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Chapter I
Activities of Medical Consultants
CHAPTER I
Medical Consultants Division
Office of the Surgeon General
Hugh J.
Morgan, M.D.
The Army of the United States in World War II was by and large a citizen's army administered at the higher levels by a relatively small number of professional soldiers. This was true for practically all arms and services, including the Medical Department which was primarily responsible for health services. A small group of career officers of the Army Medical Corps administered the complicated affairs of the Medical Department. Consultants were appointed by The Surgeon General and assigned to his office to develop medicine, surgery, and psychiatry in the Medical Department of the Army and, in a limited way, to supervise professional performance in these special fields. With few exceptions, these men were recruited from civilian life and were not from among the Regular Establishment.
The history of the development of the Medical
Consultants Division, OTSG (Office of the Surgeon General), and the
projection of its influence throughout the
Army is a story of civilian participation in military medicine. The
consultant system, beginning in the Surgeon General's Office with the
assignment of the chief
consultants, extended into the service commands in the Zone of Interior
during the mobilization and training period and overseas with the
establishment of
theaters of operations. Finally, its representatives were utilized
toward the end of the war by armies, corps, and divisions in combat. In
this history, it would be
inappropriate and unrealistic to disregard the difficulties that arose
through the consultants' lack of experience with the military and the
military's failure to
understand clearly what the consultants had to offer. On the one side,
the special problems of military medicine and, on the other side, the
value of specialized
medical services in hospitals and in the field had to be learned before
there could evolve the system of medical, surgical, and psychiatric
supervision that existed
at home and in the theaters of operations at the end of the fighting in
1945.
In the pages that follow, the author breaks many
times with the conventions of military reporting. This is inevitable,
since he and his immediate associates and
practically all of the medical consultants throughout the Army were
products of civilian medicine. It is thought that the value of this
volume will be enhanced if it
reflects accurately both failures and achievements, both helps and
hindrances, at the inception and during the development and operation
of the medical
consultant system in the Surgeon General's Office and in the Army Field
Establishment.
2
FIGURE 1.-Brig. Gen. Charles C.
Hillman,
Chief, Professional Service
Division, Office of the Surgeon General, 13 April 1942.
BEGINNING OF THE
CONSULTANT
SYSTEM
Chief Consultant in
Medicine
On 1 January 1942, Dr. Hugh J. Morgan received a
communication from Col. (later Brig. Gen.) Charles C. Hillman, MC (fig.
1), Chief, Professional Service
Division, OTSG, inviting him to become a member of the Professional
Service Division with the title of Chief Consultant in Medicine to The
Surgeon General in
the grade of colonel. The letter outlined the duties of this assignment
as follows: "With the increased tempo of military matters, expansion of
the Professional
Service Division to provide for separate subdivisions of medicine,
surgery, and neuropsychiatry appears desirable. It is contemplated that
the Chief of each
subdivision will be the Chief Consultant and Coordinator in matters
pertaining to his field of medicine throughout the Army." On 11
February 1942, Colonel
(later Brigadier General) Morgan and his personally selected assistant,
Capt. (later Col.) Harrison J. Shull, MC, reported for duty to Maj.
Gen. James C. Magee,
The Surgeon General, and were assigned to the Professional Service
Division.
Although he was strongly supported by his immediate
superior, General Hillman, it was necessary for Colonel Morgan to make
his way in the Surgeon
3
FIGURE 2.-Brig. Gen. W. Lee Hart
(seated,
center) and key members of
his Eighth Service Command medical staff.
General's Office. He participated in certain problems immediately,
assisting in the formulation of physical standards for induction into
the Army and in the
selection of new drugs and special items of medical supply. He attended
meetings of committees of the National Research Council concerned with
internal
medicine. In those early days, however, the professional consultants
were expected to confine their duties rather narrowly to clinical
problems. There was slow
acceptance of the concept that they should recommend the duty
assignments of Medical Corps specialists or should take initiative in
matters directly affecting
medical care, such as medical supply and hospitalization policy. Time
and effort had to be expended in a process of mutual enlightenment
between the newly
commissioned consultants and the seasoned Medical Corps officers in the
Surgeon General's Office. The latter, although experienced in the ways
of the Army,
were not always cognizant of the ways in which professional
consultation could best be used, either in administrative medicine or
at the bedside.
The peacetime Army of the thirties had recognized no
need in its medical operations for a consultant service, although such
a service had functioned in World
War I. Revival of position-assignments by General Magee met with the
indifference, occasionally the frank opposition, of many officers in
pivotal positions
outside the Surgeon General's Office and of some inside it. There were
notable exceptions, and to these early supporters the professional
consultant system, as it
finally evolved, owed much. Col. Sanford W. French, MC, Surgeon, Fourth
Corps Area (later Fourth Service Command), and Col. (later
4
Brig. Gen.) W. Lee Hart, MC (fig. 2), Surgeon, Eighth Corps Area (later Eighth Service Command), set an example for other surgeons of major commands. The prompt and enthusiastic cooperation of these two officers hastened the end of inertia.
Certainly no one in the Surgeon General's Office in February 1942 envisaged the magnitude and importance of the consultant system as it eventually functioned at the time of victory in Europe and in the Pacific. Colonel Morgan's initial staff consisted of two Medical Corps officers and one civilian clerk, housed in one small room and having no representation in any major command either in the Zone of Interior or overseas. In each of the major commands, there appeared in time as consultants in medicine an informally organized group of exceptionally qualified officers. These men had been carefully chosen, most of them by The Surgeon General with the advice of his chief consultant in medicine. In a practical sense, they were usually recognized by the Medical Department as representatives of the Surgeon General's Office, although they were, in fact, directly responsible to the surgeon of the command or theater or army and were separated from The Surgeon General and his chief consultant in medicine by zealously guarded command channels.
The mission of the Medical Department of the Army in time of war is to prevent disease and injury and to provide optimum treatment, to the end of maintaining the lowest possible noneffective rate. With this as his primary objective--to reduce time lost from duty--Colonel Morgan attempted to encourage, in every way possible, prompt, accurate diagnosis and optimum therapy; to expedite administrative procedure; and to help accelerate the convalescence and return of the soldier to his military assignment physically and emotionally fit. It soon appeared that this broad concept of his functions required the establishment of broad principles governing the practice of medicine in the Army and the control of specialized personnel responsible for relating these principles to the care of patients.
In the formative days, great assistance was rendered The Surgeon General and his professional consultants by the various committees of the National Research Council. These committees provided facts and expert opinion which could serve as the basis for formation of policy regarding clinical and administrative practices. Later, Colonel Morgan established, in his own organization, branches representing important subspecialties in military medicine arid assigned experts as their chiefs. Civilian consultants in medicine to the Secretary of War and to The Surgeon General were also helpful.
Much of the time of the chief consultants was occupied by many matters which were not, strictly speaking, included in their functions. For example, their early efforts to encourage an aggressive attack by hospital staffs upon the problem of excessively prolonged hospitalization after recovery from disease and injury contributed greatly to the official recognition of the importance of this matter and to the eventual establishment of a comprehensive, well-organized program for the management of convalescence and rehabilitation.
5
Command, Theater, and Army Consultants
It was evident from the beginning that
delegation
of responsibility
by the chief consultant in medicine in the Surgeon General's Office was
necessary, if the
mission assigned him was in any real sense to be executed. This became
obvious to all when hospitalization plans for the future were
disclosed. There were in
actual operation in the Army approximately 209 station hospitals, with
71,459 beds, Plans called for an additional 145 station hospitals, with
86,843 beds. The 15
general hospitals, with 14,912 beds, then in operation were to be
augmented by 15 additional installations with 20,988 beds. Thus, in
early 1942, firm plans for
hospitals in the United States provided for a total of 384 station and
general hospitals, with 194,202 fixed beds. The futility of any attempt
on the part of the
chief consultant in medicine to affect significantly the practice of
medicine in so many hospitals scattered so widely throughout the
country merely by issuing
directives and bulletins from the Surgeon General's Office was
apparent. Moreover, there was no provision for detailed control of
assignments to key positions in
these hospitals. Finally, the division of the United States into corps
areas (later service commands), each a separate military command, made
effective central
administration of medical activities from the Surgeon General's Office
impossible, since authority for centralized control did not exist.
Accordingly, on the recommendation of the
consultants of the Professional Service,
OTSG, The Surgeon General recommended the assignment of consultants to
the surgeons of corps areas.1 It was proposed that these
officers "shall act in an inspectional and consultative capacity, and
that their duties shall include the
evaluation of the professional qualifications of medical personnel,
appraisal of new therapeutic methods and agents, and the coordination
of professional practice
by local discussion with hospital staffs of such special problems as
may present themselves. It is contemplated that the consultants
selected shall be outstanding
and nationally recognized in their respective fields."
Headquarters, Services of Supply (later Army Service
Forces),
approved in principle this recommendation but refused the accompanying
request that corps areas
be authorized an increased medical officer allotment in the grade of
colonel for this purpose. Shortly thereafter, the following service
command consultants in
medicine were assigned: Lt. Col. (later Col.) Henry M. Thomas, Jr., MC,
to the Fourth Service Command; Lt. Col. (later Col.) Walter Bauer, MC,
to the Eighth
Service Command; Lt. Col. (later Col.) Verne R. Mason, MC, to the Ninth
Service Command; and Lt. Col. (later Col.) Edgar van Nuys
1 (1) Letter, The Surgeon General to Commanding
General, Services of
Supply, 28 May 1942, subject: Coordination of Medical Service
(Professional) in Corps
Area Installation, with 1st Indorsement thereto. (2) Letter, The
Surgeon General to Commanding General, Services of Supply, 23 June
1942, subject:
Coordination and Supervision of Medical Service in Station Hospitals.
(3) Letter, The Surgeon General to Commanding Generals, Service
Commands, 28 July
1942, subject: Coordination and Supervision of Professional Medical
Service Under Service Commands. (4) Letter, The Surgeon General to
Commanding
General, First Service Command, 25 Jan. 1943. subject: Assignment of
Professional Consultants.
6
Allen, MC, to the Seventh Service Command. In due time, as hospital
beds increased in number, consultants were assigned to tine remaining
service commands.
Manning tables contained no position vacancies for consultants, and
some service command surgeons were loath to accept new colonels and
lieutenant colonels
who would have to be absorbed in the rigidly fixed staff allotted to
the surgeon's office. Moreover, the concept of a consultant in
medicine, whether from a
military or a professional viewpoint was new and unattractive to some
service command surgeons.
Great patience and forbearance were required of some
of the eminent
physicians chosen to serve as consultants. Their response attests to
their tolerance and
devotion to duty. In rare instances, it was actually necessary to prove
to the surgeon of a service command that the consultant was not a
busybody,
troublemaker, or impractical reformer but a physician able to help the
surgeon provide optimum medical care and medical administration for the
patients under
his jurisdiction. To their credit, these consultants made themselves so
valuable in their commands that their subsequent placement in over-sea
theaters and with
the armies met with little or no obstruction and in some instances was
insisted upon by the surgeons concerned.
Service command, theater, and army consultants were
usually
recommended for thieir assignments by the Surgeon General on the advice
of his chief consultant
in medicine. They were judged to be eminently qualified to organize and
administer the mission entrusted to them. A loose, informal, unofficial
relationship
between the chief consultant and his associates in the field was the
only type possible, because of command boundaries. In such a large
undertaking,
decentralization was, in fact, desirable. It was the duty of the
consultant in the field so to relate himself to his command surgeon as
to insure implementation of
the policies of The Surgeon General and his chief consultant in
medicine for the care of medical patients. Once assigned, he was in
complete control of the
development of his mission and of procedures by which to carry it out
under the authority of the surgeon of the command. Inevitably, the
consultants' activities in
the various commands varied according to local circumstances.
The record attests to the efficiency and
effectiveness with which
the consultants related themselves to their missions. By precept and
example, formal and
informal talks and demonstrations, laborious and painstaking
indoctrination of military superiors and subordinates, amazing
industry, tact, patience, forbearance,
and ingenuity, they carried out their missions. In some instances,
regional- and subordinate-command consultants were appointed on the
recommendation of the
consultant in medicine to the command surgeon. An outstanding example
of this type of organization in the field existed in ETOUSA (European
Theater of
Operations, U.S. Army), under the direction of Col. William S.
Middleton, MC, Chief Consultant in Medicine, ETOUSA, and Maj. Gen. Paul
R. Hawley, Chief
Surgeon, ETOUSA.
From time to time, reassignments were made to carry
the experience
gained in one command over into another. Examples are to be found in the
7
assignments of the following medical consultants: Colonel Thomas who
was the first service command consultant appointed and who served in
the Fourth
Service Command and later in the Southwest Pacific Area; Lt. Col.
(later Col.) Herrman L. Blumgart, MC, who served in the Second Service
Command and
later in the India-Burma theater; Colonel Mason who served in the Ninth
Service Command and later in the Pacific Ocean Area; Lt. Col. (later
Col.) Roy H.
Turner, MC, who served in the Third Service Command, in the Surgeon
General's Office, and finally in the Southwest Pacific. There were
similar changes in the
assignments of Lt. Col. (later Col.) Walter B. Martin, MC; Lt. Col.
(later Col.) Irving S. Wright, MC; Lt. Col. (later Col.) F. Dennette
Adams, MC; Lt. Col.
(later Col.) Alexander Marble, MC; Lt. Col. (later Col.) Eugene C.
Eppinger, MC; Lt. Col. (later Col.) Garfield G. Duncan, MC; Lt. Col.
(later Col.) Benjamin
M. Baker, MC; Colonel Shull; and Lt. Col. Myles P. Baker, MC.
In addition to changes of assignments as part of a
long-term
program, devices used to disseminate professional information and to
meet specific local problems as
they arose included assignment of consultant from one command to
temporary duty in another, and sometimes exchanges between theaters
were arranged.
Temporary-duty assignments to the Surgeon General's Office were often
requested. For example, Colonel Marble and Colonel Duncan were assigned
to OTSG
to assist in preparing TB MED (War Department Technical Medical
Bulletin) 168, June 1945, entitled "Diabetes Mellitus," and TM (War
Departnient Technical
Manual) 8-500, March 1945, entitled "Hospital Diets," respectively.
Similarly, Col. Maurice C. Pincoffs, MC, and Col. Benjamin M. Baker
from the Pacific area,
and Lt. Col. (later Col.) Perrin H. Long, MC, from thie Mediterranean
theater, were assigned to the Surgeon General's Office to give
information and exchange
views with staff members on particular problems in their commands. An
unusual temporary-duty assignment was that of Colonel Bauer, who was
sent to Sweden
when the Swedish Government requested the U.S. Government to send an
Army internist to discuss with the Swedish medical profession advances
made in
medicine during Sweden's relative isolation because of the war.
Medical Corps officers who served as consultants in
medicine in
various commands are listed in appendix A (p. 829). Not all were
assigned on a full-time basis.
In certain of the smaller commands, an exceptionally well trained chief
of medical service in a hospital might also serve as consultant in
medicine for the
command. This dual role was not always a satisfactory substitute for
the full-time service of a professional consultant. The following
commands were served by
part-time consultants: Bermuda Base Command, Persian Gulf Service
Command, Middle East Service Command (formerly Delta Service Command),
mind U.S.
Army Forces in the South Atlantic (fig.3).
When the consultants were appointed, it was
anticipated that they
would use different approaches and techniques in their assignments.
Therefore, they were
selected with the greatest care possible. The fact that the consultants
held important posts in civilian medical education and practice added
9
FIGURE 3.-Continued. C. Headquarters,
Delta Service Command,
Heliopolis, Egypt, February 1943.
to the obligation and responsibility of The Surgeon General and his
representatives in selecting their assignments. The success of the
assignments was dependent
in large nneasure upon mutual understanding and trust between the
consultants and the Surgeon General's Office. The enviable record
attained by the Medical
Department in the field of internal medicine during the war and the
lasting appreciation of the men with whom they worked in the field are
convincing and
enduring testimonials to the medical consultants.
EVOLUTION OF MEDICAL CONSULTANTS DIVISION
Organization
The evolution of the Medical Consultants Division,
OTSG, was slow.
Reorganizations of the office, wholly or in part, were frequent. 2
As a
result, the actual
development of the organization of the chief consultant in medicine in
the Surgeon General's Office into a group adequate in number and with
sufficient support
to function properly did not take place until late in the war.
The Medicine Subdivision, Professional Service
Division, OTSG, was
created on 21 February 1942. The unit, headed by the chief consultant in
2 The reorganizations discussed in this section are
based on (1)
0ffice Orders, OTSG, U.S. Army, No. 87, 18 Apr. 1941, No. 340, 31 Mar.
1942; No. 444, 12
July 1943; No. 4, 1 Jan. 1944; and No. 175, 25 Aug. 1944; (2) Manual of
Organization and Standard Practices, OTSG, Army Service Forces, 15 Mar.
1944; and
(3) Organization Charts, OTSG, U.S. Army, 21 Feb. 1942, 26 Mar. 1942,
24 Aug. 1942, 10 July 1943, 3 Feb. 1944, and 24 Aug. 1944.
10
medicine, had to function under the Professional Service Division.
This arrangement was not satisfactory. Problems exclusively
professional in nature, such as
policies concerned with diagnosis and treatment, arose constantly as
the tempo of the war increased and the Army expanded. All
communications and
memorandums to or from the Medicine Subdivision relative to these
matters had to pass through the administrative channels of the
Professional Service Division
before reaching either The Surgeon General or other divisions of the
office. Although the officers of Professional Service Division were
cooperative and
sympathetic, the mechanics of this arrangement retarded decisions and
administrative actions.
On 26 March 1942, in a general reorganization of the
Surgeon
General's Office, the Professional Service Division became the
Professional Service, and the
Medicine Subdivision became the Medicine Division with an
organizational chart providing for branches in tropical diseases,
tuberculosis, general medicine, and
specialized medicine. These branches were not actually put into
operation, with qualified personnel assigned to them, until much
later.
Another general reorganization took place on
24
August 1942. Five
main services were created, including one designated Professional
Services. The Medicine
Division was redesignated Medicine Branch of the Medical Practice
Division, which in turn functioned as one of the divisions of
Professional Services. Medicine
Branch retained as sections its former branches, and Colonel Morgan
remained its chief, while continuing his duties as chief consultant in
medicine in the Surgeon
General's Office. On 4 November 1942, Col. Arden Freer, MC, who had
been Chief, Medical Service, Walter Reed General Hospital, Washington,
D.C., was
appointed Director, Medical Practice Division, OTSG. In spite of
Colonel Freer's consideration and understanding, this addition of still
another administrative
echelon was a further complication. Colonel Morgan repeatedly sought to
obtain for the Medicine Branch a position of greater independence, one
having more
direct approach to The Surgeon General and thus being better able to
meet promptly the pressing needs of the growing Army.
On 12 July 1943, Lt. Col. (later Col.) Esmond R.
Long, MC, who had
become Chief, Tuberculosis Section, Medicine Branch, and Chief
Consultant in
Tuberculosis to The Surgeon General, was appointed Chief, Medicine
Branch. This change was designed to give the chief consultant in
medicine in the Surgeon
General's Office greater freedom from routine administration and easier
access on professional matters to the chief of Professional Service and
to The Surgeon
General. General Morgan continued to initiate and direct the overall
policies of the Medicine Branch. On 1 January 1944, as part of another
general
reorganization, the Medicine Branch was designated the Medicine
Division, with General Morgan as director.
Finally, on 25 August 1944, the Professional Service
was dissolved,
and the Medicine Division was renamed Medical Consultants Division and
placed in an
independent status functioning directly under The Surgeon General. At
this time, the division was composed of four branches: General Medicine
11
Branch, Tuberculosis Branch, Tropical Disease Treatment Branch, and
Communicable Disease Treatment Branch, the last named having been
established in lieu
of the Specialized Medicine Branch. A final addition to the
organizational setup was the position for a consultant in dermatology,
which was filled in March
1945. With this structure and direct relationship to The Surgeon
General, the division continued its activities through V-E and V-J Days.
Thus, in order to carry out the mission of the chief
consultant in
medicine in the Surgeon General's Office, with the many routine
administrative responsibilities
which had been made a part of his mission, a staff which in the
beginning had consisted of two medical officers had been gradually
enlarged to six. It was clear at
the outset that the activities for which the chief consultant was held
responsible could be performed only by men specially trained in such
activities. As need
became urgent, trained men were usually found but not without delay or,
occasionally, out-and-out obstruction.
Obstructions can be explained to some extent by the
fact that
Services of Supply, under which the Medical Department operated,
controlled medical personnel
with an iron hand. The Surgeon General's Office was handicapped on many
occasions by edicts defining the exact personnel-allotment ceiling
under which its
operation had to be carried out and by the fact that these edicts
originated from an authority which, one is forced to conclude, was
often poorly informed if not
completely ignorant of the needs of the Office.
The Medical Consultants Division had more than its
share of
difficulties. For example, there was delay in excess of 6 months in
obtaining an officer thoroughly
familiar with tropical medicine, although the need for expert guidance
in this field had been long foreseen and repeatedly urged. Another
delay, in obtaining a
position vacancy for an officer to act as chief of a communicable
disease treatment branch, at one time threatened the very existence of
the Medical Consultants
Division as it was at that time constituted. In addition, one may cite
the extraordinary way in which the management of venereal disease
treatment was handled.
In the field, the treatment of venereal diseases,
with their high
noneffective rate, was an enormous problem and, because of the rapid
developments in therapy,
urgently required proper direction. The Venereal Disease Subcommittee
of the National Research Council was one of the most active, effective,
and important
organizations in contact with The Surgeon General. It became mandatory
that the Surgeon General's Office place the responsibility for the care
of venereal
diseases in the hands of those professional men best equipped to master
the new methods and techniques recommended to the Army by the Venereal
Disease
Subcommittee and guide these men in their application of the newer
knowledge as it became available. Colonel Morgan took the position that
the treatment of
venereal diseases was, in fact, a problem of internal medicine; that
the local treatment commonly employed at the time was harmful; and,
therefore, that the
responsibility for treatment should be given to medical rather than to
surgical (urological) experts. This position was readily agreed to by
Col. (later Brig. Gen.)
Fred W. Rankin, Chief
12
Consultant in Surgery to The Surgeon General, and in due time The
Surgeon General enunciated this as official policy. Nevertheless, it
was impossible to obtain
approval for the assignment of an officer who was a specialist in this
field. Since the Preventive Medicine Service, Office of the Surgeon
General, on the other
hand, had the personnel available, the Surgeon General, on the
recommendation of Colonel Morgan, in November 1942 created a venereal
disease treatment
section in the Venereal Disease Control Branch of the Preventive
Medicine Service,3 and throughout the remainder of the war
this clinical activity was
adnministered in that service.
Fortunately, Lt. Col. (later Col.) Thomas B. Turner,
MC, Director,
Venereal Disease Control Branch, OTSG, recognized that it would be
impossible for his field
representatives actually to supervise treatment. Most of the venereal
disease control officers had had public health training and little or
no clinical experience.
Therefore, the consultants in medicine in service commands, theaters,
and armies served as agents for implementation of venereal disease
treatment policy
enunciated by Colonel Turner and Colonel Morgan. The Medical
Consultants Division participated in all relevant activities, such as
publication of official policy
in War Department circulars and TB MED's; establishment of treatment
centers for neurosyphilis; clinical trials of various methods of
management of gonorrhea,
including duty-status treatment; and treatment of syphilis and
gonorrhea with penicillin. In the field, the medical consultants, in
their regular visits to Army
hospitals and other Medical Department installations, consulted on the
clinical management of venereal disease. Excellent Armywide liaison in
the important
functions of control and treatment existed between venereal disease
control officers and medical consultants, and the lowered noneffective
rate from venereal
disease achieved during World War II represented a triumph in military
medicine. Nevertheless, The Surgeon General's organization for the
supervision of
venereal disease treatment was a glaring example of administrative
inconsistency and improvisation (p.24).
These references to some of the organizational
difficulties which
General Morgan encountered in the Surgeon General's Office are not
cited in a spirit of criticism
of the Medical Department. They arose usually because of the position
of the Medical Department in relation to the Army as a whole. They were
the result of
restrictions and controls imposed upon The Surgeon General by higher
authority, which, often enough, was uninformed and unsympathetic. That
The Surgeon
General was held responsible for prevention and optimum treatment of
disease and injury in the Army but was not provided the authority with
which to carry out
this mission is an incontrovertible fact. It will be attested to by
experienced medical officers throughout Army. As a partial explanation
of this situation, suffice it
to say that the physician and surgeon, conditioned to professional and
social relation
3 (1) Memorandum, Brig. Gen. Charles C. Hillman for
The Surgeon
General. 3 Nov. 1942, subject: Additional Function for Venereal Disease
Control Branch.
(2) Office Order No. 466, OTSG, U.S. Army, 12 Nov.
1942, subject:
Venereal Disease Treatment Transfer Functions.
13
ships as they exist for the doctor in civilian life, often found the
military setting a trying one in which to practice their profession. In
fact, it can be said that the
Medical Department as a whole experienced similar difficulties in its
relationship to the Army which it served.
Personnel
The problem of personnel as part of the overall
problem of
organization has been indicated in broad outline as it existed in the
Surgeon General's Office and as it
was gradually resolved. It had been clear at the beginning that the
Medicine Subdivision, to function fully, required experts in several
medical specialties to
collect and collate information, outline policies in diagnosis and
treatment, initiate and supervise research, and aid in dissemination of
recently acquired
knowledge. As early as March 1942, a memorandum had been sent to the
Executive Officer, OTSG, stating the minimum requirement to be five
officers.
Nevertimeless, expansion of the staff and activities of the Medicine
Subdivision never kept pace with the expanding needs of the huge army
in training.
Tuberculosis Branch.-It was recognized
early by
General Hillman that tuberculosis was an extremely important problem
for
the Army despite careful screening
at induction centers. Therefore, Dr. Esmond R. Long, Director, Henry
Phipps Institute for the Study, Treatment and Prevention of
Tuberculosis, Professor of
Pathology, University of Pennsylvania, Philadelphia, Pa., and Chairman,
Subcommittee for Tuberculosis, Division of Medical Sciences, National
Research
Council, was asked to accept a commission in the Army, and on 1 July
1942, was assigned to the Professional Service Division, OTSG, as chief
of the
Tuberculosis Branch, Medicine Subdivision, with the rank of
lieutenant colonel. The Tuberculosis Branch was concerned with all
problems related to the
diagnosis, treatment, and disposition of military personnel with
tuberculosis. In a memorandum to The Surgeon General dated 13 July
1942, the urgent need for
an assistant to Colonel Long was outlined. None was assigned. Finally,
in October 1942, through an informal arrangement with the Army Medical
Center, Walter
Reed General Hospital, one of its medical officers, Capt. (later Lt.
Col.) William H. Stearns, MC, was placed on special duty in the
Tuberculosis Branch, OTSG,
while he was still assigned to the Center. It was not until 17 Marchi
1943 that Captain Stearns was officially assigned to the Surgeon
General's Office. Such
expedients were necessary because The Surgeon General lacked full
control in the management of medical personnel and was thus obliged to
operate under fixed
ceilings as to numbers and rank.
Tropical Disease Treatment Branch.-In the
Pacific
areas, many U.S. troops were certain to be exposed to various tropical
diseases. Although malaria was the
outstanding problem, other diseases common in time Tropics were
expected to affect significant numbers. On 21 July 1942, in a
memorandum to the Executive
Officer, Professional Service Division, OTSG, Colonel Morgan asked that
a specialist in the clinical aspects of tropical medicine be assigned
to the Medicine
Subdivision. No action was taken. On 2 November
15
1942, Colonel Freer, at Colonel Morgan's request, sent a memorandum
to General Hiliman requesting the assignment and outlining the reasons
for urgency. On
18 November, General Hillman repeated the request in a memorandum to
Time Surgeon General. No action was taken. Efforts to obtain
appointment of a
suitable officer were renewed on 5 February 1943, when war in the
Pacific was very active and malaria had become an enormous problem in
New Guinea. Urged
by General Morgan, Colonel Freer again wrote a memorandum requesting
the assignment of a specialist aid suggesting Dr. Francis R. Dieuaide,
then Clinical
Professor of Medicine, Harvard Medical School, Boston, Mass., and
formerly Professor of Medicine, Peking Union Medical College, Peking,
China. The request
was granted 8 months after its initiation, and, on 22 March 1943, Dr.
Dieuaide was finally commissioned lieutenant colonel and was assigned
to the Medical
Practice Division, OTSG, as chief of the Tropical Disease Section,
Medicine Branch.
There were now five officers assigned to the
Medicine Branch of the
Medical Practice Division. These were General Morgan, director; Colonel
Long,
Tuberculosis Section chief; Captain Stearns, assigned to the
Tuberculosis Section; Colonel Shull, General Medicine Section chief;
and Colonel Dieuaide, Tropical
Disease Treatment Section chief (fig. 4). On 1 January 1944, the
Medicine Branch was redesignated the Medicine Division of Professional
Services. When
Colonel Long became chief consultant in tuberculosis functioning
directly under the chief of Professional Services, Captain Stearns
became chief of the
Tuberculosis Branch. The other sections, now called branches, remained
unchanged.
Communicable Disease Treatment Branch.-When
Colonel Long left the Medicine Division, a numerical vacancy was
opened. To fill this vacancy General
Morgan proposed appointment of a chief of a communicable disease
treatment branch. On 2 February 1944, in a memorandum to The Surgeon
General, General
Morgan outlined the functions of such a branch and indicated the need
for it, mentioning the problems in relation to infectious hepatitis,
rheumatic fever,
gonococcal infections, and other communicable diseases. He named Col.
Roy H. Turner then Consultant in Medicine, Third Service Command, and
formerly
Associate Professor of Medicine, Tulane University Medical School, New
Orleans, La., as his choice to fill the position. No action was taken,
and on 28
February 1944, the recommendation was made again but was disapproved by
The Surgeon General. On 15 April 1944, another memorandum to The
Surgeon
General sought to have Colonel Turner assigned to the Medicine
Division. The request, at first refused, was finally approved on 19
April 1944, and Colonel
Turner was assigned as Chief, Communicable Disease Treatment Branch,
Medicine Division, OTSG, on 4 May 1944.4
Consultant in Dermatology.-Diseases
of the skin
were common throughout the Army, especially in the Tropics. In a
memorandum dated 29 November 1944,
General Morgan requested that a consultant in dermatology be assigned
4 Office Order No. 94, OTSG, U.S. Army, 4 May 1944,
subject: Chief,
Communicable Disease Treatment Branch Medicine Division.
16
to the Surgeon General's Office. This request was approved, and Maj.
(later Lt. Col.) Clarence S. Livingood, MC, (fig. 4) then assigned to
the 20th General
Hospital, located in Ledo, Burma, reported for duty in the Medical
Consultants Division, OTSG, on 30 March 1945.
The appointment of Major Livingood brought to six
the number of
officers assigned to the Medical Consultants Division. The number
remained the same until
demobilization began although several changes were necessitated by the
policy of making officers of the division available for oversea
assignments. Major
Stearns was released on 2 January 1945, to become chief of the medical
service of a numbered general hospital, and Capt. John S. Hunt, MC,
replaced him as
Tuberculosis Branch chief. Colonel Shull was released on 22 May 1945,
to become Consultant in Medicine, Sixth U.S. Army, then in the Pacific,
and was
replaced by Maj. (later Lt. Col.) Frederick T. Billings, Jr., MC, as
General Medicine Branch chief. Colonel Turner was released on 12 July
1945, to become
Consultant in Medicine to the Surgeon, Army Forces, Western Pacific,
and, later, Chief Consultant in Medicine to the Surgeon, U.S. Army
Forces, Pacific. He
was replaced by Colonel Eppinger as Communicable Disease Treatment
Branch chief. Colonel Dieuaide remained in the Medical Consultants
Division and
became its deputy director. He continued to serve as chief of the
Tropical Disease Branch.
CLASSIFICATION AND ASSIGNMENT OF PERSONNEL
Appropriate allocations of personnel with special
qualifications,
essential in maintaining high standards of medical care, required
familiarity with the requirements
of the position vacancies to be filled and accurate knowledge of the
qualifications of the men available. Early in the program, difficulty
was encountered in
assigning specialized personnel in Zone of Interior general hospitals,
which were under the direct control of The Surgeon General. It was also
difficult to assign
specialists to the service commands for reassignment to station
hospitals and other service conmmand installations.5 Thus
difficulty resulted from the apathy of
some officers in the Personnel Service, OTSG, in regard to
specialization in the practice of medicine. The Personnel Service was
engaged in the enormous job of
assigning general medical officers for the rapidly expanding Army.
Moreover, no standardized Armywide classification of medical officers
as to specialties
existed in early 1942, and no use was being made of a classification of
civilian internists furnished by civilian medical organizations.6
5 As soon as service command consultants were
appointed, the general
hospitals located in their command received from them as much attention
and
consultation and personnel management as the station hospitals. Efforts
were made to establish close liaison between the service command
consultant in medicine
and the Medical Consultants Division, OTSG, to maintain coordination
and integration in all matters, including the assignment of specialized
personnel.
6 Before the outbreak of World War H and as part of
preparation for
the emergency, the Committee on Medicine of the National Research
Council, in
cooperation with the American College of Physicians, provided The
Surgeon General of the Army with a carefully prepared list of the
internists in the United
States. This classification furnished a professional evaluation of each
person as to his potentialities for assignment as, ward officer,
section chief, assistant chief,
or chief of service. On his arrival in the Office of the Surgeon
General, Colonel Morgan procured this list from the files of the
Personnel Service. The Medical
Consultants Division and the Personnel Service also made extensive use
of it during the early months of the war.
17
Colonel Rankin and Colonel Morgan, in 1942, participated actively in
The Surgeon General's officer-procurement program. They visited
civilian medical society
meetings and insisted upon the careful, considered assignment, by The
Surgeon General, of the specialized personnel procured. These personnel
functions were
included in the duties of the chief consultants in the official
definition of the functions of the Medicine and Surgery Subdivisions,
as stated in Office Order No.
87, OTSG, U.S. Army, 18 April 1942. This order read in part as follows:
* * * approval, by liaison with the Military Personnel Division, of
selection of
personnel for key professional positions." Gradually, these personnel
functions gained the support of the Personnel Service. The fact became
recognized in the
Surgeon General's Office and, subsequently, in service commands and
theaters that only through control of specialized personnel could the
consultants perform
effectively the duties assigned them. Where this principle had the
wholehearted support of the surgeon of the command and of his personnel
officer, it yielded the
greatest returns in improved medical care.
The final acceptance by The Surgeon General of the
proposition that
the Medical and Surgical Consultants Divisions should cooperate with
the Personnel
Service in the assignment of all individuals with special
qualifications in their respective fields was basic to their success in
the Surgeon General's Office and
throughout the Army. Finally, the Personnel Service invited the Medical
and Surgical Consultants Divisions to cooperate in establishing a
classification based on
evaluation of professional qualifications. Out of the deliberations
which ensued, there developed, albeit belatedly, the method of placing
all medical officers
initially into 1 of 4 categories--A, B, C, and D--according to
arbitrarily defined standards of professional training and experience.
Subsequently, at appropriate
intervals, the classification of each officer was to be reviewed on the
basis of demonstrated ability in the Army.7 Because of
administrative difficulties, much time
was lost in instituting this method of professional evaluation.
Nevertheless, the adoption and use of the classification led to great
improvement in personnel
managenment during the latter part of the war. The consultants in
service commands and in oversea theaters were in an ideal position to
assume responsibility for
the continuing evaluation and reevaluation of medical officers to keep
the classifications current.
The responsibilities of the chief consultant in
medicine with regard
to appropriate assignments to position vacancies were defined and
accorded official
recognition in Office Order No. 175, OTSG, U.S. Army, dated 25 August
1944, which stated: "Assignments of key personnel will be made only
with the
concurrence of the appropriate Service or Division particularly
concerned with or possessing special knowledge as to the qualifications
of the officers and the
requirements of specialty assignments." The Surgeon General encouraged
the same attitude regarding the responsibilities of consultants in
medicine in service
7 TM 12-405, 30 Oct. 1943, Officer Classification;
Commissioned and
Warrant, Appendix B, Classification of Medical Corps Officers.
20
FIGURE 5.-Continued. E. 120th Station
Hospital at Tortworth Courts,
Falfield, Somerset, England. A castle is shown in the distance, 5
August 1943.
commands and in oversea theaters. The degree to which this
responsibility was given to the consultants in the various commands at
home and overseas varied
considerably. It is believed that the Medical Consultants Division,
OTSG, and the medical consultants in the field best served their
intended functions when they
were permitted to participate directly and in a detailed fashion in the
classification, evaluation, and duty asignment of the specialists in
internal medicine available
within their command. Experience in the war has shown that, wherever
the consultant was most active in this regard, the quality of medical
care was usually superior.
Tables of organization.-Early in
the emergency,
the Medical Consultants Division was not invited to take part in the
formulation or revision of tables of
allotment, as the Division was concerned with specialists in internal
medicine. Gradually, however, as the value of the Division's
contributions to personnel
management in internal medicine became recognized, consultation and
advice regarding the quantitative need for specialists in the varied
types of Medical
Department organizations were requested.
In retrospect, it is clear that the allotment of
officer personnel
for medical installations of World War II placed too much emphasis upon
the need for internists in
the fixed hospitals, especially the general hospitals in the Zone of
Interior, and too little emphasis upon needs of station hospitals in
the Zone of
21
Interior and in mobile units in theaters of operations. The Medical
Consultants Division held that the most important contribution of
internal medicine, in terms of
maintaining the effective strength of the Army, was the successful
treatment and prompt return to active duty of the acutely ill patient.
In theaters of operations,
these patients normally received their initial definitive treatment in
station, field, and evacuation hospitals. This fact was not given
proper consideration in the
staffing of these hospitals. Station hospitals in the Zone of Interior
and mobile and fixed hospitals overseas that cared for actually ill
patients should have received
a larger number of well-trained internists (fig.5). In time, this
mistake was corrected in large measure in the station hospitals of the
Zone of Interior. However,
overseas, particularly in the Pacific areas, the tables of organization
were adhered to. Late in the war, the resulting deficiencies were in
process of being
corrected by local arrangement in sonic evacuation and field hospitals.
CLINICAL SERVICES IN ARMY HOSPITALS
Organization of the Medical Service
At the beginning of the emergency, it was generally
believed that
the organization of professional services conventionally employed in
civilian hospitals would
function effectively in Army hospitals. The major services of medicine
and surgery were outlined in TM8-260, Fixed Hospitals of the Medical
Department
(General and Station Hospitals), dated 16 July 1941. The medical
service of large hospitals contained sections for general medicine,
communicable diseases,
gastrointestinal diseases, cardiovascular diseases (fig. 6) and
neuropsychiatry. Later, the section for venereal diseases was assigned
to the medical service. These
sections were commonly housed in separate wards and headed by medical
officers, who were designated chiefs, serving under the direction of
the chief of the
medical service. In addition, separate sections had to be maintained
for officers and for enlisted men, in accordance with Army customs, and
for women.
Experience indicated the desirability of a section for dermatology,
although one was not provided for in the organizational chart in TM
8-260. The Medical
Consultants Division, OTSG, attempted to provide for the selection and
assignment of personnel qualified to function in hospital staffs so
organized.
As a rule, neuropsychiatry was organized as a
section of the medical
service in Army hospitals in the early part of the war (fig.7). As the
Army grew and
neuropsychiatric conditions increasingly contributed to the
noneffective rate, the Neuropsychiatry Consultants Division, OTSG, felt
that the establishment of
separate neuropsychiatric services in Army hospitals, identical in
status with medical and surgical services, should be considered. This
separation was effected in
some of the large general hospitals in the Zone of interior, and these
hospitals became specially designated for the care of neuropsychiatric
patients. However, for
the most part, neuropsychiatry sections remained a
22
FIGURE 6.-Cardiac clinic, Lawson
General
Hospital, Atlanta, Ga.,
July 1942.
FIGURE 7.-Patient on neuropsychiatry ward, Percy Jones General Hospital, Battle Creek, Mich.
23
FIGURE 8.-Scene on ward at neurology
center, Ashburn General
Hospital, McKinney, Tex
part of the medical service in Army hospitals. The Medical and the
Neuropsychiatry Consultant Divisions, OTSG, and the consultants in the
field were in
complete agreement that the care of patients with somatic and psychic
disturbances was the common responsibility of internist and
psychiatrist and that the
closest cooperation was indicated. Neurologic diseases were officially
designated the responsibility of the neuropsychiatrists, and, in a few
hospitals designated as
neurology centers, separate and independent services were established
(fig. 8). In general, however, cooperation between the internist and
the neurologist was
considered so essential to proper treatment as to discourage
organizational trends to separate them.
Management of Diseases
The treatment of diseases in Army hospitals was under continuous scrutiny by the Medical Consultants Division, OTSG. Publications based on the best available knowledge concerning the management of various diseases were prepared in the division for publication and prompt distribution. Their effect upon practice was immediate and Army wide. Only two examples will be cited.
24
The time-honored and often complicated schedules of
therapy for
malaria were replaced with more simple regimes, after careful
evaluation of the results of
controlled experiments.8 In the management of gonorrhea,
evidence of the existence of sulfonamide-resistant gonococci led, in
July 1942, to the employment of
artificially induced fever combined with sulfonamides.9 This
treatment, however, though satisfactory in many instances, was
accompanied by appreciable danger
and was abandoned in February 1944 in favor of penicillin, 10
which had
been shown to be highly effective. These radical changes in the
treatment of two
important diseases were brought about promptly throughout the entire
hospital system of the Army. Policy governing these and many other
therapeutic
procedures was formulated in the Medical Consultants Division. The
medical consultants throughout the Army supervised implementation of
the policy.
Diphtheria.-In the Pacific, it was
observed that
a disturbance involving the peripimeral nerves frequently occurred in
the presence of certain persistent
ulcerations of the skin. Diphtheria bacilli were suspected, and careful
bacteriological studies proved them to be inhabitants of these
ulcerations. These and similar
observations from the India-Burma theater shed new light upon the
diagnostic criteria, clinical course, and therapeutic management of
cutaneous diphtheria. The
Medical Consultants Division, OTSG, prepared a comprehensive discussion
of this subject for distribution to officers throughout the Medical
Corps.11
Hepatitis.-Clinical and laboratory studies, carried out in the Army and among civilians, made it possible, in November 1945, to publish TB MED 206, Infectious Hepatitis, which contained an evaluation of the clinical criteria and laboratory procedures used in the diagnosis and management of this disease.
Tropical diseases.-Descriptions of the clinical features, laboratory findings, and therapeutic management of many clinical disorders encountered in the Army, particularly in the field of tropical disease, resulted from observations which were correlated under the guidance of the Medical Consultants Division.
Venereal diseases.-General
Morgan's opinion
regarding the management of venereal diseases in the Army led to an
important and difficult policy decision on
the part of The Surgeon General. In the peacetime Army, as in civilian
practice, the care of venereal diseases, especially gonorrhea, was
assigned to the urologist.
In gonorrhea, the conventional procedures were urethral
_
8 Circular Letter No. 153, OTSG, U.S. Army, 19 Aug.
1943, subject:
The Drug Treatment of Malaria, Suppressive and Clinical.
9 (1) Circular Letter No. 74, OTSG, U.S. Army, 25 July 1942,
subject: Diagnosis and Treatment of the Venereal Diseases. (2) Circular
Letter No. 86, OTSG,
U.S. Army, 15 Aug. 1942, subject: Fever Therapy in the Treatment of
Gonorrhea. (3) Circular Letter No. 97, OTSG, U.S. Army, 12 May 1943,
subject: The
Use of Combined Fever and Chemotherapy in Sulfonamide Resistant
Gonorrhea; and General Consideration on the Therapeutic Use of
Physically Induced Fever.
10(1) TB MED 9, 12 Feb. 1944, subject: Penicillin.
(2) TB MED 16, 6
Mar. 1944, subject: Penicillin Treatment of Resistant Gonorrhea.
11 TB MED 143, February 1945, subject: Cutaneous Diphtheria.
25
irrigations, the frequent use of prostatic massage, urethral sounds,
and bladder irrigations. Genitourinary wards equipped with batteries of
specially designed
irrigation commodes were provided as standard equipment for hospitals.
All of this was outmoded when it was found that sulfonamides by mouth
promptly cured
gonorrhea in the vast majority of cases and that local irrigations and
manipulations caused the complications which plagued therapists and
enormously increased
the noneffective rate in the Army by increasing the duration of the
disease. These revolutionary developments made it quite clear that
gonorrhea, as well as the
other venereal infections, should become the responsibility of
physicians rather than of surgeons. Recommendations to this end by the
chief consultant in
medicine were received without enthusiasm in many quarters. It appeared
to be especially difficult for Regular Army officers, whose experience
with gonorrhea
and its complications had been long and dismal, to accept the new
doctrine. It was pronmptly accepted by the Surgical Consultants
Division. The official
announcement of policy by The Surgeon General came only after the loss
of much time.12 The remarkable effectiveness of the
sulfonamides in treatment of acute
gonorrhea and the disappearance of complications when local treatments
were abandoned soon became apparent to all. Here, indeed, was arm
extraordinary
episode in the history of military medicine. No other development
during the war contributed so significantly toward lowering the
ineffective rate.
Drugs
The selection and distribution of new drugs and of
new preparations
of old drugs for use by the Medical Department was an important
function of the Medical
Consultants Division. The drug list in the Medical Department Supply
Catalog, U.S. Army, was reviewed frequently. The division actively
participated in
planning and observing clinical trials of many drugs, notably
penicillin, the production and clinical use of which were in the
experimental stage.13 in the selection
of a therapeutic agent for use in Medical Department installations, the
fullest consideration was given not only to its efficacy but also to
the dangers involved in
its use. Treatment with proprietary preparations which were not on the
Medical Department Supply List was discouraged. The Surgeon General,
upon
recommendation of the Medical Consultants Division, established policy
prohibiting the use of drugs not included in the Army Service Forces
Medical Supply
Catalog, the United States Pharmacopoeia, or the National Formulary, or
accepted by the Council on Pharmacy and Chemistry of the American
Medical
Association or the Council on Dental Therapeutics of the American
Dental Association, unless prior approval of The Surgeon General or the
appropriate theater
surgeon was obtained.14
_
12 (1) Circular letter No.195, OTSG, U.S. Army, 1
Dec. 1945,
subject: Treatment of Venereal Disease in Army Hospitals. (2) TM 8-262,
1 July 1945, ch. 1,
sec. 21, Medical Service.
13 (1) See footnote 10, p.24. (2) TB MED's 106, 11 Oct.
1944; 196,
20 Aug. 1945; 198, 20 Aug. 1945; and 172, June 1945.
14 (1) War Department Circular No. 321, August 1944,
sec. II, Use of
Medicinal Agents. (2) War Department Circular No. 264, 1 Sept. 1945.
sec. VII, Use of
Medicinal Agents.
26
Chest Examinations
Roentgenographic examination of the chest of every
inductee was
essential during mobilization, for the protection both of the
individual and the military service.
Examinations with the conventional 14- by 17-inch X-ray film were
cumbersome, time consuming, and expensive. Civilian equipment and
personmnel were
frequently employed, sometimes at great expense. The Medical
Consultants Division, through Colonel Long, Chief, Tuberculosis Branch,
was instrumental in
establishing photoroentgen units using 4- by 5-inch film in all
induction stations. It thus became possible to make routine chest X-ray
examinations without
burdening local civilian X-ray facilities and with great financial
saving to the Government.
Clinical Laboratories
The Medical Consultants Division, OTSG, had only an
indirect part in
the establishment and organization of clinical laboratories in Army
hospitals. The
Preventive Medicine Service, OTSG, was charged with thus
responsibility. Although in the Surgeon General's Office the
relationship with the Laboratories
Division of the Preventive Medicine Service was always one of
cooperation, difficulties resulted here and in the field because of
administrative separation. The
experience of World War II leads to the conclusion that a more direct
participation in the planning and supervision of laboratory work by the
Medical
Consultants Division and by the clinicians assigned to the medical
service of hospitals would be helpful to the actual operation of
clinical laboratories in the field.
The evaluation of routine and special laboratory procedures in Army
hospitals or in special laboratories in support of Army hospitals is
believed to be, to a large
extent, although not exclusively, the function of the clinician for
whose assistance the laboratory, in large part, exists. In the service
commands and in oversea
theaters, consultants in medicine interested themselves directly in the
maintenance of high standards in the clinical laboratories (fig. 9).
Thus was beneficial both
to the laboratory and to the medical service.
The appropriate use of laboratory procedures by
medical officers was
the subject of special interest both to the Medical Consultants
Division and to the medical
consultants in the field.15
Convalescence and Reconditioning
The Medical Consultants Division, OTSG, took an
early and continuing
interest in measures designed to shorten the hospital stay for the sick
and at the same
time to return the soldier to duty in the best possible condition. The
great number of patients who were hospitalized with minor illnesses and
the length of time
they spent in hospitals contributed heavily to the non-
15 Circular Letter No. 193, OTSG, U.S. Army, 30 Nov.
1943, subject:
Elimination of Unnecessary Laboratory Work.
27
effective rate. Soldiers had to remain in hospitals until they were
fit for full duty. In 1942, there was no organized effort in hospitals
to utilize time available in the
convalescence phase of illness to improve the soldiers' physical status
and morale prior to his return to duty. The Medicine Division took the
initiative in this
matter. Through visits to the field and informal correspondence, an
effort was made to develop a program to shorten the time spent in
convalescence and to
make better use of this time (fig. 10). As a result, War Department
Memorandum W40-6-43 of 11 February 1943, entitled "Convalescence and
Reconditioning in
Hospitals," was published; thus memorandum marked the official
initiation of a definite program for the rapid and complete
rehabilitation of the disabled soldier.
Although the program was far from satisfactory, it terminated the
attitude of indifference toward the matter. The service command
consultants in medicine
encouraged and, in many instances, helped initiate reconditioning
programs in hospitals under their professional supervision. In late
1942, General Morgan and
Brig. Gen. (later Maj. Gen.) David N. W. Grant, the Air Surgeon,
conferred informally with Maj. (later Col.) Howard A. Rusk, MC, Chief
of the Medical
Service, Army Air Force Station Hospital, Jefferson Barracks, Mo., on
the subject of convalescence and rehabilitation. Major Rusk promptly
organized a
reconditioning program at the Jefferson Barracks Station Hospital and
put it into operation. This marked the beginning of the extraordinarily
effective program
developed by Major Rusk for all Air Force medical units. Subsequently,
greatly stimulated by this successful program in Air Force hospitals,
The Surgeon
General established a reconditioning division to administer such
programs.
ADMINISTRATIVE AND CLINICAL ADVANCES DURING
WORLD WAR II
At the close of the war in 1945, the Director,
Historical Division,
OTSG, U.S. Army, requested the Medical Consultants Division to provide
in outline a
statement of general advances in medical treatment during World War II.
The following comments are taken from the reply to this request. They
are presented
without editing and represent attitude and opinion as of 24 September
1945.
1.Effective
utilization and
supervision of specially qualified
medical personnel.-Largely through the services of a small group
of
expert consultants in The
Surgeon General's Office, Service Command Headquarters, and Theater
Headquarters, the varied specialized skills of medical officers have
been effectively used
and supervised both in the United States and overseas. A system of
hospitals has been created with selected staff and equipment for the
treatment of special
military medical problems. In general, professional care has been
standardized at a high level. The results are reflected in shortened
periods of hospitalization and
reduced fatality rates. Days lost because of disease averaged 13 for
1942-44, against 18 days for 1917-19. Deaths from disease were 0.6 per
1,000 cases in
1942-44, against 15.6 per 1,000 cases in 1917-19.
31
2. Effective
development of sulfonamides and penicillin as
chemotherapeutic agents-The application of penicillin was
developed
in a small fraction of the time
that would have been required in peacetime. The success of the use of
sulfonamides and penicillin is reflected in periods of hospitalization
and low fatality rates
for many infections, specific examples of which are given below:
a.Meningococcus
infections, including meningitis and septicemia.-Sulfadiazine
was proved to be an extremely effective treatment, far
superior to any previous
method, even in extremely severe cases which occurred in large numbers
at various times during the war. Later, penicillin was shown to be
almost equally
effective. The case fatality rate in World War II was approximately 4
percent (to be compared with 38 percent in World War I).
b.
Bacillary dysentery.-Sulfaguanidine, the drug of choice at the
start of the war, was replaced by sulfadiazine which was found to be
the most effective
treatment available. Although a great many cases occurred, the case
fatality rate in World War II was about 0.05 percent, whereas in World
War I it was 1.6
percent.
c. Pneumonia-The
types of pneumonia which occurred in the two
World Wars differed to a considerable extent. Nevertheless, it is
noteworthy that the case
fatality rate in World War II was 0.7 per cent, as against 28 per cent
in World War I.
d. Acute
upper respiratory infection.-It was shown that in the
presence of an epidemic of this disease the daily administration of
small doses of sulfadiazine
decreases materially the incidence of complications which are commonly
associated with colds and which are usually due to streptococcus
invasions. As a
corollary, it was found that certain types of streptococci become
resistant to sulfadiazine.
e. Venereal
diseases.-The use of penicillin has revolutionized the
treatment of gonorrhea and syphilis. Days lost by soldier patients
because of gonorrhea in 1944
averaged 7, whereas the average in 1939 was 42.
f. Skin
diseases due to bacterial agents.-Medical Department
studies have shown that various methods of using penicillin greatly
improved the treatment of
many of these infections, especially impetigo, furunculosis, and
ecthymatous ulceration.
3. Streptomycin.-This
recently discovered drug is still under
study. It has already been shown, however, to be effective in certain
diseases that are resistant to
treatment with other agents, notably certain otherwise intractable
infections of the urinary bladder.
4. Effective
treatment of malarial attacks.-Largely through the
application of improved methods of using Atabrine (quinacrine
hydrochloride) and by the prompt
institution of treatment, malarial attacks have not caused chronic
physical disability and deaths from malaria in 1943 and 1944 amounted
to only 180, although
there were recorded about 320,000 attacks (0.06 deaths per 100
admissions). In 1917 - 19 there were 36 deaths due to malaria among
15,600 admissions for
malaria (0.02 deaths per 100 admissions).
5.Higher
fatty acids in the treatment of certain superficial fungus
infections.-It has been shown that preparations of undecylenic
acid
and propionic acid are both
effective drugs in the treatment of troublesome superficial fungus
infections, including "athlete's foot." In addition, these agents cause
many fewer sensitivity
reactions than drugs formerly in use.
6. Podophyllum.-Just
before World War II began civilian physicians
found that podophyllum was effective in the treatment of verrucae of
the genitalia. During
the war medical officers confirmed this finding, obtaining spectacular
results in the treatment of this condition.
7. Advances
in knowledge of the course and general management of
important diseases.-In a number of instances important advances
were
made in the
knowledge of the course of serious but poorly known diseases and at the
same time the general management of patients with these diseases was
greatly
improved, although in these instances effective specific
chemotherapeutic agents are not now available. The following instances
deserve special mention.
a. Infectious hepatitis.-Important advances were made in the diagnosis and prognosis. Much new information was obtained concerning the significance of numerous
32
tests of liver function. Early and prolonged rest in bed and
dietary
management, especially the use of high protein feedings, were shown to
be the more important
available methods of treatment.
b. Filariasis.-Experience
to date has shown that infection of
soldiers when limited in duration by prompt evacuation to nonendemic
areas is rarely, if ever,
followed by permanent disability or significant lasting bodily changes.
Psychological management and reconditioning are important aspects of
treatment.
c. Schistosomiasis.-Late in the
war, a number of soldiers
contracted this little known disease in the Philippines. Much has been
learned about the course of the
infection. The drug treatment is still a matter of research.
d.
Coccidioidomycosis.-As a result of the infection with this
disease of many soldiers in the western part of the United States, a
great deal has been learned
about its course and management.
e. Skin diseases
associated with the tropics.-Soldiers in various
parts of the tropics have acquired cutaneous diphtheria, cutaneous
leishmaniasis, atypical lichen
planus, and generalized hyperhidrosis. Such conditions were previously
little understood, especially in the United States.
8. Convalescence.-The importance of
systematic management of
convalescence was stressed early in the war and methods of proper
management were developed.
SPECIALIZATION IN ZONE OF INTERIOR HOSPITALS
In the United States, the trend toward
specialization 16 in medical
practice was very strong, long before World War II. It was carried over
into the Army by
The Surgeon General with the assignment of medical and surgical
specialists to supervise the care of the seriously ill and injured
soldiers and to assist programs
of prevention.
The framework for the assignment of individuals in
the various
specialties and subspecialties of internal medicine was, for the most
part, already established in the
organization of the medical services of Army hospitals at the outbreak
of World War II. Of course, nothing of the sort was feasible or
desirable in the assignment
of medical officers to troops in the field, where general practice was
the order of the day.
In addition to the policy of assigning specialists,
whenever
possible, where they could work in their respective fields, there
developed, during the war, the use of
hospitals especially manned and equipped to deal with certain
16 Documents which implemented the Medical
Department's policy of
specialization during World War II, as discussed in this section, are
(1) War Department
Army Regulations 40-600, 6 Oct. 1942, pars, 7b and 13; (2) War
Department Memorandum W40-14-43, 28 May 1943, subject: General
Hospitals Designated
for Special Surgical Treatment; (3) Letter, Headquarters, Army Service
Forces to Commanding Generals, All Service Commands and Commanding
Generals
Military District of Washington, 17 Dec. 1943, subject: General
Hospitals Designated for Specialized Treatment; (4) Letter, Medicine
Division, OTSG, to
Surgeons, All Service Commands, 7 Aug. 1944, subject: New Overall
Hospitalization Plan as It Affects the Medical Services of Hospitals;
(5) Memorandum,
Brig. Gen. Hugh J. Morgan for The Surgeon General, 11 Nov. 1943,
subject: The Treatment of Malaria; (6) Memorandum, Medicine Division
for Chief,
Operations Service, 18 Mar. 1944. subject: General Hospitals Designated
for Specialized Treatment; (7) Memorandum, Brig. Gen. Hugh J. Morgan
for Chief,
Operations Service, 29 May 1944, subject: Recommendation for the
Designation of a General Hospital for Specialized Treatment of Tropical
Diseases; (8)
Memorandum, Maj. Clarence S. Livingood, MC, for Brig. Gen. Hugh J.
Morgan, 23 June 1945, subject: Hospitalization of Dermatologic
Patients; (9)
Memorandum, Director, Resources Analysis Division for Medical
Regulating Officer, 26 July 1945, subject: Revision in Authorized
Patient Capicities; (10) War
Department Circular No. 347, 25 Aug. 1944, subject: General
Hospital-Designated for Specialized Treatment; and (11) Army Service
Forces Circular No. 456,
pt. II, 29 Dec. 1945, subject: Hospital Establishment of specialized
Center for Tuberculosis at Moore General Hospital
33
diseases or groups of diseases. The concentration of large numbers
of patients with similar disorders in these hospitals--designated
"centers" for special
treatment--favored optimum care for the sick soldier, while it assured
more economical use of highly specialized medical officers and gave
them an opportunity
for intensive clinical experience. Carefully planned clinical studies,
including the trial of approved therapeutic measures, were possible in
a few selected medical installations.
The Medical Consultants Division, OTSG, recommended
the designation
of certain hospitals as centers for tuberculosis, arthritis, vascular
diseases,
neurosyphilis, tropical diseases, rheumatic fever, and dermatological
diseases, and for the cure of general medical problems in patients
evacuated from overseas
late in the war under the special designation of "medicine." The
developments leading to this designation are discussed in the following
paragraph.
General medicine.-In all theaters, during
1944,
there was increasing need for Medical Corps officers qualified in
internal medicine. At this time, it was difficult
to provide full staffs for the medical services in 59 general hospitals
operating in the Zone of Interior. However, a survey indicated that
provision had been made
in these hospitals for a large number of medical patients that were
being sent to them either from station hospitals in the Zone of
Interior or from overseas. On
the other hand, beds for surgical patients were in short supply. It was
proposed that the number of general hospitals receiving medical
patients in the Zone of
Interior be reduced. A full staff of internists would be provided each
hospital designated to receive medical patients. A smaller but adequate
number of qualified
internists would be assigned to each of the remaining hospitals, in
which the surgical services would expand as the medical service
contracted. The purpose and
details of this plan were explained by General Morgan in letters to
each service command surgeon on 7 August 1944. The official designation
of certain hospitals
simply as specialty centers for medicine was announced in August 1944
(fig.11). Objections were voiced from time to time because of the
limited number of
specialists in internal medicine allotted to hospitals not so
designated. However, it is believed that this redistribution of
patients and specialists met the overall
problem by providing superior care in internal medicine in general
hospitals at home, while it made available specialists to the oversea
theaters where they were
badly needed.
Tuberculosis.-The peacetime Army had for many years maintained a center for the care of tuberculous patients at Fitzsimons General Hospital, Denver, Col. (fig.12). This designation was continued throughout the war. The numerical increase in patients from the greatly enlarged Army and the prolonged period of hospitalization required for treatment made additional beds necessary. In August 1944, Bruns General Hospital, Santa Fe, N. Mex., was designated a tuberculosis center, and its medical staff was supplemented with officers specially qualified in this field. In December 1945, Moore General Hospital, Swannanoa, N. C. (fig.13), was similarly designated and manned.
35
FIGURE 12.-Fitzsimons General Hospital,
Denver, Colo.
Arthritis.-Before World War II, the Army
had
utilized the special physiotherapy facilities of Army and Navy General
Hospital, Hot Springs, Ark., for the care
of patients with rheumatic diseases. This hospital was officially
designated an arthritis center in December 1943. However, in both the
Zone of Interior and
various theaters of operations, there were found large numbers of
arthritic patients requiring specialized therapy and prolonged periods
of hospitalization
(fig.14). To provide additional beds and a better opportunity to
evaluate methods of treatment and disposition, a second arthritis
center was established at
Ashburn General Hospital, McKinney, Tex.
Vascular diseases.-The initial
designation of
hospitals in the United States for the treatment of vascular diseases
was made in December 1943, on the
recommendation of the Surgical Consultants Division, OTSG. However,
many patients seen at these centers required medical rather than
surgical management.
Therefore, internists with special interest and experience in vascular
disorders were found and assigned to these hospitals early in 1944, and
the official
designation was changed from "vascular-surgery centers" to "vascular
centers." Here, on the medicine services, clinical investigation of a
high order was carried
out in relation to trenchfoot, immersion foot, and frostbite. Optimum
methods of treatment and disposition were defined. Physicians with
special knowledge of
the physiology of the circulatory system cooperated closely with
surgeons of similar training and interest, to the great advantage of
both.
Neurosyphilis.-By the spring of 1944, the number of patients with manifestations of neurosyphilis had begun to mount considerably. It was difficult to assure uniform and optimum management when patients were admitted
36
FIGURE 13.- Moore General
hospital, Swannanoa, N.C.
37
FIGURE 14.-Therapy used in treatment of
arthritic patients. A. Creeper
device used to develop range of motion. B. Arthritic patient in pool
working upper
arms while attendant gives proper exercise to lower limbs
38
indiscriminately to any of the Army general hospitals. Therefore, in
June 1944, seven general hospitals located conveniently throughout the
Zone of Interior
were specially staffed and designated for care of neurosyphilis
patients.
Rheumatic fever.-Two needs--one for uniform
management of patients with rheumatic fever in a favorable climate, the
other for increased knowledge
regarding all aspects of the disease--suggested the establishment of
specially staffed centers. However, air transportation of acutely ill
rheumatic fever patients
created special problems. Again, plans to coordinate clinical st udies with similar studies carried on
in hospitals under the direct supervision of the Air Surgeon were
difficult to administer. Discussions begun in the early spring of
1944 did not produce the actual designation of hospitals until August 1
944, when the establishment of three rheumatic fever centers was
announced. These
were Foster General Hospital, Jackson, Miss., Birmingham General
Hospital, Van Nuys, Calif., and Torney General Hospital, Palm Springs,
Calif.
Tropical diseases.-Clinical problems in
tropical diseases were difficult and numerous. In particular, reliable
information regarding prognosis and optimum
treatment was lacking for malaria, filariasis, and schistosomiasis. The
Medical Consultants Division, OTSG, recommended early in 1943 the
establishment of
centers, both in the United States and overseas, for the observation,
study, and special treatment of patients with tropical diseases. Since
at that time malaria
was the only tropical disease occurring with troublesome frequency and
since higher authority in the Surgeon General's Office was
unsympathetic to the
project, no action was taken. On 11 November 1 943, the establishment
of a number of malaria treatment study units, both in the United States
and overseas,
was again recommended. The Surgeon General responded to this request by
establishing, on 15 November 1943, the Board for Study of the Clinical
Treatment
of Malaria (p.50). This board used four general hospitals in the United
States and studied the relative value of eight different plans of
treatment. One definite
conclusion arrived at was that Plasmochin naphthoate (pamaquine
naphthoate) did not cure malaria caused by infections from Plasmodium
vivax.
Believing that special study and special treatment
facilities for tropical diseases were, in fact, mandatory, the Medical
Consultants Division again
recommended, on 29 May 1944, that at least one center be established
and in this connection cited a simple administrative problem. At about
that time, it had
become necessary to make provision in one hospital for a large number
of filariasis patients returning from overseas. The administrative
requirement carried
weight, and, on 25 August 1944, Moore General Hospital was finally
designated a tropical disease center. Highly qualified clinical and
laboratory staffs were
assembled. Eventually, studies of filariasis, malaria, tropical skin
diseases, schistosomiasis, and leishmaniasis were carried out under the
direction of Maj.
Harry Most, MC, chief of the tropical disease section Lt. Col. (later
Col.) Joseph M. Hayman, Jr., MC, chief of the medical service, and Lt.
Col. (later Col.)
Frank W. Wilson, MC, commanding officer.
39
Harmon General Hospital, Longview, Tex., had been
selected by The Surgeon General's board on malaria in 1943 to try 1 of
its 8 plans for treatment. After
The Surgeon General's board filed its final report on the treatment of
malaria on 26 March 1944, 4 months and 11 days after its organization,
the malaria
studies were taken over, continued, and expanded by the staff in
medicine at Harmon General Hospital. Finally, in April 1945, Harmon
also was designated a
tropical disease center. The contributions of this hospital ex tended
over a period of 2 ½ years and were of great value in connection
with malaria, filariasis,
schistosomiasis, and tropical skin disorders. Those chiefly responsible
for this work were Maj. (later Lt. Col.) Harry H. Gordon, MC, chief of
the tropical
disease section; Colonel Marble and Lt. Col. (later Col.) Worth B.
Daniels, MC, successively chiefs of the medical service; and Col.
Gouverneur V. Emerson,
MC, commanding officer.
Dermatologic conditions.-In the spring of 1945, after a careful survey of the problem in general hospitals in this country, Major Livingood of the Medical Consultants Division recommended that the management of patients with dermatological conditions be concentrated in seven general hospitals, where the small number of specialists then available could more adequately care for them. In a memorandum of 23 June 1945, this plan was described by Major Livingood, and it was officially adopted on 26 July 1945.
The results which accrued from the use of hospitals designated as special centers for the care of certain diseases or groups of diseases were impressive. The centers provided good patient care, efficient use of limited personnel with specialty qualifications, opportunities for clinical investigation, specialized programs for convalescent care and rehabilitation, and opportunities to plan the ultimate disposition of certain large groups of patients. It is clear in retrospect that the establishment of these centers earlier in the emergency would have been wise administration.
EXCHANGE OF PROFESSIONAL INFORMATION
A major interest of the Medical Consultants Division, OTSG, was the collection and dissemination of professional information throughout the Medical Department, particularly information concerned with recent advances in medical knowledge and techniques and with the development of new approaches based upon observations and study in the field. The Medical Consultants Division, in the highest echelon of the Medical Department, was strategically situated to encourage and direct this activity.
Early in the development of the Medical Consultants Division, a great deal of time was devoted to the study and manipulation of channels of communication through which important medical information could flow from field to headquarters. With the establishment of consultants in the service commands and oversea theaters, the interchange of professional news and opinion became a compelling necessity. The difficulties resulting from rigid adherence to command channels during the early days of the war were of such magnitude
40
and importance that they should be mentioned. Those difficulties were
not confined solely to prohibitions issued by officers of the line
against the transmission
of medical intelligence. Certain service command and theater surgeons,
either of their own volition or because of orders from higher
authority, forbade the
forwarding of technical information by the service command or theater
medical consultant to the chief consultant in the Surgeon General's
Office. The
conclusion is inescapable that much of the difficulty regarding
interchange of technical information which characterized the early
period of the war could have
been avoided had line and medical officers alike adopted a sane
commonsense attitude toward the interpretation of directives dealing
with command channels
and military security.
Reports, correspondence, and meetings.-The ETMD (Essential Technical Medical Data) reports initiated by the Medical Department in 1943 helped greatly to facilitate the interchange of professional news and opinion. These reports, gathered in the major oversea headquarters, contained data concerning the incidence and management of disease in the various subordinate units; the satisfactoriness of treatment agents, equipment, and supplies and the availability of qualified professional personnel. Though far from adequate for the needs of the Medical Consultants Division, these ETMD reports furnished one medium at least through which professional information could be exchanged between personnel in oversea theaters and the Zone of Interior.
Service command medical consultants in the Zone of Interior usually forwarded to the Medical Consultants Division carefully prepared reports of visits which they made to each medical installation within their command. These formal reports were frequently supplemented by personal correspondence. The service command consultants were encouraged to communicate freely when they felt that the Division could give assistance or that the Surgeon General's Office or the medical installations in other commands should be informed concerning professional matters. These personal letters permitted rapid transmission of news and ideas and free expressions of opinion.???
Annual meetings of medical consultants in the Zone of Interior were held, with programs divided between clinical and administrative topics (appendix B p. 831). In 1943, the meeting was held in the Surgeon General's Office (fig.15); in 1944, at Ashford General Hospital, White Sulphur Springs, W. Va. (fig. 16); and in 1945, at Thomas M. England General Hospital, Atlantic City, N.J. At the first of these meetings, in 1943, the neuropsychiatrists were in attendance. Subsequently, in 1944 and 1945, attendance was confined to the medical consultants from the service commands and the civilian consultants in medicine to The Surgeon General. The Surgeon General or his deputy and the chiefs of personnel and hospitalization services also attended. At the meetings in 1944 and 1945, it was possible to have representatives, temporarily in this country, from some of the oversea theaters.
In addition to encouraging exchange of information on professional matters throughout the Army, the Medical Consultants Division, OTSG, maintained liaison with other individuals active in the field of clinical investi-
41
FIGURE l5.-Meeting of consultants in
medicine, OTSG, 25-26 October 1943.
Left to right, first
row, seated: Col. W. Bauer (Eighth Service Command), Col. A. Freer
(Director, Medical Division), Brig, Gen. C. C. Hillman (Chief,
Professional Service), Brig. Gen. H. J. Morgan (Chief Consultant in
Medicine to The Surgeon General), and Lt. Col. V. R. Mason (Ninth
Service Command).
Second row,
standing: Lt. Col. E. R. Long (Chief, Medicine Branch), Lt. Col. F. D.
Adams (Fourth Service Command), Lt. Col. H. L. Blumgart (Second
Service Command), Col. W. B. Martin (Fifth Service Command), and Lt.
Col. F. R. Dieuaide (Medicine Branch).
Third row: Lt. Col. R. H. Turner, Lt. Col. E. V.
Allen (Seventh Service
Command), Lt. Col. I. S. Wright, Lt. Col. G. P. Denny, Lt. Col. H. J.
Shull (Medicine
Branch), and Capt. W. H. Stearns (Medicine Branch).
gation. Members of the staff regularly attended important civilian
medical meetings and meetings of appropriate committees of the National
Research Council.
Publications-In the fall of 1942, representatives of the
Surgical and Medical Consultants Division suggested to others in the
Surgeon General's Office that a
medical newsletter be established. Such a medium was made available in
January 1943. Only two issues were published before the project had to
be abandoned
because of administrative difficulties.17 Further
discussions within the Surgeon General's Office resulted in converting
the quarterly Army Medical Bulletin to a
monthly publication called the Bulletin of
17 (1) Circular Letter No. 8, OTSG, U.S. Army, 2 Jan.
1943, subject: Medical News Letter, 1 Jan. 1943, (2) Circular Letter
No. 26, OTSG, U.S. Army, 15 Jan. 1943, subject: Medical
News
Letter No. 2.
42
FIGURE 16.-(See opposite page for
legend.)
43
the U.S. Army Medical Department. In this bulletin, there appeared
regularly through the remainder of the war both articles and news items
relating to current
problems in the field of medicine. The establishment of the bulletin
was announced in Circular Letter No. 165, OTSG, U.S. Army, 15 September
1943, and the
first issue appeared the following month. The chief consultants in
surgery and medicine became member's of the editorial staff.
Unfortunately, distribution of
this bulletin, even in the Zone of Interior, constituted a major
problem. Copies were never received by many medical officers in oversea
installations, although
direct mailing to officers at their APO's improved distribution to some
extent.
Another medium for dissemination of official
communications concerning diagnosis, treatment, and disposition of
patients in Army hospitals was the circular
letters of the Surgeon General's Office. These were discontinued on 31
December 1943. They were replaced by TB MED's and to a less extent, by
War
Department circular's, Army regulations, FM's (War Department Field
Manuals) and TM's.
FIGURE l6 - Conference of military and
civilian consultants in
medicine, Ashford General Hospital, White Sulphur
Springs, W. Va., 30-31 October 1944.
Left to
right, first row,
seated: Col. D. M. Pillsbury (Consultant, Dermatology, ETOUSA), Col. F.
P. Strome (Surgeon, Third Service Command), Col. E. A.
Noves (Surgeon, Fifth Service Command), Brig. Gen. H. J. Morgan (Chief
Consultant in Medicine to The Surgeon General), Col. C. M. Beck
(Commanding
Officer, Ashford General Hospital), Col, A. Freer (Chief, Professional
Administrative Service, OTSG), and Col. W.P. Holbrook (Chief,
Professional Division,
Army Air Forces).
Second row: Lt.. Col. T. H. Sternberg (Director,
Venereal Disease
Control Division, OTSG), Col. E. V. Allen (Consultant, Seventh Service
Command), Col. T.
Fitz-Hugh, Jr. (Consultant, Third Service Command), Col. W. Bauer
(Consultant, Eighth Service Command), Dr. J. H. Stokes (Consultant,
Dermatology), Dr.
W. L. Palmer (Consultant, Gastroenterology), Dr. J. E. Moore
(Consultant, Venereal Diseases), Col. I. S. Wright (Consultant, Sixth
Service Command), Dr. M.
F. Boyd (Consultant, Tropical Diseases), Dr. R. B. Watson (Consultant,
Tropical Diseases), Lt. Col. H. J. Shull (Chief, General Medicine
Branch, OTSG), and
Dr. P. D. White (Consultant, Cardiovascular Diseases).
Third row : Col. V. R. Mason (Consultant, Ninth
Service Command), Col.
F. D. Adams (Consultant, Fourth Service Command), Dr. R. L. Levy
(Consultant,
Cardiovascular Diseases), Dr. C. B. Thomas (Consultant, Infectious
Diseases), and Dr. R. A. Cooke (Consultant, Allergy)
Fourth row: Lt. Col. F. R. Dieuaide (Chief, Tropical
Disease Treatment
Branch, OTSG, Dr. C. M. Jones (Consultant, Gastroenterology), Lt. Col.
H. L.
Blumgart (Consultant, Second Service Command), and Dr. C .M MacLeod
(Consultant, Infectious Diseases).
Fifth row: Dr. W. B. Wood, Jr. (Consultant,
Infectious Diseases), Lt.
Col. M. J. Farrell (Deputy Director, Neuropsychiatry Consultants
Division, OTSG), and
Maj. A. C. Vami Ravenswaay (Chief, Medicine Branch, Army Air Forces).
Sixth row: Col. B. M. Baker (Consultant, South
Pacific Base Command),
Lt. Col. J. McGuire (Consultant, Fifth Service Command), and Dr. H. W.
Brown
(Consultant, Tropical Diseases)
Seventh row: Dr. F. M. Rackemann (Consultant,
Allergy), and Lt. Col. G.
P. Denny (Consultant, First Service Command)
44
Circular letters of the Surgeon General's Office and T B MED's were the
usual vehicles for conveying useful clinical information and outlining
professional
procedures. Each of these publications, when written by the Medical
Consultants Division, was the editorial responsibility of one member of
the staff. Its
contents expressed, in general, a summation of the best available
information on the subject under discussion. Throughout the emergency,
the Division's staff
devoted much time and effort to the preparation of these publications.
The circular letters, TB MED's and other publications which were
prepared wholly or in
considerable part by the Division are listed in table 1.
TABLE 1.-Publications prepared wholly
or in part by the Medical
Consultants Division 1
45
TABLE 1- Continued - Publications
prepared wholly or in part by the Medical Consultants Division 1.
It should be repeated
that the distribution of professional publications was neither so
prompt nor so complete as it should have been, especially in oversea
theaters. Journals and books received at oversea depots had low
priority ratings for distribution, and delivery to hospitals was often
delayed or failed
completely. Individual medical officers in forward units who might have
profited most from the medical technical bulletins frequently did not
receive them at
all or received them only after great delay. Often, careless handling
at medical installations delayed or defeated proper distribution.
Educational media.-General Morgan believed
that the assignments of most physicians in
the Medical Department provided them an opportunity
46
for professional
improvement. He also believed that the Medical Department was obligated
to render all practical assistance possible to medical officers in
their efforts to improve their professional knowledge. Consequently,
procedures of educational value were encouraged in Medical Department
installations.
Medical consultants in the major commands, both in the Zone of Interior
and overseas, were the pivotal personnel in this undertaking. Circular
Letter No.27,
OTSG, United States Army, 22 January 1943, and TB MED 210, December
1945, stressed importance of staff rounds and staff meetings in
hospitals. The
Medical Consultants Division was successful in its efforts to modernize
and enlarge hospital libraries in respect to internal medicine. The
Board for Review of
Books and Periodicals, OTSG, theoretically made selections of
professional texts and journals available to each medical installation
caring for patients (p.49).
Facilities of the Army Medical Museum were opened to all hospitals. To
speed up the procurement of special information from medical
literature, the Army
Medical Library enlarged its facilities for the reproduction and
distribution of microfilm for any medical officer or installation
requesting it. Visits of civilian
consultants to hospitals of service commands in the Zone of Interior
were encouraged and assisted. Wartime graduate medical meetings were
held under the
auspices of the American College of Physicians and the American College
of Surgeons, in cooperation with the Surgeons General of the Army and
Navy.
Medical Corps officers were encouraged to qualify themselves for
certification by the American specialty boards and, wherever practical,
to attend important
medical meetings of both Army and civilian physicians.
Important contributions
to the continuing education and training of Army medical officers were
made by civilian organizations such as the American Medical
Association, the State societies, the American College of Physicians,
the American College of Surgeons, and other medical groups, the
Rockefeller Foundation,
and the Commonwealth Fund. Especially in the early months of the war,
the Medical Consultants Division, OTSG, served as a coordinating agency
between
the Army medical officer's and these civilian organizations.
INTRAOFFICE AND
INTEROFFICE RELATIONSHIPS
In the large and complex
organization of the Surgeon General's Office, the operations of certain
services and divisions were of special importance to the
Medical Consultants Division.
Personnel Service.-It is obvious that
accurate classification and proper assignment of
professional personnel directly affects the quality of medical care
furnished patients.
As has been noted (p. 17), the medical consultants' group cooperated actively in the procurement of immedical officers. Many civilian internists were personally acquainted with members of the staff of the Medical Consultants Division and, in the process of becoming commissioned, made their first contact with the Army in that Division. Through such contacts, Gen-
47
eral Morgan assisted the
Personnel Service, OTSG, by acquainting himself with the availability
of individuals with special qualifications in internal medicine.
Through personal knowledge of civilian physicians, he was able to
select and procure for the Army, by informal means, individuals best
suited to fill certain
key positions. Generals Morgan and Rankin made frequent visits to
civilian medical meetings in the interest of Medical Corps officer
procurement during the
early days of the war.
A close, effective relationship between the Medical Consultants Division and the Personnel Service was clearly essential to the proper utilization of internists by the Army. When this relationship finally received official approval, the Medical Consultants Division assumed one of its most important duties-- that of determining, by recommendation, the classification and assignment of medical specialists in Army installations. This activity involved constant exchange of information between the Personnel and Medical Consultants Divisions regarding the need for and availability of medical specialists, the continuing evaluation and classification of individual medical officer's with experience in internal medicine, and recommendations as to where these individuals could best be used.???
The
information used by
the Medical Consultants Division in personnel evaluation covered many
aspects of an officer's qualifications but chiefly had to do
with his participation in postgraduate education and training programs
and his record of professional performance. The service command
consultants regularly
reviewed the classification of the internists assigned to their
commands, evaluating their on-the-job performance.
The
Civilian Personnel
Division, OTSG, was important to the Medical Consultants Division
because it provided not only secretarial and clerical personnel but
also civilian consultants to The Surgeon General. The role of the
latter is described elsewhere in this chapter (pp. 66-67). As to the
former, the Medical
Consultants Division was fortunate in having capable, industrious, and
loyal office employees, whose work was essential to the success of the
division.
Operations Service.-The Medical Consultants Division cooperated with the Operations Service, OTSG, and the Personnel Service, OTSG, in studying the need for medical officers qualified in internal medicine in the various types of Army medical installations. These studies formed the basis for the tables of organization for numbered oversea units and for the manning guides for the fixed installations in the Zone of Interior. Unfortunately, these tables and guides proved to be unsatisfactory in the light of actual field experience. Even when hostilities ceased, they had not been revised insofar as professional personnel was concerned.
The Hospital Division of the Operations Service designated hospitals to receive certain types of patients, recommended establishment of centers for the care of special disorders, and evolved and administered plans for the transfer of patients from one hospital to another. Under the leadership of the Hospital Division, group visits to selected hospitals throughout the Zone of Interior
48
were made by
representatives from the Medical Consultants Division, the Surgical
Consultants Division, and certain other divisions within the Surgeon
General's Office. The Hospital Division frequently requested the
Medical Consultants Division to recommend administrative changes which
would result in
more efficient management of medical patients. The relationship between
the Medical Consultants Division and the Operations Service was
extremely cordial,
to the greater effectiveness of both divisions in relation to the care
of the sick. This was the state of affairs during the last 18 months of
the war. It is
unfortunately true that, during 1942 and 1943, opportunity for
cooperative endeavor of this sort was very limited.
Supply Service.-In the earliest days of his
assignment, Colonel Morgan was asked his
opinion concerning medicinal agents for use in the Medical
Department of the Army. To a somewhat lesser extent, he and his staff
became concerned also with the distribution of medicines and items of
equipment to the
various medical installations in the Army. As the war continued, the
Supply Service, OTSG, requested the Medical Consultants Division's
cooperation in the
review of tables of equipment with a view toward adding new items,
immeluding medicinal agents, and deleting old ones no longer in demand.
The Medical
Consultants Division was often asked for an opinion on the misc of
nonstandard medical items. From time to time, it provided background
information and
assistance in developing therapeutic agents and in expanding
production. The development of production facilities for penicillin,
streptomycin, and blood
plasma was obviously a matter of great concern to the Division.
Other services
and divisions.-The Medical Consultants Division and the
divisions representing preventive medicine, surgery, and
neuropsychiatry
cooperated closely in the formulation of professional policies. This
cooperation was essential to the planning of a balanced professional
program. The Medical
Consultants Division regularly gave assistance also to the Physical
Standards Division, OTSG, in refereeing questions pertaining to
borderline physical
findings in military personnel. It cooperated actively with the editor
of the Bulletin of the U.S. Army Medical Department in
the preparation, approval, and
editing of professional material for dissemination to the field and
with the Technical Information Division, OTSG, in reviewing
professional articles submitted
for publication and also material to be released to public information
mediums. In addition, the Medical Consultants Division was called upon
from time to
time to advise and assist other divisions of the Surgeon General's
Office in the preparation of bulletins and manuals for dissemination to
the Armed Forces.
Such a publication was FM 21-11, First Aid for Soldiers, 7 April 1943.
The Medical Consultants Division cooperated with the Surgical
Consultants Division,
OTSG, in preparing the manuscript and supervising the collection of
data. A large part of TM 8-500, Hospital Diets, published in March
1945, was prepared
under the Medical Consultants Division's direction.
49
Special boards.-The Medical Consultants
Division, OTSG, provided members for a number
of special boards, five of which were of special interest to the
Division.
1. Board to prepare, develop, and implement the medical portion of the War Department's program for aid to civilian populations in liberated countries.-This board was established on 28 June 1943, by Office Order No. 419, OTSG, U.S. Army. Colonel Dieuaide of the Medical Consultants Division, served on this board until after the end of the war. In many meetings, supplemented by individual interim study, comprehensive plans were developed for furnishing medical supplies to civilian populations in the countries to be liberated by Allied forces. Items to be included in various supply assemblies were carefully selected, and instruction sheets were prepared by Colonel Dieuaide outlining the purposes and recommended method of using these supplies, particularly drugs.18
2. Board for Review of Books and Periodicals.-The Medical Consultants Division was represented on this board by General Morgan and Colonel Shull, chairman and secretary respectively.19 The board provided reviews by appropriate professional authorities of all medical textbooks and periodicals submitted by publishers to The Surgeon General for purchase. It recommended to The Surgeon General medical textbooks and journals for the libraries of Medical Department installations of all types and, at regular intervals, revised the recommended list. The board also provided the Supply Service, OTSG, with authoritative opinion when requisitions were received for nonstandard books and journals.20 The consultants in medicine throughout the Army stimulated commanding officers to provide libraries in Army hospitals with adequate physical facilities and personnel and to supplement the supply of books where local funds were available for that purpose.
The actual delivery of journals to oversea installations remained a problem throughout the war (p.45). The Board for the Review of Books and Periodicals finally arranged for the direct mailing of journals by the publishers to the individual units. This was found to be an improvement in the theaters where it was tried, but no genuinely satisfactory method for the continuing and prompt distribution of current journals and books to Army libraries was developed during World War II.
The Board for the Review of Books and Periodicals also took a lively interest in a method, developed by the Army Medical Library, for the rapid transmission of professional data on microfilm to medical installations in the Zone of Interior and overseas. This very important aid to professional education and training was one of many successful efforts of the Army Medical
18 TB MED 149, 17 Mar.
1945, subject: Descriptive List of Drugs and Chemicals in Far East CAD
Units.
19
Office Order No. 350,
OTSG. U.S. Army, 4 June 1943, subject: Board for the Review of Books
and Periodicals.
20 (1)
Circular Letter
No. 158, OTSG, U.S. Army, 27 Nov. 1942, subject: Medical Books. (2)
Circular Letter No. 126, OTSG, U.S. Army, 16 July 1943, subject:
Medical Books and Journals,
Including Authorization for Limited Local Procurement. (3) War
Department Supply Bulletin 8-3, 21 Mar. 1944, subject: Medical
Department Professional Books, (4) \Var Department Supply
Bulletin 8-4, 21 Mar. 1944, subject: Medical Department Professional
Journals. (5) War Department Supply Bulletin 8-20, May 1945, subject:
Medical Department Professional Books.
50
Library to project its
influence into the oversea theaters and, in rare instances, even to
individual medical officers assigned to combat units. Facilities were
enlarged at the Army Medical Library for photoduplication, and
projectors for reading the microfilms were made available to all Army
installations.21
3. Board for Study
of the Clinical Treatment of Malaria.-The initiation of clinical
studies of malaria treatment was impeded by the opinion of a few
medical
officers in high position that sufficient knowledge was already at
hand, based on prewar experience of the Army in the Tropics. Early
attempts to modify this
sentiment were unsuccessful. Finally, on 15 November 1943 in Office
Order No. 890, The Surgeon General appointed a special board to
surpervise studies in
the field of malaria. Colonel Dieuaide served on this board. Trials of
eight plans of treatment for malaria were conducted at Bushnell General
Hospital,
Brigham City, Utah, Kennedy General Hospital, Memphis, Tenn., Percy
Jones General Hospital, Battle Creek, Mich., and Harmon General
Hospital.
Plasmochin naphthoate was one of the drugs especially studied in the
hope of curing malaria caused by infection from Plasmodium vivax.
The Plasmochin
naphthoate method was unsuccessful, as indicated in the final report of
the board, dated 26 March 1944. 22
4. Board for the
Coordination of Malarial Studies.-Early in November 1943, an
interservice Board for the Coordination of Malarial Studies was created
by
joint action of the Director, Office of Scientific Research and
Development; the Director, National Research Council; and the Surgeons
General of the Army,
Navy, and U.S. Public Health Service. This board continued the
functions of the Subcommittee on Malaria of the National Research
Council and established
means for direct collaboration with the services. It was brought into
existence because the usual consultative arrangement with committees of
the National
Research Council was found inadequate in the face of the complexities
and size of the malaria problem then confronting the armed services.
Colonel Dieuaide,
on the recommendation of General Morgan, was appointed by The Surgeon
General of the Army as a member of this board and served until after
the end of the
war. The Malaria Board, as it was called, was a clearinghouse for all
available information about malaria, as well as a forum for the
discussion of plans and a
directing body for the supervision of research in the field (fig.17).
Through the Malaria Board, most of the planned studies of malaria
treatment in the Army in
the United States, and to a less extent overseas, were coordinated with
research carried on outside the Army. The Board for Coordination of
Malarial Studies
published several volumes of malaria reports from 1943 to 1946. Of 600
numbered reports approximately 90 were contributed by various Army
sources. Although the efforts of the board failed to disclose any new
curative drug, several powerful and important new drugs
________
21 (1)
Monocular
Microfilm Viewer. The Army Medical Library Microfilm Service. Bull.
U.S. Army M. Dept. 74: 118-119, March 1944. (2) Journals Available on
Microfilm. Bull. U.S.
Army M. Dept. 75:12 Apr. 1944. (3) Microfilming Research Material.
Bull. U.S. Army M. Dept. 79:29 Aug. 1944. (4) Microfilm Projector for
Army Hospitals. Bull. U.S. Army M. Dept. 88:
62-63, May 1945.
22
Memorandum, Board for
Study of the Clinical Treatment of Malaria for The Surgeon General, 26
Mar. 1945, subect: Final Report on the Treatment of Malaria.
51
FIGURE l7.-Collecting
mosquito larvae in the field for study, 8th Medical Laboratory,
Australia, 1943.
were studied (including SN-7618 and SN-8713), and the routine treatment of malaria with the drugs then available was vastly improved. Important contributions included a definitive comparison of quinine and Atabrine, which demonstrated conclusively the superiority of the latter and the determination of the optimum methods for its use. 23
???5. Board to survey and evaluate the medical problems of repatriated American prisoners of war.-With the cessation of hostilities in the Pacific, a large number of American prisoners of war were released from Japanese prison camps. The length of captivity ranged from a few days to 3 ½ years. The environmental conditions had varied considerably but for the most part had been extremely poor (fig.18). Thousands died as a result of disease and starvation (fig.19). The Medical Consultants Division believed that a careful health survey of the survivors would be of value in planning their future medical care, in preventing the spread by them of communicable diseases to families and communities, and in providing a better understanding of the changes that take place in men during exposure to such hardships (fig.20). Accord-
23 (1)
The Board for the
Coordination of Malarial Studies. Wartime Research in Malaria. Science
103: 8-9, 4 Jan.1946. (2) The Suppressive Treatment of Malaria with
Mepacrine
(Quinacrine).J. A. M. A. 126: 1098, 23 Dec. 1944. (3) Quinacrine
Hydrochloride (Atabrine) for Malaria. .J. A. M. A. 125: 977, 5 Aug.
1944. (4) Shannon, J. A., Earle, D, P., Jr., Brodie, B. B.,
Taggart, J. V., and Berliner, R. W.: The Pharmacological Basis for the
Rational Use of Atabrine in the Treatment of Malaria. J. Pharmacol.
& Exper. Therap. 81:307-330, August 1944.
55
FIGURE 19-Typical
picture of malnutrition in an American prisoner of war recovered in
Japan.
ingly, in Office Order
218, dated 30 August 1945, The Surgeon General established a board to
survey and evaluate the medical problems of repatriated
American prisoners of war returning from the Far East. General Morgan
served as president of this board, Colonel Wright as coordinator, and
Captain Hunt as
recorder. The work of the survey teams that made the study and the
results of the undertaking are described in a published report.24
Army Air Forces-Contact between the offices of The Surgeon General, the Air Surgeon, and, to a lesser extent, the Surgeon, Army Ground Forces, was not close. This was a reflection of the separation by command boundaries and the compartmentation of responsibilities in the various fields of Army medicine which existed at the beginning of World War II. In spite of the inherent difficulties, the Medical Consultants Division attempted to serve the Air Surgeon and the Ground Surgeon, as well as The Surgeon General of the Army. The organizational and physical separation of the offices rendered the efforts difficult and, on the whole, unrewarding.
__
24
Morgan, H. J.,
Wright, I. S., and Van Ravenswaay, A.: Health of Repatriated Prisoners
of War from the Far East. J.A.M.A. 130:995-999, 13 Apr.1946.
57
FIGURE 20.-Continued.
C. Disinfestation of clothing. D. Taking a medical and social history.
58
In the fall of 1942 and
spring of 1943, service command medical consultants in the Zone of Interior regularly visited
Air Force hospitals. However, autonomy
of Air Force operations, coupled with misunderstandings which
occasionally grew out of the consultants' suggestions designed to
improve the quality of
medical care or to change medical officer assignments, often resulted
in friction. When friction occurred, it almost invariably involved
administrative or
command personnel rather than the professional personnel in hospitals.
Because of such friction, medical consultants in certain service
commands ceased
visiting Air Force medical installations.
Fortunately, the value of these visits by professional consultants was apparent to Air Force clinicians. Therefore, the Air Surgeon established a svsteni of consultation within the Air Forces, with visits by the senior clinicians in Air Force regional hospitals to the smaller hospitals in their areas.25 The Air Surgeon also appointed consultants who functioned in his office much as did medical consultants in the Surgeon General's Office. The relationship between the consultants in the Air Surgeon's Office and those in the Surgeon General's Office was good, and many professional problems which would have been difficult to consider through regular channels were handled well on an informal basis. Examples of cooperative undertakings carried on in spite of administrative difficulties are clinical observations on atypical lichen planus, clinical trials of penicillin in certain infections, notably gonorrhea, and observations on the management of rheumatic fever and other diseases related to streptococcal infection. There was little cooperation between the two offices with regard to the assignment of specialists. During World War II, The Surgeon General of the Arniy had virtually no control over the professional personnel of the Army Air Forces.
Army Ground
Forces.-In the Army Ground Forces, the importance of the
quality of professional medical services was overshadowed in the early
months of
Army expansion by more pressing quantitative needs and the necessity
for field training of medical officers. It is unfortunate that no
professional consultants
regularly visited Ground Force units in training in the Unted States.
It was not until the early months of 1944 that the consultants
divisions of the Surgeon
General's Office participated in personnel selection and assignment to
the professional staffs of numbered hospital units destined for oversea
service with the
Ground Forces. The training program for medical officers in these units
emphasized physical conditionmg and practice in triage and
transportation and
evacuation of patients, especially the wounded, but little emphasis was
placed upon the curative treatment of disease and injury with prompt
return of the
soldier to duty (fig. 21). Thus, the primary mission of the Medical
Department in time of war--the maintenance of the lowest noneffective
rate possible--was
often neglected. The emphasis upon surgery
________
25
This system was also
in operation in certain Army Service Forces hospitals as a supplement
to the consultation provided by the service command consultants.
59
FIGURE 21-Training in
triage and evacuation of wounded. Placards on trees announce (left to
right): ''Capt. MC,'' ''1st Lt. Med. Officer,'' ''Litter
wounded,'' and ''Water,'' Lawson General Hospital, Atlanta, Ga.,
September 1943.
in the manning tables for numbered hospitals destined to function with combat troops in the theaters of operations is understandable, but it often proved to be unrealistic (fig.22). The number of surgical patients returned to duty from hospitals in the theaters of operations was small indeed when compared with the number of medical patients returned. The greatest contribution to the maintenance of the lowest noneffective rate possible came from medical officers, who were concerned with the prevention and cure of disease,
American
National Red Cross.-Contacts between the Medical Consultants
Division and headquarters of the American National Red Cross and
between
consultants in medicine in the field and Red Cross field
representatives were frequent, cordial, and mutually beneficial. The
Medical Consultants Division,
through Colonel Dieuaide, assisted the Red Cross in formulating lists
of drugs to be included in packages for delivery to American prisoners
of war in enemy
hands. Accompanying these packages was a statement prepared by Colonel
Dieuaide describing in lay terms the indications for dosage of these
drugs.26
_________
26American
Red Cross.
Booklet of Instruction for the Use of Drugs Contained in the 100-man
Unit of the Medical List for Allied Prisoners of War in the Far East,
May 1944.
60
FIGURE 22.-Emphasis on
surgery during training. Actual operation under field conditions in a
mobile hospital unit attached to Lawson General Hospital,
Atlanta, Ga., January 1944.
RESEARCH
In the early days of the
emergency, The Surgeon General, while urging full use of civilian
research facilities, discouraged efforts to carry on planned and
coordinated clinical investigation in the Army. This official attitude
appeared to be due to a number of factors. There was enormous pressure
to meet the
practical medical needs of the rapidly expanding Army, and, although
important scientific research had been done in the past by Army
officers, the tradition of
clinical research was not established in Army thinking. The function of
the Medical Corps in time of war was generally judged to be the optimum
application
of knowledge already available, not research and discovery. Moreover,
the National Research Council, which the National Academy of Sciences
had
established in 1916 for the benefit of Government agencies, was fully
organized and geared to a high degree of activity.27
During World War II and the
emergency period preceding it, the committees of experts of the
National Research Council were available to the Medical Department for
consultation and for
the planning and actual execution of research projects.
________
27 The National Academy
of Sciences was a private nonprofit organization of scientists
recognized by act of Congress and by President Lincoln in 1863 to
further science and to advise the
Federal Government in scientific matters upon request.
61
As the war progressed,
the need for answers to medical problems, both new and old, became
increasingly urgent. The facilities of the National Research
Council were used widely. It may be said that without this help the
Medical Consultants Division, in relation to many problems, would have
functioned often
in a vacuum and almost always would have been less effective. The
Committee on Chemotherapeutics and Other Agents, together with its
special
subcommittees, gave invaluable assistance, especially in regard to the
sulfonamides, penicillin, and streptomycin. Also, the Committee on
Medicine and each
of its Subcommittees on Tuberculosis, Infectious Diseases, Clinical
Investigation, Cardiovascular Diseases, and Medical Nutrition assisted
the Medical
Consultants Division in solving problems in these specific fields. The
Subcommittee on Tropical Diseases initiated and coordinated
investigations in its field.
Upon official request of The Surgeon General, the following topics of
special importance to the Medical Consultants Division were made the
subject of study
and reports by the appropriate committees: Amebiasis, schistosomiasis,
leishmaniasis, filariasis, malaria, poliomyelitis, and tuberculosis;
the treatment of ill
effects of heat upon troops; the treatment of venereal diseases; the
use of sulfonamide drugs; the use of penicillin and of streptomycin;
and the management of
fungus infections of the skin.
The facilities available to the National Research Council for its study of Army medical problems were confined, in large measure, to civilian institutions. As the Army was organized and administered in World War II, it was not practicable for the National Research Council systematically to carry on studies in military installations. Nevertheless, many of the problems facing The Surgeon General had special military aspects that could be studied only in Army installations.
???The need
for such
clinical studies, initiated and directed by the Medical Consultants
Division, was evident when War Department technical bulletins were in
preparation. These official publications were intended to guide medical
officers throughout the Army in diagnosis, treatment, prognosis, and
disposition of
soldiers with certain unethical disorders. In many instances,
information was not available for specific statements and directions
regarding the particular
professional problems seen by the Army. The choice of the Medical
Consultants Division was either to depend upon impressions, guesses,
and conclusions
arrived at on hypothetical grounds or to make studies designed to
provide the answers. It was extremely difficult to do the latter at any
time during World War
II.
The criteria for the
early diagnosis of infectious hepatitis constitute a case in point.
There was little information in the medical literature, and that little
was not
certainly applicable to time disease as it was experienced by the Army.
It was soon apparent that time patient with hepatitis should have
prompt and prolonged
hospital care, but there were many uncertainties concerning diagnostic
laboratory procedures. Even the piecemeal information available on
these points
reached the Medical Consultants Division by means so indirect and slow
that the problem was never completely and satisfactorily solved,
62
although useful
information was obtained through civilian consultants and Army
personnel in selected hospitals. Patients with naturally acquired
infectious
hepatitis were not seen in sufficient numbers in Zone of interior
installations, nor were enough qualified investigators ever
concentrated in one or more of the
oversea commands to permit thorough study of the problem.
Such research as was
undertaken in Army installations in the management of disease was often
fragmentary and poorly coordinated. There was no established
administrative machinery for carrying out these studies. The initiation
of each project required special approval, special arrangements for
equipment and
personnel, special instructions to the commanders of the installations
concerned, and the approval of several organizations within the Surgeon
General's
Office. It was difficult to get information about clinical research in
oversea commands because early in the war there were no direct channels
of
communication between the field installations and the Medical
Consultants Division. It is true that clinical investigation carried
out both in the Zone of
Interior and in oversea theaters was excellent, but investigations were
often hampered and their accomplishments rendered less valuable to the
Army as a
whole because means of communication and coordination were tenuous or
nonexistent. The Medical Consultants Division was especially sensitive
to this
serious handicap in relation to its problems with malaria, filariasis,
schistosomiasis, hepatitis, and penicillin.
The following are
examples of clinical research with which the Medical Consultants
Division was actively concerned:
1. Hepatitis.-In the spring of 1942,
numerous cases of infectious hepatitis
occurred in soldiers who had been vaccinated for yellow fever. The
Medical
Consultants Division succeeded in obtaining the assignment of four
medical officers to four separate Army hospitals to observe the
chemical course and the
effects of various forms of treatment. These studies provided early
clinical experience in a problem that was to develop into one of great
magnitude and
importance.
The Division encouraged as best it could the extensive field studies on hepatitis which were carried out under difficult circumstances in the Zone of Interior.
???2. Tropical diseases.-Extensive and valuable clinical observations and therapeutic trials were made in the field of tropical medicine, especially at Moore and Harmon General Hospitals and in the Pacific. Such studies increased knowledge of filariasis and of schistosomiasis and gave information of the greatest practical value on the use of Atabrine in malaria. From the Southwest Pacific in 1944 and 1945, large numbers of patients were returned to this country with an unusual skin disorder, which came to be called atypical lichen planus. A concise, clear-cut clinical description eventually resulted from carefully organized studies of related groups of eases in hospitals in this country as well as overseas.
3. Trenchfoot.-Selected hospitals, manned and equipped for the purpose, made special studies of a great many trenchfoot patients returned from the
63
European theater. These
studies yielded useful information applicable throughout the Army.
4. Penicillin and
streptomycin.-The Medical Consultants Division was active in
planning and developing within the Army opportunities for studying the
use
of penicillin. Studies on the absorption, excretion, and methods of
prolonging the action of penicillin were carried forward at two
specially designated Army
hospitals, Walter Reed General Hospital, and Fort Bragg Regional
Hospital, Fort Bragg, N.C. As the war closed, extensive observations on
the use of a newer
antibiotic, streptomycin, were under way.
By the spring of 1945, there was fairly widespread acceptance of the concept that it is the province and duty of the Medical Department of the Army to pursue actively, by whatever means available, clinical research in Army hospitals and laboratories. There was increasing (but never complete) agreement in the Surgeon General's Office that it was sound and proper policy to establish facilities and assign medical personnel for this purpose. Earlier efforts made in this direction from time to time had met with resistance or failure. Members of the Medical Consultants Division and others contended that establishment of a special board, within the framework of the Surgeon General's Office, composed of Medical Corps officers with research interest and training, would facilitate research undertakings. Establishment of such a board, to be designated the Army Board for Clinical Research, was formally proposed by the Medical and Surgical Consultants Division in March 1945, with the belief that its creation would strengthen and extend administrative provisions then existing for the initiation, supervision, and coordination of research by The Surgeon General. The proposal was not approved during the war.
VISITS TO
SERVICE AND OVERSEA COMMANDS
From the beginning, it
was apparent that firsthand knowledge of the problems of medicine as
encountered in the field was essential if a bureaucratic, theoretical
approach was to be avoided. Experience strengthened this opinion (fig.
23). Accordingly, General Morgan, during his tour of duty in the Army,
spent
approximately one-half of the time in the field, including more than 8
months in oversea theaters, As the Medical Consultants Division, OTSG,
grew, the
chiefs of branches also made frequent field trips. This personal
contact was maintained with the medical consultants assigned to service
commands, theaters,
and armies.
In 1942, General Morgan
attended Army maneuvers in the California desert (fig.24). During this
year and subsequently, he and members of his division made
frequent visits to the nine service command headquarters and the
medical units (general and station hospitals) in these commands
(fig.25). In 1943, General
Morgan visited the North African theater; the Middle East theater,
including Egypt, Eritrea, Palestine, and the Persian Gulf Service
Command; the China-Burma-India theater; the Southwest Pacific Area
(Australia, New Guinea); and the Hawaiian Islands, Colonel Dieuaide
visited the
64
FIGURE 23 - Brig.Gen.
Hugh J. Morgan visiting Col. Frank W. Wilson, MC, Moore General
Hospital, Swannanoa, NC., 1944.
Pacific in 1943-44 to
survey the tropical disease problems in general and malaria in
particular. In 1944, Colonel Turner of the Communicable Disease
Treatment Branch visited the Mediterranean theater to study infectious
hepatitis. In the spring of 1945, General Morgan visited the European
and
Mediterranean theaters, and, after V-J Day, accompanied by Colonel
Dieuaide, he visited the following commands: U.S. Army Forces, Pacific
(including U.S.
Army Forces, Western Pacific, and the Sixth and Eighth U.S. Armies,
which were then occupying the Japanese islands), and the China theater.
The value of these
visits to field headquarters and installations may be summarized as
follows:
1. Through direct
contacts between the chief consultant and his assistants and the
medical consultants and command surgeons in the field, the visits
promoted
unity of purpose and mutual understanding and confidence.
2. They were a means for direct and immediate interchange of ideas and information that were often of Armywide significance.
3. They improved specialized personnel management within commands and between commands.
4. To some extent, they associated the Medical Corps officers in field assignments in remote places with The Surgeon General and his headquarters organization. At the least, they were interpreted as a token of the interest of The Surgeon General in all of the officers of the Medical Department.
5. They brought to the attention of the commanding officers of major
65
FIGURE 24.- Maneuvers
in California desert. Armored halftracks approach Blythe, Calif., 7
October 1942.
and subsidiary commands
the functions of The Surgeon General and his office in relation to the
Army as a whole.
6. They encouraged, by example, a continuing and lively interest in clinical problems. Time and time again, medical officers expressed appreciation for visits made by individuals from the Surgeon General's Office to the bedside of sick or injured patients. Inspections by men in high position in the Army often completely ignored the actual care of the sick or injured soldier and the clinical problems incident thereto. This care was the chief activity of the majority of medical officers, and they rightly viewed it as their primary mission. The morale and performance of these officers were improved when The Surgeon General or his representatives took a similar view.
7. They bridged the chasm which inevitably develops between the men in field assignments and the headquarters group.
8. They brought to the Surgeon General's Office the problems of the field for such contributions to their solution as could be provided.
???It should be stated that administrative duties in the Surgeon General's Office did not permit enough visitation by the staff to field units, whether in the Zone of Interior or overseas. In addition, visits to oversea installations were often discouraged by the War Department and, at times, by the oversea theaters.
66
FIGURE 25.- Medical
installation, Ninth Service Command. Hospital (foreground) of Desert
Training Center, Calif., 1943.
CIVILIAN
CONSULTANTS IN MEDICINE
Every effort was made by
The Surgeon General to bring into the Medical Department of the Army
the best personnel available and to choose from them
military consultants for assignment to commands in the field. The
demands of medical education, research, and practice in civilian life,
however, were so great
that many eminent specialists in medicine were required to remain at
their civilian posts. Moreover, many who were anxious to serve in the
Army could not
meet Army physical requirements. Through membership in the National
Research Council committees, the services of most of these specialists
were made
available to The Surgeon General. In the early years of the war, much
good for the Army was accomplished by informal contacts and personal
correspondence
between the chief consultant in medicine and his staff and this group
of physicians. In January 1944, General Morgan recommended, and The
Surgeon General
approved, the formal appointment of civilian consultants in medicine to
The Surgeon General. These consultants were recognized authorities in
the fields of
gastroenterology, cardiovascular diseases, dermatology, infectious
diseases, chemotherapy, allergy, tropical diseases, and tuberculosis.
In subsequent months,
as special needs arose, additional consultants in special fields were
appointed, as follows: In November 1944, a consultant each in hepatic
diseases and in
tropical medicine; in January 1945, an additional consultant in
dermatology; and in March 1945, a consultant in vascular diseases. The
internists who served as
civilian consultants to The Surgeon General during World War II are
listed in appendix C, p. 839.
67
General Morgan, his
staff in the Surgeon General's Office, and the military medical
consultants in the field were aided greatly by the civilian
consultants.
Through these consultants, both medical societies and individuals had
direct access, through official channels, to The Surgeon General and
the chief consultant
in medicine, anti developments in civilian medicine were immediately
available to the Army. Frequently, advice on urgent matters was asked
by letter or
telephone. The civilian consultants prepared material to be
incorporated in War Department technical bulletins for Armywide
distribution; they attended
conferences with the Medical Consultants Division and the service
command consultants; and they offered suggestions and recommendations
regarding
Medical Department administrative procedure and professional practices.
In short, they provided a close and effective liaison between civilian
medical practice
and research and Army medical practice and research, to the great
benefit of both. Occasionally, the civilian consultants were ordered on
active duty as
commissioned officers with the Army for a few days, following which
they submitted comments and recommendations regarding the problem at
hand. They
visited Army hospitals in the Zone of Interior in company with the
military consultant of the command. Such visits, made jointly by
civilian and military
consultants, were found to be stimulating to the morale and
professional performance of medical officers on duty in hospitals. It
should be recorded that each
of these civilian consultants gave freely and willingly of time and
knowledge. Their extraordinary competence and their availability made
them a valuable
source of advice and professional assistance for the Surgeon General's
Office and for medical officers in the field. Their appointments were
terminated as of 31
December 1945.
PLANS FOR THE
POSTWAR ARMY
Planning for the
Medical Department.-General Morgan and his colleagues in
surgery and psychiatry devoted a great deal of thought and energy to
plans for
retaining an adequate number of properly trained general medical
officers and specialists in the postwar Army in order to preserve the
excellent wartime
standards of professional care. The problem was the procurement of
specialized personnel for the Army Medical Corps. Suggestions and
recommendations
were submitted as early as 1942 and were resubmitted periodically.28
These suggestions involved increasing the Army Medical Corps
through admission of
interested officers of ability who were either certified specialists or
candidates for certification. During the war, these suggestions were
considered
impracticable because there were few, if any, vacancies in appropriate
grades and it required an act of Congress to increase the size of the
Army Medical
Corps. Following cessation of hostilities, there was a sharp drop in
interest on the part of both the Medical Department and the personnel
under consideration.
________
28 Memorandum, Chief
Consultant in Medicine for Director, Historical Division, 14 Sept.
1945, subject: General Recommendations for the Medical Department in a
Future Emergency.
68
Plan to continue
the consultants system.-The professional consultants system,
as employed during World War II, had gained general acceptance
throughout
the Army. The following directive, War Department Circular No. 101, was
published 4 April 1946, months after cessation of hostilities and at a
time when
demobilization of the Army was well under way. Indirectly, it is an
appraisal of the consultant system in the form of a statement of what
the Army had come to
expect of it and how the Army planned for continued operation of the
system in the postwar period.
III. PROFESSIONAL
CONSULTANTS. 1. During World War II, The Surgeon General developed a
system of utilizing professional consultants from which great benefit
was derived
(reference is made to paragraph 2d, section II, WD Circular 12, 1946).
In order to insure the maintenance of the highest professional
standards and to provide close liaison with leaders in the
medical profession at large, this system will be continued and extended
in the future. Professional consultants who are
recognized experts in the medical and allied specialties, including
internal medicine, surgery,
neuropsychiatry, preventive medicine, dentistry, veterinary medicine,
and other special medical fields, will be designated by The Surgeon
General.
Recommendations for appointments in connection with special subjects,
such as dentistry and veterinary medicine, will be made by the senior
officer in these fields. They may be either
appropriate officers commissioned in the military service (Regular
Army, Army of the United States, Officers' Reserve Corps, or National
Guard of the United States) or qualified civilians
selected to render consultant service (see par. 4). Although the
provisions of this circular apply particularly to the United States,
oversea commanders will utilize appropriate medical officers in
their commands for similar duties or may procure professional advice
from locally available civilian medical experts.
2. As representatives of The Surgeon General, the professional consultants are concerned essentially with the maintenance of the highest standards of medical practice. It is their function to evaluate, promote, and improve further the quality of medical care and sanitation by every possible means, and to advise in the formulation of the professional policies of The Surgeon General and to aid in their implementation. The proper performance of these functions necessarily involves an appraisal of all factors concerned with the prevention of disease and the professional care of patients, including particularly the organization and program of professional services in medical installations, the quality, numbers, distribution and assignment of specially qualified professional personnel, the diagnostic facilities including roentgenologic and laboratory procedures, the availability and suitability of equipment and supplies for professional needs, and the nursing care, dietary provisions, recreational and reconditioning facilities, and other ancillary services which are essential to the welfare and morale of patients. The professional consultants exercise their functions by assisting and advising The Surgeon General, the surgeons of major forces and commands, and the commanding officers of hospitals and other medical installations on all matters pertaining to professional practice and preventive medicine, by providing advice on professional subjects in general and on newer developments in prophylaxis, diagnosis) treatment, and technical procedures, by stimulating interest in professional problems and aiding in their investigation, and by encouraging and participating in educational programs such as conferences, ward rounds, and journal clubs, and by giving advice on matters pertaining to research and development. The execution of these functions involves periodic visits to medical installations and other types of units concerned with the medical care of military personnel. The functions of professional consultants vary somewhat according to their assignments.??????
a. Office of The Surgeon General. In addition to medical officers permanently assigned as professional consultants, other specially qualified individuals will be placed on temporary duty from time to time, for the purpose of rendering advice and assistance to The Surgeon
69
General on broad
problems connected with policy and practice in the prevention of
disease, the care of patients, evaluation and maximum utilization of
specialized personnel, medical research,
postgraduate medical education, and other important professional
matters throughout the Army both in the United States and overseas.
b. Lower echelon headquarters.
Designated professional consultants will be placed on temporary duty
from time to time in service commands, Military District of Washington,
and air force
command headquarters for the purpose of rendering expert advice to
surgeons of these headquarters. It is desirable that such consultants
be individuals with military experience. Their services
will be utilized regularly in connection with problems within the
command which relate to the care of patients and other professional
matters as indicated above.
c. Army hospitals and other
medical installations in United States. Professional consultants
will be placed on duty from time to time in Army hospitals and other
medical installations in the
United States which are designated by The Surgeon General to provide
graduate education for medical officers in certain medical specialties.
Such consultants will have the particular duties in
hospitals of furthering in every possible way the educational program
for the advancement of medical officers in the specialties and of
maintaining the highest standards on the professional
services of the installations. They may, however, he called upon by the
commanding officer for any professional advice or appropriate
professional assistance he may desire of them. Their
services will be utilized regularly. For further information regarding
the educational program of the Medical Department in the medical
specialties, see AR 350-1010. Professional consultants
in the various medical and allied specialties will also be used in
other types of medical installations, including especially those
devoted to research and development.
3. At the completion of a
special mission and at such other times as may be required, each
professional consultant who has been on duty shall direct a
communication to The Surgeon General
dealing with the functions set forth in paragraph 2, including
recommendations (if any). These communications, with appropriate
indorsements including those of hospital commanders and
surgeons of commands concerned, will be promptly forwarded through
technical channels to The Surgeon General. Indorsements will show what
action has been taken on consultants
recommendations and will give an evaluation in terms of the consultants
services.
4. Qualified individuals
designated by The Surgeon General will be utilized as medical
consultants in one of two capacities--that is, either by being ordered
to active duty as officers
commissioned in the Officers' Reserve Corps or the National Guard of
the United States in accordance with War Department policy, or by being
employed as consultants holding excepted
civilian appointments under the authority of the Secretary of War. The
consent of the individual concerned will be obtained prior to placing
him on duty. The Surgeon General will maintain
up-to-date lists and from time to time inform all concerned of the
names, addresses, and qualifications of medical experts selected and
approved for consultant duty. He will also furnish details
regarding the procedures for placing consultants on duty.
5. The above
instructions are equally applicable to dental and veterinary
consultants.
6. These instructions do
not relate to the provision of civilian medical care, specialized or
otherwise, for individual military patients at public expense, as
outlined in paragraphs 3 and 4, AR
40-505.
ROLE OF THE INTERNIST IN WORLD WAR II
Among many miscellaneous topics claiming General Morgan's interest was the relative importance of the internist in the Medical Department of the Army. The topic was forced into the foreground of attention by the tendency on the part of some to emphasize the Medical Department's surgical activities in such a way as to belittle the contribution of those who cared for the sick.
70
This attitude on the
part of laymen is not surprising, for, when their attention is directed
to the Medical Department of the Army during wartime, it naturally
focuses upon the wounded man and his care. Actually, the noneffective
rate and the factors that affect it adversely are equally the concern
of the Army Medical
Department; they are, indeed, its chief concern in respect to its
mission to help win wars. Viewed in this light, the wounded man, aside
from the great
emotional reaction experienced by all regarding his plight, of
necessity assumes a position of secondary importance, for he is often
noneffective for a very long
time, if not permanently. Preventive and curative medicine are more
immediately effective in reducing medical noneffectiveness, which
fortunately constitutes
the bulk of the problem of the Medical Department as a whole. In the
Italian campaigns of World War II, 80 percent of noneffective soldiers
returned to duty
by the Medical Department were medical patients; only 20 percent were
surgical. The internist, thanks to the developments in medical
therapeutics since the
early 1920's, has become the most effective therapist extant, and this
fact is reflected in Army records.
Nevertheless, the
traditional tendency in military medical planning and administration is
to lay the greatest stress upon the surgical aspects of military
medicine, often to the detriment or neglect of the medical aspects.
General Morgan considered it one of his important duties as chief
consultant in medicine to
represent the professional interests and to emphasize the practical
importance of the internist with the Army in the field in order to
claim for himself, in the
councils of the Surgeon General's Office, his proper place and to urge
that he be properly recognized and adequately supported. In this
position, General
Morgan was strongly supported by many medical officers with field
experience in the Ground Forces, notably Col, (Later Maj. Gen.) Joseph
I. Martin, MC,
Surgeon, Fifth U.S. Army. Nevertheless, the maximum exploitation of
what internal medicine had to offer in reducing the noneffective rate
of troops in the
field was not undertaken during World War II. To do this, a revision of
the tables of organization and equipment for Ground Forces medical
installations
would have been necessary. In the field of psychiatry, much was
accomplished in this direction during the war, with notable returns in
reduction of psychiatric
noneffectiveness. The Ground Forces administration of problems in the
field of internal medicine during World War II differed little from the
practices of
1917-18, the management of the venereal diseases being almost the sole
exception. Because Army Medical Department installations were planned
and
administered primarily for a surgical mission, inefficiency and
improvisation characterized their performance with regard to medical
problems. In the theaters
of operations, the lack of specialized personnel in internal medicine
and the paucity of beds for the care of the sick in installations under
Army jurisdiction
resulted in much unnecessary evacuation to the communications zones,
prolonged hospitalization, and increased noneffectiveness. The
assignment of medical
consultants to field any headquarters in this war was an extremely
important initial step in the direction of correction. Much still
remained to be done when
hostilities ceased.
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