exposed to sun, the usual coloration was reversed; the involved areas appeared white against the tanned areas of normal skin. Some native physicians, for obvious reasons, called the condition tinea alba. Some explained it by the growth of saprophytic molds on the skin, with consequent protection of it from ultraviolet rays.

Tinea versicolor in the Tropics was undoubtedly the same disease that was observed in temperate climates, but in the Tropics, it was more frequent as an acute eruption of small, round macules.

Scrapings from representative cases showed a fungus indistinguishable from the Malassezia furfur found in temperate climates. Dr. Hopkins observed a typical case of achromia parasitica in a Philippine child, whose

29See footnote 20, p. 588.


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lesions resembled tinea versicolor, though they were less scaly. Malassezia could not be demonstrated.

Applications of saturated solution of sodium thiosulfate, followed by a 3-percent aqueous solution of tartaric acid, were often effective. Lesions refractory to this method were painted with 3 percent iodine in spirits of camphor. The disease was more resistant to treatment in the Southwest Pacific Area than it was in temperate climates.

Tinea imbricata.- Tinea imbricata was extremely common in natives of New Guinea but does not seem to have been reported in either United States or Australian troops. The disease was readily identified by the beautiful, scroll-like patterns that often covered the trunk and extremities. If it was of long standing, this pattern changed to sheets of large rhomboidal scales, firmly adherent at the center but free at the border.

On slide examination, an astonishing amount of delicate branching mycelium was found in these scales. Cultivation of the causative organism, Endodermophyton tropicale, was difficult because it is slow growing and flora of the Papuan epidermis proved extremely luxuriant. The few cultures resembling this parasite that were isolated were sent to the United States for identification.

Australian physicians reported that tinea imbricata had disappeared in natives employed to spray pools with Diesel oil, an observation that was confirmed by several U.S. medical officers. Dr. Hopkins suggested further investigation of the possible fungicidal properties of Diesel oil.

Otomycosis

Otomycosis (otitis externa) was a frequent diagnosis in patients received from tropical oversea theaters, but hospitals such as Fitzsimons General Hospital reported that the diagnosis could seldom if ever be confirmed by culture of pathogenic fungi.30 The opinion of dermatologists in the Zone of Interior was that none of these patients had fungal infections of the external auditory canal but that, instead, they could be divided into two groups, a larger group composed of those with seborrheic dermatitis and another composed of those with eczematous dermatitis caused by maceration of the skin, collections of cutaneous debris, and secondary pyogenic infections.

Otitis externa was reported to be prevalent in the Pacific Ocean Areas31 but was seldom observed on dermatologic wards. Dr. Hopkins had the opportunity to study a small number of patients with this condition at the 37th General Hospital, where Capt. A. Reas Anneberg, MC, had separated them into two groups. In the first group, the clinical diagnosis of otomycosis was made because a fluffy mycelium was visible on the surface of the aural

30See footnote 20, p. 588.
31Medical Department, United States Army. Surgery In World War II. Ophthalmology and Otolaryngology. Washington: U.S. Government Printing Office, 1957, pp. 417-426.


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canal. Aspergillus (species not identified) was demonstrated on slide examination, and the response to undecylenic ointment was good and was even better when peroxide of hydrogen was added to it. The second group of cases was characterized by fissures, exudation, and crusting, and fungi were not found on slide examination. These patients, whose disease was assumed to be of bacterial origin, responded well to penicillin ointment.

Dr. Hopkins' opinion, which was concurred in by many otolaryngologists in the area,32 was that most of the reported cases diagnosed as otomycosis were not fungal infections, though a sizable number were. He believed that fatty acids offered a more satisfactory treatment for them than any method previously used and recommended a systematic trial of these agents.

BACTERIAL DISEASES

General Considerations

Bacterial infections of the skin (figs. 82, 83, and 84) were present in all theaters, and the experience of the Mediterranean theater may be described as typical. In this theater, the principal etiologic agent in the largest number of such cases was Staphylococcus or Streptococcus. Bacterial infections were consistently responsible for the highest morbidity rates in statistics collected from representative hospitals, and in a spot check of three divisions for the 3-week period ending on 22 September 1944, they were found responsible for 69.6 percent of lost man-days. A considerable number were also caused by Corynebacterium diphtheriae (p. 614).

The high incidence of bacterial infections is easy to explain-irregular bathing habits; the difficulties of access to, or lack of access to, facilities for personal hygiene; irritation of the skin by rough clothing; exposure to oils and greases; minor traumatic abrasions incidental to combat; insects bites, which were frequent; patronizing civilian barber shops; and mingling with the native population.

Bacterial infections in the Mediterranean theater fell into two chief groups:

1. Cellulitis, which had its highest incidence in field troops because of lack of facilities for personal hygiene; antecedent trichophytosis, whether treated or untreated; and antecedent insect bites and trauma, including trauma from ill-fitting shoes.

2. Furunculosis, which was extremely frequent, again because of lack of facilities for personal hygiene; the high incidence of scabies reported from all dispensaries and other installations; and repeated chronic reinfections from equipment and clothing.

32See footnote 31, p. 606.


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FIGURE 82.-Epidermophytosis with eczematoid dermatitis.

FIGURE 83.-Phagendenic ulcer of lower leg in North African native. Destructive lesions of this degree of severity sometimes developed within 2 to 4 weeks after the initial infection.


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FIGURE 84.-Recurrent erysipeloid infection of lower leg.

Diagnosis of bacterial infections was made by clinical observation, supplemented by laboratory studies (smears and cultures), which were carried out whenever practical before therapy of any kind was instituted. A survey of 50 bacterial infections at one general hospital revealed that 6 distinct groups of diseases were present, including sycosis vulgaris, impetigo contagiosa, impetiginous dermatitis, secondarily infected trichophytosis pedis, generalized furunculosis, in addition to a small group of miscellaneous conditions. In 48 of the 50 cases, the predominant organism cultured was Staphylococcus aureus haemolyticus. Streptococcus haemolyticus, which was the sole organism cultured in 2 cases, was also present in 11 of these 48 cases.

Penicillin, which became available in the spring of 1944, proved remarkably effective in the treatment of carbuncles and miscellaneous staph-


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ylococcic and streptococcic infections of the skin and subcutaneous tissues. The usual effective dose was 1 million units given in 25,000-unit doses every 3 hours intramuscularly for 5 days or until obvious regression of the lesions. In the 50 cases just described culturally, cure was achieved in 43, and only 4 were entirely unimproved. In 90 cases treated by penicillin in another general hospital, the period of hospitalization was shortened on an average of 12 days per case as compared with 124 cases in which penicillin was not employed. Hot compresses, local antiseptics, and topical sulfonamide therapy were used in conjunction with penicillin therapy, and when necessary, accumulations of pus were incised and drained.

Ecthyma

Zone of Interior.-Ecthyma was one of the most frequent causes of disability in men evacuated from overseas to Fitzsimons General Hospital.33 The lesions were chiefly on the legs, ankles, and feet, though they also appeared on other portions of the body. Questioning revealed that important antecedent causes were insect bites, small scratches, abrasions, and cuts, particularly cuts caused by coral in the Southwest Pacific Area. Apparently any small abrasion, when constantly macerated by perspiration and infected with surface organisms, could produce ecthymatous ulcers. C. diphtheriae was cultured from the lesions of some patients evacuated from the Mediterranean theater, the China-Burma-India theater, and the Pacific Ocean Areas.

Most ecthymas cleared up promptly in the cool, dry climate of Denver. Local treatment consisted of cleansing with soap and water, simple boric acid dressings, and the application of 3-percent ammoniated mercury ointment. Specific medications were unnecessary in most cases, but penicillin parenterally, sulfadiazine orally, or both agents in combination were useful in lesions surrounded by a considerable inflammatory response. Ulcerated areas that were clean but were slow in healing were sometimes managed by the application of Unna's gelatin boot.

Southwest Pacific Area.-Dr. Hopkins, who discussed ecthyma and tropical ulcer under the same heading, noted that ecthyma was usually a mixed infection caused by hemolytic streptococci and hemolytic staphylococci. Unlike impetigo, which was confined to the stratum corneum, ecthyma invaded the deeper epidermis and, at times, the cutis. It usually took the form of discrete lesions covered with a thick crust and somewhat undermined at the border. The location of the lesions on the lower legs and the dorsum of the feet suggested that venous stasis might be a possible factor, though similar lesions were frequently observed on the dorsum of the hands, on the arms, and, occasionally, on the trunk.

33See footnote 20, p. 588.


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Deeper ecthymatous lesions often became persistent ulcers. All lesions diagnosed as tropical ulcer that Dr. Hopkins observed in U.S. troops he regarded as deep ecthyma and unrelated to the destructive ulcers seen in the native population.

Ecthyma usually resulted from infection of an insignificant scratch or insect bite. It was extraordinarily prevalent among U.S. troops on the Rosario Front in the Philippines; Dr. Hopkins was informed by battalion officers that, exclusive of battle wounds, 70 to 80 percent of the men who attended sick call complained of these lesions. At the time of his survey, flies were an uncontrollable plague and were probably the chief factor in spreading the infection, for they promptly attacked any exposed bleeding or exuding surface. Two situations explained the presence of flies in such numbers-there had been no time to construct latrines, and enemy dead and dead animals were often inadequately buried because of shellfire.

Bed rest was apparently the most important component of treatment. Healing was usually satisfactory if the part were kept elevated and covered with boric acid dressings. Ambulant patients treated with mercurial antiseptics and sulfonamides improved only moderately. The application of iodine and other irritating solutions caused dermatitis.

Penicillin, however, produced spectacularly good results. Hospitalized patients were treated with penicillin solutions applied as wet dressings. This technique was less practical for ambulant patients, but equally good results were obtained by another method: Crusts were removed as thoroughly (and as atraumatically) as possible, by cutting them off or by wiping them off after they had been moistened with water or peroxide of hydrogen. Penicillin incorporated in a water-miscible base was then applied in a thick layer, which was covered by a gauze dressing. The patient was instructed to keep the dressing moist with water from his canteen. The effect of a wet dressing was thus obtained with the expenditure of only a small amount of penicillin, which was usually in short supply. As soon as exudation was ended, ointment was applied until healing was complete. Exposure to sunlight was helpful during the later stages of healing if covering was not necessary for protection from flies. Whenever practical, the dressing was changed at least once daily, and more often if practical. Every medical officer interviewed by Dr. Hopkins regarded this technique with great favor.

Good results were also reported from the use of penicillin in lanolin or in combinations of lanolin and petrolatum. In general, however, ointments with these bases were not well tolerated in the climate of the Southwest Pacific Area. Droplets of penicillin emulsified in a continuous phase of oil seemed to reach the skin less effectively than in an emulsion in which the continuous phase was aqueous.

The prophylaxis of ecthyma was based on cleaning any visible scratch or traumatic lesion with soap and water. An antiseptic was sometimes added. The use of iodine was not recommended, as it destroyed tissue and


612

created foci of lowered resistance. Tincture of Merthiolate (thimerosal), Mercresin, and tincture of Zephiran (bensalkonium chloride) were preferable. In the special circumstances that prevailed on the Rosario Front, control of flies was extremely important. Fairly effective protection against them could be obtained, as well as protection against mosquitoes, if the foxhole was covered with a shelter half or a bit of thatch and if a Freon-12 aerosol "bomb" was used. It was found at aid stations that if a bandage was sprayed with Freon-12 aerosol insecticide (the so-called "mosquito bomb") before it was removed and the wound or inflamed area was sprayed as soon as it was exposed, flies could usually be kept from contact with the lesion. DDT was not available until later, but it was thought that it would be even more effective. Under battle conditions, men were prone to neglect anything they considered unessential to their safety, but if they were properly instructed and were provided with the mosquito bomb, it was found that they were likely to use it.

Impetigo

Ordinary impetigo of the face was frequently encountered in the Southwest Pacific Area under battle conditions. Numerous lesions of the toes and feet that were essentially impetiginous were also encountered. These lesions occurred on the face in the form of large, discrete pustules, which ruptured quickly, in contrast to lesions on the feet, which tended to remain intact and to penetrate the underlying soft tissues. A survey of dermatoses in the 43d Infantry Division by Capt. Charles S. D'Avanzo, MC, showed that they tended to occur most frequently in men who sweated excessively. It was generally observed that inadequately treated impetigo tended to persist longer in the Tropics than in temperate climates.

Another eruption, variously called tropical impetigo, pyosis Mansoni, or bullous impetigo, was widely prevalent. The characteristic lesion was a flaccid bulla, from 5 to 8 millimeters in diameter, filled with thick, purulent fluid, often without surrounding erythema. These lesions occurred in groups, especially just below the axillary fold and in and below the groin. They appeared only on the parts of the body covered by clothing. Cultures were reported to show Staphylococcus aureus, and clinically the lesions resembled the type of staphylococcic impetigo observed in troublesome epidemics in the newborn. It was Dr. Hopkins' opinion that so-called tropical impetigo resulted from excessive sweating and was closely related to skin conditions of miliarian etiology. He did not consider contagion important. He observed a number of extremely interesting generalized eruptions on the trunk that appeared to be circinate impetigo. They simulated dermatophytosis of the trunk so closely that differential diagnosis was difficult. No fungi could be found after repeated search.

Treatment directed toward aeration of the skin and prevention of sweating was apparently much more important in the management of these


613

cases than the application of antiseptics. When circumstances permitted, patients were allowed to remove their shirts and take short sunbaths. Bathing the skin with a mild antiseptic or antipruritic lotion was useful, as was the use of talc or foot powder. In obstinate cases, rupture of the bullae and painting of their bases with 10 percent silver nitrate usually effected a cure.

Pyogenic Intertrigo of the Feet and Groin

Many of the intertrigos of the feet in the Southwest Pacific Area that were inflamed and troublesome were apparently pyogenic in origin, though the general assumption was that the infection was secondary to an original fungal infection. Dr. Hopkins thought there was little reason for this assumption, since fungi could seldom be demonstrated.

Reliable differentiation of these lesions from dermatophytosis was impossible without laboratory study, which was frequently not practical (p. 604). Certain clinical criteria, however, were useful: The lesions were more likely to be pyogenic than mycotic if (1) the patient suffered from hyperhidrosis; (2) the inflammation was more pronounced on the dorsal than on the plantar aspect of the feet; (3) there was about equal involvement of all the toes; (4) the skin was red and edematous and there was weeping from pinpoint vesicles; (5) the patient complained of pain rather than itching; and (6) pustules were present on the dorsum or the sole.

Without facilities for laboratory diagnosis, the best plan was to treat these very common dermatoses of the feet with penicillin ointment or wet dressings and to resort to fungicides only if there was no improvement or only slight improvement. Instances were observed in which a change of therapy from penicillin to fungicides resulted in prompt cures of hitherto refractory lesions. Since the causes of intertrigo of the feet were probably the same as those of dermatophytosis, the same methods of prophylaxis were employed.

Intertrigos of the groin of pyogenic and seborrheic origin rather than mycotic origin were rather frequently encountered.

Diphtheria34

Zone of Interior-In the detailed study of skin conditions made at Foster General Hospital, it was found that in indolent cutaneous ulcers organisms of the diphtheria group, which in most instances were biologically avirulent, could often be recovered. In August 1945, a special investigation of cutaneous diphtheria and tropical ulcers included a survey of all incoming patients with medical and dermatologic conditions. These patients were studied bacteriologically and by the Schick test, and special attention was

34McGuinness, Aims C.: Diphtheria. In Medical Dcpartment, United States Army. Preventive Medicine in World War II. Volume IV. Communicable Diseases. Washington: U.S. Government Printing Office, 1958, pp. 167-189.


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paid to those received from tropical theaters. All hospital personnel were also Schick tested.

Of 70 patients admitted to isolation wards because of the proved or suspected presence of diphtheria bacilli, 56 had ulcerative lesions. Two patients with faucial diphtheria were identified in this group, and 12 suspected or proved faucial carriers were found.

Therapy of the ulcerative lesions consisted of dressings of physiologic salt solution; local or parenteral penicillin therapy; or combined local and parenteral penicillin therapy. Local application of penicillin was generally the preferable treatment.

Mediterranean theater-In a survey of bacterial lesions in 6 hospitals in the Mediterranean theater, 32 cases were found in which the diagnosis of cutaneous diphtheria had been made. Although this was a rather large number of cases in itself, it was thought that the condition was even more frequent than the figures suggested and that additional instances would be found if there were a more diligent effort to culture the organisms, especially when faucial diphtheria was present in the local area. Of the 32 patients, 2 died, both of myocarditis, and 2 others survived serious complications (myocarditis with cardiac failure, peripheral neuritis).

Nothing in the clinical appearance of a diphtheritic ulcer distinguished it from other ulcers. Diagnosis was possible only by culture, but certain suggestive observations were made:

1. The lesions were painful when they were exposed to air.

2. The lymphatics draining the ulcers showed noninflammatory hypertrophy in the form of thickened vocal cords.

3. The regional lymph nodes were enlarged.

4. All forms of therapy failed except penicillin.

Most instances of diphtheria in the Mediterranean theater occurred before penicillin became generally available. It was important to remember that this agent so altered the bacterial flora of cutaneous ulcers that cultures positive for C. diphtheriae could not be obtained. In other words, a man might have cutaneous diphtheria and might be improving under penicillin therapy but at the same time be harboring toxins from which polyneuritis, myocarditis, and other serious complications might develop.

Once the diagnosis of diphtheria was established, 100,000 units of diphtheria antitoxin were given. If the patient demonstrated any of the clinical features typical of absorption of diphtheria toxins, and if he had a cutaneous lesion possibly caused by C. diphtheriae, the antitoxin was given without waiting for the results of cultures.

European theater-Diphtheria cutis occurred in the European theater but was uncommon as compared with its incidence in the Pacific Ocean Areas and the China-Burma-India theater. The small number of cases, however, engendered lack of suspicion, and there were sometimes dangerous delays in diagnosis. In one of the first cases observed in the theater, for


615

instance, myocarditis appeared before it was realized that an ulcer on the genitalia was diphtheritic and not an unusual type of venereal disease.

Southwest Pacific Area.-In his survey of dermatologic disease in the Southwest Pacific Area, Dr. Hopkins observed that at several bases virulent diphtheria bacilli had been recovered from chronic ulcers resembling those usually described as ecthyma (p. 610). He believed that several other exceptionally deep and necrotic ulcers that he observed might also be of the same origin. There was little doubt that the paralyses reported in these cases were diphtheritic. Major Webster, at the 13th General Hospital, was able to recover diphtheria bacilli from eczematous lesions of the eyebrow, paronychia of the toe, suppurating keratosis of the heel, and otitis externa. Brigadier Robert M. B. MacKenna, RAMC, Consulting Dermatologist to the British Army, made a study of diphtheria of the skin in Iraq in 1944.35 He reported acute bullous diphtheria on the basis of previous erythema; diphtheritic cellulitis that often went on to ulceration; and a chronic type of cutaneous diphtheria that simulated infectious eczematoid dermatitis.

Diphtheria bacilli were seldom isolated from cutaneous lesions in the Southwest Pacific Area, except in patients known to have been exposed to pharyngeal diphtheria. Mixed streptococcic-staphylococcic infections could produce ulcers clinically indistinguishable from most of those from which the Klebs-Löffler bacillus was recovered. It was Dr. Hopkins' opinion that the bacilli found in most cutaneous lesions in the Southwest Pacific Area were secondary invaders and that, if there was sufficient exposure, they could infect any severely damaged area of skin. He doubted that they could invade normal skin. Their presence sometimes seemed to have no effect on the clinical picture, but they sometimes increased the severity and chronicity of the lesions, and in a few instances, they seemed responsible for regional or distant paralyses.

Most diphtheritic infections of the skin responded well to dressings wet with penicillin solution. Some healed only after antitoxin was given. Brigadier MacKenna recommended the use of antitoxin in all cases, but Dr. Hopkins did not consider the information then available (1944-45) sufficiently conclusive to warrant the recommendation of definitive policies. He emphasized the risk of contagion, considering skin lesions at least as dangerous as pharyngeal diphtheria as a source of infection, and perhaps more dangerous.

China-Burma-India theater.-The whole group of tropical dermatoses was of little significance in China-Burma-India as regards total disability except for cutaneous diphtheria, which can properly be classified as a tropical disease since it is very much more common in hot, humid climates than in temperate climates. In this theater in the summer of 1944, during and after the Myitkyina campaign, its incidence reached epidemic proportions. Capt. (later Maj.) Harvey Blank, MC, Chief of Dermatology and

35MacKenna, R. M. B.: Notes on Military Dermatology. Brit. J. Dermat. 56: 1-11, January 1944.


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Syphilology at the 69th General Hospital, reported 70 cases, and Major Livingood and his associates observed 140 at the 20th General Hospital.36 In most instances, the disease was contracted initially in Burma, but later cases were contracted in Assam, and some occurred in hospital personnel who were attending infected patients.

Cutaneous diphtheria occurs in epidemic form under the following circumstances:

1. A significant percentage of exposed individuals must be susceptible to the infection.

2. There must be a source of diphtheritic infection. Among military personnel, the source was either the native population or a high carrier rate in their group.

3. Factors must exist which make for multiple superficial traumata to the skin. Poor personal hygiene and close personal contact must prevail.

All these circumstances were present in the Mitykyina combat area during the campaign which began in the latter part of May 1944 and ended the first week of August 1944. The high incidence of leech and other insect bites and the constant maceration of the skin, combined with lack of bathing and laundry facilities, predisposed to superficial abrasions and cutaneous infections of all types. The epidemic of cutaneous diphtheria that ensued reached its height during combat activities and the hot, humid monsoon (rainy) season, and decreased after the cessation of fighting, the advent of cooler weather, and improved facilities for personal hygiene.

According to Captain Blank, neurologic complications occurred in about 40 percent of all cases of cutaneous diphtheria, and cardiac complications occurred in about 5 percent. Other studies bore out these figures.37 There were two deaths, both caused by myocarditis.

Almost all patients with cutaneous diphtheria required at least 4 months of hospitalization before their return to duty. The slow healing of the lesions was characteristic. On the average, skin ulcers persisted for about 3 months. In 6 of the 140 patients observed at the 20th General Hospital, the lesions were still unhealed at the end of 6 months.

It should be emphasized that almost all the patients who contracted diphtheria in the China-Burma-India theater had secondary diphtheritic infection of skin lesions, such as insect bites. None of them had faucial diphtheria, and diphtheritic infection of surgical wounds was extremely uncommon.

36Livingood, C. S., Perry, D. J., and Forrester, J. S.: Cutaneous Diphtheria: A Report of 140 Cases. J. Invest. Dermat. 7: 341-364, December 1946.
37(1) Gaskill, H. S., and Korb, M.: Occurrence of Multiple Neuritis in Cases of Cutaneous Diphtheria. Arch. Neurol. & Psychiat. 55: 559-572, June 1946. (2) Kay, C. F., and Livingood, C. S.: Myocardial Complications of Cutaneous Diphtheria. Am. Heart J. 31: 744-756, June 1946.


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Acne

Zone of Interior.-The survey of skin conditions (fig. 85) at Fitzsimons General Hospital38 showed oily skins and seborrheic dermatitis to be less frequent there than in similar civilian groups, probably because of the vigorous outdoor activity that was a part of military life in the United States. Acne vulgaris (often called tropical acne) was, however, definitely activated by military service in the Tropics, particularly in older men, many of whom were returned from overseas to this hospital.

A typical history revealed that the patient had had some trouble with blackheads and acneiform lesions when he was 15 to 18 years of age, but none since, including his period of training in the Zone of Interior. Trouble began, however, some 6 months after his arrival in the Southwest Pacific Area or some other tropical area. The first manifestation was the development of large, tender, inflammatory cystic lesions on the shoulder and back, which made it impossible to carry a pack. After he was treated for a considerable time by the battalion surgeon, sometimes in a forward hospital and occasionally in a general hospital, the patient was evacuated to the Zone of Interior.

Such patients, on their arrival, presented the usual combination of comedones, papulopustular lesions, and numerous deep, inflammatory, tender cystic lesions from which oily, purulent material could be expressed. Many lesions, particularly on the dorsal surface of the neck, shoulders, hips, and thighs, had become confluent. Extension over the buttocks and over the dorsal and lateral surfaces of the thighs was not uncommon in these patients, though such an extension is seldom observed in acne vulgaris seen in civilian practice.

Most acne vulgaris observed at Fitzsimons General Hospital originated in tropical theaters, in combat troops who had been deprived of proper bathing facilities and who had been in an environment characterized by extreme heat and poor hygienic conditions for long periods of time. This disease was not observed in supply or garrison troops evacuated from tropical theaters or in men evacuated from the European theater. In that theater, it was a condition of no consequence.

Southwest Pacific Area.-In his survey of skin conditions in the Southwest Pacific Area in 1944-45, Dr. Hopkins was impressed with the complications that could arise from the type of acne characterized by double comedones and cysts, even in men who had had little trouble with acne in civilian life. The original lesions became very large, exquisitely tender, and suppurative. If packs were carried, the infected cysts often ruptured, and rupture was followed by painful ulceration.

Treatment was not satisfactory. The care required to evacuate and dress multiple individual lesions was more than could be afforded in a mili-

38See footnote 20, p. 588.


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FIGURE 85.-Acne vulgaris. A. Cystic acne of face. B. Subsiding tropical acne of trunk. C. Extensive acne of chest and shoulders.

tary hospital. Some men were returned to duty after drainage of the suppurative lesions and treatment with sunbaths, hotpacks, and drying lotions, but relapses were prompt. In Dr. Hopkins' opinion, the SWPA policy of hospitalization of men with relatively mild acne was unwise. He believed that they should be kept on duty as long as possible and that, if the lesions became severe enough to require hospitalization, immediate return to the Zone of Interior was preferable, because of the risk of relapse after any treatment.


619

China-Burma-India theater.-The experiences in Burma and India with acne was much the same as in the Southwest Pacific Area. There was a notable tendency for the condition, particularly the cystic type (acne conglobata), to increase in severity after affected individuals had been overseas for a short time. The development of large, painful cystic lesions on the shoulders, back, neck, and face resulted in varying degrees of disability. It was necessary to hospitalize many of these patients for prolonged periods. Exacerbations were common after they had been returned to duty, and it soon became obvious that the best course to follow was the evacuation of men with severe cystic acne to the Zone of Interior.

Miliaria

The condition loosely known as prickly heat (fig. 86) was one of the three dermatologic diseases most frequently encountered in the Tropics, and all Army and Navy dermatologic statistics placed it near the top of the list.39 It was also something of a problem in the Zone of Interior.

Zone of Interior.-The clinical picture of miliaria in the Zone of Interior was usually typical. The eruption, which was originally confined to the flexural and intertriginous areas of the body, was a brightly erythematous, follicular, vesicopapular dermatitis. It tended to flare up during the heat of the day and subside at night. Pruritus was usually intense, and many patients also complained of severe burning. As time passed without treatment, the eruptions became more and more extensive and, after varying periods, failed to involute during the night. Its character also changed; it became more inflammatory and more fixed, and individual lesions appeared as single hypertrophic sweat glands. When perspiration was excessive, the papules were capped with small, hard vesicles.

Miliaria was one of the conditions associated with dysfunction of the sweat apparatus that were not incapacitating in themselves but that had a propensity for damaging the protective barriers of the skin and thus increasing the tendency to both mycotic and pyogenic infection. Impetigo contagiosa and bullous impetigo were frequent complications.

Southwest Pacific Area.-Miliaria was widely prevalent and extremely troublesome in the Southwest Pacific Area. British observers, according to Dr. Hopkins, considered it to be a Monilia infection, and it was generally believed to be caused by sodium depletion. He considered both theories worth further investigation.

The usual routine of management was exposure to air and sun and application of drying and cooling lotions. No form of therapy was really satisfactory.

According to Dr. Hopkins, a condition generally known as heat rash was even more common in the Southwest Pacific Area than true vesicular

39The others were Atabrine dermatitis and bacterial infections.


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FIGURE 86.-Miliaria rubra.

miliaria. It took the form of blotchy, red, wheal-like eruptions that appeared suddenly on the trunk after exposure to heat. The condition was not described in texts, and he thought that both etiology and therapy should be investigated.

DERMATITIS VENENATA

Zone of Interior.-Contact dermatitis (figs. 87, 88, 89, and 90) was a rather frequent form of disability in soldiers observed in outpatient clinics and on dermatologic sections in Zone of Interior hospitals. As a rule, a single agent was responsible for only small numbers of cases and was therefore of no particular military importance, though this was not always true. The so-called rubber dermatitis seen early in the war is an illustration. The etiologic agent was the rubber used in gas masks, and the dermatitis characteristically appeared on the forehead, the chin, and the lateral aspects of the cheeks. The responsible agents were probably the antioxidants and accelerators used in the manufacture of the rubber. Men who were sensitive to them were provided with gas masks of different manufacture, such as the older black rubber type or the cloth-impregnated type.

Rhus toxicodendron (poison ivy) was the most frequent cause of plant dermatitis (figs. 87 and 88), but dermatitis caused by ragweed and marsh elder was also relatively frequent.


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FIGURE 87.-Reaction to poison ivy.

FIGURE 88.-Reaction to poison ivy.


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FIGURE 89.-Reaction to Merthiolate (thimerosal) applied before spinal puncture.

FIGURE 90.-Reaction to elastic in shorts.


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The experience at Fitzsimons General Hospital40 and other hospitals in the United States indicated that sensitization and primary irritant reactions caused by topical medication were more significant and more frequent causes of disability than other types of contact dermatitis. Dermatologists in the Zone of Interior, observing the cases of contact dermatitis due to the unwise use of Whitfield's ointment in the treatment of acute and subacute dermatitis, took the position that correct training of battalion surgeons and other medical officers doing dispensary practice would have resulted in a considerable decrease in the incidence of the so-called over-treatment syndrome. Their reasoning seems particularly sound when one recalls that in some oversea theaters, dermatologic diseases accounted for as much as 75 percent of dispensary practice.

Sulfonamides were also responsible for a high incidence of dermatitis medicamentosa in Zone of Interior hospitals. As time passed, the original routines were modified in the light of experience, but many medical officers failed to learn the lesson and continued to use sulfonamide ointments in the treatment of pyogenic infections as well as for other cutaneous diseases. Some of the most serious drug reactions encountered were the generalized id type of sulfonamide dermatitis first reported by Major Livingood and Colonel Pillsbury.41 Several patients in this group were seriously ill for as long as 4 to 6 weeks. Other sulfonamide reactions were reported by Peterkin,42 Weiner,43 and Cohen and his associates.44

Mediterranean theater.-In the Mediterranean theater, true dermatitis medicamentosa (fig. 91) was infrequent, which is remarkable, considering the widespread administration of drugs capable of producing rashes, particularly the sulfonamides and barbiturates. Reactions to the sulfonamides most often followed their topical use on moist, eczematized lesions. Subsequent exposure to sunlight precipitated the appearance of eruptions on exposed parts, and oral medication after local sensitization sometimes precipitated exfoliative dermatitis.

Dermatitis venenata, especially of the face, ears, and eyelids, was frequently reported in men preparing penicillin solutions for injection. Once the danger was realized, enlightened techniques usually permitted individuals who had been sensitized to penicillin to work safely with it.

Contact dermatitis ordinarily responded promptly to avoidance of the offending contact and the use of soothing and drying topical agents. Local therapy with sulfonamides was discouraged because sensitization to it after

40See footnote 20, p. 588.
41Livingood, C. S., and Pillsbury, D. M.: Sulfathiazole in Eczematoid Pyoderma; Sensitization Reaction in Successive Local and Oral Therapy; Report of 12 Cases. J.A.M.A. 121: 406-408, 6 Feb. 1943.
42Peterkin, G. A. G.: Skin Eruptions Due to the Local Application of Sulphonamides. Brit. J. Dermat. 57: 1-9, January-February 1945.
43(1) Weiner, A. L.: Cutaneous Hypersensitivity to Topical Application of Sulfathiazole. J.A.M.A. 121: 411-413, 6 Feb. 1943. (2) Weiner, A. L.: Cutaneous Eruptions Following Topical and Oral Sulfathiazole (Correspondence) J.A.M.A. 123: 436, 16 Oct. 1943.
44Cohen, M. H., Thomas, H. B., and Kalisch, A. C.: Hypersensitivity Produced by the Topical Application of Sulfathiazole. J.A.M.A. 121: 408-410, 6 Feb. 1943.


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FIGURE 91.-Drug eruptions. A. Bullous dermatitis medicamentosa caused by sulfathiazole. B. Fixed drug eruption caused by phenolphthalein. C. Bullous erythema multiforme. D. Diffuse photosensitivity reaction.

its topical use prevented its later administration in infections in which such therapy might be lifesaving.

Plant dermatitis was conspicuously absent in the Mediterranean theater, because of the absence of common plant offenders. Contact with gasolines and oils, however, was often the cause of a refractory dermatitis and folliculitis, which sometimes required change in duty assignments. Deter-


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gents used for dishwashing sometimes produced a severe dermatitis, which was responsible for a large loss of man-days among Italian civilians working in Army kitchens.

European theater-Contact dermatitis was extensively prevalent in the European theater, but since poison ivy is not indigenous to the British Isles or continental Europe, there were no cases of that origin.

The topical application of sulfonamide ointments was responsible for many cases of contact dermatitis, sometimes with associated photosensitivity. After penicillin became available, dermatitis caused by it became increasingly frequent, and as in the Mediterranean theater, it occurred in hospital teams engaged solely in the preparation and administration of penicillin solutions.

In retrospect, many dermatologists who had served in the European theater expressed the opinion that, in spite of their immediate value, it might have been better if topical sulfonamide and penicillin preparations had not become available, for individuals who became sensitized to them from their local use frequently had systemic reactions when either agent was used, either orally or parenterally, for more serious conditions.

Southwest Pacific Area.-There were some reports of acute but short-lived eruptions from contact with unidentified plant or animal life encountered in sea bathing in New Guinea, but as a rule, dermatitis from contact with plants was a problem of minor importance in that area.

Dermatitis venenata in New Guinea was also reported as caused by the sap of palms used in building bridges and other structures. It began on exposed areas but often became generalized. The eruption was sometimes severe but did not last very long. Dr. Hopkins did not observe any instances of this type of dermatitis himself, but obtained his information about it from Maj. Delmar R. Gillespie, MC, at the 233d Station Hospital, who had studied it carefully.

China-Burma-India theater-A number of special forms of contact dermatitis were observed in military personnel stationed in China-Burma-India:

1. Tree sap dermatitis was caused by contact with the foliage and sap of certain indigenous trees encountered by the Corps of Engineers when they were clearing the forest in the early stages of construction of the Ledo (Burma) Road in Assam and Burma. Contact caused considerable disability in susceptible personnel, who amounted to some 15 to 20 percent of those exposed and represented the manpower loss of several hundred badly needed workers. The sap of these trees (family Anacardiaceae) was originally milky-white, but on contact with air it turned black or dark red.

2. In some areas of India and Burma, a lacquer prepared from another tree of the Anacardiaceae family and used to paint toilet seats gave rise to dermatitis of the anogenital area in susceptible individuals.


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3. The most interesting type of contact dermatitis encountered in China-Burma-India was the result of sensitivity to the substance used by native washermen (dhobies) for marking clothes to be laundered.45 Soon after the 20th General Hospital arrived in the theater and its personnel sent their clothes to be laundered by dhobies, a small epidemic of patchy dermatitis made its appearance. The eruption always involved, singly or in several areas, the nape of the neck, the upper back, the waistline (anterior, posterior, or unilateral), the lateral aspects of the ankles, the dorsal surface and sides of the feet, and the lower third of the legs. It soon became apparent that these circumscribed patches of dermatitis exactly corresponded with the parts of the body in contact with the laundry mark used by the dhobies. They marked shirts on the collar, which accounted for the localization of the dermatitis on the dorsal surface of the neck. Shorts were marked on the waistband, socks at various places, and nurses' brassieres at the point at which the strap was attached to the cup (fig. 92).

Dhobie mark dermatitis was characterized by intense pruritus, vesiculation, oozing, and, in some instances, a more or less chronic eczematoid

FIGURE 92.-Dhobie mark dermatitis. The skin involvement corresponds exactly with the dhobie laundry mark which is just under the buckle of the brassiere strap at its attachment to the cup.

45Livingood, C. S., Rogers, A. M., and FitzHugh, T.: Dhobie Mark Dermatitis. J.A.M.A. 123: 23-26, 4 Sept. 1943.


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reaction. The intensity of the process depended upon the sensitivity of the individual. The incidence of the condition was some 15 to 20 percent of those exposed.

Investigation of the condition at the 20th General Hospital in Assam in collaboration with the Forest Research Institute in Derha Dun, India, and the Indian Botanical Institute in Calcutta resulted in the identification of the offending trees as members of the Anacardiaceae family. This family includes poison ivy, poison oak, sumac, the cashew nut tree, the Bhilawanut tree, and the Japanese lacquer tree. Persons sensitive to poison ivy will almost always be sensitive to the nut of the Bella gutti tree, the sap of which the dhobies were using for laundry marks, as well as to other plants and trees of this family.

When the native washermen were questioned, it was found that the marking fluid they were using was obtained from the nut of the Ral or Bella gutti (Bhilawanut) tree, which grows all over India. A straight pin was pushed through the hard capsule of the nut, and enough brown or black fluid adhered to it for the marking of garments with small crosses, dots, or lines in varying identifying combinations. The marks were fairly permanent and withstood repeated washings.

The term "dhobie itch" had been in use in dermatology for some time. Sutton and Sutton,46 in the 1935 edition of their textbook on diseases of the skin, defined it, with washerman's itch as a synonym, as tropical epidermatophytosis, corresponding to eczema marginatum observed in other climates. They pointed out that symptoms were greatly exacerbated by warmth and perspiration and that violent scratching and secondary pyogenic infections often rendered the parts raw and inflamed, so that impetigo, infectious eczematoid dermatitis, and even furunculosis might result.

In India and other countries, the terms "dhobie itch" and "tinea cruris" seem to have been used more or less interchangeably for many years. The explanation was that the nomenclature was associated with the premise that clothing was infected by the dhobies when it was washed. The concept was entirely erroneous. It was never demonstrated that cutaneous fungal infections were transmitted via clothing washed by dhobies. On the contrary, the World War II experience showed that dhobie-mark dermatitis was exactly what the term implies, a contact dermatitis caused by an allergen, the marking fluid, which is not unlike the allergen that causes Rhus dermatitis.

PSORIASIS

Mediterranean theater.-Psoriasis was not a problem in the Mediterranean theater because of its frequency. The difficulties connected with it,

46Sutton, Richard L., and Sutton, Richard L., Jr.: Diseases of the Skin, 9th ed. St. Louis: C. V. Mosby Co., 1935.


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like those connected with seborrheic dermatitis (figs. 93 and 94), arose from the chronicity of these diseases, their resistance to treatment, and their tendency to recurrence. The causes of both were unknown, but it was recognized that good personal hygiene, if it did not prevent them entirely, at least maintained the underlying dermatitis at a subclinical level. Exposure to direct sunshine was of prophylactic as well as therapeutic value. Cold, wet weather had a particularly adverse influence on psoriasis, and patients seeking treatment for it increased sharply in numbers as winter came on.

In addition to sunlight, certain other measures were at least temporarily successful, including local applications of tar, resorcin (resorcinol), and chrysarobin (Goa powder). With the use of these agents, it was possible to discharge the majority of patients to duty, but relapses were frequent and repeated hospitalization was necessary. When the condition developed or became apparent overseas, relapses could be reduced by assigning the men to duty in base sections or other areas where good personal hygiene was possible and specialized medical care was available. This was not a desirable expedient, however, and it was the conclusion of dermatologists in the Mediterranean theater that it was highly questionable whether men with significant psoriasis and seborrheic dermatitis should ever be sent overseas. There was no doubt at all that only in the most unusual circumstances should they be assigned to combat units.

There was also an important psychic factor in psoriasis. Men with this disease, who understood their problems and adjusted to them, could be given what medicine had to offer and returned to their units, occasionally even to combat units. Often they became sterling soldiers. Others, however, when the going became hard, were willing to use their disease as a means of getting into the hospital or being sent home. It is fair to assume that perhaps 20 percent of all patients with seborrheic dermatitis and psoriasis became liabilities rather than assets to the troops in the Mediterranean theater and had to be evacuated to the Zone of Interior.

Observations at Fitzsimons General Hospital47 bore out these conclusions. The histories showed that good soldiers had ignored their disease and continued on duty until they were incapacitated, while others who were indifferent to their responsibilities continued to report at sick call until they were hospitalized and returned to the United States.

Southwest Pacific Area.-Dr. Hopkins' 1944-45 survey of dermatologic conditions in the Southwest Pacific Area revealed only a few instances of severe psoriasis.

PARASITIC INFECTIONS

Parasitic infestations (scabies and pediculosis) were among the major sources of disability in the American and British Expeditionary Forces in

47See footnote 20, p. 588.


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FIGURE 93.-Extensive acute psoriasis of trunk.

FIGURE 94.-Acute seborrheic dermatitis of suprapubic and crural region.


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World War I. The principal reasons were not the primary infestation but the sequelae of secondary bacterial infection and chronic dermatitis from excoriation and overtreatment.

In World War II, scabies was very common in some theaters, but pediculosis was a most infrequent reason for seeking medical attention.

Mediterranean theater.-Parasitic infestations of the skin accounted for 4 to 18.5 percent of the admissions to dermatologic services in six hospitals in the Mediterranean theater surveyed in 1943, with the great majority of cases scabies. These percentages cover only primary diagnoses and require some explanation: It was repeatedly noted in this theater that patients who presented themselves for treatment for furunculosis, pyoderma, cellulitis, impetigo, and similar conditions were referred with those diagnoses, while the coexisting parasitic infestation, which frequently was the underlying cause of these infections, was either reported as a secondary diagnosis or was not reported at all. It is therefore fair to conclude that the actual prevalence of parasitic diseases in this theater was higher than collected statistics indicate. This consideration is of special importance in the evaluation of figures collected from forward hospitals, where opportunities for examination with the patient stripped, in a good light, and for detailed history taking were frequently lacking.

Pediculosis, sample checks showed, was not frequent in the Mediterranean theater. Over a 3-week period in 1944, no cases were reported from the 34th, 85th, and 88th Infantry Divisions; none were reported from 10 hospitals surveyed in the spring of 1944, and none from the Fifth U.S. Army for the week of 15-22 September 1944. For the entire year, only 2 cases were reported from the 64th General Hospital and only 11, from the 8th Evacuation Hospital.

Soldiers with pediculosis pubis frequently treated the condition themselves with aerosol bomb sprays or blue ointment, and an occasional patient presented himself with dermatitis caused by such self-treatment. There was no doubt that aerosol sprays would kill the irritating parasite and that repeated applications of blue ointment to infested areas would kill both adults and eggs, but less irritating methods were more desirable. Pubic lice were readily eliminated by the application of calomel ointment on 2 successive days. For head lice, the hair was cut short and the head was shampooed for 3 successive nights with a mixture of 1 part kerosene to 3 parts of hot, soapy water. Both patient and clothing were sprayed with Army louse powder, which was extremely efficient.

The most frequent parasitic infection in the Mediterranean theater was scabies, caused by the itch mite Acarus scabiei hominis. The condition was acquired, as in civilian life, by contact with the person, personal clothing, or, less often, bedding of an infected individual. In this theater, the great reservoir for the spread of infection was the native population, in whom the incidence was very high and by whom it was regarded with amazing in-


631

difference. The incidence in U.S. troops reflected the extent of their co-mingling with the natives.

Uncomplicated scabies could be treated effectively with sulfur ointment or benzyl benzoate by the unit surgeon. Both produced good results, but sulfur was preferable in cases complicated by scratching, secondary infection, or dermatitis. Clothing and bedding were disinfested by laundering, dry heat, live steam, louse powder, or the use of a methyl bromide bag. The reward of early diagnosis and treatment was a lower incidence of contact cases, less discomfort for the patient, shorter duration of treatment, and fewer days lost from duty.

Men with complications of scabies were usually hospitalized, for soap and water baths, moist compresses as indicated, and treatment for 3 or 4 days, preferably with the active assistance of a medical aidman, by the application of sulfur ointment from chin to toes. The application was followed by a warm soap and water bath and the use of an antipruritic lotion.

If a second course of treatment was necessary, modified sulfur ointment was used, containing 2 to 5 percent of balsam of Peru. If dermatitis was only slight, benzyl benzoate ointment could be used instead of sulfur ointment. Benzyl benzoate, however, was extremely irritating and had to be used with caution if there were many breaks in the skin and in fair-haired, blue-eyed blonds.

The average stay for patients with scabies in station and general hospitals in the Mediterranean theater was 14 days, because of the high proportion admitted with either secondary infection or complications of earlier treatment. Return to duty was practically total.

Experience showed, however, that it was not sufficient to supply these patients with antiscabitic ointment and oral instructions. It was necessary to give them printed sheets, setting forth the routine in simple, detailed fashion and stressing also the absolute necessity for 100-percent compliance with it. The difficulties of managing scabies could be considerable, and complications could be alarmingly frequent, but both were overcome by complete adherence to the routine of treatment prescribed.

European theater.-In 1942, scabies was rife in the British civilian population, in which it constituted such a problem that the Emergency Medical Service was forced to set up numerous units devoted entirely to its treatment. The high incidence was clearly related to the severe dislocation of civilians, to overcrowding, and to the disruption of hygienic facilities caused by German bombing raids.

The increased incidence of scabies in the British civilian population was soon reflected in the British Armed Forces. The incidence in the U.S. Army in the United Kingdom never reached particularly high levels, but the number of cases, from 3.8 to 8.35 per 1,000 per year for the period 1942-45, was accompanied in the early years by delays in diagnosis and by therapeutic mismanagement that led to complications and required unnecessary


632

FIGURE 95.-Scabies.

hospitalization for many patients. In 1943, ward rounds in station and general hospitals invariably revealed that from 20 to 30 percent of all admissions on dermatology services were for scabies and for complications of it that were entirely preventable and that would not have developed if the diagnosis had been made promptly and if adequate treatment had been instituted.

An intensive campaign was undertaken to remedy the situation. Brigadier MacKenna was extremely helpful, as was Dr. Kenneth Mellanby, whose studies, which were of great value, had been carried out with the support of the British Medical Research Council.48 It was not only important to train medical officers in the early recognition of scabies (figs. 95, 96, and 97), which many of them had seldom observed in their civilian careers, but it was also necessary to discontinue useless and outmoded methods of disinfestation of clothing and gear, frequently by techniques that were destructive to both. Treatment in 1943 also differed sharply from methods recommended in most standard texts.

The regulation methods of diagnosis and treatment were outlined in Circular Letter No. 77, Office of the Chief Surgeon, Headquarters, ETOUSA,

48Mellanby, K.: The Transmission of Scabies. Brit. M.J. 2: 405-406, 20 Sept. 1941.


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FIGURE 96.-Scabies, with louse infestation and malnutrition.

8 May 1943. The basis of treatment was the use of benzyl benzoate, but the shortages of shipping delayed the receipt of the emulsion in which it was used, and sulfur ointment had to be substituted. Sulfur therapy was entirely satisfactory if a strength of 10 percent rather than USP 15 percent was used and if the specified details of application were scrupulously adhered to. The film on scabies, prepared under the auspices of the British Medical Research Council, was widely used in the instruction of medical officers.

Once the correct principles and practices were put into operation, disability from the complications of scabies decreased sharply and hospital admissions for this condition became uncommon.

Southwest Pacific Area.-Most of the scabies seen in U.S. troops in New Guinea occurred in men returning from leave in Australia. The incidence was high in Japanese prisoners of war; one group showed a 25-per-


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FIGURE 97.-Scabies, with secondary infection, malnutrition, and edema.

cent infestation. Dr. Hopkins pointed out in his March 1945 report to General Denit that scabies was likely to be a more serious problem in the Philippines and in other populated areas. He believed, however, that the successful results obtained with benzyl benzoate in the European theater could be duplicated in the Southwest Pacific Area.

OTHER DERMATOSES

Zone of Interior.-Experiences with miscellaneous dermatoses in the Zone of Interior did not differ materially from experiences in civilian practice (figs. 98, 99, 100, and 101). At Fitzsimons General Hospital, for instance, six patients were encountered with chronic discoid lupus erythematosus, together with two with acute disseminated lupus erythematosus and one with subacute disease.49 The incidence was considered somewhat

49See footnote 20, p. 588.


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FIGURE 98.-Psoriasis of soles.

FIGURE 99.-Congenital keratosis plantaris occurring at site of pressure.


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FIGURE 100.-Psoriasis of palms.

FIGURE 101.-Circinate tinea of buttocks.


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lower than would be encountered in civilian life, probably because, as Dr. Hopkins pointed out in commenting on the few cases he had observed in the Southwest Pacific Area, medical officers were dealing with a selected population of healthy young men. He had seen no instances of granuloma fungoides or of pemphigus and had seen only a very few cases of severe psoriasis and chronic urticaria, probably for the same reason.

Dermatophytid was a fairly frequent admission diagnosis at Fitzsimons General Hospital, but it was seldom supported by clinical and laboratory findings. At this hospital, the minimum criteria for diagnosis were:

1. A proved fungal infection, almost always inflammatory and acute.

2. A positive trichophytin test.

3. A symmetrical, erythematous, maculopapular or vesicular eruption compatible with the diagnosis.

4. Disappearance of the id eruption on elimination of the primary focus of infection.

Tuberculosis of the skin was important on the dermatology service at Fitzsimons General Hospital, as well as interesting, because this hospital served as a tuberculosis center. All patients on the tuberculosis wards who presented any type of skin disease were seen routinely in consultation with the dermatology service. It was considered significant that tuberculous adenopathy was observed in only three patients, all from racial groups (Negro, American Indian) peculiarly susceptible to tuberculosis, and that the only three cases of lichen scrofulosus observed at this hospital all occurred in Negro patients with pulmonary tuberculosis. Tuberculosis verrucosa cutis, the rosacea-like tuberculid of Levandowski, and lupus miliaris disseminatus fasceii were seen in one case each. Papulonecrotic tuberculids were infrequent, and no instance of lupus vulgaris was observed.

Mediterranean theater-Atopic dermatitis (neurodermatitis disseminata), along with allergic dermatitis, was not frequent in the Mediterranean theater but was a cause for prolonged and repeated hospitalization when it was encountered. The final disposition of most patients was reclassification or return to the Zone of Interior. Dermatologists in this theater shared the opinion of many dermatologists in the Zone of Interior as to the unwisdom of sending overseas any men with a background of allergic skin disease and eczema. Inability to control such causative factors as diet, inhaled and contact allergens, and emotional stress made it impossible for most of them to be useful soldiers.

In the Mediterranean theater, a large proportion of the patients admitted to dermatology services had eczematoid dermatitis. Their lesions were either localized or diffuse. They might have been produced by scabicides, fungicides, or sulfonamides, though most of the time the exact cause was not apparent. Psychic tension often predisposed to, or resulted from, dermatitis in this category.


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Therapy consisted of simple, soothing remedies, such as compresses, calamine lotion, crude coal tar, and Lassar's paste, plus protection of the lesions. Superficial X-ray was often useful, but it had to be employed judiciously and administered only by qualified personnel.

Infectious eczematoid dermatitis, which was rebellious to treatment and accounted for many hospital admissions, was secondary to infected wounds, draining sinuses, chronic otitis media, otitis externa, and other septic foci. It responded to elimination of the local focus, penicillin parenterally, and local compresses of penicillin solution in concentrations of 250 to 2,500 units per cubic centimeter.

Southwest Pacific Area.-Warts (figs. 102, 103, 104, and 105) were surprisingly frequent on the hands in the Southwest Pacific Area. They were less frequent on the feet, but there they could be extremely painful and practically disabling. They responded well to X-ray therapy, but it had to be given with great caution to prevent damage.

Exfoliative dermatitis was infrequent in the Southwest Pacific Area, but a sufficient number of severe cases occurred to make it of medical importance. Fatal sepsis or aplastic anemia developed in a number of patients. The use of plasma to combat hypoproteinemia that often resulted from voluminous exudation was strikingly successful, as was the use of penicillin parenterally to combat secondary infection. The absence of fatalities in uncomplicated cases was, in Dr. Hopkins' opinion, "a striking tribute to the therapy employed."

LICHENOID AND ECZEMATOID DERMATITIS (ATABRINE DERMATITIS, ATYPICAL LICHEN PLANUS)

In the latter part of 1943, medical officers in the Southwest Pacific Area began to call attention to a characteristic cutaneous syndrome beginning to be observed in men who were serving in New Guinea and adjacent islands or who had been evacuated from these areas.50 The condition was termed, provisionally, "atypical lichen planus," because of resemblances of the lesions to those of lichen planus or lichen planus hyptertrophicus. Most of these patients, however, also had skin lesions with other morphologic characteristics, particularly certain eczematoid characteristics, while some patients with these eczematoid lesions did not have any lichenoid lesions (figs. 106, 107, 108, and 109).

50As a convenience for the reader, references to the periodical literature are listed whenever official reports of observations or investigations are known to have been published. In addition, the following are presented as a matter of interest: (1) Agress, C. M.: Atabrine as a Cause of Fatal Exfoliative Dermatitis and Hepatitis. J.A.M.A. 131: 14-21, 4 May 1946; (2) Bereston, E. S., and Saslaw, M. S.: Complications of Lichenoid Dermatitis: Glomerulonephritis and Severe Pigmentary Changes in Exfoliative Stage of Lichenoid Dermatitis. Arch. Dermat. & Syph. 54: 325-329, September 1946; (3) Ginsberg, J. E., and Shallenberger, P. L.: Wood's Fluorescence Phenomenon in Quinacrine Medication. J.A.M.A. 131: 808-809, 6 July 1946: (4) Livingood, C. S., and Dieuaide, F. R.: Untoward Reactions Attributable to Atabrine. J.A.M.A. 129: 1091-1093, 15 Dec. 1945; (5) Rosenthal, J.: Atypical Lichen Planus. Am. J. Path. 22: 473-491, May 1946; (6) Sugar, H. S., and Waddell, W. W.: Ochronosis-Like Pigmentation Associated With the Use of Atabrine. Illinois M. J. 89: 234-239, May 1946.


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FIGURE 102.-Warts on fingers.

FIGURE 103.-Wart on plantar surface of great toe.


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FIGURE 104.-Condyloma acuminatum of penis.

FIGURE 105.-Painful X-ray atrophy and ulceration following excessive radiation for plantar wart.


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FIGURE 106.-Lichenoid dermatitis with secondary infection.

FIGURE 107.-Lichenoid dermatitis with secondary infection.


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FIGURE 108.-Lichen planus.

It seemed reasonable at this time to conclude that the lichenoid lesions were only part of a multiforme complex and also to assume that certain cases of eczematoid dermatitis in which no lichenoid lesions were present probably fell into the same etiologic group.

Realization that this group of dermatoses represented a new and hitherto unknown disease developed only gradually, as did the realization that the frequency of the condition might make it a significant military problem, not only in itself but because of its relation to Atabrine, the drug by which the devastating effects of malaria were being held in check.51 Once the existence of the new syndrome was recognized, it became the subject of

51Medical Department, United States Army. Preventive Medicine in World War II. Volume VI. Communicable Diseases: Malaria. Washington: U.S. Government Printing Office, 1963.


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FIGURE 109.-Lichen planus affecting lip.

more reports and publications than any other cutaneous disease encountered in World War II.

Evolution of the Concept

The account of this new syndrome might profitably begin with the overall report made to General Denit in March 1945 by Dr. Hopkins after his survey of dermatologic conditions in the Southwest Pacific Area. He found that three groups of cases, symmetrical eczematoid dermatitis, atypical lichen planus, and blue nails, constituted, numerically, the major dermatologic conditions encountered in this area. Blue nails had no clinical significance (p. 582), but the other two conditions constituted major military problems. Dr. Hopkins had not observed any of these dermatoses in his previous (very wide) experience, and he regarded them either as three new entities or as three separate phases of a new entity.

The eczematoid eruption, as he observed it in his movements about the Southwest Pacific Area, usually began on the hands (fig. 110) but frequently involved the arms, feet, legs, and sometimes the entire body. The most striking features of the disease, to him, were the remarkable bilateral symmetry of the lesions; the frequent involvement of the nail bed and the


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FIGURE 110.-Eczematoid Atabrine dermatitis. A and B. Bilateral symmetrical involvement of hands.

skin of the nail fold; and the frequent exfoliation of the nails in the absence of true suppurative paronychia. The involved areas, particularly those in which dry involuting lesions were present after acute vesiculation had subsided, often presented the bluish tinge common in many skin lesions in the theater (p. 661). Another striking feature was the appearance of dermatitis in a band extending along the radial side of the index finger and the ulnar aspect of the thumb; the first lesions were often observed in these locations. The vesicles on the fingers seemed larger, deeper, and less fragile than those typical of contact dermatitis or dermatophytids.

The involvement of the hands, in itself, made this disease of military importance, for even relatively slight eruptions disqualified men for full military duty. Moreover, Dr. Hopkins found that no curative treatment had been devised, relapse was almost certain after return to duty, and it had already become clear that prompt evacuation to the Zone of Interior was the best therapeutic policy.

At the time he made his survey, Dr. Hopkins considered the etiology of symmetrical eczematoid dermatitis entirely obscure. Fungi were demonstrable in the cases he examined in only a single instance: Capt. P. A. Beal, MC, at the 27th Medical Laboratory, had isolated a Monilia, apparently M. albicans, from the nail of this patient. The finding was probably coincidental, but in view of the paucity of other leads, it seemed worth following up. A small series of patients had been tested for hypersensitivity to Monilia, Staphylococcus, and trichophyton, but the uniformly negative results were


645

FIGURE 110.-Continued. C. Eczematous lesions on palmar surfaces of fingers, combined with verrucous, somewhat inflammatory, lichenoid papules and plaques on palms.

regarded as unreliable because the extracts used in the test had been exposed for a long period to room temperatures. Much more careful and more systematic work would be necessary before it could be said with certainty that these lesions were not the result of sensitivity to bacteria or fungi, though no evidence existed that they were.

The absence of interdigital lesions on the feet in many patients was strongly against the then prevalent assumption that these lesions were dermatophytids. In most instances, no history of an external irritant or allergen could be obtained, and while the theory that this was a contact dermatitis could not be excluded, it was a remote possibility, if only because of the sharp circumscription and striking symmetry of the lesions.

Both of these latter features pointed to some internal cause. The single clue to this assumption was the fact that the lesions Dr. Hopkins observed were frequently seen in patients with atypical lichen planus and that many patients with atypical lichen planus described inflammatory lesions on the


646

dorsum of the hand or on the fingers as the first manifestation of their disease. Although it might be that the etiology of atypical lichen planus and symmetrical eczematoid dermatitis was the same, the fact that patients with eczematoid dermatitis seemed to recover more promptly than patients with atypical lichen planus was against the supposition that Atabrine was the causative factor. It would be profitable, Dr. Hopkins thought, to run control studies, continuing Atabrine in one group of patients but keeping the other group off it long enough to permit its complete elimination from the body. Results would determine whether the withdrawal of Atabrine was essential for cure.

As time passed, it became quite clear that Atabrine was the responsible factor in both symmetrical eczematoid dermatitis and atypical lichen planus, and it did not seem advisable to make a sharp distinction between them, for many of the same patients exhibited lesions of both types. In the 118 cases, for instance, observed by Maj. (later Lt. Col.) Charles L. Schmitt, MC, at the 27th General Hospital (table 103), a small number of patients had only lichenoid lesions, a larger group had both lichenoid and eczematoid lesions, and a still larger group had only eczematoid lesions. Exfoliative dermatitis could occur in any of these groups.

TABLE 103.-Anatomic distribution of lichenoid papules and nodules in 118 patients with so-called atypical lichenoid planus

Site

Number of cases

Percent

Thighs and legs

31

26

Hands and fingers

31

26

Arms

25

21

Torso

24

20

Buttocks

20

17

Eyelids

17

14

Feet

17

14

Penis

13

11

Neck

11

9

Ears

10

8

Waistline

10

8

Scalp

7

6

Groins

7

6

Scrotum

6

5

Face

6

5

Listed as generalized

37

31

Source: Collected in the Southwest Pacific Area by Maj. Charles L. Schmitt, MC, 27th General Hospital.

Incidence and Etiology

Southwest Pacific Area

No doubt many of the earliest cases of atypical lichen planus were overlooked because they were classified under such diagnoses as dermatitis,


647

unclassified, or trichophytosis corporis. While it is impossible to state positively when the first case occurred, in retrospect it seems likely that two patients evacuated from New Guinea to the Zone of Interior in March 1943, with the diagnosis of dermatitis, chronic, lichenoid, might have had atypical lichen planus. In July 1943, two patients who were later found to have had atypical lichen planus (though it was not then diagnosed under that terminology) were evacuated from the same area, one from the 4th and the other from the 118th General Hospital. At least nine additional patients were evacuated during the remainder of this year with the same condition.

Meantime, reports were being received concerning the increasing frequency of this new disease. In November 1943, Maj. (later Lt. Col.) Robert B. Palmer, MC, reported (verbally) that he had seen a remarkable number of patients with hypertrophic lichen planus. The station hospital at Port Moresby received 14 patients with severe lichenoid disease between September 1943 and February 1944. In January 1944, Major Ambler observed 16 cases in his tours of various hospitals in the Southwest Pacific Area. In April 1944, he reported on 28 cases he had observed in forward areas. By July of this year, he had personally observed 130 cases, and by December, the number had risen to 200.52

Several comprehensive reports on the condition were prepared for The Surgeon General through the Surgeon, SWPA, by Maj. Thomas W. Nisbet, MC, in June and again in August 1944, covering the cases observed at Milne Bay, New Guinea;53 by Major Schmitt, in collaboration with Capt. George Chambers, MC, and Maj. O. Alpins, MC, of the Australian Army;54 and by Major Ambler, Dr. Hopkins, and Col. Maurice C. Pincoffs, MC.55 Numerous other reports covered smaller numbers of cases and less extensive observations.

The possible relation of Atabrine to this new syndrome, in which both eczematoid and lichenoid manifestations were often present in combination, seems to have been mentioned for the first time in the Southwest Pacific Area in November 1943, when the Consultant in Dermatology for the Australian Army, at a meeting of the Sydney Medical Society, presented a patient with severe lichen planus, which he attributed to this drug. Major Nisbet and Major Schmitt were the first U.S. Army Medical Corps officers to point out, in separate official reports to The Surgeon General, that Atabrine was probably the essential etiologic factor in this new type of dermatitis.

52Report, Maj. John V. Ambler, MC, to the Theater Surgeon, Southwest Pacific Area, 15 Dec. 1944, subject: Statistical Survey of 200 Cases of Atypical Lichen Planus.
53Nisbet, T. W.: A New Cutaneous Syndrome Occurring in New Guinea and Adjacent Islands: Preliminary Report. Arch. Dermat. & Syph. 52: 221-225, October 1945.
54Schmitt, C. L., Alpins, O., and Chambers, G.: Clinical Investigation of a New Cutaneous Entity. Arch. Dermat. & Syph. 52: 226-238, October 1945.
55Minutes of the Conference on Atypical Lichen Planus, Board for the Coordination of Malarial Studies, 6 June 1945, exhibit V thereto, "Atypical Lichen Planus: Present Status of the Problem."


648

These officers based their conclusions on the observations (1) that all patients with this new skin disease had taken suppressive Atabrine; (2) that their skin lesions had progressed as long as they were on the drug; (3) that improvement or complete healing had followed its withdrawal; and (4) that in some instances new lesions appeared when the medication was resumed. Major Nisbet also called attention to the occurrence of fixed eruptions of exfoliative dermatitis and the occasional development of aplastic anemia in these patients; both of these manifestations were suggestive of a drug etiology. He also stated that until Atabrine was introduced into the Southwest Pacific Area, he could find no record of any such cases at Mime Bay or elsewhere in New Guinea.

When the mounting number of cases of atypical lichen planus indicated that the disease might become a serious military problem in relation to suppressive Atabrine, the use of which was considered essential,56 26 patients with the disease were assembled, in July 1944, for study by a group of officers of the Malarial Research Unit attached to the 3d Medical Laboratory at Base B (Oro Bay, New Guinea). The group consisted of Maj. (later Lt. Col.) Abner M. Harvey, MC, Capt. (later Maj.) Frederik B. Bang, MC, Lt. (later Maj.) John M. Myer, MC, and Lt. Nelson G. Hairston, SnC.57 Maj. A. M. Pappenheimer, SnC, was later assigned to the project, to conduct nutritional studies. These 26 patients, who had both lichenoid and eczematoid manifestations, were kept under constant observation for a 5-month period. In addition to studies of the skin lesions in relation to the administration and withdrawal of Atabrine, laboratory studies were carried out to determine the levels of the drug in skin and plasma. Vitamin saturation tests were also carried out.

These studies showed that in 18 of 22 patients kept on Atabrine after hospitalization, the original lesions continued to progress and new ones appeared. The condition of three other patients in this group remained unchanged. The remaining patient showed some improvement.

In another test, Atabrine was discontinued in 19 patients, 15 of whom then showed improvement. Two showed no improvement, and the other two, both of whom had had bismuth injections, had progressive lesions.

When Atabrine was readministered to nine patients whose lesions had begun to heal after it was discontinued, seven had acute exacerbations of the disease within 24 to 72 hours.

A significant finding in this study was the appreciable amounts of Atabrine found in the skin of the patients, from 7 to 9 weeks after the drug had been discontinued, although at these times there were no detectable amounts in either urine or blood.

56See footnote 51, p. 642.
57Minutes of the Conference on Atypical Lichen Planus, Board for the Coordination of Malarial Studies, 6 June 1945, exhibit IV thereto, "Clinical and Laboratory Studies on Atypical Lichen Planus With Particular Reference to the Role of Atabrine."


649

Mediterranean Theater of Operations

All of the data presented up to this point concern the Southwest Pacific Area. Informal communications from medical officers in the South Pacific Base Command also described patients with atypical lichen planus but commented on its infrequency.

Meantime, cases were being reported from both the Mediterranean and the China-Burma-India theaters. In July 1944, Capt. (later Maj.) Lawrence M. Nelson, MC, reported from the Mediterranean theater two cases of a characteristic type of eczematoid dermatitis without lichenoid lesions.58 He attributed the eruption to Atabrine.

In January 1945, Maj. (later Lt. Col.) R. N. Buchanan, Jr., MC, reported from the same theater five cases of symmetrical, generalized eczematoid dermatitis that subsided when Atabrine was discontinued and recurred when its administration was resumed.59 In July of this year, Major Nelson reported six cases of atypical lichen planus apparently caused by Atabrine; all the patients had acquired the disease late in 1944.60 For the last several months, evacuees with this condition had been reaching the Zone of Interior from the Mediterranean Theater of Operations. Available evidence indicates, however, that the incidence of both the lichenoid and the eczematoid syndrome was much less in the Mediterranean theater than in either the Southwest Pacific Area or the China-Burma-India theater.

China-Burma-India theater

The first three cases of atypical lichen planus in the China-Burma-India theater were recognized and reported to The Surgeon General through the theater surgeon by Major Livingood in November 1944.61 Later reports indicated that the incidence of this condition in this theater was perhaps as high as it was in the Southwest Pacific Area.

In March 1945, in view of the data that he had accumulated since this condition was first recognized, Major Livingood recommended that suppressive Atabrine be discontinued not only in men with lichenoid dermatitis but also in those with characteristic prodromal eczematoid lesions. He made the same recommendation for sulfathiazole, the arsenicals, and other potentially sensitizing drugs.62

58Report, Capt. Lawrence M. Nelson, MC, to The Surgeon General, through the Surgeon, Mediterranean Theater of Operations, U.S. Army, 3 July 1944, subject: Eczematoid Dermatitis Due to Atabrine.
59Report, Maj. R. N. Buchanan, Jr., MC, to The Surgeon General, through the Surgeon, Mediterranean Theater of Operations, U.S. Army, January 1945, subject: Dermatology in an Army General Hospital Located in a Theater of Operations.
60Report, Maj. Lawrence M. Nelson, MC, to The Surgeon General, through the Surgeon, Mediterranean Theater of Operations, 20 July 1945, subject: An Unusual Dermatitis Simulating Lichen Planus and Lichen Corneus Hypertrophicus.
61Letter, Maj. C. S. Livingood, MC, to The Surgeon General, November 1944, subject: Report of the Occurrence of an Unusual Skin Disease.
62Report, Dr. Clarence S. Livingood, 14 Feb. 1951, subject: Lichenoid and Eczematous Dermatitis Syndrome Due to Atabrine.


650

In July 1945, Maj. James M. Flood, MC, reported his observations on the relation between atypical lichen planus and Atabrine in the 20th General Hospital.63 They covered not only patients but the 800 officers, nurses, and enlisted men on the staff and in the personnel. He considered the evidence for the relationship convincing for several reasons:

1. There was a large number of troops in the theater between March 1943 and November 1945.

2. No cases of this syndrome were observed between March 1943 and March 1944. Suppressive Atabrine was not used during this period.

3. After March 1944, Atabrine therapy was used in two distinct programs. Between March 1944 and 15 February 1945, it was used in selected troops in the forward area, and so-called Atabrine discipline was poor. Scattered cases of atypical lichen planus began to occur about 6 weeks after the program was instituted. Between 15 February 1945 and 1 November of that year, all troops in Assam and north Burma received Atabrine, and discipline in respect to its use was reported excellent. By April 1945, the number of cases of atypical lichen planus had begun to increase sharply.

4. Patients with this syndrome were observed only in Assam and north Burma, the only sections of the theater in which suppressive Atabrine medication was used.

5. All other factors in the theater, including climate, working conditions, and diet were approximately the same during the entire time except for a considerable improvement in diet later in the period.

Major Flood's and Major Livingood's studies, as already indicated, covered the 800-member personnel of the 20th General Hospital. Most of them had been in the same area and worked under the same conditions for about 20 months before suppressive Atabrine therapy was instituted. During this period, not a single individual acquired cutaneous lesion in any way suggestive of either atypical lichen planus or eczematoid dermatitis. Within 5 months after the regimen had been instituted, seven persons had acquired the complex. Most of the lesions improved when Atabrine was discontinued, but new lesions appeared in some cases when it was reinstituted.

Investigations in the Zone of Interior

The study of atypical lichen planus in the Zone of Interior was facilitated by concentrating the patients with this syndrome first at hospitals designated as tropical disease centers and later at Moore General Hospital and Harmon General Hospital, which were designated as dermatology centers. Here they were studied by a routine devised by the Medical Consultants Division, OTSG, with the cooperation of the civilian consultants and the Board for the Coordination of Malarial Studies.

63Letter, Maj. James M. Flood, MC, to Commanding General, 20th General Hospital, APO 689, 27 July 1945, subject: Atypical Lichen Planus.


651

At Moore General Hospital, Maj. James M. Bazemore, MC, and his associates studied intensively 51 patients who were selected because their lesions were predominantly lichenoid and had involuted after withdrawal of Atabrine for varying periods.64 When suppressive therapy was reinstituted, two distinct reactions were observed:

1. Five patients developed an eczematoid type of eruption that began characteristically as a generalized pruritus and was followed by erythema of the skin, most marked in the antecubital and popliteal spaces, the anterior aspect of the neck, and friction points. In the most severe cases, the eruption became red and generalized and went on to scaling. The time of development after the first dose of Atabrine given after the period of withdrawal varied from 4 hours to 7 days. All five patients, all of whom had to be dropped from the study group, had positive patch tests to Atabrine.65

2. The second type of reaction observed at Moore General Hospital was a clear-cut exacerbation of the lichenoid lesions, manifested by recurrences at the sites of previous lesions and development of new lesions. The earliest recurrences were observed 23 days after the reinstitution of Atabrine therapy; the majority occurred between 40 and 63 days afterward. Only two of the nine patients who manifested this second type of reaction had positive patch tests.

The proportion of patients in the experimental group who developed exacerbations of their lesions within 3 months after the reinstitution of Atabrine therapy was practically identical with the proportion who had developed the syndrome within a similar period after beginning suppressive Atabrine. This particular phase of the investigation at Moore General Hospital explains why some observers reported no exacerbations of the original lesions when Atabrine was readministered for short periods of time. On the other hand, all investigators in oversea theaters who had the opportunity to readminister the drug to patients with atypical lichen planus or eczematoid dermatitis reported a higher incidence of exacerbations than were observed when experimental readministration was carried out in patients who had been evacuated to the Zone of Interior.

Geographic Distribution and Incidence

The more careful investigation that was possible after the war left no doubt that atypical lichen planus and eczematoid dermatitis occurred in all areas and commands in which suppressive Atabrine was in general use. It was recorded in New Guinea and neighboring islands on the north coast;

64Bazemore, J. M., Johnson, H. H., Swanson, E. R., and Hayman, J. M., Jr.: Relation of Quinacrine Hydrochloride to Lichenoid Dermatitis (Atypical Lichen Planus). Arch. Dermat. & Syph. 54: 308-324, September 1946.
65Capt. Harvey Blank, MC, Chief of Dermatology and Syphilology, 69th General Hospital, informed the writers of this chapter that in the 33 cases he personally observed, patients with typical lichenoid lesions were generally patch-test negative to Atabrine while those with the eczematous and exfoliative types were likely to be patch-test positive.


652

Bougainville; Guadalcanal; Green Island; the Carolines; New Britain; Morotai Island; the Solomon Islands; the Admiralty Islands; the Trobriand Islands; Okinawa; Assam; north Burma; the Philippine Islands; parts of Australia; and Italy.

No data are available on the incidence of atypical lichen planus and eczematoid dermatitis in relation to troop strengths in the various areas in which these diseases were encountered. The largest numbers of cases are known to have occurred in New Guinea and adjacent islands and in the Assam-Burma area. Major Ambler estimated the incidence in the Southwest Pacific Area at 2 or 3 per 1,000 per year, which most observers considered too low. Colonel Schmitt, basing his estimates on his experience in a general hospital in New Guinea, estimated the incidence at 11-14 per 1,000 per year, and Major Flood, using his experience in a general hospital in Assam, estimated the incidence at 10 per 1,000 per year.

Contributory Factors

The fact that the incidence of this syndrome was so much higher in New Guinea and adjacent islands, and in Assam and north Burma, than in other areas suggests that factors other than Atabrine might also play contributory roles in its causation. Some investigations substantiated this theory, at least to a limited degree.

Major Ambler and his associates,66 Major Livingood,67 Lt. Col. Donald J. Wilson, MC,68 and others presented evidence that indicated that various forms of cutaneous trauma contributed to the onset and localization of the lesions, particularly during the eczematoid phase of the eruption. The assumption was that something happened to the skin of a certain proportion of men who were taking Atabrine regularly that made them particularly vulnerable to irritation and infection. As a result, they developed an increased tendency to acquire chronic eczematoid dermatitis on contact with external allergens. It naturally followed that a larger proportion of men on suppressive Atabrine would develop cutaneous eruptions in hot, humid climates such as New Guinea, Assam, and north Burma, than in other parts of the world, where the skin was less subject to trauma, infection, and inflammation.

Dietary deficiencies and psychosomatic factors were also investigated as possible principal contributory causes of this syndrome. Major Harvey and his group found a slightly lower nutritional status in patients with this disease than in a control group, but they did not implicate dietary deficiency as a cause. It was emphasized by Col. Benjamin M. Baker, MC, Consultant in

66See footnote 55, p. 647.
67See footnote 62, p. 649.
68Wilson, D. J.: Eczematous and Pigmentary Lichenoid Dermatitis: Atypical Lichen Planus. Arch. Dermat. & Syph. 54: 377-396, October 1946.


653

Medicine, in the South Pacific Area,69 that a greater variety of fresh vegetables and fruits, as well as larger quantities of milk and eggs, was available in that area than in the Southwest Pacific Area. These facts might explain the much lower incidence of the syndrome in the Solomon Islands than in New Guinea and its adjacent islands, although the use of suppressive Atabrine was approximately the same in both regions.

A number of observers analyzed the available data in reference to race, sex, age, and complexion. The only finding of any possible statistical significance was that patients with the lichenoid and eczematoid dermatitis syndromes were in a somewhat higher age group than the average military population.

Virus studies carried out at Moore General Hospital,70 as well as cultural studies for fungi and bacteria carried out here and elsewhere, produced no significant data.

Clinical Considerations

It was the combination of various types of lesions in a characteristic fashion, plus their occurrence in large groups of individuals under similar circumstances, that made this syndrome a new entity. All observers agreed that the lesions were polymorphous and that they appeared in many different combinations. At the same time, they emphasized also that these patients reacted dermatologically in a highly characteristic fashion and that the clinical picture soon became unmistakable, even to medical officers with little or no experience in dermatology.

Initial manifestations.-The disease almost invariably began with a prodromal inflammatory cutaneous eruption that varied in character and distribution. The most typical initial manifestation was a rather sharply marginated, patchy, eczematoid eruption, either exudative or nonexudative, most frequently on the dorsal surfaces of the hands, feet and legs, and in the crural region. The wrists, eyelids, ears, and neck were other sites of predilection.

Other clinical manifestations seen early in the illness included an eruption resembling seborrheic dermatitis in the scalp, eyebrows, bearded region, axilla, and suprapubic region; discrete and confluent erythematous, pinhead-size vesicles and papules that resembled miliaria; and flat, erythematous patches that soon became scaly and sometimes exfoliative. Often, the eczematoid and intertriginous lesions became impetiginized; in such instances, they were apt to extend more rapidly.

As this description indicates, these early eruptions often so closely resembled other forms of eczematoid dermatitis that an exact clinical diag-

69Baker, Benjamin M.: South Pacific Area. In Medical Department, United States Army. Internal Medicine in World War II. Volume I. Activities of Medical Consultants. Washington: U. S. Government Printing Office, 1961, pp. 569-623.
70
See footnote 64, p. 651.


654

nosis was difficult. So-called nummular eczema, contact dermatitis, seborrheic dermatitis, pyoderma, tineal infections, miliaria, and dermatophytids all had to be excluded. It was sometimes necessary to follow the eruption from day to day in order to detect the lichenoid lesions upon which the diagnosis of atypical lichen planus was based. In other cases, the symmetry, distribution, and violaceous color of the initial lesions were sufficiently characteristic for an experienced dermatologist to make the diagnosis very early in the course of the disease.

The personally collected data of Major Ambler on 200 cases in the Southwest Pacific Area71 (table 104) and of Major Schmitt and his group on 118 cases in the same area72 (table 103) closely parallel the observations of Major Bazemore and his associates on 302 cases at Moore General Hospital in respect to the initial sites of cutaneous involvement.73 Opinions differed, however, as to the significance of these early, antecedent eruptions. Some dermatologists regarded them as unrelated dermatoses that predisposed to lichenoid lesions. There was some evidence to support this opinion; trauma of various types, sunlight, and mechanical and chemical agents unquestionably predisposed to the development of lichenoid lesions. Other observers pointed out that eczematoid patches, crusted plaques, and

TABLE 104.-Anatomic distribution of lesions of fully developed lichenoid and eczematoid dermatitis complex in 200 patients

Sites

Number of cases

Percent

Dorsum of hands

152

76

Lower legs

137

69

Lips

127

64

Eyelids1

114

57

Dorsum of feet

102

51

Forearms

99

50

Ears1

86

43

Buccal mucosa

70

35

Palms

70

35

Penis

63

32

Manubrial region

56

28

Scalp

51

26

Soles

49

25

Buttocks

49

25

Face

39

20


1Originally, only 1.5 percent of these patients had lesions of the eyelids and only 3 percent lesions of the ears. The percentages shown in this table were a later development in each instance.
Source: Report, Maj. John V. Ambler, MC, to the Theater Surgeon, Southwest Pacific Area, 15 Dec. 1944, subject: Statistical Survey of 200 Cases of Atypical Lichen Planus.

71See footnote 52, p. 647.
72See footnote 54, p. 647.
73See footnote 64, p. 651.


655

severe intertriginous dermatitis frequently developed in the presence of lichenoid lesions. Whatever the causation, it seems probable that the initial lesions, even though they occurred independently and in advance of the lichenoid eruption, were still part of the lichenoid complex.

Later manifestations.-The lichenoid lesions characteristic of atypical lichen planus assumed a variety of forms, as follows:

1. Annular, scaling violaceous lichenoid papules occurred singly or in sharply outlined patches of varying sizes. Pigmentation (melanin) that became deeper as time passed regularly accompanied some of these lesions74 (figs. 111 and 112). The papules resembled those seen in lichen planus ruber but were not angular and their surfaces were not ordinarily shiny. Wickham's striae seen in true lichen planus were only occasionally observed.

2. Hypertrophic and hyperkeratotic lichenoid plaques represented another secondary manifestation of the syndrome (fig. 113). Large, elevated plaques and nodules began as such; they were not the result of coalescence of small papules. These plaques, which were either annular or linear, ranged in diameter from 0.5 to 5.0 centimeters. They were often elevated 0.5 cm. or more above the surface of the skin, but they did not usually infiltrate it deeply. Initially, their coloration varied from erythematous to a deep violaceous hue. Later, they assumed a dark brown or slate-gray color. Extremely dense, grayish scales were seen in lesions that became verrucous. This variety, as well as lichenoid papules, usually developed at the sites of healing eczematoid lesions. While they might occur almost anywhere on the face, trunk, or extremities, they were most often localized on the dorsal surface of the hands, the extensor surface of the forearms and legs, and the dorsal surface of the feet. These lesions, in general, resembled those seen in lichen planus hypertrophicus.

3. Lichenoid lesions of the mouth (fig. 114) involved the vermilion borders of the lips, the buccal surface of the cheeks, and the dorsal surface of the tongue. They took the form of whitish or violaceous-tinged, slightly elevated, reticular leukokeratoses that resembled true lichen planus except that the involvement was usually more extensive. Erythema and some degree of erosion were quite common. Major Nisbet described several instances of severe stomatitis, with bullous lesions.75

Concomitant lesions.-In addition to the lichenoid lesions just described, the fully developed syndrome included a wide variety of other lesions, not all of which were observed in all patients, though the lesions were always polymorphous. Among these lesions were the following:

1. Pigmented patches, which were frequently at sites other than those of the earlier lichenoid or eczematoid lesions (figs. 115 and 116). The coloration varied from violaceous to slate-gray, dark brown, or almost coal-black.

74Lutterloch, C. H., and Shallenberger, P. L.: Unusual Pigmentation Developing After Prolonged Suppressive Therapy With Quinacrine Hydrochloride. Arch. Dermat. & Syph. 53: 349-354, April 1946.
75Nisbet, T. W.: Dermatitis Due to Quinacrine Hydrochloride ("Atabrine"). J.A.M.A. 134: 446-450, 31 May 1947.


656

FIGURE 111.-Lichenoid Atabrine dermatitis. A. Lichenoid lesions of hands with hyperpigmentation and some tendency to superficial scarring.

These patches resembled, in some respects, the fixed drug eruptions caused by phenolphthalein and other compounds.

2. Faintly erythematous, scaling, papulosquamous lesions with an axial distribution not unlike that of pityriasis rosea (figs. 117 and 118).

3. Flat, squamous, well-demarcated geographic plaques on the trunk, axilla, and groin, which resembled fungal lesions.

4. A diffuse, exfoliative type of generalized eczematoid dermatitis (fig. 119), with increased involvement and marked weeping of the intertriginous sites, the flexors of the knees and elbows, the inner surfaces of the thighs, and the neck.


657

FIGURE 111.-Continued. B. Lichenoid lesions of hand and forearm (this same patient is shown in figures 111C and 112). Note the somewhat verrucous character of the lesions.

5. Follicular involvement, which took the form of either (1) a patchy or a diffuse keratosis pilaris or (2) papular lesions in the hair follicles. These lesions were most frequent on the buttocks, shoulders, back, arms, and legs.

6. A scaling, erythematous, eczematoid dermatitis of the eyelids (fig. 120). This was a very common finding.

7. Hyperkeratosis, superficial fissuring, and pigmentation of the vermilion border of the lips (fig. 121); fissures at the angles of the lips; and, occasionally eczematous cheilitis with edema, fissuring, and oozing.

8. Erythematous and violaceous-tinged, oozing, scaling, eczematoid plaques, well demarcated in some instances and ill defined in others.


658

FIGURE 111.-Continued. C. Lichenoid, verrucous-like lesions on anterolateral surface of foot.

9. Oozing intertriginous dermatitis of the groins, axillas, and intergluteal surfaces.

10. Scaling, hyperkeratotic papules of the palms and soles. The entire area was occasionally so greatly thickened, fissured, and glazed as to suggest a hyperkeratotic eczema.


659

FIGURE 112.-Lichenoid Atabrine dermatitis. Closeup of elevated, shiny, violaceous papules and plaques on lateral surface of neck and preauricular region, 2½ months after onset.

11. Scaling, bilateral, dry dermatitis of the ears, especially the tips of the auricles, or a weeping dermatitis involving the entire auricle and the retro-aural folds. The lesions observed in these cases resembled seborrheic dermatitis with secondary streptoderma.

12. Diffuse, adherent, thick scaling of the scalp, with or without hyperkeratotic plaques, usually accompanied by diffuse or patchy alopecia. Alopecia occurred in some instances, however, without lesions of the scalp.

13. Crusted pyogenic lesions, which in some instances went on to generalized pyoderma and septicemia. These were extremely serious complications.

14. Ecthymatous ulcerations, which were in part the result of excoriation of the hypertrophic nodules and plaques just described. In the strictly


660

FIGURE 113.-Lichenoid Atabrine dermatitis. Note symmetry and extensive involvement. Superficially, these lesions resembled psoriasis.


661

FIGURE 114.-Lichenoid lesions of mouth in Atabrine dermatitis. A. Cheilitis limited to commissures. B. Lesions of oral mucous membrane characterized by whitish, lacy plaques with a predilection for the buccal mucosa. Note the superficial fissuring and inflammatory response at the oral commissure.

accurate sense of the word, it seems more logical to classify the various types of pyoderma observed not as an integral component of atypical lichen planus but rather as secondary complications.

15. Abnormalities of the nails, which took various forms (fig. 122), including separation of the distal margin with accumulations of whitish, cellular debris under it; roughening or destruction of the nail near the matrix; linear striation and transverse depression; brittleness; pitting and lack of luster; and, in some cases, subacute paronychial infections. All of these varieties of nail involvement occurred more frequently when the hands, feet, or both had been involved in the process for some time.

In his trips about the Southwest Pacific Area, as already mentioned, Dr. Hopkins was greatly impressed by the frequency of a blue discoloration of the nail beds in men in the area. The first such cases he observed were in patients with atypical lichen planus, who frequently had pigmented plaques elsewhere in the body which resembled the fixed eruption caused by phenolphthalein. The nail anomaly appeared as a wide, transverse band, ranging from slate-colored to violet. The band, which was usually located in the mid zone of one (or more) of the nails on the fingers or the toes did not shift as the nail grew. Small macules of the same color were sometimes seen beneath the nails. It was reported to Dr. Hopkins, though it was no more than a rumor, that some men with blue nails had similar pigmented areas elsewhere on the body. Some lesions were said to resemble argyria,


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FIGURE 115.-Atabrine dermatitis. Marked, very extensive hyperpigmentation, 6 months after onset of eruption, which was mixture of lichenoid and eczematoid lesions.

but he himself saw no such cases, and he doubted the accuracy of the description. The discoloration of the nails gave rise to no symptoms, and soldiers seldom sought medical attention except to satisfy their curiosity.

One patient observed by Capt. William D. Wolfe, MC, at the 35th General Hospital, presented a wide zone of deep violet pigmentation across the anterior aspect of the neck and extending onto the upper chest, where it ended sharply. Except for its extent, it suggested (as did the first cases observed by Dr. Hopkins) a phenolphthalein reaction. Biopsy revealed a strip of lymphocytic infiltration in the papillary zone of the cutis. The violet color was explained by the presence of numerous chromatophores stuffed with melanin.


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FIGURE 116.-Pigmented patches in Atabrine dermatitis.

Dr. Hopkins conceded that the occurrence of blue nails with lichen planus might be no more than a coincidence. Many other skin lesions in the Southwest Pacific Area, especially ecthyma, showed puzzling blue to violet tinges and scars, sometimes when there was no other evidence of skin disease. He believed that the problem should be investigated but confessed that he could see no approach that offered any promise.

16. Cutaneous sequelae, including the pigmentation already described; atrophy of the skin, varying from slight to marked and occurring after involution of some of the lichenoid nodules and plaques; the development, in some cases, of paper-thin skin, mottled with areas of pigmentation and depigmentation and usually occurring on the dorsal surfaces of the feet and hands; alopecia; exfoliation of the nails; and, in severe cases, generalized and localized anhidrosis that exempted the forehead and axillas.

Figures collected by Major Schmitt and Major Ambler (tables 103 and 104) show the respective anatomic distribution of lesions in the fully developed lichenoid and eczematous complex and of lichenoid papules and nodules. It is notable that the distribution of the lichenoid papules differs from that of combined lichenoid and eczematoid lesions.

Symptoms.-Pruritus was present in all cases, but varied greatly in severity. As a rule, it was severe initially and then moderated. Acute inter-


664

FIGURE 117.-Atabrine dermatitis, with papulosquamous lesions resembling pityriasis rosea.

triginous lesions caused pain on movement, and lesions on the hands interfered with useful work.

Constitutional manifestations.-The majority of patients with uncomplicated diseases had little evidence of systemic involvement, and many with serious lichenoid lesions appeared well nourished and in excellent general health. Major Ambler, however, and a number of other observers noted significant losses of weight in about half of their cases. Patients with extensive exfoliative dermatitic complications usually suffered from malaise, asthenia, fever, and lymphadenopathy, though the proportion of such manifestations was no greater in this syndrome than in generalized cutaneous eczematoid eruptions from other causes.

In very occasional cases, aplastic anemia, other severe blood dyscrasia such as agranulocytosis, and severe acute hepatitis occurred in association with the lichenoid-eczematoid syndrome. Similar complications, however, were occasionally observed in men taking Atabrine who did not develop skin lesions. The case fatality rate of hematopoietic complications was very high. The relation between them and the skin disease was not clear, but the association was striking.

Chronology and course.-The sequence of events in atypical lichen planus and eczematoid dermatitis, as well as the types and combinations


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FIGURE l18.-Atabrine dermatitis, showing closeup of lesions which resemble pityriasis rosea.

of lesions, varied from patient to patient, though many reports emphasized that most men who developed the syndrome had been on suppressive Atabrine therapy for relatively long periods before the disease appeared. Lesions sometimes occurred abruptly, in the form of a widespread eruption, and attained a lichenoid appearance within a week. In many other cases, the prodromal lesions were present for weeks and the lichenoid lesions developed insidiously.

In the cases analyzed at Moore General Hospital,76 only 20 percent of the patients developed the disease within 3 months after institution of Atabrine therapy, as compared with 70 percent within 6 months and 90 percent within 10 months. In the 200 cases analyzed by Major Ambler (table 104), the onset of the lichenoid lesions was sudden (within 2 weeks) in 126 cases and gradual in the remainder. In the 118 cases studied by Major Schmitt (table 103), the initial eruption appeared within 1 and 3 months after suppressive Atabrine therapy was begun. The largest number of cases developed in the fourth and fifth months; 85.3 percent of the

76See footnote 64, p. 651.


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FIGURE 119.-Chinese patient with severe generalized exfoliative dermatitis complicated by severe hepatitis and aplastic anemia. This patient died.

eruptions became evident within the first 8 months, and only 3 percent appeared after a year.

Major Harvey's group,77 as well as other observers, thought that, when daily doses of Atabrine were larger than the routine prescribed dosage (0.1 gm.), the percentage of cutaneous reactions was unusually high. Numerous patients were observed who tolerated routine suppressive therapy for long periods and who acquired the lichenoid and eczematoid syndrome only when the suppressive dosage was increased or when malarial symptoms required therapeutic dosages.

In many instances the general course of the disease was slowly progressive, with enlargement of old lesions and the appearance of new lesions

77See footnote 57, p. 648.


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FIGURE 120.-Atabrine dermatitis of eyelids. Note scaling, eczematous character of lesions. The eyelids were a frequent early site of involvement. This patient also had mucous membrane lesions similar to those observed in lichen planus; scattered inflammatory, violaceous plaques; and oozing intertriginous dermatitis of the groins, axillas, and perianal region.

in other locations. It was often many weeks before the comfort and efficiency of the patient were seriously affected. In other cases, however, there was rapid, generalized development of eczematoid lesions, and the clinical picture was almost identical with that of exfoliative dermatitis except that the skin was less uniformly involved and there was less infiltration. These generalized exacerbations, which could occur at any time during the course of the disease but which were likely to occur early, were always serious and were potentially fatal. When the lesions involuted, the eruption became dry and scaly and often progressed to the development of pigmented flat or hyperkeratotic lichenoid lesions on the sites of former eczematoid plaques.

In some instances, there was definite evidence of photosensitivity, with lesions on the face, the anterior surface of the neck, and the dorsal surface of the hands. In other instances, no reactions of this kind were seen, even after prolonged exposure to sunlight.

In general, the lesions persisted for weeks and months, depending upon a number of factors, some of which were poorly understood.

To summarize the clinical course: A few patients had a gradual or rapid onset of lichenoid lesions, either preceded or accompanied by eczematoid lesions. A large group presented prodromal eczematoid or inflammatory lesions of one type or another, followed by gradual or rapid onset of lichenoid lesions that developed primarily or at the sites of the eczematoid lesions. In these cases, the eruptions were a mixture of lichenoid and eczematoid lesions, with one type or the other predominating. Still another group of patients had an almost concomitant onset and development of lichenoid and eczematoid lesions. Some patients had eczematoid lesions followed in a short time by explosive generalized exacerbations suggestive of exfoliative dermatitis; when the eczematoid-exfoliative reaction subsided,


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FIGURE 121.-Atabrine dermatitis. Note the cheilitis characterized by superficial fissuring. Note also the diffuse violaceous hyperpigmentation of the face and neck. This picture was taken 2½ months after an acute exacerbation, characterized by oozing dermatitis of the face and neck.

there was an onset of lichenoid papules and plaques. Finally, some patients had lesions that remained primarily eczematoid throughout the course of the eruption, with the lichenoid phase limited to relatively transitory lesions of the mucous membranes.

The degree and rate of improvement also varied. In the majority of the cases studied at Moore General Hospital,78 improvement progressed to a point at which the lesions became flat, erythema subsided, and, at the end of 6 to 9 months, pigmentation was the only evidence of the disease.

Although precise data on comparable groups of cases are not available, it seems clear that improvement was much more rapid when patients were removed to a temperate climate from the hot, humid climate in which their disease had developed. On the other hand, their lesions sometimes cleared up completely even when they were hospitalized in the Tropics.

81See footnote 64, p. 651.


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FIGURE 122.-Nail changes in Atabrine dermatitis, 3 months after onset. Note linear striation and thickening of distal part of nails. In this case, all the toenails and all the fingernails were involved.

Laboratory Investigations

The reports of the laboratory studies on this syndrome carried out by various observers and groups in the Southwest Pacific Area were collected and analyzed by Major Ambler and his associates.79 They included urinalysis, blood counts, blood sedimentation rates, serum protein determinations, serologic tests, and examinations for fungi. All results were negative except for (1) leukocytosis and increased sedimentation rates, both of which, when they occurred, could be attributed to secondary pyogenic infection, and (2) low serum protein levels in patients with exfoliative dermatitis and extensive exudation.

The (summarized) report that follows concerns the results of multiple tests of hepatic function carried out on 24 patients who had contracted the disease in Assam and north Burma by Maj. Thomas E. Machella, MC.80

1. Definite evidence of abnormalities in the role of the liver in carbohydrate metabolism was found in patients with active skin lesions of atypical lichen planus. There was evidence of impairment of glycogenolysis in all cases; increased tolerance to glucose in 11; and decreased tolerance to it in 2.

79See footnote 55, p. 647.
80Letter, Maj. Thomas E. Machella, MC, 20th General Hospital, to The Surgeon General, War Department, Washington, D.C., through the Commanding General, 20th General Hospital, Advance Section, U.S. Forces in IBT, APO 689, 6 Aug. 1945, subject: Atypical Lichen Planus.


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2. Impairment of the ability of the liver to remove bromsulphthalein from the bloodstream was found in 16 of the more severe cases of atypical lichen planus and in 3 of those with mild lesions or lesions that had involuted.

3. The mean total serum proteins were low normal or actually low, with the albumin fraction decreased. The lowest values occurred in those patients with the more severe skin lesions who also had disturbances in carbohydrate metabolism and excretory function.

4. No significant disturbances were found in cholesterol or the cholesterol esters, the plasma fibrinogen, or the detoxifying function of the liver.

5. The disturbances observed in these cases in carbohydrate metabolism, serum protein levels, and excretory hepatic function were comparable with the abnormalities that may occur when a liver is low in glycogen and high in fat. They were such as might occur when the sympathetic nervous system is not functioning properly.

The liver function tests performed on 35 patients at Moore General Hospital81 included hippuric acid synthesis, bromsulphthalein retention, cephalin-cholesterol flocculation, icterus index, and prothrombin time. Three of these tests were abnormal in 1 patient, 2 were abnormal in 7, and 1 was abnormal in 6. It should be emphasized that these studies were made in a hospital in the Zone of Interior weeks and months after the onset of the disease, in contrast to Major Machella's studies, which were carried out in an oversea theater a few weeks after the onset.

Therapy

Recognition of the fact that Atabrine was the basic etiologic factor in eczematoid dermatitis and atypical lichen planus pointed to the basic therapeutic measure, withdrawal of the causative drug. Majors Schmitt, Ambler, Nisbet, and Harvey promptly arrived at this conclusion in the Southwest Pacific Area, as did Major Livingood and others in China-Burma-India. It was also soon learned, as already mentioned, that these patients were likely to clear more rapidly if they were removed to a cooler climate and that relapse was likely to occur if they were returned to the Tropics.

Time-honored textbook remedies for lichen planus, such as bismuth and arsenic, had no effect on the course of this new syndrome, and on theoretical grounds, these drugs were strictly contraindicated. These patients would not tolerate irritating local treatment, such as salicylic acid and tincture of iodine. In fact, the commonest mistake in the treatment of the eczematoid phase of the eruption was the use of strong fungicidal measures.

Penicillin, used parenterally and locally, was beneficial, and was sometimes lifesaving, in the treatment of secondary pyogenic infection, particularly of exacerbations in the form of generalized exfoliative dermatitis.

81See footnote 64, p. 651.


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Other useful measures in generalized involvement were plasma and glucose infusions, vitamin therapy, and liver extract.

Major Machella pointed out, in view of the abnormalities found in the liver function studies made, that correction of these dysfunctions should be an integral part of the therapeutic regimen.82 An important component of treatment was a diet high in protein and carbohydrate but low in fat. A vitamin supplement was also recommended.

In the 118 cases studied by Major Schmitt and his Australian associates,83 well over half of the patients experienced improvement within a month after Atabrine was discontinued, but 20 percent noted no improvement for 2 to 3 months. About 10 percent began to improve while they were still in New Guinea and still taking Atabrine. Of the patients not taking Atabrine when improvement began, 57 were in the United States, 20 were en route there, and 7 were still in New Guinea.

Administrative Action

Administrative action in this matter had to be undertaken carefully. Widespread dissemination of information concerning the relation between Atabrine and lichenoid and eczematoid dermatitis would have resulted in a sharp decrease in the use of suppressive malaria therapy. The increased malaria rate that would inevitably have resulted might have seriously impaired the military effort in both the Southwest Pacific Area and the China-Burma-India theater. For these reasons, as soon as the causal relation was recognized, every effort was made to avoid open discussion of the subject, and The Surgeon General placed a RESTRICTED classification on all oral and written communications concerning it. On the other hand, it was essential that medical officers in the theaters and areas affected should have the information. It was widely disseminated by appropriate consultants, but the restriction was so effective that many medical officers did not learn of the relation of Atabrine to the lichenoid-eczematoid syndrome until after the war.

The increasing proof that Atabrine was the basic etiologic factor in this new syndrome, the evident magnitude of the problem, and the realization that many medical officers were aware of the data that had been accumulated prompted the Medical Consultants Division, OTSG, to issue a RESTRICTED letter on the subject which was eventually disseminated to all theaters and commands.84 In substance, this letter contained the following information:

82See footnote 80, p. 669.
83See footnote 54, p. 647.
84Restricted Letter, Office of The Surgeon General, U. S. Army, to Surgeons, all major oversea theaters, all Army Service Forces service commands, and the Military District of Washington, 14 Aug. 1945, subject: Reactions Attributed to Atabrine.


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1. The military value of Atabrine in suppressing vivax malaria and in attacks of falciparum malaria far outweighs the untoward effects that have been attributed, with reason, to the use of this drug.

2. Suppressive doses greater than 0.7 gm. per week should not be employed routinely. This amount has been shown to provide adequate protection against clinical attacks of malaria if Atabrine discipline is strictly enforced. In the clinical treatment of malarial attacks, the routine dosage of Atabrine should not exceed 2.8 gm. over a 7-day period.

3. Suppressive Atabrine medication should be discontinued promptly, and Atabrine should not be used therapeutically, if troops develop any of the following conditions: Atypical lichen planus; unexplained chronic eczematoid dermatoses; unexplained toxic erythematous eruptions; exfoliative dermatitis; severe leukopenia, agranulocytosis, and aplastic anemia; acute hepatitis (not including disturbances believed to be caused by malaria) ; and any toxic psychoses that, after careful clinical study, can be reasonably attributed to Atabrine.

4. Quinine is available for the treatment of individuals who are known to be sensitive to Atabrine or to be seriously intolerant of it. Quinine should not be used, however, for units or organizations as a whole.

5. When, after thorough study, it is concluded that an individual is definitely sensitive to Atabrine (or quinine), an appropriate entry should be made, as in the case of other drugs, on WD AGO Form 8-117 (Immunization Register).

6. Caution should be exercised in attributing disease conditions to Atabrine until careful and complete studies over a period of time have established the relation. Because of the widespread use of this agent, its administration inevitably coincides with the existence of many diseases with which it has no connection. Even if a connection is established between Atabrine and any given untoward effect, the connection must be evaluated in relation to the military value of Atabrine. Since suppressive Atabrine therapy came into general use, clinical attacks of falciparum malaria have been almost eliminated and deaths from malaria have become extremely uncommon. There is no question concerning the general superiority of Atabrine over quinine, both for suppression and for clinical treatment of malaria.

7. Detailed information and instructions in regard to the possible toxic effects of Atabrine and the management of men for whom it is considered contraindicated should be disseminated to medical officers, especially those in direct charge of patients. In all discussions of the toxicity of Atabrine, its great military usefulness and the low incidence of all types of serious reactions to it should be emphasized. Discussions of its role in various disease conditions should be avoided in the presence of patients. Public discussions should be discouraged. At this time, the relation between Atabrine and the atypical lichen planus complex is classified as RESTRICTED.

8. It is recommended that the contents of this letter be communicated to medical consultants and that they be instructed to inform and advise all medical officers concerned.

Prognosis

The prognosis of both atypical lichen planus and eczematoid dermatitis was excellent, especially when Atabrine was discontinued and the patient was hospitalized and evacuated from the Tropics. Once these facts were appreciated and acted upon, the period of recovery was significantly shortened. Patients with severe eczematoid dermatitis were prone to relapse, especially if treatment was delayed until the lesions were well established on the hands, feet, or both, Perhaps 5 to 10 percent were left with a semipermanent increased sensitivity to trauma and external allergens.


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FIGURE 123.-Atabrine dermatitis, showing hyperpigmentation and thickening of skin which sometimes followed bilateral eczematoid lesions, particularly on the dorsum of the hands and feet.

Cases complicated by blood dyscrasia, severe hepatitis, or septicemia were usually fatal. These complications, which fortunately were uncommon, tended to occur in patients with severe generalized exfoliative dermatitis. Patients who recovered from them always had protracted courses.

Alopecia and sweating abnormalities cleared up spontaneously in almost all cases, though in some patients with deep obstruction of the sweat glands, severe intolerance to heat and apparently permanent anhidrosis developed. It was thought that the hyperpigmentation (fig. 123), which was frequently striking and sometimes disfiguring when the patients were received from overseas, would eventually disappear entirely, an expectation that has been largely fulfilled.

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